Atrial and ventricular phenotypes in a cohort of patients with functional tricuspid regurgitation: clinical, echocardiographic and prognostic aspects
Authors: Gavazzoni M , Heilbron HF , Florescu FD , Ciampi PC , Guta AG , Ochoa RO , Tomaselli TM , Volpato VV , Oliveiro OG , Caravita SC , Mene RM , Parati PG , Muraru DM , Badano LB 
Published: February 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial functional tricuspid regurgitation (A-FTR) has emerged as a newly recognized phenotype of functional tricuspid regurgitation (FTR), occurring in patients with atrial fibrillation and right atrial (RA) dilation but normal right ventricular (RV) size and function. Its prevalence, echocardiographic features and prognosis have not yet clarified since most evidence to date has included indiscriminately FTR patients with A-FTR and ventricular form (V-FTR). 

Aim

Aim of this study was to investigate the differences between these two phenotypes of FTR in terms of clinical correlates, echocardiographic aspects and prognosis. 

Material and methods

A total of 180 consecutive patients with moderate to severe FTR referred for echocardiography in two Italian centers were retrospectively enrolled. A-FTR was defined according to most recent guidelines criteria.  The composite endpoint of death for any cause and heart failure (HF) hospitalization was used as primary outcome of this analysis; secondary end point was HF-hospitalization. 

Results. Patients with A-FTR were 30% of the population; they were older than those one with V-FTR; with higher systolic blood pressure and less advanced symptoms (table 1). Chronic obstructive pulmonary disease was more prevalent in V-FTR.  Patients with V-FTR had larger 3D-derived right ventricle (RV) volumes, both diastolic and systolic, while right ventricle ejection fraction (RVEF) was similar. RV functional parameters as TAPSE, RVFWLS, RVGLS were significantly lower in the V-FTR patients as well as all the parameters of RV-pulmonary arterial (PA) coupling.  After a median follow-up of 24 months (IQR: 2-48), 72 patients (40%) reached the primary end-point and 64 (36%) hospitalized for HF.  The rate of composite end point tended to be lower in A-FTR than in V-FTR ( 29% vs 44%, p value: 0,1); the rate of hospitalization for HF was higher in V-FTR patients (22% vs 41%, p value: 0,04) (Kaplan Meier shown in figure1). Correlates of combined end point in both groups were: functional class of dyspnea (NYHA class III-IV vs I-II), severe TR grade (HR in V-FTR: 2,88 [1.63-5.06], P &lt;0,01; HR in A-FTR: 8[3-17], P &lt;0.01); RV volumes, RA volumes (table 2).  Estimated SPAP as well as all the parameters of RV function and of RV-PA coupling were correlates of prognosis only in V-FTR; conversely, parameters of TA dimensions were related to combined end point in A-FTR phenotype, while RV function and RV-PA coupling indexes did not. 

Conclusions

Patients having A-FTR have an incidence of combined end point slightly different, without reaching a statistically significant difference, thus remarking the fact that A-FTR could not be considered "more benign" and should therefore be targeted.  Prognostic predictors are different between A-.FTR and V-FTR patients. Abstract Figure.