Aetiological phenotypes of atrial and ventricular secondary tricuspid regurgitation and their prognostic implications: insights from the CARE-TR registry

Aims: To report prevalence and clinical outcomes of different aetiological phenotypes of atrial and ventricular secondary tricuspid regurgitation (ASTR/VSTR). Methods and results: The Consecutive pAtients with seveRE Tricuspid Regurgitation evaluated in Heart Failure (HF) and Valve Clinics (CARE-TR) registry collected data from patients with at least severe tricuspid regurgitation (TR) enrolled at three Italian centres. The present analysis includes 648 patients with secondary TR, 22.1% with ASTR and 77.9% with VSTR. Patients with ASTR were further stratified in those with atrial fibrillation (AF, 25.2%), HF with preserved ejection fraction (HFpEF, 37.8%), and both (37.0%). Patients with VSTR were subdivided into those with severe left-sided valvular heart disease (LS-VHD, 28.5%), HF with reduced or mildly reduced ejection fraction (HFrEF/HFmrEF, 29.1%), HFpEF (35.5%), pre-capillary pulmonary hypertension (PH, 4.0%) and isolated right ventricular dysfunction (RVD, 2.9%). After a median follow-up of 498 days, 118 (18.2%) patients died and 153 (23.6%) were hospitalized for HF. Two-year survival free from the composite outcome of death or HF hospitalization was higher in patients with ASTR compared with those with VSTR (73.5% vs. 54.4%; p < 0.001). After adjustment for variables related with HF severity, VSTR remained independently associated with an increased risk of events (adjusted hazard ratio 2.00; 95% confidence interval 1.33–3.02; p = 0.001). Among ASTR patients, combined AF and HFpEF was associated with a poorer outcome compared with AF or HFpEF alone (60.2% vs. 80.5% vs. 83.6%; p = 0.022). Among patients with VSTR, overall survival free from the composite outcome was 85%, 65%, 54%, 39% and 38% for RVD, HFpEF, HFrEF/HFmrEF, severe LS-VHD, and pre-capillary PH, respectively (p < 0.001). Conclusions: In a real-world population with at least severe secondary TR, 22% had ASTR and showed better outcomes as compared to VSTR. Among patients with ASTR, combination of AF and HFpEF was common and associated with the worst prognosis. Among patients with VSTR, those with pre-capillary PH had the poorest outcomes, followed by those with LS-VHD.