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Tricuspid regurgitation thresholds reassessed
The proposed framework classified 30% of patients as high or extreme risk, compared with 12% classified as having severe or greater tricuspid regurgitation under established grading schemes.
To assess disease-specific echocardiographic thresholds for tricuspid regurgitation in patients with transthyretin amyloid cardiomyopathy and compare prognostic discrimination with existing guidelines.
Approach:
Study Design: Enrolled 1,124 patients with newly diagnosed transthyretin amyloid cardiomyopathy across 8 centers in Europe, excluding those with prior tricuspid valve intervention or severe aortic conditions.
Echocardiographic Assessment: Conducted standardized transthoracic echocardiography with centralized assessment of tricuspid regurgitation using specific metrics.
Cohorts: Divided into derivation cohort (745 patients) and validation cohort (379 patients) for establishing and confirming prognostic thresholds.
Follow-up: Median follow-up of 25 months to assess all-cause mortality and heart failure hospitalizations.
Key Findings:
Identified intermediate-risk thresholds: 3 mm for vena contracta width, 0.15 cm² for effective regurgitant orifice area, and 10 mL for regurgitant volume, with 324 patients (29%) dying and 251 (22%) experiencing at least 1 heart failure hospitalization during follow-up.
High-risk thresholds were established at 5 mm, 0.25 cm², and 20 mL; extreme-risk thresholds at 8 mm, 0.50 cm², and 40 mL.
The proposed framework classified 413 patients (37%) as low risk, 377 (34%) as intermediate risk, 234 (21%) as high risk, and 100 (9%) as extreme risk.
The framework showed significantly greater discrimination for mortality and heart failure hospitalization compared to existing guidelines.
Limitations:
Developed thresholds are for prognostic assessment, not for determining eligibility for intervention.
Causal conclusions cannot be drawn due to the observational nature of the study.
Residual confounding may affect results.
Tricuspid regurgitation measurements were limited to baseline assessments.
Advanced heart failure does not always present as a single defining event. Referring physicians may instead notice a pattern of worsening symptoms, recurrent hospitalizations or increasing difficulty maintaining a patient’s clinical stability.
