Quantitative assessment of effective regurgitant orifice: impact on risk stratification, and cut-off for severe and torrential tricuspid regurgitation grade. (23rd October 2019)

• Record Type: Journal Article
• Authors: Peri, Yogev; Sadeh, Ben; Sherez, Chen; Hochstadt, Aviram; Biner, Simon; Aviram, Galit; Ingbir, Meirav; Nachmany, Ido; Topaz, Guy; Flint, Nir; Keren, Gad; Topilsky, Yan
• Is Part Of: European heart journal. Volume 21:Number 7(2020)
• Page Start: 768
• Page End: 776
• Publication Date: 2019-10-23
• Subjects: effective regurgitant orifice (ERO) -- regurgitant volume (RVol) -- tricuspid regurgitation (TR); Cardiovascular system -- Imaging -- Periodicals; Heart -- Imaging -- Periodicals; 616.10754
• DOI: 10.1093/ehjci/jez267
• Languages: English
• ISSNs: 2047-2404

Abstract

Abstract: Aims : Asses the added value of quantitative evaluation of tricuspid regurgitation (TR), the proper cut-off value for severe TR and 'torrential TR' based on outcome data. The added value of quantitative evaluation of TR, and the cut-off values associated with increased mortality are unknown. Methods and results: In patients with all-cause TR assessed both qualitatively and quantitatively by proximal iso-velocity surface area method, long-term and 1-year outcome analysis was conducted. Thresholds for excess mortality were assessed using spline curves, receiver-operating characteristic curves, and minimum P- value analysis. The study involved 676 patients with all-cause TR (age 73.9 ± 14 years, male 45%, ejection fraction 52.9 ± 14%). Effective regurgitant orifice (ERO) was strongly associated with decreased survival in unadjusted [hazard ratio (HR) 2.38 (1.79–3.01), P < 0.0001 per 0.1 cm 2 increment] and adjusted [2.6 (1.25–5.0), P = 0.01] analyses. Quantitative grading was superior to qualitative grading in prediction of outcome ( P < 0.01). The optimal cut-off value for the best separation in survival between groups of patients with severe vs. lesser degree of TR was 0.35 cm 2 [ P < 0.0001, HR =2.0 (1.5–2.7)]. ERO negatively impacted survival, even when including only the subgroup of patients with severe TR [HR 1.5 (1.01–2.3); P = 0.04]. The optimal threshold corresponding for the best separation for survival between groups of patients with severe vs. 'torrential' TR was 0.7 cm 2 [ P = 0.005, HR =2.6 (1.2–5.1)]. Conclusion : TR can be severe and even 'torrential' and is associated with excess mortality. Quantitative assessment of TR by ERO measurement is a powerful independent predictor of outcome, superior to standard qualitative assessment. The optimal cut-off above which mortality is increased is 0.35 cm 2, similar albeit slightly lower than suggested in recent guidelines. Torrential TR >0.7 cm 2 is associated with poorer survival compared to patients with severe TR (ERO > 0.4 cm 2 and <0.7 cm 2 ).