Prevalence and predictive factors for clinical outcomes of isolated functional tricuspid regurgitation

Published:January 03, 2023DOI:


      • We evaluated prognosis of a large number of patients with severe tricuspid regurgitation (TR) (N = 1001).
      • A considerable number of patients (22 %) had isolated functional TR.
      • Renal function and anemia are prognostic predictors of isolated functional TR.



      A substantial number of patients have functional tricuspid regurgitation (TR).
      Isolated functional TR has been undertreated and may be a next target for transcatheter intervention. However, the prevalence, patient characteristics, and predictive factors for prognosis remain unclear.


      From patients in our echocardiographic database (N = 64,242), we extracted those with severe TR and examined prognosis according to etiologies of TR. Thereafter, we focused on two types of isolated functional TR; progressive TR after left-sided valve surgery (postoperative TR) and TR associated with annular dilatation (atrial TR). Composite adverse events were defined as all-cause death or hospitalization for heart failure (HF).


      Of 1001 patients with severe TR (median age, 77 years; female, 58 %), 71 (7 %) patients were classified as postoperative TR, and 149 (15 %) as atrial TR. During the follow-up period (median, 1.6 years), 30 composite adverse events were observed (postoperative TR, n = 14; atrial TR, n = 16). Composite adverse events were less frequent in these two types of functional TR than TR of other etiologies. Multivariate analysis adjusted for age and sex showed that a history of hospitalization for HF, history of cardiac surgery >2 times, loop diuretics, estimated glomerular filtration rate, blood urea nitrogen, hemoglobin, platelet level, left ventricular ejection fraction, and right ventricular dimension were associated with clinical adverse events (p < 0.05), while B-type natriuretic peptide level was not.


      A considerable number of patients had isolated functional TR. Extracardiac factors such as renal function, hemoglobin and platelet are important in determining clinical outcomes.

      Graphical abstract


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        • Nath J.
        • Foster E.
        • Heidenreich P.A.
        Impact of tricuspid regurgitation on long-term survival.
        J Am Coll Cardiol. 2004; 43: 405-409
        • Shiran A.
        • Najjar R.
        • Adawi S.
        • Aronson D.
        Risk factors for progression of functional tricuspid regurgitation.
        Am J Cardiol. 2014; 113: 995-1000
        • Topilsky Y.
        • Nkomo V.T.
        • Vatury O.
        • Michelena H.I.
        • Letourneau T.
        • Suri R.M.
        • et al.
        Clinical outcome of isolated tricuspid regurgitation.
        JACC Cardiovasc Imaging. 2014; 7: 1185-1194
        • Topilsky Y.
        • Maltais S.
        • Medina Inojosa J.
        • Oguz D.
        • Michelena H.
        • Maalouf J.
        • et al.
        Burden of tricuspid regurgitation in patients diagnosed in the community setting.
        JACC Cardiovasc Imaging. 2019; 12: 433-442
        • Topilsky Y.
        • Khanna A.
        • Le Tourneau T.
        • Park S.
        • Michelena H.
        • Suri R.
        • et al.
        Clinical context and mechanism of functional tricuspid regurgitation in patients with and without pulmonary hypertension.
        Circ Cardiovasc Imaging. 2012; 5: 314-323
        • Utsunomiya H.
        • Itabashi Y.
        • Mihara H.
        • Berdejo J.
        • Kobayashi S.
        • Siegel R.J.
        • et al.
        Functional tricuspid regurgitation caused by chronic atrial fibrillation: a real-time 3-dimensional transesophageal echocardiography study.
        Circ Cardiovasc Imaging. 2017; 10e004897
        • Dreyfus G.D.
        • Martin R.P.
        • Chan K.M.
        • Dulguerov F.
        • Alexandrescu C.
        Functional tricuspid regurgitation: a need to revise our understanding.
        J Am Coll Cardiol. 2015; 65: 2331-2336
        • Izumi C.
        • Eishi K.
        • Ashihara K.
        • Arita T.
        • Otsuji Y.
        • Kunihara T.
        • et al.
        JCS/JSCS/JATS/JSVS 2020 guidelines on the management of valvular heart disease.
        Circ J. 2020; 84: 2037-2119
        • Izumi C.
        • Miyake M.
        • Takahashi S.
        • Matsutani H.
        • Hashiwada S.
        • Kuwano K.
        • et al.
        Progression of isolated tricuspid regurgitation late after left-sided valve surgery. Clinical features and mechanisms.
        Circ J. 2011; 75: 2902-2907
        • Izumi C.
        Tricuspid regurgitation following left-sided valve surgery: echocardiographic evaluation and optimal timing of surgical treatment.
        J Echocardiogr. 2015; 13: 15-19
        • Takahashi Y.
        • Izumi C.
        • Miyake M.
        • Imanaka M.
        • Kuroda M.
        • Nishimura S.
        • et al.
        Actual management and prognosis of severe isolated tricuspid regurgitation associated with atrial fibrillation without structural heart disease.
        Int J Cardiol. 2017; 243: 251-257
        • Chang C.C.
        • Veen K.M.
        • Hahn R.T.
        • Bogers A.
        • Latib A.
        • Oei F.B.S.
        • et al.
        Uncertainties and challenges in surgical and transcatheter tricuspid valve therapy: a state-of-the-art expert review.
        Eur Heart J. 2020; 41: 1932-1940
        • Alqahtani F.
        • Berzingi C.O.
        • Aljohani S.
        • Hijazi M.
        • Al-Hallak A.
        • Alkhouli M.
        Contemporary trends in the use and outcomes of surgical treatment of tricuspid regurgitation.
        J Am Heart Assoc. 2017; 6e007597
        • Lurz P.
        • Stephan von Bardeleben R.
        • Weber M.
        • Sitges M.
        • Sorajja P.
        • Hausleiter J.
        • et al.
        Transcatheter edge-to-edge repair for treatment of tricuspid regurgitation.
        J Am Coll Cardiol. 2021; 77: 229-239
        • Mehr M.
        • Taramasso M.
        • Besler C.
        • Ruf T.
        • Connelly K.A.
        • Weber M.
        • et al.
        1-year outcomes after edge-to-edge valve repair for symptomatic tricuspid regurgitation: results from the TriValve registry.
        JACC Cardiovasc Interv. 2019; 12: 1451-1461
        • Lang R.M.
        • Badano L.P.
        • Mor-Avi V.
        • Afilalo J.
        • Armstrong A.
        • Ernande L.
        • et al.
        Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the european Association of Cardiovascular Imaging.
        J Am Soc Echocardiogr. 2015; 28: 1-39.e14
        • Zoghbi W.A.
        • Enriquez-Sarano M.
        • Foster E.
        • Grayburn P.A.
        • Kraft C.D.
        • Levine R.A.
        • et al.
        Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography.
        J Am Soc Echocardiogr. 2003; 16: 777-802
        • Yock P.G.
        • Popp R.L.
        Noninvasive estimation of right ventricular systolic pressure by doppler ultrasound in patients with tricuspid regurgitation.
        Circulation. 1984; 70: 657-662
        • Rudski L.G.
        • Lai W.W.
        • Afilalo J.
        • Hua L.
        • Handschumacher M.D.
        • Chandrasekaran K.
        • et al.
        Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the european Association of Echocardiography, a registered branch of the european Society of Cardiology, and the Canadian Society of Echocardiography.
        J Am Soc Echocardiogr. 2010; 23: 685-713
        • Matsuo S.
        • Imai E.
        • Horio M.
        • Yasuda Y.
        • Tomita K.
        • Nitta K.
        • et al.
        Revised equations for estimated GFR from serum creatinine in Japan.
        Am J Kidney Dis. 2009; 53: 982-992
        • Heuman D.M.
        • Mihas A.A.
        • Habib A.
        • Gilles H.S.
        • Stravitz R.T.
        • Sanyal A.J.
        • et al.
        MELD-XI: a rational approach to "sickest first" liver transplantation in cirrhotic patients requiring anticoagulant therapy.
        Liver Transpl. 2007; 13: 30-37
        • Nishimura S.
        • Izumi C.
        • Yamasaki S.
        • Obayashi Y.
        • Kuroda M.
        • Amano M.
        • et al.
        Impact of right ventricular function on development of significant tricuspid regurgitation in patients with chronic atrial fibrillation.
        J Cardiol. 2020; 76: 431-437
        • Kim Y.J.
        • Kwon D.A.
        • Kim H.K.
        • Park J.S.
        • Hahn S.
        • Kim K.H.
        • et al.
        Determinants of surgical outcome in patients with isolated tricuspid regurgitation.
        Circulation. 2009; 120: 1672-1678
        • Maeder M.T.
        • Holst D.P.
        • Kaye D.M.
        Tricuspid regurgitation contributes to renal dysfunction in patients with heart failure.
        J Card Fail. 2008; 14: 824-830
        • Fender E.A.
        • Petrescu I.
        • Ionescu F.
        • Zack C.J.
        • Pislaru S.V.
        • Nkomo V.T.
        • et al.
        Prognostic importance and predictors of survival in isolated tricuspid regurgitation: a growing problem.
        Mayo Clin Proc. 2019; 94: 2032-2039
        • Izumi C.
        Isolated functional tricuspid regurgitation: when should we go to surgical treatment?.
        J Cardiol. 2020; 75: 339-343
        • Mullens W.
        • Abrahams Z.
        • Francis G.S.
        • Sokos G.
        • Taylor D.O.
        • Starling R.C.
        • et al.
        Importance of venous congestion for worsening of renal function in advanced decompensated heart failure.
        J Am Coll Cardiol. 2009; 53: 589-596
        • Iida N.
        • Seo Y.
        • Sai S.
        • Machino-Ohtsuka T.
        • Yamamoto M.
        • Ishizu T.
        • et al.
        Clinical implications of intrarenal hemodynamic evaluation by doppler ultrasonography in heart failure.
        JACC Heart Fail. 2016; 4: 674-682
        • Anand I.S.
        • Gupta P.
        Anemia and iron deficiency in heart failure: current concepts and emerging therapies.
        Circulation. 2018; 138: 80-98
        • Grote Beverborg N.
        • van Veldhuisen D.J.
        • van der Meer P.
        Anemia in heart failure: still relevant?.
        JACC Heart Fail. 2018; 6: 201-208
        • Otto C.M.
        • Nishimura R.A.
        • Bonow R.O.
        • Carabello B.A.
        • Erwin 3rd, J.P.
        • Gentile F.
        • et al.
        2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the american College of Cardiology/American Heart Association joint committee on clinical practice guidelines.
        Circulation. 2021; 143: e72-e227
        • Vahanian A.
        • Beyersdorf F.
        • Praz F.
        • Milojevic M.
        • Baldus S.
        • Bauersachs J.
        • et al.
        2021 ESC/EACTS guidelines for the management of valvular heart disease.
        Eur Heart J. 2022; 43: 561-632
        • Dreyfus J.
        • Audureau E.
        • Bohbot Y.
        • Coisne A.
        • Lavie-Badie Y.
        • Bouchery M.
        • et al.
        TRI-SCORE: a new risk score for in-hospital mortality prediction after isolated tricuspid valve surgery.
        Eur Heart J. 2022; 43: 654-662