Tricuspid regurgitation tied to outcomes in PAH patients

By Eleanor McDermid

Tricuspid regurgitation (TR) progresses in line with right ventricular (RV) remodelling and increasing pulmonary artery systolic pressure (PASP) in patients with pulmonary arterial hypertension (PAH), research shows.

"Persistent TR progression appears to signal a poor outcome in PAH patients", say Avinoam Shiran (Israel Institute of Technology, Haifa) and study co-authors, noting that 88% of the 35 PAH patients with TR progression died within 3 years, despite 71% receiving treatment.

"These patients should be considered for additional therapeutic options including lung transplantation", the team writes in the European Heart Journal - Cardiovascular Imaging.

The patients' TR was observed to progress between echocardiograms conducted an average of 3.5 years apart, during which time their PASP also significantly increased. TR remained stable in an additional 36 patients and regressed in 17.

As PASP and TR progressed, so did RV remodelling, with the changes most prominent at the mid-ventricular level, resulting in increased sphericity. At the same time, tricuspid annular diameter, and tenting height and area significantly increased, while tricuspid valve leaflet length increased, resulting in reduced tricuspid valve coverage.

The researchers did not identify any baseline predictors of TR progression, which they say, together with other study findings, suggests that "dynamic changes in pulmonary pressures are key determinants of TR progression."

Indeed, after adjusting for confounders, a PASP increase of greater than 15 mmHg was associated with a 4.0-fold increase in the odds of TR progression, a tricuspid valve coverage decrease of more than 0.1 per cm was associated with a 3.6-fold increased odds and each cm² per m² increase in RV end diastolic area was associated with a 1.3-fold increased odds.

Contrariwise, Shiran et al found "a marked plasticity of the RV and tricuspid apparatus"; patients with TR regression also had reduced PASP and reversal of RV remodelling, although the team notes that cause and effect cannot be attributed in this observational study. Just 22% of these patients died within 3 years, as did 39% of those with stable TR.

But they say: "Because of the remarkable capacity of the RV to undergo reverse remodelling, moderate or severe TR during the first echocardiographic examination does not necessarily imply poor prognosis."

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