Quantitative assessment of effective regurgitant orifice: Impact on risk stratification, and cut-off for severe and torrential tricuspid regurgitation grade

Yogev Peri, Ben Sadeh, Chen Sherez, Aviram Hochstadt, Simon Biner, Galit Aviram, Meirav Ingbir, Ido Nachmany, Guy Topaz, Nir Flint, Gad Keren, Yan Topilsky

Research output: Contribution to journalArticlepeer-review

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 cm2 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 cm2 [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 cm2 [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 cm2, similar albeit slightly lower than suggested in recent guidelines. Torrential TR >0.7 cm2 is associated with poorer survival compared to patients with severe TR (ERO > 0.4 cm2 and <0.7 cm2).

Original languageEnglish
Pages (from-to)768-776
Number of pages9
JournalEuropean Heart Journal Cardiovascular Imaging
Volume21
Issue number7
DOIs
StatePublished - 1 Jul 2020

Keywords

  • effective regurgitant orifice (ERO)
  • regurgitant volume (RVol)
  • tricuspid regurgitation (TR)

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