Natural History of Tricuspid Valve Regurgitation: Understanding the Limitations of Medical Therapy

To evaluate the natural course of medically managed ≥ moderate tricuspid regurgitation (TR) of any etiology, identify factors linked to progression and regression, and assess long-term clinical consequences.

Retrospective analysis of 4051 adults with ≥ moderate TR (57.0% moderate, 43.0% severe) from January 1, 2004, to December 31, 2016, having at least one follow-up echocardiogram 6 months or more later. TR change was defined as at least one grade shift in severity, and all-cause mortality was the primary endpoint.

At 1 year, TR regressed in 1499 (37.0%) patients and progressed in 417 (10.3%). Of 1603 with ≥ moderate TR at 1 year, only 346 (21.6%) experienced regression after the first year. Among 586 patients in whom TR regressed to mild or less at 1-year, 285 (48.6%) developed significant TR again long-term. Factors associated with TR progression included atrial fibrillation (odds ratio [OR], 1.55), chronic kidney disease (OR, 1.44), right ventricular dilatation (OR, 1.77), right atrial dilatation (OR, 1.94), pulmonary hypertension (OR, 1.25), and those associated with regression were coronary artery disease, diabetes, hypertension, and left ventricle dysfunction. Mortality was highest in patients whose TR progressed to or remained severe (HRs, 1.73 and 1.92, respectively), followed by those with stable moderate (HR, 1.18), and was lowest in whom TR regressed to mild or less.

In patients with ≥ moderate TR, regurgitation severity improved in one-third and remained unchanged in half at 1 year. Additionally, 10% of patients with moderate TR progressed to severe TR. Severe TR at 1 year was associated with a worse prognosis, with approximately 70% of these being patients whose TR did not improve with medical therapy. Although most improvements occurred within the first year, a considerable number experienced a recurrence afterward.