Effectiveness of Rhythm Control of Atrial Fibrillation in Moderate-to-Severe or Severe Secondary Tricuspid Regurgitation

Secondary tricuspid regurgitation (STR) is heterogeneous and associated with increased morbidity and mortality, but there remains limited evidence on the optimal management strategy. Atrial fibrillation (AF) increases the risk of all types of STR.

The authors aimed to study the association of successful rhythm control of AF with decreased severity of moderate-severe/severe STR across clinically relevant subgroups and different etiologies of STR.

Patients with moderate-severe/severe STR, AF, and follow-up echocardiograms were identified retrospectively. STR types were left-sided valve disease, reduced left ventricular ejection fraction, other causes of pulmonary hypertension, and isolated STR. The primary endpoint was decrease of STR severity to ≤ mild. Recurrence of AF was determined. Follow-up was censored at tricuspid valve intervention or last follow-up.

Among 1,896 patients (median age 79; 60% women), rhythm control was attempted in 367 (19%) over a median of 21 days. Recurrence of AF occurred in 210 (57%) and was associated with older age, chronic, persistent AF, and lack of antiarrhythmic medication use. Over a median of 1.7 years, tricuspid regurgitation (TR) decreased to ≤ mild in 550 patients. Successful control of rhythm without recurrence of AF was strongly associated with decreased TR to ≤ mild at the multivariable level (HR: 3.65 [95% CI: 2.24-5.95]; P < 0.01). The association remained across different subgroups divided according to TR etiology, age, sex, obesity, burden and chronicity of AF, impaired left ventricular systolic or diastolic function, coexistent significant mitral regurgitation, pulmonary hypertension, and right ventricular remodeling.

Successful rhythm control of AF is associated with improved severity of STR in patients with moderate-severe or severe STR, and an early aggressive attempt should be considered in these patients to decrease risk of recurrence.