Interaction of secondary ventricular tricuspid regurgitation with RV in HFREF: an invasive pressure-volume loop study

Heart failure with reduced ejection fraction (HFrEF) accompanied by moderate or severe ventricular tricuspid-valve leaflet regurgitation (vTR2/3) is prognostically unfavourable; however, the underlying pathophysiology has not yet been sufficiently clarified. The hypothesis of a causative role of left ventricular (LV) dysfunction +/- secondary mitral regurgitation (sMR) on the extent and severity of secondary vTR was investigated.

We integrated right ventricular (RV) pressure-volume loop and Swan-Ganz catheter data with RV/LV imaging findings in a retrospective analysis of 134 HFrEF patients.

Parameters independently associated with the presence of vTR2/3 were (i) presence of sMR (adjusted odds-ratio [aOR] = 1.67, P = .045), (ii) increased pulmonary vascular pulsatile RV loads (lower pulmonary artery [PA] compliance, aOR = 0.43, P = .021; area under the curve [AUC] = 0.82, cut-off <2.24 ml/mmHg, P < .001), mainly due to concomitant moderate/severe sMR (sMR2/3) (aOR = 4.56, P = .012), and (iii) progressive uncoupling of RV elastance/contractility (Ees) to an increasing total afterload (pulmonary elastance, Ea) (Ees/Ea ratio: aOR = 0.024, P = .005; AUC = 0.84, cut-off <0.6, P < .001). In addition, the RV-PA uncoupling was not only determined by the higher afterload in vTR2/3, but was also observed across the entire total afterload range (Ea tertile). This resulted in a larger and more dysfunctional RV in vTR2/3 compared with vTR0/1, independent of the afterload. RV-PA uncoupling and reduced PA compliance were independently associated with all-cause mortality.

The vTR2/3 in context of HFrEF was independently associated with the presence of sMR, increased pulsatile loads, and a pronounced RV-PA uncoupling over almost the entire afterload range. Future studies will need to determine under which haemodynamic conditions a mechanical tricuspid regurgitation reduction in HFrEF patients is advisable.