Advanced right heart failure stage at first documentation of severe tricuspid regurgitation: beyond the late-referral...

Patients with severe tricuspid regurgitation (TR) frequently present with advanced right heart failure (RHF), commonly attributed to delayed referral for intervention. Whether this reflects delayed referral or the stage at which severe TR is first documented remains uncertain.

We retrospectively analyzed 625 consecutive patients with a first echocardiographic diagnosis of severe TR. RHF severity was classified using a validated hierarchical staging system (Stages 1-4). In a subgroup of 310 patients with a previous echocardiogram documenting non-severe TR, RHF stage was retrospectively assessed before severe TR was first documented. Two-year all-cause mortality was evaluated.

At first documentation of severe TR, 66.4% of patients were classified as Stage 3 and 17.3% as Stage 4, whereas only 16.3% were in Stages 1-2. Functional TR accounted for 85% of cases. RHF stage was associated with progressively higher TRI-SCORE and two-year mortality. Among patients with prior non-severe TR, 78% were already in Stage 3-4 before severe TR was first documented, whereas only 7% had reached Stage 4.

Severe TR was predominantly diagnosed in patients with stage 3-4 RHF. Higher RHF stages were already present in most patients before severe TR was first documented. These findings suggest that delayed referral alone may not fully explain the advanced clinical profile of severe TR and that eligibility for guideline-directed intervention frequently coincides with an already advanced stage of disease.