Right Heart Failure Pheno-Endotype Drives Prognosis after Tricuspid Valve Surgery

Tricuspid valve surgery is neither complex nor time-consuming yet is associated with high surgical mortality. Our goal was to characterize heterogeneity of right heart variables and manifestations of right heart failure in patients with severe tricuspid regurgitation and evaluate survival after tricuspid valve surgery.

From 1/2007 to 1/2014, 522 adults with severe tricuspid regurgitation underwent cardiac surgery. Median follow-up was 3.7 years. Right heart morphology and function variables were measured de novo from stored echocardiographic images. To discover possible pheno-endotypes, unsupervised cluster analysis was performed by sidClustering.rfsrc using preoperative clinical, morphologic, ventricular function, and hemodynamic variables. Variable priority classification was used to characterize resulting pheno-endotypes. Post-surgery survival was assessed by cluster.

Three pheno-endotype clusters were identified, each with distinct 10-year survival: Cluster 1 (n=220), predominantly patients with left-sided disease, 59%; Cluster 2 (n=78), predominantly patients with the most dilated right ventricles (diastolic area 42±10 cm²), 46%; and Cluster 3 (n=224), predominantly patients with worse right ventricular dysfunction (fractional area change 30%±12%), 21% (worst prognosis). Elevated model for end-stage liver disease with sodium was the most important predictor of time-related mortality and separated Clusters 1 and 2 from Cluster 3.

Patients presenting for cardiac surgery with severe tricuspid regurgitation cluster into 3 pheno-endotypes, illustrating clinical presentation and patient heterogeneity and predicting distinctive prognosis. Right heart function and right heart failure severity need to be recognized to guide patient selection and management.