Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association
Study Supports Lower Tricuspid Regurgitation Velocity For Pulmonary ...
December 23, 2021
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New data published in Chest support a lower tricuspid regurgitation velocity of 2.7 m per second for pulmonary hypertension screening.
To assess the probability of pulmonary hypertension, guidelines from the European Respiratory Society and European Society of Cardiology recommend tricuspid regurgitation velocity cutoffs of 2.8 m per second and 3.4 m per second, and additional right cardiac chamber size.
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"Recently, the Sixth World Symposium on Pulmonary Hypertension recommended that the hemodynamic threshold for the diagnosis of pulmonary hypertension be lowered, based on normative data that shows that the upper limit of normal mean pulmonary artery pressure is 20 mm Hg and increased deaths in patients with a mean pulmonary artery pressure between 20 and 24 mm Hg," Bryce E. Montané, MD, internist in the department of internal medicine at the Cleveland Clinic, and colleagues wrote. "With the new definition of pulmonary hypertension, we hypothesized that lower tricuspid regurgitation velocity cutoffs and assessment of right cardiac chamber size could be used to improve detection of pulmonary hypertension."
The multicenter, retrospective study included 1,608 patients who underwent echocardiography and right heart catherization within 4 weeks from 1996 to 2019 (deemed the discovery cohort) and from 2000 to 2018 (deemed the validation cohort). The discovery cohort included 1,081 patients (mean age, 57.8 years; 63.3% women) and the validation cohort included 527 patients (mean age, 52.5 years; 49.1% women).
The primary outcome was presence of pulmonary hypertension, defined as mean pulmonary arterial pressure greater than 20 mm Hg by right heart catherization.
The researchers reported that, in the discovery cohort, echocardiographic tricuspid regurgitation velocity had a good discrimination for pulmonary hypertension (area under the curve, 88.4).
Use of the 3.4 m per second threshold yielded a 78% sensitivity, 87% specificity and 6.13 positive likelihood ratio for detection of pulmonary hypertension in the discovery cohort , according to the results. Use of the 2.7 m per second threshold yielded a 95% sensitivity and a 0.12 negative likelihood ratio for exclusion of pulmonary hypertension.
In the validation cohort, use of the 2.7 m per second threshold yielded an 80% sensitivity and a 0.31 negative likelihood ratio to exclude pulmonary hypertension. In addition, researchers observed right cardiac size improved the detection of pulmonary hypertension among patients in the lower tricuspid regurgitation velocity groups.
"Our aggregate data suggest a lower tricuspid regurgitation velocity threshold of 2.7 m/s to screen for pulmonary hypertension," the researchers wrote. "In addition, our study supports current guidelines; right cardiac chamber size, when used in combination with tricuspid regurgitation velocity, can improve probability assessment for the diagnosis of pulmonary hypertension, particularly in patients with a lower tricuspid regurgitation velocity."
Sources/DisclosuresCollapse Disclosures: Montané reports no relevant financial disclosures. Please see the study for all other authors' relevant financial disclosures.Add topic to email alerts
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Tricuspid Regurgitation Reliable Prognostic Indicator Of PAH Severity
Despite knowledge of the benefits of right heart hemodynamic measures for evaluating patient prognosis in the setting of pulmonary arterial hypertension (PAH), gaps remain in a defined role for tricuspid regurgitation as it relates to echocardiographic phenotype.
Following a diagnosis of low-risk pulmonary arterial hypertension (PAH), treatment-naive patients could benefit from an evaluation of tricuspid regurgitation and how it may contribute to their prognosis, with severity deemed critical by study authors based on tricuspid annular plane systolic excursion (TAPSE) or systolic pulmonary artery pressure (sPAP) findings.
Their single-center, retrospective, longitudinal analysis, published recently in European Respiratory Journal Open Research,1 compared outcomes between patients with mild tricuspid regurgitation or no evidence of it and patients with a moderate or higher degree of tricuspid regurgitation. The primary survival end point was all-cause death, and the primary study objective was the prognostic value of tricuspid regurgitation in patients with incident PAH. Patients (N = 147) were enrolled from the National Heart and Lung Institute, Imperial College, Hammersmith Hospital, London, between 2011 and 2021. To be included, their PAH diagnostic work-up had to conform to European Society of Cardiology/European Respiratory Society guidelines and meet the criteria for precapillary pulmonary hypertension, and they had to be nonresponders to acute vasodilator testing with nitric oxide at diagnosis.
The mean (SD) patient age was 58 (18) years, 71% were women, the median body mass index was 27.2 (95% CI, 23.1-31.0) kg/m2, and 86% had World Health Organization functional class III/IV disease. The most common types of PAH seen were idiopathic (45%) and connective tissue disease (33%), mean baseline systolic blood pressure was 124 (20) mm Hg, median baseline creatinine was 0.81 (95% CI, 0.70-1.3) mg/dL-1, mean right atrium area was 25 (8) cm2, and the top therapies at discharge were an endothelin receptor antagonist (ERA) plus a phosphodiesterase (PDE) inhibitor (52%) or monotherapy with either an ERA or a PDE inhibitor.
The present study authors write that tricuspid regurgitation holds significant prognostic value and that its measure "is critical to stratify the prognosis of patients who would have been considered at low risk based on normal values of TAPSE or of TAPSE/sPAP."Image Credit: © Richelle-stock.Adobe.Com
Per degree of tricuspid regurgitation (0/1+, mild/none; 2/3+, moderate/severe), patients diagnosed with moderate tricuspid regurgitation or worse saw correlations with worse TAPSE and TAPSE/sPAP; had similar right ventricular (RV) areas, transverse diameters, and short:long axis ratio on echocardiography; and worsened RV longitudinal diameter:
Peak oxygen consumption and right atrial pressure also were also impaired among those with moderate or severe tricuspid regurgitation, according to right heart catheterization, which is used to confirm diagnosis following evidence of pulmonary hypertension seen on echocardiography.2 The median follow-up was 38.8 (95% CI, 21.5-56.3) months.1
Overall, on univariate Cox analysis, moderate/severe tricuspid regurgitation was the only echocardiographic parameter linked to worse survival (HR, 3.34; 95% CI, 1.73-6.45; P < .001) after adjusting for demographics. However, a subanalysis conducted among patients with reduced or preserved TAPSE showed moderate/severe tricuspid regurgitation had a negative prognostic value solely among patients with preserved TAPSE (HR, 9.26; 95% CI, 2.62-31.69; P < .001), and among patients with low- or intermediate/high-risk TAPSE/sPAP, moderate or worse tricuspid regurgitation had a negative prognostic value only in low-risk patients (HR, 17.9; 95% CI, 2.1-150.1; P = .008).
Regarding their findings, the study authors write that tricuspid regurgitation holds significant prognostic value and that its measure "is critical to stratify the prognosis of patients who would have been considered at low risk based on normal values of TAPSE or of TAPSE/sPAP." Their results also hold value because they both echo previous research and expand on those findings.
Still, there are limitations to their data, including the small sample size and the fact that tricuspid regurgitation degree was not quantitatively measured beyond the mild/none and moderate/severe classification. Future studies are needed to evaluate their results.
References
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Caval Valve Implantation For Tricuspid Regurgitation
The tricuspid valve sits between the right atrium and right ventricle of the heart. Tricuspid regurgitation occurs because the tricuspid valve does not close properly during systole. It can result in blood refluxing back into the right atrium (leading to haemodynamically significant tricuspid regurgitation) and the 2 main caval veins (the superior vena cava and inferior vena cava). This makes the heart work harder and, if severe, can lead to heart failure. Tricuspid regurgitation can mainly be because of a problem with the valve anatomy itself. But it is more commonly secondary to an underlying cardiac problem that causes tricuspid annular dilatation or leaflet tethering. The valve leaflets and chords may be normal but, because of annulus dilatation, the valve leaflets fail to close properly and regurgitation of blood occurs.
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