Association of Moderate to Severe Tricuspid Regurgitation With Exercise Hemodynamics and Outcomes in Patients With Heart Failure With Preserved Ejection Fraction: Multicenter Study.

BACKGROUND: The clinical significance of at least moderate tricuspid regurgitation (TR) during evaluation for unexplained dyspnea is unclear. This study describes the characteristics, exercise hemodynamics, and 5-year outcomes among patients with moderate to severe TR found to have exercise heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS: We included 258 consecutive patients undergoing exercise right heart catheterization for unexplained dyspnea at 2 academic centers in the United States and Italy from April 2017 to October 2024 if they met exercise criteria for HFpEF (peak pulmonary artery wedge pressure [PAWP] of ≥25 or PAWP-cardiac output [CO] slope of ≥2). We dichotomized patients by degree of TR (absent or mild vs moderate to severe) during resting echocardiography. We compared hemodynamics by regression analyses and 5-year composite HF hospitalization or death by Cox regression analyses, adjusting for age, sex, and country. There were 206 patients (80%) who met the exercise criteria for HFpEF; 41 (20%) had moderate to severe TR and 165 (80%) had absent or mild TR. Those with worse TR were older (75 years [IQR 68-79 years] vs 70 years [IQR 62-76 years]) and had higher resting mean pulmonary artery pressure and PAWP, but a lower CO; after adjustment, worse TR was associated with lower maximum CO (6.6 L/min [IQR 5.1-8.1 L/min] vs 8.4 L/min [IQR 7.0-11.0 L/min], P < 0.001) and higher mean pulmonary artery pressure-CO slope (5.7 [IQR 3.6-9.0] vs 4.0 [IQR 2.4-5.9], P = 0.022) despite similar exercise time. The worse TR group had higher 5-year composite events (29% vs 11%) (adjusted hazard ratio 3.33, 95% confidence interval 1.46-7.57, P = 0.004). CONCLUSIONS: In patients with exercise HFpEF, the presence of moderate to severe TR was associated with worse cardiac reserve and worse 5-year composite heart failure hospitalization or death.

Duke Scholars

Author Vishal Narasinga Rao Medicine, Cardiology