Atrial Functional Tricuspid Regurgitation: Importance of Atrial Fibrillation and Right Atrial Remodeling and Prognostic Significance

doi:10.1016/j.jcmg.2022.11.014

JACC: Cardiovascular Imaging

Volume 16, Issue 5, May 2023, Pages 575-587

https://doi.org/10.1016/j.jcmg.2022.11.014 Get rights and content

Abstract

Background

Little is known about the determinants and outcomes of significant atrial functional tricuspid regurgitation (AFTR).

Objectives

The authors aimed to identify risk factors for significant TR in relation to atrial fibrillation-flutter (AF-AFL) and assess its prognostic implications.

Methods

The authors retrospectively studied patients with mild TR with follow-up echocardiography examinations. Significant TR was defined as greater than or equal to moderate TR. AFTR was defined as TR, attributed to right atrial (RA) remodeling or isolated tricuspid annular dilatation, without other primary or secondary etiology, except for AF-AFL. The Mantel-Byar test was used to compare clinical outcomes by progression of AFTR.

Results

Of 833 patients with mild TR, 291 (34.9%) had AF-AFL. During the median 4.6 years, significant TR developed in 35 patients, including 33 AFTRs. Significant AFTR occurred in patients with AF-AFL more predominantly than in those patients without AF-AFL (10.3% vs 0.6%; P < 0.001). In Cox analysis, AF-AFL was a strong risk factor for AFTR (adjusted HR: 8.33 [95% CI: 2.34-29.69]; P = 0.001). Among patients with AF-AFL, those who developed significant AFTR had larger baseline RA areas (23.8 vs 19.4 cm²; P < 0.001) and RA area-to-right ventricle end-systolic area ratio (3.0 vs 2.3; P < 0.001) than those who did not. These parameters were independent predictors of AFTR progression. The 10-year major adverse cardiovascular event was significantly higher after progression of AFTR than before or without progression (79.8% vs 8.6%; Mantel-Byar P < 0.001).

Conclusions

In patients with mild TR, significant AFTR developed predominantly in patients with AF-AFL, conferring poor prognosis. RA enlargement, especially with increased RA area-to-right ventricle end-systolic area ratio, was a strong risk factor for progression of AFTR.

Central Illustration

Section snippets

Study population

This study was conducted at a large tertiary university hospital (Seoul National University Hospital, South Korea). We retrospectively collected patients with mild TR identified on echocardiography between 2007 and 2019 (Figure 1A). The eligibility criterion was the availability of follow-up echocardiography data at least 1 year after the mild TR identification.

In this study, we classified the types of TR following the recent report¹⁵: primary TR is defined as TR caused by congenital or

Patients’ characteristics according to AF-AFL

Of 833 patients with mild TR at baseline, 291 (34.9%) had AF-AFL (Table 1). Among patients with AF-AFL, 19 (6.5%) had AFL, and 43 (14.8%) had paroxysmal AF-AFL. Patients with AF-AFL were older (age 69 vs 65 years; P < 0.001) and more frequently men than those without AF-AFL (56.0% vs 33.0%; P < 0.001). Patients with AF-AFL had more diabetes mellitus and impaired renal function, whereas coronary artery disease was more prevalent in patients without AF-AFL (8.9% vs 25.5%; P < 0.001). Dyspnea and

Discussion

We demonstrated that 4% of patients with mild TR developed significant progression of TR during 4.6 years of follow-up. Significant progression of TR almost exclusively occurred in patients with AF-AFL (32 of 35 cases), of which 30 were AF-AFL-related AFTR cases. In patients with AF-AFL, RA enlargement, especially with a higher RA-RV end-systolic area ratio, was a significant risk factor for progression of AFTR. Patients who developed significant AFTR exhibited markedly higher MACEs and deaths

Conclusions

In patients with mild TR, significant AFTR developed predominantly in those with AF-AFL. RA enlargement was a strong risk factor for progression of AFTR in the presence of AF-AFL. Development of significant AFTR conferred poor cardiovascular outcomes. Closer echocardiographic surveillance may be advisable for patients with mild TR, AF-AFL, and increased RA size.

COMPETENCY IN PATIENT CARE AND PROCEDURAL SKILLS: In patients with mild TR, AF-AFL, and RA enlargement are strong risk factors for the

Funding Support and Author Disclosures

This work was supported by the National Research Foundation of Korea of the Ministry of Science and ICT (NRF-2020R1C1C1010890). The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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Original ResearchAtrial Functional Tricuspid Regurgitation: Importance of Atrial Fibrillation and Right Atrial Remodeling and Prognostic Significance

Abstract

Background

Objectives

Methods

Results

Conclusions

Central Illustration

Section snippets

Study population

Patients’ characteristics according to AF-AFL

Discussion

Conclusions

Funding Support and Author Disclosures

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol Img

J Am Coll Cardiol Img

J Am Soc Echocardiogr

J Am Soc Echocardiogr

CASE (Phila)

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Am J Cardiol

J Am Coll Cardiol Img

J Thorac Cardiovasc Surg

Am J Cardiol

Int J Cardiol

Original Research
Atrial Functional Tricuspid Regurgitation: Importance of Atrial Fibrillation and Right Atrial Remodeling and Prognostic Significance