title: Clinical outcome of isolated tricuspid regurgitation.
abstract: OBJECTIVE
  The aim of this study was to assess the outcome of isolated tricuspid regurgitation (TR) and the added value of quantitative evaluation of its severity.
  
  
  BACKGROUND
  TR is of uncertain clinical outcome due to confounding comorbidities. Isolated TR (without significant comorbidities, structural valve disease, significant pulmonary artery systolic pressure elevation by Doppler, or overt cardiac cause) is of unknown clinical outcome.
  
  
  METHODS
  In patients with isolated TR assessed both qualitatively and quantitatively by a proximal isovelocity surface area method, a long-term outcome analysis was conducted. Patients with severe comorbid diseases were excluded.
  
  
  RESULTS
  The study involved 353 patients with isolated TR (age 70 years; 33% male; ejection fraction, 63%; all with right ventricular systolic pressure <50 mm Hg). Severe isolated TR was diagnosed in 76 patients (21.5%) qualitatively and 68 patients (19.3%) by quantitative criteria (effective regurgitant orifice [ERO] ≥40 mm(2)). The 10-year survival and cardiac event rates were 63 ± 5% and 29 ± 5%. Severe isolated TR independently predicted higher mortality (adjusted hazard ratio: 1.78 [95% confidence interval (CI): 1.10 to 2.82], p = 0.02 for qualitative definition and 2.67 [95% CI: 1.66 to 4.23] for an ERO ≥40 mm(2), p < 0.0001). The addition of grading by quantitative criteria in nested models eliminated the significance of the qualitative grading and improved the model prediction (p < 0.001 for survival and p = 0.02 for cardiac events). The 10-year survival rate was lower with an ERO ≥40 mm(2) versus <40 mm(2) (38 ± 7% vs. 70 ± 6%; p < 0.0001), independent of all characteristics, right ventricular size or function, comorbidity, or pulmonary pressure (p < 0.0001 for all), and lower than expected in the general population (p < 0.001). Freedom from cardiac events was lower with an ERO ≥40 mm(2) versus <40 mm(2) independently of all characteristics, right ventricular size or function, comorbidity, or pulmonary pressure (p < 0.0001 for all). Cardiac surgery for severe isolated TR was rarely performed (16 ± 5% 5 years after diagnosis).
  
  
  CONCLUSIONS
  Isolated TR can be severe and is associated with excess mortality and morbidity, warranting heightened attention to diagnosis and quantitation. Quantitative assessment of TR, particularly ERO measurement, is a powerful independent predictor of outcome, superior to standard qualitative assessment.
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Yan
authors.initials: Y
authors.lastname: Topilsky
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Vuyisile T
authors.initials: VT
authors.lastname: Nkomo
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Ori
authors.initials: O
authors.lastname: Vatury
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Hector I
authors.initials: HI
authors.lastname: Michelena
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Thierry
authors.initials: T
authors.lastname: Letourneau
authors.affiliation: Division of Cardiovascular Surgery, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Rakesh M
authors.initials: RM
authors.lastname: Suri
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Sorin
authors.initials: S
authors.lastname: Pislaru
authors.affiliation: Division of Cardiovascular Surgery, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Soon
authors.initials: S
authors.lastname: Park
authors.affiliation: Department of Health Science Research, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Douglas W
authors.initials: DW
authors.lastname: Mahoney
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Simon
authors.initials: S
authors.lastname: Biner
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota. Electronic address: Sarano.maurice@mayo.edu.
authors.forename: Maurice
authors.initials: M
authors.lastname: Enriquez-Sarano
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D018450:Disease Progression; D018572:Disease-Free Survival; D015150:Echocardiography, Doppler; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D014261:Tricuspid Valve / Q000000981:diagnostic imaging / Q000503:physiopathology*; D014262:Tricuspid Valve Insufficiency / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy
keywords: effective regurgitant orifice; isolated tricuspid regurgitation; prognosis; tricuspid regurgitation