Incremental Prognostic Value of Right Ventricular-pulmonary Artery Coupling to a Clinical Risk Score in Tricuspid Regurgitation: the TRIO-RV Score.

Abstract

Objectives: There are limited data evaluating echocardiographic parameters of risk in tricuspid regurgitation (TR) patients. We sought to evaluate the incremental prognostic value of quantitative right ventricle (RV) function and RV-pulmonary artery (RV-PA) coupling to an established clinical risk score in TR patients.

Methods: We retrospectively identified patients with ≥moderate TR from January 1st, 2019 to June 30th, 2019. Univariable and multivariable cox proportional hazards regression were used to test the association of right ventricular free wall strain (RVFWS), RVFWS indexed to right ventricular systolic pressure (RVSP), and the TRIO risk score with mortality. A novel TRIO-RV risk score was developed by incorporating RVFWS/RVSP into the clinical TRIO risk score.

Results: Among 417 patients, age 73±11.5 years, 47% female, TRIO score was 3.5±2. TRIO score was low-risk in 213 (51%), intermediate-risk in 162 (39%), and high-risk in 42 (10%). During median follow up of 3.96 years (IQR 1.66-4.34 years), death occurred in 157 patients (38%). Baseline TRIO risk category was associated with mortality (p<0.001). After adjustment by TRIO risk score, both RVFWS <18.6% (adjusted HR 3.08, 95% CI 2.01-4.72, p<0.001) and RVFWS/RVSP <0.43 %/mmHg (adjusted HR 2.76, 95% CI 1.75-4.35, p<0.001) remained significantly correlated with mortality. With the addition of RVFWS/RVSP, 151 (40%) patients with low- and intermediate-risk TRIO scores were reclassified to a higher-risk TRIO-RV score. The ChiSquare value increased in sequential models predictive of mortality for the TRIO score alone, the TRIO score plus RVFWS <18.6%, and the TRIO score plus RVFWS/RVSP <0.43 %/mmHg (model ChiSquare 38.3, 72.2, and 82.3, respectively).

Conclusion: Quantitative parameters of RV function are associated with mortality in TR patients even after correction for an existing clinical risk score. Incorporating RVFWS/RVSP into the TRIO clinical risk score, the TRIO-RV score, reclassifies a substantial number of low- and intermediate-risk patients into higher risk categories and improves risk stratification.