Although the classification of secondary tricuspid regurgitation (STR) by atrial or ventricular etiology (A-STR or V-STR) carries prognostic importance, the confounding effects of NYHA class have not yet been elucidated.

We aimed to correlate STR and NYHA classification with patient outcomes.

We studied 281 patients with severe STR who presented to 16 French hospitals between 2017–2019. Patients were separated into A-STR and V-STR categories using echocardiographic criteria (A-STR=tricuspid tenting height≤10mm, right mid-ventricular diameter≤38mm, and LVEF≥50%). We tracked time to cardiovascular disease-related hospitalization or death, whichever came first.

In all, 91/281 (32.7%) patients had A-STR, 164/281 (58.4%) had mixed/V-STR, and 25/281 (8.9%) could not be classified. Baseline age, labs, comorbidities, and NYHA category (class I–II=mildly symptomatic, class III–IV=very symptomatic) did not differ between groups (P>0.05). Although there were no differences in event-free survival among groups (70.7% vs. 65.9%, P=0.59), this was confounded by NYHA class (P=0.0104). Thus, among mildly symptomatic patients, estimated five-year event-free survival was 76.4% in the A-STR group and 53.2% in the mixed/V-STR group (P<0.05). Among very symptomatic patients, there was no difference in estimated event-free survival (39.4% vs. 17.2%, P>0.05) (Fig. 1).

Though A-STR carries a more favorable prognosis in mildly symptomatic patients, this distinction is irrelevant in patients with advanced disease. Thus, the value of tricuspid valve intervention may become “too little, too late” if A-STR is not promptly addressed.