Tricuspid regurgitation and right ventricular contraction pattern in heart failure with reduced ejection fraction: a 3D echocardiography study

The development of secondary tricuspid regurgitation (TR) is associated with poor outcomes in patients with heart failure and reduced left ventricular (LV) ejection fraction (HFrEF). Data are scarce concerning the right ventricular (RV) morphological and functional remodeling in HFrEF in relation to the severity of TR. Accordingly, we aimed to characterize RV remodeling in HFrEF patients with and without significant TR using three-dimensional (3D) echocardiography. We retrospectively identified 138 patients with HFrEF. In this cohort, we graded TR severity according to current guidelines and compared patients with no to mild TR (non-significant TR, n=78) versus patients with moderate to severe TR (significant TR, n=60). All patients underwent clinically indicated 3D transthoracic echocardiography. 3D LV and RV end-diastolic volumes (EDVi) and ejection fractions (EF) were measured. To characterize RV mechanical pattern, the ReVISION method was used to quantify the contribution of the longitudinal, radial, and anteroposterior motion components to total RV EF. Patients with significant TR had higher LV EDVi and lower LV EF compared with patients with non-significant TR (LV EDVi: 117.2±34.9 vs. 102.6±39.6 ml/m2; LV EF: 27.0±6.6 vs. 30.2±7.7%, both p<0.05). Concerning the right heart, RV EDVi was significantly higher in patients with significant TR compared with those without (92.1±32.4 vs. 74.1±26.9 ml/m2; p<0.01). RV EF was lower in patients with significant TR (36±10.3 vs. 42.5±9.3%, p<0.05). Regarding RV mechanics, anteroposterior and longitudinal components were significantly decreased in patients with significant TR compared with patients with non-significant TR (anteroposterior relative contribution: 10.0±4.5 vs. 11.7±3.7%; longitudinal: 8.2±3.8 vs. 11.1±3.8%; both p<0.05). On the other hand, the radial component did not show a difference between patients with or without significant TR (17.8±6.9 vs. 19.8±6.2%; p=NS). By assessing RV mechanics using 3D echocardiography, we have shown that HFrEF patients with significant TR presented with reduced RV global function, mainly attributable to the deterioration of the longitudinal and anteroposterior motion components. Identification of the turning point where RV plasticity diminishes, and significant TR develops would be of high clinical interest for more tailored therapeutic decisions.