Right heart, wrong again: why do we keep ignoring tricuspid regurgitation in cardiogenic shock?

describe the incidence and the prognostic relevance of TR in patients with CS, a setting in which few data are available.

We enrolled 725 consecutive patients admitted to the Altshock-2 registry (a multicenter prospective study including 12 Italian tertiary CICUs) from March 2020 to January 2024. Survival was assessed at 30 and at 180 days, as well as freedom from a composite outcome of death, LVAD implantation, or heart transplantation (HTx), and survival analysis was performed with Cox regression. Clinical, hemodynamic and echocardiographic data were assessed on admission. Shock etiology and temporary mechanical circulatory support (tMCS) use were also documented. Patients were divided in 4 groups according to TR status and median TAPSE values (<15 or ≥ 15 mm)

more than mild TR (TR>1+) was present in 259/512 patients (pts) with data available (50.6%) on CICU admission.

At univariable Cox regression, TR>1+ was significantly associated with death, LVAD or HTx at 30 days (HR 1.57, 95% CI 1.15-2.14, p=0.004, 454 pts), with death at 180 days (HR 1.38, 95% CI 1.038-1.84, p=0.027, 366 pts) and with death, LVAD or HTx at 180 days (HR 1.43, 95% CI 1.10-1.87, p=0.008, 374 pts).

Among the 200 pts with complete data available, TR>1+ was independently associated with death at 180 days (HR 1.66, 95% CI 1.03-2.67, p=0.036) after correction for CVP, MAP, TAPSE, shock etiology, tMCS use and more than mild mitral regurgitation (MR>1+).

Among the 205 pts with complete data available, TR>1+ was independently associated with death, LVAD or HTx at 180 days (HR 1.58, 95% CI 1.005-2.48, p=0.048) after correction for CVP, MAP, TAPSE, shock etiology, tMCS use and MR>1+.

At univariable Cox regression, patients without TR>1+ and with TAPSE ≥ 15 mm showed lower death at 180 days (HR 0.53, 95% CI 0.34-0.82, p=0.005); interestingly, patients with either TR>1+ and/or TAPSE <15 showed no statistically significant differences in prognosis. These results suggest that relatively preserved right ventricular function is not associated with improved outcomes in presence of TR>1+ in this setting.

more than mild tricuspid regurgitation in associated with poor outcomes in patients admitted in the CICU with a diagnosis of CS. These results may suggest targeting TR, along with other measures of congestion, in order to optimize decongestive therapies in this patient’s population.