Sex-specific differences in right heart remodeling and patient outcomes in secondary tricuspid regurgitation

Recent evidence shows sex differences in secondary tricuspid regurgitation (STR). However, guidelines do not provide sex-specific echocardiographic thresholds for assessing STR severity and identifying adverse remodeling of the right ventricle (RV) and tricuspid annulus (TA).

We sought to evaluate whether cutoff values for regurgitation severity, as well as RV and TA remodeling associated with adverse outcomes differ between men and women with STR.

554 consecutive patients (74±13 years, 51% women) with moderate and severe STR underwent conventional and advanced echocardiography. The primary study endpoint was the occurrence of all-cause mortality or hospitalization for heart failure (HHF).

Women were older (p<0.001), had a higher prevalence of atrial fibrillation (p=0.008) and higher systolic blood pressure (p<0.001). In contrast, men were more likely to have coronary artery disease (p<0.001), stage IV-V chronic kidney disease (p=0.005), and significant mitral regurgitation (p<0.001). RV ejection fraction (RVEF) was higher in women (p<0.001). Furthermore, women also exhibited smaller RV, right atrium and TA than men. Importantly, atrial-STR was more prevalent in women (p<0.001). During a follow-up period of 19(8-27) months, 230 patients reached the composite endpoint. At the 2-year follow-up, event-free survival rates were comparable for both sexes (p=0.183), even after inverse-propensity weighting (p=0.342) (Figure 1). Risk-based sex-specific thresholds for STR severity differed between men and women, with lower cutoffs in women for the effective regurgitant orifice area (EROA) (0.36cm² vs. 0.43cm²), regurgitant volume (RegVol) (31mL vs. 35mL), and a higher regurgitant fraction (46% vs. 39%). Women also exhibited higher risk at lower thresholds for RV end-diastolic volume (81mL/m² vs. 96mL/m²), RV end-systolic volume (37mL/m² vs. 49mL/m²), and higher RVEF (49% vs. 41%). Similarly, sex-specific differences were observed in TA dimensions, with a 4-chamber TA diameter threshold of 19mm/m² for women versus 22mm/m² for men.

Although both sexes exhibit similar survival rates in STR, women face a higher risk at lower EROA and RegVol, as well as with smaller RV volumes, higher RVEF, and smaller TA dimensions. These findings highlight the importance of incorporating sex-specific thresholds into clinical decision-making when assessing STR severity and right heart remodeling to improve patient outcomes.

Sex-Specific Differences in Right Heart