Severe Tricuspid Regurgitation in AFMR Patients: Key Insights for Better Management

Researchers explore clinical characteristics, determinants, and prognostic impact of severe tricuspid regurgitation in patients with atrial functional mitral regurgitation

Tricuspid regurgitation (TR) is common in patients with atrial functional mitral regurgitation (AFMR) but its impact is not well understood. Japanese researchers have now examined severe TR in AFMR patients, revealing it affects one in seven to eight patients and significantly raises the risk of death or heart failure-related hospitalization by 1.65 times (95% confidence interval 1.09–2.47). These findings highlight the importance of monitoring TR severity to improve outcomes for AFMR patients.

Atrial functional mitral regurgitation (AFMR) is a common type of MR linked to high rates of heart failure, highlighting the need to understand its prognostic factors. Tricuspid regurgitation (TR) is a known prognostic factor in heart diseases like heart failure and degenerative MR. It is also frequently observed in AFMR patients, making it crucial to understand its impact on AFMR outcomes.

To address this gap, a research team led by Dr. Tomohiro Kaneko and Dr. Nobuyuki Kagiyama from the Department of Cardiovascular Biology and Medicine at the Juntendo University School of Medicine, Japan, conducted a comprehensive study to investigate the clinical characteristics, determinants, and prognostic impact of severe TR in AFMR patients. Their findings were published in the European Journal of Heart Failure on February 19, 2025, and shed new light on the importance of monitoring TR severity in AFMR patients.

The study involved a post-hoc analysis of data from the REVEAL-AFMR study, a multicenter observational study investigating AFMR prevalence and treatment options. Researchers analyzed echocardiographic reports of 792 adult patients with moderate or severe AFMR, dilated left atrium, and preserved left ventricular function, who underwent transthoracic echocardiography at 26 Japanese facilities in 2019. Patients were categorized into two groups: those with severe TR and those without. The primary outcome was a composite of heart failure-related hospitalization and all-cause mortality, while the secondary outcome was all-cause mortality.

The results revealed that 14.9% of AFMR patients had severe TR, affecting approximately one in seven patients. These patients were generally older and more likely to have atrial fibrillation (AFib), advanced heart failure symptoms, and significant right heart remodeling compared to those without severe TR. The study identified advanced age (over 75), permanent AFib, chronic obstructive pulmonary disease (COPD), and higher right atrial pressure as independent determinants of severe TR.

Permanent AFib and COPD emerged as key risk factors for severe TR. “AFib can often be detected early through routine pulse checks or health examinations, making early detection and management crucial. Additionally, since most cases of COPD are linked to smoking, preventive measures such as smoking cessation could also play a vital role,” explains Dr. Kaneko.

The study also investigated the causes of TR in AFMR patients, distinguishing between ventricular functional TR (VFTR), caused by right ventricular remodeling, and atrial functional TR (AFTR), resulting from atrial dilation and tricuspid annular enlargement. Among patients with moderate or severe TR, 41% had AFTR, while 59% had VFTR. VFTR was more common in patients with severe TR and was linked to more persistent AFib and advanced heart failure symptoms. Despite these differences, the prognosis was similar for both VFTR and AFTR groups, suggesting that TR severity, rather than its cause, is the key determinant of adverse outcomes.

“These findings provide crucial insights into the clinical characteristics and impact of severe TR in AFMR patients, which could help define better treatment strategies. It is essential to explore optimal management approaches, including transcatheter interventions for mitral and tricuspid valves,” says Dr. Kaneko.

The research emphasizes the need for targeted therapeutic strategies for TR in AFMR patients. “Our findings highlight the importance of investigating the effectiveness of simultaneous surgical interventions and transcatheter treatments for both the mitral and tricuspid valves,” Dr. Kaneko adds.

Additionally, the study stresses the significance of early detection and management of TR determinants. Routine pulse checks can help detect AFib early, while lifestyle changes, such as quitting smoking, can lower the risk of COPD, a significant determinant of severe TR. These preventive strategies could be crucial in reducing the risk of severe TR and improving long-term outcomes.

This study not only sheds light on the clinical significance of severe TR in AFMR patients but also lays the groundwork for future research aimed at improving clinical outcomes. It calls for increased awareness among healthcare providers and highlights the need for comprehensive management strategies for this complex condition. By elucidating the clinical characteristics, risk factors, and prognostic impact of severe TR in AFMR, this study establishes a solid foundation for developing targeted therapeutic strategies to enhance patient care.