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Original Research |

Functional Tricuspid Regurgitation in Patients With Pulmonary Hypertension: Is Pulmonary Artery Pressure the Only Determinant of Regurgitation Severity?

Diab Mutlak, MD*; Doron Aronson, MD; Jonathan Lessick, MD, DSc; Shimon A. Reisner, MD; Salim Dabbah, MD; Yoram Agmon, MD
Author and Funding Information

*From the Echocardiography Laboratory and Heart Valves Clinic, Department of Cardiology, Rambam Health Care Campus and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.

Correspondence to: Yoram Agmon, MD, Department of Cardiology, Rambam Health Care Campus, PO Box 9602, Haifa 31096, Israel; e-mail: agmon@rambam.health.gov.il

*Values are given as mean ± SD or No. (%), unless otherwise indicated. Data were available in > 90% of patients, unless otherwise indicated.

†p < 0.01 vs moderate and severe TR.

‡p < 0.05 vs severe TR.

§p < 0.01 vs severe TR.

∥Moderate or severe.

¶Data available in 84% of patients with PASP ≥ 50 mm Hg and in 82% of patients with and PASP ≥ 70 mm Hg.

#Primarily calcific aortic valve disease.

*Values adjusted for age, sex, and pulmonary artery systolic pressure.

†Moderate or severe.

*Age, sex, and PASP were forced into the models; only statistically significant variables are presented.

†Moderate or severe.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.


The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.


Chest. 2009;135(1):115-121. doi:10.1378/chest.08-0277
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Background:  Pulmonary hypertension is a common cause of functional tricuspid regurgitation (TR), but other factors play a role in determining TR severity. The objectives of our study were to determine the distribution of TR severity in relation to pulmonary artery systolic pressure (PASP) and to define the determinants of TR severity.

Methods:  The echocardiographic reports and selected echocardiographic studies of patients with echocardiographic estimation of PASP were reviewed. Patients with organic tricuspid valve (TV) disease were excluded from the analysis.

Results:  Among 2,139 patients, the frequency of moderate or severe TR was progressively greater in patients with higher PASP. Nevertheless, TR was only mild in a substantial proportion of patients with high PASP (mild TR in 65.4% of patients with PASP 50–69 mm Hg and in 45.6% of patients with PASP ≥ 70 mm Hg). By multivariate analysis, age, female gender, PASP (odds ratio, 2.26 per 10-mm Hg increase; 95% confidence interval, 1.95 to 2.61), pacemaker lead, right atrial (RA) and right ventricular enlargement, left atrial enlargement, and organic mitral valve disease were independently associated with greater degrees of TR. In patients with PASP ≥ 70 mm Hg, RA size, tricuspid annular diameter, and TV tethering area were greater in patients with greater degrees of TR.

Conclusions:  PASP is a strong determinant of TR severity, but many patients with pulmonary hypertension do not exhibit significant TR. In addition to PASP, demographic characteristics, mechanical factors, remodeling of the right heart cavities, and other factors (possibly reflecting the presence of atrial fibrillation or occult organic TV disease) are predictive of TR severity.

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