ImportanceSecondary tricuspid regurgitation (STR) is observed in multiple cardiac and pulmonary diseases. Heart failure with preserved ejection fraction (HFpEF) is a common cause of STR that may be overlooked, along with precapillary etiologies of pulmonary hypertension (PH).ObjectivesTo investigate the prevalence of HFpEF and precapillary PH in patients with severe STR of undefined etiology (isolated STR) referred for exercise right heart catheterization (RHC), and to evaluate the performance of noninvasive measures to identify HFpEF.Design, Setting, and ParticipantsThis retrospective cross-sectional study included consecutive adults with severe STR in the absence of EF less than 50%, hemodynamically significant left-sided valve disease, congenital heart disease, infiltrative or hypertrophic cardiomyopathy, pericardial disease, or prior cardiac procedures who underwent rest-and-exercise RHC between February 2006 and June 2023 at Mayo Clinic and transthoracic echocardiography less than 90 days prior. Diastolic dysfunction (DD) was defined by at least 3 of 4 or 2 of 3 abnormal diastolic parameters (medial e’, medial E/e’, tricuspid regurgitation [TR] velocity, left atrial volume index). HFpEF was diagnosed when pulmonary arterial wedge pressure was at least 15 mm Hg at rest, at least 19 mm Hg with feet up, or at least 25 mm Hg during exercise. Data analysis was performed from November 2023 to March 2024.Main Outcomes and MeasuresThe prevalence of HFpEF and precapillary PH in severe isolated STR was determined, and performance of noninvasive measures to identify HFpEF was evaluated.ResultsOverall, 54 patients with severe isolated STR (mean [SD] age, 70.8 [12.5] years; 34 [63%] female) were identified. The primary indication for RHC was evaluation of TR prior to potential intervention in 36 patients (67%), evaluation of PH in 13 (24%), and confirmation of HFpEF in 5 (9%). HFpEF was identified in 40 patients (74%) but was recognized prior to RHC in only 19 patients (35%). Of the 14 remaining patients without HFpEF, precapillary PH was diagnosed in 10 (71%). Guideline-defined DD was absent in 24 patients (60%) who were subsequently diagnosed with HFpEF. Left atrial emptying fraction (area under the receiver operating characteristic curve [AUC] = 0.90; 95% CI, 0.82-0.98) and strain (AUC = 0.91; 95% CI, 0.83-0.99) had robust discrimination for HFpEF.Conclusions and RelevanceThe findings suggest that HFpEF is underdiagnosed and should be rigorously evaluated for in patients with severe isolated STR, along with precapillary PH, as both have distinct requirements for management. Resting DD based on current guidelines is insufficiently sensitive in these patients, indicating a pressing need for other noninvasive diagnostic tools, such as left atrial function assessment.

中文翻译：

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HFpEF 在孤立性重度继发性三尖瓣反流中的患病率


重要性继发性三尖瓣反流 （STR） 见于多种心脏和肺部疾病。射血分数保留的心力衰竭 （HFpEF） 是 STR 的常见原因，可能被忽视，肺动脉高压 （PH） 的毛细血管前病因也被忽视。目的调查因病因不明的严重 STR （孤立性 STR） 转诊进行运动右心导管插入术 （RHC） 的患者 HFpEF 和毛细血管前 PH 的患病率，并评估无创措施确定 HFpEF.Design、环境和参与者的性能本回顾性横断面研究包括连续的严重 STR 成人，但 EF 低于 50%， 血流动力学显着的左侧瓣膜疾病、先天性心脏病、浸润性或肥厚性心肌病、心包疾病或既往心脏手术，在 2006 年 2 月至 2023 年 6 月期间在梅奥诊所接受休息和运动 RHC 且经胸超声心动图检查不到 90 天。舒张功能障碍 （DD） 定义为 3 个异常舒张参数 （内侧 e'、内侧 E/e'、三尖瓣反流 [TR] 速度、左心房容积指数）中至少 4 个或 2 个。当静息时肺动脉楔压至少为 15 mmHg，双脚抬起时至少 19 mm Hg，或运动时至少为 25 mm Hg，则诊断为 HFpEF。主要结局和措施确定了严重孤立性 STR 中 HFpEF 和毛细血管前 PH 的患病率，并评估了识别 HFpEF 的无创措施的效果。结果共确定了 54 例严重孤立性 STR 患者 （平均 [SD] 年龄，70.8 [12.5] 岁;34 例 [63%] 女性）。 RHC 的主要适应症是 36 例患者 （67%） 在潜在干预前评估 TR，13 例 （24%） 评估 PH，5 例 （9%） 确认 HFpEF。在 40 例患者 （74%） 中发现了 HFpEF，但只有 19 例患者 （35%） 在 RHC 之前被发现。在其余 14 例无 HFpEF 的患者中，10 例 （71%） 诊断为毛细血管前 PH。随后诊断为 HFpEF 的 24 例患者 （60%） 不存在指南定义的 DD。左心房排空分数 （受试者工作特征曲线下面积 [AUC] = 0.90;95% CI，0.82-0.98）和应变 （AUC = 0.91;95% CI，0.83-0.99） 对 HFpEF 具有很强的区分度。结论和相关性研究结果表明，HFpEF 诊断不足，应在严重孤立性 STR 和毛细血管前 PH 患者中进行严格评估，因为两者具有不同的管理要求。根据当前指南，静息 DD 在这些患者中的敏感性不足，表明迫切需要其他无创诊断工具，例如左心房功能评估。