Integrated Right-Heart Remodeling Phenotypes and Prognosis in Tricuspid Regurgitation: An Automated Strain Echocardiography Study
Authors
Abstract
BackgroundEchocardiographic assessment of tricuspid regurgitation (TR) remains valve-centric, and right-heart remodeling is not captured. Strain parameters carry prognostic value but are evaluated in isolation. ObjectivesTo develop integrated right atrial (RA) and right ventricular (RV) remodeling indices using automated echocardiography and assess their utility for TR severity grading, phenotyping, and prognostic stratification. MethodsWe analyzed 8,231 patients with functional TR (mild-or-greater) from two tertiary centers (2023-2024) using an automated AI-based echocardiographic solution. The RA remodeling index (RA reservoir strain/RA volume index) and RV remodeling index (RV free wall strain/RV end-diastolic area) were derived automatically; patients were classified into four RA-RV remodeling phenotypes. The primary outcome was all-cause death or heart failure (HF) hospitalization. ResultsDuring median follow-up of 19.3 months, the primary outcome occurred in 574 patients (7.0%). Both indices outperformed individual components for severe TR discrimination (RA: AUC 0.857 vs. 0.757; RV: 0.710 vs. 0.601; both P<0.05). After multivariate adjustment, the RA (HR per unit decrease, 1.27; 95% CI, 1.09-1.49; P=0.002) and RV remodeling indices (2.32; 1.76-3.06; P<0.001) were independently associated with the primary outcome; on mutual adjustment, only the RV index retained significance and provided incremental prognostic value ({Delta}C-index +0.010; NRI +0.237; both P<0.05). The four phenotypes showed progressively divergent risk (log-rank P<0.001), with combined remodeling (Low RA/Low RV) carrying the highest risk. ConclusionsAutomated integrated RA and RV remodeling indices improved TR severity discrimination and enabled clinically meaningful right-heart phenotyping. The RV index conferred incremental prognostic value, whereas the RA index better reflected atrial-stage remodeling and disease burden. CONDENSED ABSTRACTIn 8,231 patients with functional tricuspid regurgitation from two tertiary centers, we derived integrated right atrial (RA) and right ventricular (RV) remodeling indices combining strain with chamber structure using automated echocardiography. These indices outperformed individual strain parameters for severe TR discrimination and stratified patients into four prognostically distinct RA and RV remodeling phenotypes. Both indices independently predicted the composite of all-cause death and heart failure hospitalization. The RV index emerged as the dominant prognostic marker with incremental value over the clinical model, whereas the RA index primarily characterized atrial-stage remodeling and disease burden.