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

Aims Current guidelines lack sex-specific thresholds for assessing secondary tricuspid regurgitation (STR) severity and right ventricular (RV) and tricuspid annulus (TA) remodelling. We aimed to determine whether risk-based cut-offs for these parameters differ between men and women with STR. Methods and results We included 554 patients (74 ± 13 years, 51% women) with moderate or severe STR. The primary endpoint was all-cause mortality or heart failure hospitalization. Women were older (P < 0.001) and had a higher prevalence of atrial fibrillation (P = 0.008) and atrial STR (P < 0.001), whereas men more frequently had coronary artery disease (P < 0.001), chronic kidney disease (P = 0.005), and mitral regurgitation (P < 0.001). Women exhibited smaller RV and TA dimensions and higher RV ejection fraction (RVEF) (P < 0.001). Over a median follow-up of 19 (8–27) months, 230 patients reached the composite endpoint. Event-free survival at 2 years was comparable between sexes (P = 0.183), even after inverse propensity weighting (P = 0.342). Sex-specific thresholds for STR severity were lower in women for effective regurgitant orifice area (EROA) (0.36 cm2 vs. 0.43 cm2) and regurgitant volume (RegVol) (31 mL vs. 35 mL) but higher for regurgitant fraction (46% vs. 39%). Women also exhibited comparable risk at lower RV end-diastolic (81 mL/m2 vs. 96 mL/m2) and end-systolic volumes (37 mL/m2 vs. 49 mL/m2), higher RVEF (49% vs. 41%), and smaller TA diameter (19 mm/m2 vs. 22 mm/m2). Conclusion In STR, women face a similar risk at lower EROAs and RegVols, along with smaller RV volumes, higher RVEF, and reduced TA dimensions. These findings highlight the importance of incorporating sex-specific thresholds into clinical decision-making when assessing STR severity and right heart remodelling.