Mortality in heart failure with tricuspid regurgitation: Prognostic roles of TR severity and TRI-SCORE categories. Insights from the HEROES registry

Background: Significant tricuspid regurgitation (TR) is associated with adverse outcomes in heart failure (HF), yet risk stratification remains challenging. The TRI-SCORE was developed for in-hospital mortality after isolated tricuspid valve surgery, and its prognostic performance in HF is uncertain. Aims: Our aim was to compare outcomes in moderate vs. severe TR and determine whether TRI-SCORE provides prognostic information beyond TR severity. Methods: This analysis included 365 patients with HF and moderate (n = 270) or severe TR (n = 95) from the prospective multicenter HEROES registry. The primary endpoint was all-cause mortality. Survival was assessed using Kaplan–Meier analysis and Cox regression, and discrimination using Harrell’s C-statistic. Multivariable Cox models were fitted separately within moderate- and severe-TR subgroups. Results: During a median follow-up of 61.9 weeks, 34 patients with severe TR (35.8%) and 67 with moderate TR (24.8%) died. Severe TR was associated with worse unadjusted survival (hazard ratio [HR], 1.60; 95% confidence interval [CI], 1.06–2.42; P = 0.03). Higher TRI-SCORE categories were associated with progressively greater mortality. In moderate TR, TRI-SCORE remained associated with mortality after multivariable adjustment (adjusted HR per 1-point increase, 1.25; 95% CI, 1.03–1.53; P = 0.023), whereas in severe TR it was not associated with mortality in univariable analysis (HR, 1.12; 95% CI, 0.90–1.38; P = 0.316). In complete cases, the combined model showed better discrimination than TR severity alone but not than TRI-SCORE alone. Conclusions: Severe TR was associated with worse unadjusted prognosis. TRI-SCORE provided additional prognostic information, with an independent association with mortality in moderate TR in exploratory multivariable analysis, and may identify high-risk patients not recognized by anatomical grading alone.