Gender differences in clinical phenotype, right-heart remodelling and outcomes in severe tricuspid regurgitation: a cardiac magnetic resonance study

AIMS: Severe tricuspid regurgitation (TR) is more prevalent in women; however, whether sex influences clinical outcomes remains unclear. This study investigated sex-related differences in clinical presentation, right ventricular (RV) remodelling assessed by cardiac magnetic resonance (CMR), and all-cause mortality in patients with severe TR. METHODS AND RESULTS: Patients with at least severe TR assessed by echocardiography who subsequently underwent CMR were enrolled from five tertiary hospitals. The primary outcome was all-cause mortality under medical therapy. Patients undergoing tricuspid valve intervention were censored at the time of the procedure. Patients were followed for up to 10 years (median 35 months; interquartile range (IQR) 12-60). A total of 326 patients (mean age 71 ± 11 years; 67% women) were included. Women had a lower prevalence of diabetes, coronary artery disease, and chronic kidney disease (all P < 0.05). Atrial functional TR was more prevalent in women, whereas ventricular TR predominated in men (P < 0.05). On CMR, women demonstrated lower indexed RV and right atrial volumes and higher right ventricular ejection fraction (P < 0.01). Rates of tricuspid valve intervention were similar between groups (28% vs. 29%, P = 0.53). Women showed better 10-year survival than men (53% vs. 25%, P < 0.001). Male sex remained independently associated with all-cause mortality in multivariable analysis after inverse probability of treatment weighting [hazard ratio (HR) 2.08 (1.30-3.33), P = 0.002] and after propensity score matching [HR 1.81 (1.04-3.15), P = 0.036]. CONCLUSION: Women with severe TR exhibited fewer comorbidities, predominantly atrial TR, less RV remodelling, and better long-term survival compared with men. Sex-specific phenotyping may improve risk stratification and support more individualized therapeutic strategies.