Marked Underreferral to Structural Heart Specialists in Severe Tricuspid Regurgitation Despite High Clinical Burden: An Adjusted Registry Analysis
- 1Internal Medicine Department, Piedmont Athens Regional Medical Center, Athens, Georgia, USA.
- 2Internal Medicine Department, Mercer University School of Medicine, Macon, Georgia, USA.
Abstract
Background: Severe tricuspid regurgitation (TR) carries mortality risk comparable to untreated severe aortic stenosis, yet specialist referral rates remain poorly characterized. Methods: We analyzed 1000 patients with severe TR from CardioCare registry from a single center in Georgia. The primary outcome was the absence of structural heart disease (SHD) specialist evaluation. Multivariable logistic regression identified predictors of referral failure adjusted for age, heart failure (HF), kidney and liver disease, symptoms, right ventricular systolic pressure (RVSP), and ejection fraction, with an extended model adding coronary artery disease, conduction delay, and New York Heart Association (NYHA) class III–IV. Kaplan-Meier and Cox analyses assessed survival by evaluation status and clinical subgroup. Results: Only 328 patients (32.8%) underwent SHD evaluation despite symptoms (86.4%), HF (86.5%), kidney disease (65.1%), and liver disease (32.0%). HF was the strongest referral predictor (adjusted odds ratio [OR] 0.20, 95% CI 0.11–0.36); NYHA class III–IV, coronary artery disease, and conduction delay were also independently associated, whereas kidney disease, liver disease, and symptoms were not, and higher RVSP paradoxically predicted lower referral (OR 1.02/mmHg; both p < 0.001). Only 13.2% of symptomatic patients without HF were evaluated, and those with combined HF, kidney, and liver disease had the highest mortality (22.4%) but no preferential referral. Survival was worse with HF, increasing organ burden, and RVSP ≥40 mmHg; these factors plus age remained independent mortality predictors on Cox analysis, though this association attenuated in sensitivity analysis. Conclusions: More than two-thirds of patients with severe TR never reach an SHD specialist despite substantial clinical burden, highlighting the need for echocardiography-triggered referral pathways and quality metrics.
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BibTeX
@article{darko2026marked,
title = {{Marked Underreferral to Structural Heart Specialists in Severe Tricuspid Regurgitation Despite High Clinical Burden: An Adjusted Registry Analysis}},
author = {Prince Darko and John Costner and Brennan Carter and Baffour Otchere and Christopher Chinnatambi and Papa Beeko and Patrick Berchie and Oladipo Odeyinka and Eunice Hama and Swethapriya Chaparala},
journal = {Structural Heart},
year = {2026},
month = jun,
doi = {10.1016/j.shj.2026.101075},
url = {https://doi.org/10.1016/j.shj.2026.101075},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Marked Underreferral to Structural Heart Specialists in Severe Tricuspid Regurgitation Despite High Clinical Burden: An Adjusted Registry Analysis
AU - Prince Darko
AU - John Costner
AU - Brennan Carter
AU - Baffour Otchere
AU - Christopher Chinnatambi
AU - Papa Beeko
AU - Patrick Berchie
AU - Oladipo Odeyinka
AU - Eunice Hama
AU - Swethapriya Chaparala
PY - 2026
DA - 2026/06/24
JO - Structural Heart
DO - 10.1016/j.shj.2026.101075
UR - https://doi.org/10.1016/j.shj.2026.101075
AB - Background: Severe tricuspid regurgitation (TR) carries mortality risk comparable to untreated severe aortic stenosis, yet specialist referral rates remain poorly characterized. Methods: We analyzed 1000 patients with severe TR from CardioCare registry from a single center in Georgia. The primary outcome was the absence of structural heart disease (SHD) specialist evaluation. Multivariable logistic regression identified predictors of referral failure adjusted for age, heart failure (HF), kidney and liver disease, symptoms, right ventricular systolic pressure (RVSP), and ejection fraction, with an extended model adding coronary artery disease, conduction delay, and New York Heart Association (NYHA) class III–IV. Kaplan-Meier and Cox analyses assessed survival by evaluation status and clinical subgroup. Results: Only 328 patients (32.8%) underwent SHD evaluation despite symptoms (86.4%), HF (86.5%), kidney disease (65.1%), and liver disease (32.0%). HF was the strongest referral predictor (adjusted odds ratio [OR] 0.20, 95% CI 0.11–0.36); NYHA class III–IV, coronary artery disease, and conduction delay were also independently associated, whereas kidney disease, liver disease, and symptoms were not, and higher RVSP paradoxically predicted lower referral (OR 1.02/mmHg; both p < 0.001). Only 13.2% of symptomatic patients without HF were evaluated, and those with combined HF, kidney, and liver disease had the highest mortality (22.4%) but no preferential referral. Survival was worse with HF, increasing organ burden, and RVSP ≥40 mmHg; these factors plus age remained independent mortality predictors on Cox analysis, though this association attenuated in sensitivity analysis. Conclusions: More than two-thirds of patients with severe TR never reach an SHD specialist despite substantial clinical burden, highlighting the need for echocardiography-triggered referral pathways and quality metrics.
SN - 2474-8706
SN - 2474-8714
ER -