Moderate TR on cardiac MRI may identify patients at higher long-term risk than current guidelines suggest. Published in Circulation, this retrospective study examined whether MRI-based quantification of TR and its systemic consequences could improve risk detection in routine clinical practice.

The analysis included 489 adults referred for cardiac MRI between 2019 and 2024. All participants underwent TRF assessment and, when available, liver extracellular volume (L-ECV) mapping. The median TRF was 21% with an interquartile range of 14% to 33%. Over a 2.3-year follow-up, TRF thresholds of ≥20% and ≥40% corresponded to increasing hazards of the composite endpoint of death or heart failure hospitalization (P < 0.001). A TRF ≥40% remained an independent predictor of both outcomes after adjustment.

Among the 371 patients with liver mapping data, L-ECV ≥32% was strongly linked to markers of right-sided heart failure and to worse long-term outcomes (all P < 0.001). Patients with both TRF ≥20% and L-ECV ≥32% had the highest rates of adverse events, highlighting the added prognostic value of assessing hepatic congestion.

These findings show that cardiac MRI can identify high-risk features even when TR severity appears only moderate. Combining TRF with L-ECV may allow earlier recognition of vulnerable patients and support more informed surveillance or intervention strategies.