Pharmacological Reduction of Right Ventricular Enlargement

Inclusion Criteria:

• Patients must agree to the study protocol and provide written informed consent

• Outpatients ≥ 20 years of age, male or female

• Patients with severe functional tricuspid regurgitation

• TR whose vena contracta ≥0.7cm or central jet area > 10 square cm and whichlasted > 6 months under medical treatment

• LV ejection fraction ≥ 50%

• Dyspnea of NYHA functional class II or III

Exclusion Criteria:

• History of hypersensitivity or allergy to the study drugs, drugs of similar chemicalclasses, as well as known or suspected contraindications to the study drug

• Current use or prior use of a SGLT-2 inhibitor or combined SGLT-1 and 2 inhibitor

• Significant left-sided valve disease

• Left ventricular ejection fraction <40%

• Marked bradycardia (<50 beats/min) or 2nd or 3rd degree AVB, sinus node dysfunction

• Severe pulmonary hypertension: TR Vmax >4m/s at screening (including Cor pulmonale)

• Medical history of hospitalization within 6 weeks

• Current acute decompensated heart failure or dyspnea of NYHA functional class IV

• Symptomatic hypotension and/or a SBP < 90 mmHg at screening Estimated GFR < 30mL/min/1.73 square m

• History of ketoacidosis, Type 1 diabetes

• Evidence of hepatic disease as determined by any one of the following: AST or ALTvalues exceeding 2 x upper limit of normal (ULN) at screening visit (Visit 0),history of hepatic encephalopathy, history of esophageal varices, or history ofportocaval shunt.

• Acute coronary syndrome, stroke, severe peripheral artery disease or major CVsurgery or PCI within 3 months

• History of severe pulmonary disease (asthma, COPD with bronchial hypersensitivity)

• Secondary hypertension such as pheochromocyotoma

• Acute pulmonary thromboembolism

• Variant angina, vocal cord edema, severe allergic rhinitis

• Women of child-bearing potential, defined as all women physiologically capable ofbecoming pregnant, unless they are using a barrier method plus a hormonal method

• Pregnant or nursing (lactating) women

• Contraindication for MRI

• Presence of pacemaker or ICD, implanted metallic objects, claustrophobia

• Severe beat-to-beat variation

• Galactose intolerance, Lapp lactose deficiency, glucose-galactose malabsorption

• Any clinically significant abnormality identified at the screening visit, physicalexamination, laboratory tests, or electrocardiogram which, in the judgment of theinvestigator, would preclude safe completion of the study