Predictors of Survival After TTVR for Severe Tricuspid Regurgitation With Chronic Heart Failure

Invasive assessment of cardiopulmonary hemodynamics may predict survival after transcatheter tricuspid edge-to-edge valve repair (TTVR) in patients with severe tricuspid regurgitation (TR) and symptomatic heart failure, according to a study published in JACC: Cardiovascular Interventions.

A total of 236 patients (median age, 78 years; 53% women) who were undergoing TTVR were enrolled in this international, multicenter study. Researchers analyzed data from clinical assessment, echocardiography, intraprocedural right heart catheterization, and noninvasive cardiac output measurement and identified hemodynamic predictors for mortality.

At baseline, all patients had severe TR (TR grade ≥3+) with symptomatic heart failure (New York Heart Association functional class III or IV: 89%; median N-terminal (NT)-pro brain natriuretic peptide (2952 ng/L). Left ventricular systolic function was preserved and mitral regurgitation was predominantly mild to moderate.

TTVR was found to significantly reduce TR at discharge compared with admission (TR grade ≥3+: 16%; P <.001), with a corresponding 19% reduction of the right atrial v-wave (21 vs 16 mm Hg, respectively; P <.001) and improved cardiac output (3.5 to 4.0 L/min, respectively; P <.01).

In addition, invasive mean pulmonary artery pressure (mPAP), transpulmonary gradient (TPG), pulmonary vascular resistance (PVR), and right ventricular stroke work (RVSW) were found to be significant predictors of 1-year mortality (P <.05 for all). Hemodynamic stratification by mPAP and TPG best predicted 1-year survival (P <.001). Patients with precapillary dominant pulmonary hypertension (PH) had an unfavorable prognosis (1-year survival, 38%), and those without or with postcapillary PH had a favorable outcome (1-year survival, 92% or 78%, respectively).

“In the majority of patients, we observed a significant and immediate reduction of the right atrial pressure profile in response to TTVR,” noted the researchers. “In a smaller fraction of 16% of treated patients, the right atrial v-wave remained unchanged or slightly increased after TTVR.”

Study limitations include a small cohort, and the use of different methods for the invasive measurement of cardiac output before TTVR.

“The results from this study demonstrate that TTVR beneficially modulates hemodynamics in right-sided heart failure facilitating functional improvement and symptomatic relief. Preprocedural assessment of the cardiopulmonary hemodynamic profile allows risk stratification of patients scheduled for TTVR and should be implemented in the routine patient selection process,” concluded the study authors.

“This study demonstrated that patients without significant pulmonary hypertension and dominant postcapillary pulmonary hypertension have a good prognosis after TTVR. The results from this study further demonstrate the need for complementary medical or alternative treatment strategies in patients with severe TR and significant precapillary pulmonary hypertension.”

Disclosures: Some of the authors reported affiliations with medical device and technology companies. Please see the original reference for a full list of disclosures.

Reference

Stocker TJ, Hertell H, Orban M, et al. Cardiopulmonary hemodynamic profile predicts mortality after transcatheter tricuspid valve repair in chronic heart failure [published online December 9, 2020]. JACC Cardiovasc Interv. doi: https://doi.org/10.1016/j.jcin.2020.09.033