Left-sided heart failure determines outcomes in patients with severe tricuspid regurgitation undergoing percutaneous repair

A. Schöber (Mainz)¹, S. Rosch (Mainz)¹, K.-P. Rommel (Mainz)¹, T. Ruf (Mainz)¹, P. Doldi (München)², J. von Stein (Köln)³, V. Fortmeier (Bad Oeynhausen)⁴, B. Köll (Hamburg)⁵, W. Rottbauer (Ulm)⁶, M. Kassar (Bern)⁷, B. Goebel (Bad Berka)⁸, P. Denti (Milan)⁹, P. Achouh (Paris)¹⁰, T. Rassaf (Essen)¹¹, M. Barreiro-Perez (Vigo)¹², P. Boekstegers (Siegburg)¹³, A. Rück (Stockholm)¹⁴, J. Novotny (München)², M. Zdanyte (Tübingen)¹⁵, M. Adamo (Brescia)¹⁶, F. Vincent (Lille)¹⁷, P. Schlegel (Heidelberg)¹⁸, L. Weckbach (München)², M. Wild (Bad Krozingen)¹⁹, C. Besler (Bad Krozingen)²⁰, S. Brunner (München)², S. Toggweiler (Luzern)²¹, J. Grapsa (London)²², T. Patterson (London)²², H. Thiele (Leipzig)²³, T. Kister (Leipzig)²³, G. Tarantini (Padova)²⁴, G. Masiero (Padova)²⁴, M. De Carlo (Pisa)²⁵, A. Sticchi (Pisa)²⁵, F. Voß (Düsseldorf)²⁶, A. Polzin (Düsseldorf)²⁶, M. Konstandin (Heidelberg)¹⁸, E. Van Belle (Lille)¹⁷, M. Metra (Brescia)¹⁶, T. Geisler (Tübingen)¹⁵, R. Estévez-Loureiro (Vigo)¹², P. Lüdike (Osnabrück)²⁷, N. Karam (Paris)²⁸, F. Maisano (Milan)⁹, P. Lauten (Bad Berka)⁸, F. Praz (Bern)⁷, M. Keßler (Ulm)⁶, D. Kalbacher (Hamburg)²⁹, V. Rudolph (Bad Oeynhausen)⁴, C. Iliadis (Köln)³⁰, R. S. von Bardeleben (Mainz)³¹, J. Hausleiter (München)², P. Lurz (Mainz)¹, L. Stolz (München)², K.-P. Kresoja (Mainz)^1
1Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland; ²LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; ³Herzzentrum der Universität zu Köln Klinik für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland; ⁴Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; ⁵Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ⁶Universitätsklinikum Ulm Klinik für Innere Medizin II Ulm, Deutschland; ⁷Inselspital - Universitätsspital Bern Universitätsklinik für Kardiologie Bern, Schweiz; ⁸Zentralklinik Bad Berka GmbH Klinik für Kardiologie und Internistische Intensivmedizin Bad Berka, Deutschland; ⁹San Raffaele Hospital IRCCS Ospedale San Raffaele Milan, Italien; ¹⁰European Hospital Georges Pompidou, Université Cité Cardiology Department Paris, Frankreich; ¹¹Universitätsklinikum Essen Klinik für Kardiologie und Angiologie Essen, Deutschland; ¹²University Hospital Alvaro Cunqueiro Vigo, Spanien; ¹³HELIOS Klinikum Siegburg Abteilung für Kardiologie und Angiologie Siegburg, Deutschland; ¹⁴Karolinska University Hospital Cardiology Stockholm, Schweden; ¹⁵Universitätsklinikum Tübingen Innere Medizin III, Kardiologie und Kreislauferkrankungen Tübingen, Deutschland; ¹⁶University of Brescia Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health Brescia, Italien; ¹⁷Centre Hospitalier Universitaire de Lille Cardiology Department Lille, Frankreich; ¹⁸Universitätsklinikum Heidelberg Klinik für Innere Med. III, Kardiologie, Angiologie u. Pneumologie Heidelberg, Deutschland; ¹⁹Universitäts-Herzzentrum Freiburg / Bad Krozingen Klinik für Kardiologie und Angiologie II Bad Krozingen, Deutschland; ²⁰Universitäts-Herzzentrum Freiburg / Bad Krozingen Klinik für Kardiologie und Angiologie Bad Krozingen, Deutschland; ²¹Luzerner Kantonsspital Heart Center Lucerne Luzern, Schweiz; ²²Guy's and St Thomas' NHS Foundation Trust Department of Cardiology London, Großbritannien; ²³Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; ²⁴University of Padua Department of cardiac, thoracic vascular sciences and public health Padova, Italien; ²⁵Azienda Ospedaliero-Universitaria Pisana Cardiothoracic and Vascular Department Pisa, Italien; ²⁶Universitätsklinikum Düsseldorf Klinik für Kardiologie, Pneumologie und Angiologie Düsseldorf, Deutschland; ²⁷Marienhospital Osnabrück Klinik für Innere Medizin / Kardiologie und Intensivmedizin Osnabrück, Deutschland; ²⁸European Hospital, Georges Pompidou, Paris, France; and the eUniversity of Paris, PARCC, INSERM, Paris, France Advanced Heart Failure Unit Paris, Frankreich; ²⁹Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland; ³⁰Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; ³¹Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie im Herz- und Gefäßzentrum Mainz, Deutschland

Background: Severe tricuspid regurgitation (TR) is often associated with left-sided heart failure (HF) and both conditions are associated with impaired prognosis. Transcatheter tricuspid edge-to-edge repair (T-TEER) has emerged as a therapeutic option for patients with severe TR, but little is known about the impact of left-sided HF in those patients. We therefore aimed to assess the role of T-TEER across the spectrum of left ventricular ejection fraction (LVEF).

Methods: Using the European Registry of Transcatheter Repair for Tricuspid Regurgitation (EuroTR registry) the impact of LVEF on 1-year all-cause mortality after T-TEER was investigated. Patients were divided according to LVEF as HFrEF (LVEF ≤40%), HFmrEF (LVEF 41-49%) and preserved LVEF (LVEF ≥50%) whereas the latter group was further stratified according to pulmonary-capillary wedge pressure (PCWP) ≤/> 15 mmHg.

Results: A total of 1.670 patients were included in the analysis (mean age 79±7 years, 53% ♀). Overall, 250 patients (15%) presented with HFrEF, 252 (15%) with HFmrEF and 1.168 (70%) had preserved LVEF. Of those, data for PCWP were available for 607 patients (52%), whereas 214 (35%) had PCWP ≤15mmHg further referred to as isolated right heart failure (iRHF) and 393 (65%) PCWP >15mmHg further referred to as HFpEF patients.

Irrespective of LVEF, New-York Heart Association functional class showed improvement in all patients (p<0.001). Kaplan-Meier curves showed a strong discrimination with regards to all-cause mortality for LVEF, with highest mortality observed in patients with HFrEF, followed by HFmrEF and lowest mortality in patients with preserved LVEF (p log-rank=0.002, Figure 1A). Stratifying patients with preserved LVEF according to filling pressures showed that HFpEF patients had worse survival as compared to iRHF patients (p log-rank=0.004, Figure 1B). While residual TR severity ≤II following T-TEER was comparable between HF entities (~77%), patients with iRHF showed best results (residual TR ≤II 87%, p=0.002).

Conclusion: Most patients undergoing T-TEER present with left-sided HF, with HFpEF being the predominant entity. All subgroups showed functional improvements irrespective of the underlying left-sided HF phenotype, but outcomes are worst alongside decreasing LVEF. In patients with iRHF the highest procedural success rates and lowest 1-year mortality were observed, for the first time showing a novel cohort with favourable response to therapy with its intrinsic pathophysiological properties, yet to be explored.