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

Clin Res Cardiol (2025). DOI 10.1007/s00392-025-02625-4
A. Schöber (Mainz)¹, S. Rosch (Mainz)¹, K.-P. Rommel (Mainz)², T. Ruf (Mainz)¹, P. Doldi (München)³, J. von Stein (Köln)⁴, V. Fortmeier (Bad Oeynhausen)⁵, B. Köll (Hamburg)⁶, W. Rottbauer (Ulm)⁷, M. Kassar (Bern)⁸, B. Goebel (Bad Berka)⁹, P. Denti (Milan)¹⁰, P. Achouh (Paris)¹¹, T. Rassaf (Essen)¹², M. Barreiro-Perez (Vigo)¹³, P. Boekstegers (Siegburg)¹⁴, A. Rück (Stockholm)¹⁵, J. Novotny (München)³, M. Zdanyte (Tübingen)¹⁶, M. Adamo (Brescia)¹⁷, F. Vincent (Lille)¹⁸, P. Schlegel (Heidelberg)¹⁹, L. Weckbach (München)³, M. Wild (Bad Krozingen)²⁰, C. Besler (Bad Krozingen)²¹, S. Brunner (München)³, S. Toggweiler (Luzern 16)²², J. Grapsa (London)²³, T. Patterson (London)²³, H. Thiele (Leipzig)²⁴, T. Kister (Leipzig)²⁴, G. Tarantini (Padova)²⁵, G. Masiero (Padova)²⁵, M. De Carlo (Pisa)²⁶, A. Sticchi (Pisa)²⁶, F. Voß (Düsseldorf)²⁷, A. Polzin (Düsseldorf)²⁷, M. Konstandin (Heidelberg)¹⁹, E. Van Belle (Lille)¹⁸, M. Metra (Brescia)¹⁷, T. Geisler (Tübingen)¹⁶, R. Estévez-Loureiro (Vigo)¹³, P. Lüdike (Osnabrück)²⁸, N. Karam (Paris)²⁹, F. Maisano (Milan)¹⁰, P. Lauten (Bad Berka)⁹, F. Praz (Bern)⁸, M. Keßler (Ulm)⁷, D. Kalbacher (Hamburg)³⁰, V. Rudolph (Bad Oeynhausen)⁵, C. Iliadis (Köln)³¹, R. S. von Bardeleben (Mainz)³², J. Hausleiter (München)³, P. Lurz (Mainz)¹, L. Stolz (München)³, K.-P. Kresoja (Mainz)^1
1Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland; ²Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie Mainz, Deutschland; ³LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; ⁴Herzzentrum der Universität zu Köln Klinik für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland; ⁵Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; ⁶Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ⁷Universitätsklinikum Ulm Klinik für Innere Medizin II Ulm, Deutschland; ⁸Inselspital - Universitätsspital Bern Universitätsklinik für Kardiologie Bern, Schweiz; ⁹Zentralklinik Bad Berka GmbH Klinik für Kardiologie und Internistische Intensivmedizin Bad Berka, Deutschland; ¹⁰San Raffaele Hospital IRCCS Ospedale San Raffaele Milan, Italien; ¹¹European Hospital Georges Pompidou, Université Cité Cardiology Department Paris, Frankreich; ¹²Universitätsklinikum Essen Klinik für Kardiologie und Angiologie Essen, Deutschland; ¹³University Hospital Alvaro Cunqueiro Vigo, Spanien; ¹⁴HELIOS Klinikum Siegburg Abteilung für Kardiologie und Angiologie Siegburg, Deutschland; ¹⁵Karolinska University Hospital Dept. of Cardiology Stockholm, Schweden; ¹⁶Universitätsklinikum Tübingen Innere Medizin III, Kardiologie und Kreislauferkrankungen Tübingen, Deutschland; ¹⁷University of Brescia Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health Brescia, Italien; ¹⁸Centre Hospitalier Universitaire de Lille Cardiology Department Lille, Frankreich; ¹⁹Universitätsklinikum Heidelberg Klinik für Innere Med. III, Kardiologie, Angiologie u. Pneumologie Heidelberg, Deutschland; ²⁰Universitäts-Herzzentrum Freiburg / Bad Krozingen Klinik für Kardiologie und Angiologie II Bad Krozingen, Deutschland; ²¹Universitäts-Herzzentrum Freiburg / Bad Krozingen Klinik für Kardiologie und Angiologie Bad Krozingen, Deutschland; ²²Luzerner Kantonsspital Herzzentrum Luzern 16, Schweiz; ²³Guy's and St Thomas' NHS Foundation Trust Department of Cardiology London, Großbritannien; ²⁴Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; ²⁵University of Padua Department of cardiac, thoracic vascular sciences and public health Padova, Italien; ²⁶Azienda Ospedaliero-Universitaria Pisana Cardiothoracic and Vascular Department Pisa, Italien; ²⁷Universitätsklinikum Düsseldorf Klinik für Kardiologie, Pneumologie und Angiologie Düsseldorf, Deutschland; ²⁸Marienhospital Osnabrück Klinik für Innere Medizin / Kardiologie und Intensivmedizin Osnabrück, Deutschland; ²⁹European Hospital, Georges Pompidou, Paris, France; and the eUniversity of Paris, PARCC, INSERM, Paris, France Advanced Heart Failure Unit Paris, Frankreich; ³⁰Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland; ³¹Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; ³²Universitätsmedizin 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.