Cold and Wet Before the Clip: A Hemodynamic Profile Associated with Poor Outcomes After Transcatheter Edge-to-Edge Repair

K. Diehl (Bremen)¹, U. Hanses (Bremen)¹, S. Alo (Bremen)¹, S. Rühle (Bremen)¹, A. Fach (Bremen)¹, J. Schmucker (Bremen)¹, C. Frerker (Lübeck)², I. Eitel (Lübeck)², H. Wienbergen (Bremen)¹, R. Hambrecht (Bremen)³, R. Osteresch (Bremen)^1
1Bremer Institut für Herz- und Kreislaufforschung (BIHKF) Bremen, Deutschland; ²Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland; ³Klinikum Links der Weser Innere Medizin I Bremen, Deutschland

Background:

Transcatheter edge-to-edge repair (T-TEER) for severe tricuspid regurgitation (TR) is an established therapeutic option in high-risk patients. Hemodynamic parameters derived from invasive catheterization, such as the left ventricular stroke work index (LVSWI) and pulmonary capillary wedge pressure (PCWP), provide integrative insights into systolic performance and left ventricular congestion. Their combined prognostic relevance in patients undergoing T-TEER remains poorly defined.

Objective:

This study investigates the prognostic impact of LVSWI and PCWP-derived hemodynamic profiles on all-cause mortality after T-TEER for severe TR.

Methods:

All consecutive patients who underwent right heart catheterization prior to T-TEER between August 2020 and August 2025 were included. Based on LVSWI and PCWP, four hemodynamic profiles were defined representing combinations of preserved or reduced contractility and low or high left ventricular congestion – warm and dry, warm and wet, cold and dry, cold and wet. Baseline clinical, echocardiographic, and invasive parameters were compared across groups. Survival was assessed using Kaplan–Meier analysis, and predictors of all-cause mortality were evaluated by multivariable Cox regression. Optimal cutoff values for LVSWI and PCWP were determined by receiver operating characteristic (ROC) analysis using the Youden index.

Results:

A total of 207 patients (mean age 81 ± 6.7 years, 59% female) were analyzed. According to the Youden-derived thresholds (LVSWI 27 cJ/m², PCWP 24 mmHg), 75 patients were classified as warm and dry, 34 as warm and wet, 52 as cold and dry, 46 as cold and wet. During a median follow-up of 12 months, all-cause mortality was 26%. Mortality differed significantly among profiles (cold and wet 53%, cold and dry 31%, warm and wet 22%, warm and dry 7%; p < 0.001). Kaplan–Meier analysis confirmed the worst survival in cold and wet patients (log-rank p < 0.0001 LVSWI was independently associated with all-cause mortality (HR 0.45, 95% CI 0.29–0.68, p < 0.001), whereas PCWP was not. Both LVSWI (AUC 0.70) and PCWP (AUC 0.69) demonstrated modest discriminatory power.

Conclusions:

Pre-procedural hemodynamic profiling using LVSWI and PCWP identifies distinct phenotypes with prognostic implications after T-TEER. The cold and wet subgroup, combining reduced stroke work and elevated congestion, exhibited the highest mortality. LVSWI emerged as the most robust independent predictor of outcome, underscoring the importance of forward contractile performance in risk assessment and peri-interventional management.