Prognostic Impact of Tricuspid Regurgitation Improvement after Transcatheter Mitral Valve Replacement: Results from an International Multicenter Registry

I. von der Heide (Hamburg)¹, L. S. Strotmann (Hamburg)², A. Fischer (Hamburg)³, B. Köll (Hamburg)⁴, D. Kalbacher (Hamburg)⁵, L. Waldschmidt (Hamburg)⁵, A. Scotti (New York)⁶, A. Coisne (Lille)⁷, W. Ali (Montréal)⁸, C. Succar (Vancouver)⁹, D. Regazzoli (Mailand)¹⁰, A. Duncan (London)¹¹, T. K. Rudolph (Bad Oeynhausen)¹², G. Nickenig (Bonn)¹³, H. Ruge (München)¹⁴, M. Adam (Köln)¹⁵, C. Giannini (Pisa)¹⁶, N. Dumonteil (Toulouse)¹⁷, O. De Backer (Copenhagen)¹⁸, M. Adamo (Brescia)¹⁹, A. Garatti (Mailand)²⁰, C. Frerker (Lübeck)²¹, G. Dahle (Oslo)²², M. Taramasso (Zürich)²³, T. Walther (Frankfurt am Main)²⁴, J. Kempfert (Berlin)²⁵, J.-F. Obadia (Lyon)²⁶, N. Tahirkheli (Oklahoma City)²⁷, M. Grygier (Poznan)²⁸, P. Généreux (Morristown)²⁹, H. G. Bezerra (Tampa)³⁰, K. Wróbel (Warschau)³¹, T. Waggoner (Tucson)³², M. Andreas (Wien)³³, S. Redwood (London)³⁴, G. H. L. Tang (New York)³⁵, M. Reardon (Houston)³⁶, P. Sorajja (Minneapolis)³⁷, N. Fam (Toronto)³⁸, D. W. Muller (Sydney)³⁹, F. Praz (Bern)⁴⁰, R. S. von Bardeleben (Mainz)⁴¹, J. Hausleiter (München)⁴², A. Mangieri (Milan)⁴³, V. Ninios (Thessaloniki)⁴⁴, P. Denti (Milan)⁴⁵, W. Rottbauer (Ulm)⁴⁶, J. G. Webb (Vancouver)⁴⁷, J. Rodés-Cabau (Québec)⁴⁸, A. Latib (Ney York)⁴⁹, S. Blankenberg (Hamburg)⁴, J. Granada (New York)⁵⁰, T. Modine (Bordeaux)⁵¹, L. Conradi (Köln)⁵², S. Ludwig (Hamburg)^4
1Universitätsklinikum Hamburg-Eppendorf Klinik für Kardiologie Hamburg, Deutschland; ²Universitätsklinikum Hamburg-Eppendorf Universitäres Herzzentrum Hamburg, Deutschland; ³Universitäres Herz- und Gefäßzentrum Hamburg, Deutschland; ⁴Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ⁵Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland; ⁶Montefiore Medical Center, Albert Einstein College of Medicine Montefiore-Einstein Center for Heart and Vascular Care New York, USA; ⁷Heart Valve Clinic, CHU Lille Department of Clinical Physiology and Echocardiography Lille, Frankreich; ⁸Université de Montréal Montreal Heart Institute Montréal, Kanada; ⁹St. Paul´s Hospital Vancouver, Kanada; ¹⁰Humanitas Research Hospital Mailand, Italien; ¹¹Royal Brompton and Harefield Hospital Consultant Cardiologist London, Großbritannien; ¹²Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; ¹³Universitätsklinikum Bonn Medizinische Klinik und Poliklinik II Bonn, Deutschland; ¹⁴Deutsches Herzzentrum München Klinik für Herz- und Gefäßchirurgie München, Deutschland; ¹⁵Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; ¹⁶University of Pisa Pisa, Italien; ¹⁷Clinique Pasteur Toulouse, Frankreich; ¹⁸University hospital Copenhagen Copenhagen, Dänemark; ¹⁹University of Brescia Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health Brescia, Italien; ²⁰San Donato Hospital Mailand, Italien; ²¹Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland; ²²Rikshospitalet Oslo, Norwegen; ²³HerzZentrum Hirslanden Cardiology Zürich, Schweiz; ²⁴Universitätsklinikum Frankfurt Klinik für Thorax-, Herz- und Thorakale Gefäßchirurgie Frankfurt am Main, Deutschland; ²⁵Deutsches Herzzentrum der Charite (DHZC) Klinik für Herz-, Thorax- und Gefäßchirurgie Berlin, Deutschland; ²⁶Civils Hospices of Lyon Lyon, Frankreich; ²⁷Oklahoma Heart Hospital Oklahoma City, USA; ²⁸Poznan University of Medical Sciences Poznan, Polen; ²⁹Gagnon Cardiovascular Institute Morristown, USA; ³⁰Tampa General Hospital Interventional Tampa, USA; ³¹Warsaw Medicover Hospital Warschau, Polen; ³²Pima Heart & Vascular Tucson, USA; ³³Medical University Vienna Wien, Österreich; ³⁴St. Thomas' Hospital Department of Cardiology London, Deutschland; ³⁵Mount Sinai Hospital New York, USA; ³⁶Houston Methodist Hospital Houston, USA; ³⁷Minneapolis Heart Institute Minneapolis, USA; ³⁸St. Michael's Hospital Toronto, Kanada; ³⁹St. Vincent's Hospital Sydney, Australien; ⁴⁰Inselspital - Universitätsspital Bern Universitätsklinik für Kardiologie Bern, Schweiz; ⁴¹Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie im Herz- und Gefäßzentrum Mainz, Deutschland; ⁴²LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; ⁴³Humanitas Research Hospital IRCCS Milan, Italien; ⁴⁴Thessaloniki, Griechenland; ⁴⁵San Raffaele Hospital IRCCS Ospedale San Raffaele Milan, Italien; ⁴⁶Universitätsklinikum Ulm Klinik für Innere Medizin II Ulm, Deutschland; ⁴⁷St. Paul’s Hospital, University of British Columbia Vancouver, Kanada; ⁴⁸Québec Heart and Lung Institute Québec, Kanada; ⁴⁹Montefiore Medical Center, Albert Einstein College of Medicine Montefiore-Einstein Center for Heart and Vascular Care Ney York, USA; ⁵⁰Cardiovascular Research Foundation New York, Deutschland; ⁵¹Centre Hospitalier Universitaire Bordeaux Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle Bordeaux, Frankreich; ⁵²Universitätsklinikum Köln Klinik und Poliklinik für Herzchirurgie Köln, Deutschland

Background: Tricuspid regurgitation (TR) is a common bystander in patients with severe mitral regurgitation (MR).Transcatheter mitral valve replacement (TMVR) using dedicated devices offers an alternative treatment for high-risk MR patients and may also affect TR severity by effectively eliminating MR.
Objectives: This study aimed to assess incidence and prognostic value of TR improvement after TMVR using data from an international multicenter registry.
Methods: The CHOICE-MI registry included patients with symptomatic MR treated with dedicated TMVR devices at 41 international centers. Patients with TR ≥1+ at baseline and available post-procedural echocardiography were included. TR improvement was defined as a ≥1 grade reduction of TR severity at discharge.Kaplan-Meier estimates compared TR improvement vs. No TR improvement for all-cause-, cardiovascular (CV) mortality, heart failure hospitalization (HFH) and combined endpoints after 1 year. The primary endpoint was all-cause mortality or HFH at 1 year.The adjusted prognostic impact of TR improvement was assessed using stepwise Cox regression, and  predictors were assessed in a multivariable analysis.
Results: A total of 316 patients undergoing TMVR (age 77.0 years [IQR 72.0-81.0], 56.6% male, EuroSCORE II 6.2% [3.7, 12.0]) were included. Baseline TR was mild in 35.8% (N=113), moderate in 43.7% (N=138), severe in 18.4% (N=58), massive in 1.6% (N=5) and torrential in 0.6% (N=2).TMVR was performed using transapical access (TA-TMVR) in 79.1% (N=250) and transfemoral/transseptal access (TF-TMVR) in 20.9% (N=66).TR improvement was observed in 103 patients (32.6%) following TMVR, which was more common in the TA-TMVR (38.4%) compared to the TF-TMVR group (10.6%, p<0.001).Patients with TR improvement were younger (75.0 years [IQR 70.0-79.8] vs. 78.0 years [IQR 73.0-82.0], p=0.003), had less coronary artery disease (CAD) 55.3% (N=57) vs. 68.5% (N=146; p=0.03) and lower TAPSE (15.0mm [IQR 12.0-20.0] vs. 17.0mm [IQR 14.0-20.0], p=0.012).Regardless of TR improvement, MR was eliminated (none/trace) in most patients (86.4% vs. 82.9%, p=0.27) with high technical success rates.The rate of all-cause mortality or HFH at 1 year was numerically lower in patients with TR improvement without reaching statistical significance (26.7% vs. 36.9%, p=0.13).Following stepwise Cox regression, TR improvement was not independently associated with lower all-cause mortality or HFH at 1 year in the overall TMVR cohort (HR 0.62, 95% CI 0.38–1.02, p=0.062).In a subgroup analysis according to TA and TF access, TR improvement was an independent predictor of lower all-cause mortality or HFH at 1 year in patients undergoing TA-TMVR (HR 0.58, 95% CI 0.34–0.99, p=0.046), but not in TF-TMVR patients.CAD (HR 0.47, 95%-CI 0.27-0.81, p=0.007) and TAPSE (HR 0.93, 95%-CI 0.88-0.98, p=0.009) were inversely predictive of TR improvement following multivariable analysis.
Conclusion: In this large real-world TMVR registry, TR improvement was observed in over one third of MR patients undergoing TMVR and occurred more often after TA-TMVR.Clinical event rates at follow-up were higher in patients without TR improvement, and TR improvement was identified as an independent predictor of 1-year all-cause mortality and HFH in patients undergoing TA-TMVR.These findings highlight the prognostic importance of TR monitoring after TMVR as it identifies a subgroup at risk for adverse clinical outcome.