Right Atrial Pressure Corrected Cardiac Power Index Predicts 1 Year Outcome after Transcatheter Edge-to-Edge-Repair for Severe Tricuspid Valve Regurgitation

Clin Res Cardiol (2024). DOI 10.1007/s00392-024-02406-5
U. Hanses (Bremen)¹, K. Diehl (Bremen)¹, A. Ben Ammar (Bremen)¹, P. Dierks (Bremen)¹, S. Alo (Bremen)¹, A. Fach (Bremen)¹, J. Schmucker (Bremen)², C. Frerker (Lübeck, German Center for Cardiovascular Research (DZHK), Partner site Hamburg - Kiel - Lübeck, Lübeck, Germany.)³, I. Eitel (Lübeck, German Center for Cardiovascular Research (DZHK), Partner site Hamburg - Kiel - Lübeck, Lübeck, Germany.)³, H. Wienbergen (Bremen)¹, R. Hambrecht (Bremen)¹, R. Osteresch (Bremen)^1
1Klinikum Links der Weser Klinik für Kardiologie und Angiologie Bremen, Deutschland; ²Klinikum Bremen-Mitte Klinik für Innere Medizin III Bremen, Deutschland; ³Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, German Center for Cardiovascular Research (DZHK), Partner site Hamburg - Kiel - Lübeck, Lübeck, Germany., Deutschland

Background: Transcatheter edge-to-edge repair (TEER) has emerged as an effective treatment option for patients with severe tricuspid regurgitation (TR) not amenable to surgery. However, information on independent risk factors for worse prognosis is scarce. 

Objective: The study sought to investigate the impact of the right atrial pressure corrected cardiac power index (RAPcCPI) on 1-year outcome in patients. with severe symptomatic TR undergoing TEER.

Methods: Consecutive patients. with severe TR who underwent TEER between 08/2020 to 06/2023 were included and followed prospectively. Baseline clinical and invasive hemodynamic variables, changes in echocardiographic parameters and New York Heart Association (NYHA) functional class, periprocedural and in-hospital major adverse events were assessed. Primary endpoint was defined as all-cause mortality at 1-year after TEER. RAPcCPI was calculated in consideration of mean arterial pressure (MAP), right atrial pressure (RAP) and cardiac index (CI):  . 
A multivariable Cox proportional-hazards regression analysis was performed to identify independent risk factors for all-cause mortality. Receiver operator characteristic (ROC) analysis was used to determine the discriminative capacity of RAPcCPI and define a threshold to divide the population into a high and low RAPcCPI group, respectively. The prognostic value of RAPcCPI threshold was tested using Kaplan-Meier analysis.

Results: A single-center cohort of 107 patients (mean age 81 ± 5.9 years, 53% women) at high operative risk (median LogEuro-Score 13 %; IQR 8 %, 24 %) underwent TEER for severe TR. Primary endpoint occurred in 29 patients (28 %). ROC curve analysis demonstrated that RAPcCPI was associated with an area under the curve of 0.62 (95% confidence interval 0.51 – 0.74). RAPcCPI threshold of 0.37 W/m² (Youden's J statistic) was associated with 82 % sensitivity and 47 % specificity for all-cause mortality. Event-free survival was significantly higher in the RAPcCPI ≥ 0.37 W/m² group compared to those with RAPcCPI < 0.37 W/m² (86 % vs. 62 %; log-rank p = 0.007). In Cox regression analysis RAPcCPI was an independent predictor for all-cause mortality (Hazard ratio 0.57; 95 % confidence interval 0.35 – 0.94; p = 0.027).

Conclusions: RAPcCPI is associated with all-cause mortality among patients. undergoing TEER for severe TR. 

Respecting the RAP in the CPI calculation improves the predictability of the hemodynamic predictor and therefore might be useful in risk stratification of TEER candidates with severe TR.

Figure 1: Kaplan-Meier analysis of RAPcCPI for the primary endpoint all-cause mortality