Gender-specific aspects in transcatheter edge-to-edge tricuspid valve repair – a single center experience

Introduction:
There are fundamental differences between women and men regarding pathophysiology and comorbidities of tricuspid regurgitation (TR). Differences in outcome between genders after tricuspid valve transcatheter edge-to-edge repair (T-TEER) have not been studied well. The aim of this study was to assess the postprocedural course of men and women after T-TEER and to identify gender-specific predictors of adverse outcome.

 Methods:
350 patients were included in this analysis. All patients underwent transcatheter tricuspid valve repair at our center. Patients were stratified by gender at birth. Baseline clinical characteristics, course of TR and heart failure (HF) symptoms as well as a combined endpoint of hospitalisations for heart failure (HFH) and all-cause mortality up to 2 years post-TEER were registered.

 Results:
156 patients (44.6%) were male, 194 (55.4%) were female. Female patients were older (median age 81.0 years (interquartile range 76.0 – 84.0 years) vs. 80.0 years (73.0 – 83.0 years), p = 0.031). However, men had more severe comorbidities: both left-ventricular ejection fraction (LV-EF) was lower (48.0% (40.0 – 54.0%) vs. 55.0% (48.5 – 61.0%), p < 0.001) and right-ventricular longitudinal function as assessed by tricuspid annular plane systolic excursion (TAPSE) were lower (16.0 mm (14.0 – 20.0 mm) vs. 18.0 mm (15.0 – 22.0 mm), p = 0.007). Tricuspid valve annular diameter was larger in men (50.0 mm (40.5 – 55.5 mm) vs. 46.0 mm (40.0 – 52.0 mm),
p = 0.012) and massive or torrential TR was more prevalent (73.1 vs. 57.0%, p = 0.002). Men also more often had chronic coronary syndrome (60.3 vs. 44.9%, p = 0.006). The higher overall morbidity burden in men resulted in a significantly higher TRI-SCORE (5.0 (3.0 – 6.0) vs. 4.0 (3.0 – 6.0), p = 0.001). No differences were seen regarding heart failure symptoms by NYHA functional class.

Procedural success (TR grade ≤ 2+ after the procedure) was achieved irrespectively of gender (80.6% in men, 82.7% in women, p = 0.62). At latest echocardiographic follow-up (median 215.0 days (92.0 – 408.3 days)) 73.0% of men and 79.6% of women had sustained TR reduction to ≤ 2+ (p = 0.22). Symptom reduction occurred similarly in both genders with 56.3% of men and 57.1% of women being in NYHA functional class ≤ II at latest follow-up (p = 0.89).

However, over a median follow-up period of 260.5 days (82.9 – 504.5 days) the combined endpoint was reached significantly more often by men compared to women (42.9 vs. 29.9%, p = 0.02). This difference was mainly driven by higher all-cause mortality in males (23.1 vs. 10.8%, p = 0.002). While a NYHA functional class of ≥ III was identified as an independent predictor of the combined endpoint in men (Hazard Ratio (HR) 2.355, 95% Confidence Interval (CI) 1.168 – 4.746, p = 0.017), a TAPSE of < 17 mm trended towards independent association with adverse outcome in women (HR 1.854, 95% CI 0.972 – 3.536, p = 0.061).  

 Conclusion:
Similar reduction of TR severity and HF symptoms can be achieved by T-TEER in men and women. Men however have more severe comorbidities and more severe TR at baseline and their 2-year outcome is worse than that of women. A NYHA functional class of III or higher is an independent predictor of all-cause death or rehospitalization for heart failure in men.