Congestion Patterns in Severe Tricuspid Regurgitation and Transcatheter Treatment – Insights from a Multicenter Registry

Karl-Philipp Rommel (Leipzig)1, G. Bonnet (Bordeaux)2, V. Fortmeier (Bad Oeynhausen)3, L. Stolz (München)4, J. von Stein (Köln)5, M. Kassar (Bern)6, M. Gercek (Bad Oeynhausen)3, A. Schöber (Leipzig)1, T. Stocker (München)4, M. I. Körber (Köln)7, K. Friedrichs (Bad Oeynhausen)8, T. K. Rudolph (Bad Oeynhausen)3, R. Pfister (Köln)7, S. Baldus (Köln)5, H. Thiele (Leipzig)1, F. Praz (Bern)6, J. Hausleiter (München)4, V. Rudolph (Bad Oeynhausen)3, D. Burkhoff (New York)9, P. Lurz (Mainz)10

1Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; 2Hopital Cardiologique Haut-Lévêque Cardiology Bordeaux, Frankreich; 3Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; 4LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; 5Herzzentrum der Universität zu Köln Klinik für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland; 6Inselspital - Universitätsspital Bern Universitätsklinik für Kardiologie Bern, Schweiz; 7Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; 8Herz- und Diabeteszentrum NRW Klinik für Kardiologie Bad Oeynhausen, Deutschland; 9Cardiovascular Research Foundation New York, USA; 10Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland


Objectives: To investigate the role of biventricuar filling pressures and congestion patterns in patients with severe tricuspid regurgitation (TR) and its implications for transcatheter tricuspid interventions (TTVI).

Background: While invasively determined congestion holds mechanistic and prognostic significance in acute heart failure (HF), its role in patients with TR-related right-HF undergoing TTVI is less well established. A comprehensive understanding of congestion patterns might aid in procedural planning, risk stratification, and the identification of patients who may benefit from adjunctive therapies before undergoing TTVI.

Methods and Results: Within a multicenter, international TTVI registry, 813 patients underwent right heart catheterization (RHC) prior to TTVI and were followed up to 24 months. The median age was 80 (IQR 76, 83) years and 54% of the patients were women.

Both right atrial mean pressure (RAP) and pulmonary capillary wedge pressure (PCWP) were associated with mortality on Cox regression analyses with Youden-index derived cut-offs of 17mmHG and 19mmHg respectively (p<0.01 for all). Pre-interventionally, 42% of patients were classified as euvolemic (RAP<17mmHg, PCWP<19mmHg), 23% as having left-sided congestion (RAP<17mmHg, PCWP≥19mmHg), 8% as right-sided congestion (RAP≥17mmHg, PCWP<19mmHg), and 27% as bilateral congestion (RAP≥17mmHg, PCWP≥19mmHg).

Patients with congestion had elevated interventional risk according to EuroScore II, worse renal function, higher NT-pro-BNP levels, poorer biventricular function, and higher systolic pulmonary artery (PA) pressures compared to euvolemic patients (p<0.01, Figure). Patients with right-sided and bilateral congestion were slightly younger but exhibited worse renal function, NT-pro-BNP levels and biventricular function compared to patients with left-sided congestion and euvolemia (p<0.01, Figure). In addition, patients with right-sided congestion exhibited the most severe TR grades and the greatest right ventricular (RV) dimensions. However, RV to PA coupling was preserved in patients with right-sided congestion and euvolemia, while it was compromised in those with left-sided and bilateral congestion (p<0.01).  A TR grade reduction by TTVI was more likely in patients with euvolemia and left-sided congestion, compared to those involving right-sided congestion (95 vs. 88%, p<0.01). In addition, residual TR grade >2 was more frequent in the latter patients (14 vs. 29%, p<0.01). Patients with right-sided and bilateral congestion had the shortest event-free survival times, even after adjusting for differences in baseline characteristics (Figure).

Conclusion: In this large cohort of invasively characterized patients undergoing tricuspid TTVI, a relevant proportion of patient showed signs of pre-interventional congestion. Congestion patterns involving right-sided congestion were associated with low procedural success and higher mortality rates after TTVI. Whether pre-interventional reduction of right-sided congestion can improve outcomes after TTVI should be established in dedicated trials. 

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