Impact of preinterventional tricuspid regurgitation on outcome of MitraClip therapy in patients with severely reduced ejection fraction

Abstract

AimTo evaluate the impact of preinterventional moderate-to-severe functional tricuspid regurgitation (FTR) on early outcome after percutaneous edge-to-edge mitral valve repair (pMVR) with MitraClip procedures for functional mitral regurgitation (FMR) in patients with heart failure with reduced ejection fraction (HFrEF).Methods and resultsFrom January 2013 to December 2017, 80 patients with HFrEF (ejection fraction 22%±5.3%) and FMR (grade 3.0±0.36) underwent successful pMVR. The 3-year actuarial survival was 58%. However, 73% (n=22) of non-survivors died of cardiac failure within 1 year. Patients were categorised into none-to-mild (n=36) and moderate-to-severe (n=44) postinterventional FTR groups according to pre-MitraClip tricuspid regurgitation grade. Cox regression analysis on 1-year survival demonstrated an impact of FTR severity (HR=1.8, 95% CI 1.01% to 3.09%, p=0.047), preoperative New York Heart Association class (HR=2.8, 95% CI 1.2% to 6.5%, p=0.015) and peripheral artery disease (HR=5.4, 95% CI 1.6 to 18, p=0.0054). Kaplan-Meier analysis showed that 1-year cardiac death was higher in the moderate-to-severe FTR group (p=0.048). In our study, 77% of pre-MitraClip moderate-to-severe FTR cannot be significantly reduced. Post-MitraClip moderate-to-severe FTR grade was related to lower survival (p<0.001).ConclusionIn patients with HFrEF treated with MitraClip for FMR, moderate-to-severe FTR was an independent predictor of cardiac death within 1 year. To improve survival, additional therapy to residual FTR should be considered in early phase after MitraClip therapy.

Tricuspid regurgitation after transcatheter mitral valve repair: Clinical course and impact on outcome

“…We speculate that reduction of TR also compromises the effect of RV reverse remodeling, which is likely to be a process with a duration up to 6 months. 23 Studies with short TTE follow-up 13,[24][25][26] Our reduction rate of 25% after 6 months potentially reflects the effect of both acute and chronic reduction of TR. The less pronounced reduction of severe TR is likely explained by lack of structural reverse remodeling.…”

“… 23 Studies with short TTE follow‐up interval (< 3 months) could therefore underestimate the benefit of TMVR regarding TR improvement. 13 , 24 , 25 , 26 Our reduction rate of 25% after 6 months potentially reflects the effect of both acute and chronic reduction of TR. The less pronounced reduction of severe TR is likely explained by lack of structural reverse remodeling.…”

“…The impact on short‐ and long‐term survival has been shown to be tremendous in earlier studies. 12 , 13 However, the concern remained why TR failed to improve in some patients after TMVR and which factors were associated with this phenomena. 14 , 15 The current study revealed that (1) advanced age (2) presence of AF (3) RV dysfunction and (4) a limited reduction of MR during the procedure were independent predictors for severe TR after TMVR.…”

Predictors for procedural success and all-cause mortality in patients undergoing transcatheter mitral valve edge-to-edge repair for mitral regurgitation

“…Data about the role of concomitant TR in SMR patients are ambiguous, while again dedicated data of concomitant valvular pathology for PMR patients undergoing TMVr is unknown. While some authors found preprocedural severe TR as a predictor worsening prognosis after TMVr [77] others, including the large COAPT trial with echocardiographic core lab assessment, did not [25,78] [ Table 4]. We believe that moderate or severe TR in patients with SMR is tightly connected to the prevalent biventricular failure, thus a bystander.…”

Right ventricular dysfunction and tricuspid regurgitation in functional mitral regurgitation

“… 17 Studies were included if the articles met the following criteria: (i) reporting an association between RVD or tricuspid regurgitation and an outcome, either mortality or heart failure (HF) related hospitalization among patients with FMR; (ii) having at least 6 month follow‐up; (iii) controlling for other important covariates in multivariable survival analysis; (iv) having low risk of bias assessed by the Newcastle‐Ottawa scale (see Quality assessment section for more details). In the studies that reported an association of RVD or TR with outcomes among those with FMR mixed with primary MR, we contacted the authors of the studies for accessing data related to FMR 18,19 . Paediatric populations were excluded to minimize heterogeneity between studies.…”