Transcatheter mitral and tricuspid interventions-the bigger picture: valvular disease as part of heart failure

Abstract

The prevalence of mitral (MR) and tricuspid regurgitation (TR), especially in heart failure (HF) populations, is high. However, the distinct role of atrioventricular valve diseases in HF, whether they are merely indicators of disease status or rather independent contributors in a vicious disease cycle, is still not fully understood. For decades, tricuspid regurgitation (TR) was considered an innocent bystander subsequent to other heart or lung pathologies, thus, not needing dedicated treatment. Recent increasing awareness towards the role of atrioventricular valve diseases has revealed that MR and TR are, in fact, independent predictors of outcome in HF, thus, warranting attention in the HF treatment algorithm. This awareness arose, especially, with the development of minimally invasive transcatheter solutions providing new treatment options, which can also be used for patients considered as having increased surgical risk. However, outcomes of such transcatheter treatments have, in part, been sub-optimal and likely influenced by the status of the concomitant HF disease. Thus, this review aims to summarize data on the current understanding regarding the role of MR and TR in HF, how HF impacts outcomes of transcatheter MR and TR interventions, and how the understanding of this relationship might help to identify patients that benefit most from these therapies, which have proven to be lifesaving in properly selected candidates.

Keywords: heart failure; mitral regurgitation; transcatheter treatment; tricuspid regurgitation; valvular disease of the heart.

Figure 1

MR and TR in the HF disease conundrum and as part of a systemic disease—implications for interventional therapies. AFib, atrial fibrillation; CRT, cardiac resynchronization therapy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; LA, left atrium; LV, left ventricle; LVEDD, left ventricular end-diastolic diameter; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; M-TEER, mitral transcatheter edge-to-edge repair; PA, pulmonary artery; PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular resistance; RV, right ventricle; SPAP, systolic pulmonary artery pressure; TAPSE, tricuspid annular plane systolic excursion, TDI, tissue Doppler imaging; TPG, trans pulmonary gradient; T-TEER, tricuspid transcatheter edge-to-edge repair, TR, tricuspid regurgitation.

Figure 2

The number needed to treat (NNT) to prevent one mortality for established heart failure medications in comparison to MitraClip based on data from respective landmark trials of heart failure medications and data from the COAPT trial. Adapted from Pfister et al. (51).