Tricuspid regurgitation and outcomes in mitral valve transcatheter edge-to-edge repair

Abstract

Background and aims: The association between periprocedural change in tricuspid regurgitation (TR) and outcomes in patients undergoing mitral transcatheter edge-to-edge repair (M-TEER) is unclear. This study aimed to examine the prognostic value of TR before and after M-TEER.

Methods: Patients in the OCEAN-Mitral registry were divided into four groups according to baseline and post-procedure echocardiographic assessments: no TR/no TR (no TR), no TR/significant TR (new-onset TR), significant TR/no TR (normalized TR), and significant TR/significant TR (residual TR) (all represents before/after M-TEER). Tricuspid regurgitation ≥ moderate was defined as significant. The primary outcome was cardiovascular death or heart failure hospitalization. Tricuspid regurgitation pressure gradient was also evaluated.

Results: The numbers of patients in each group were 2103 (no TR), 201 (new-onset TR), 504 (normalized TR), and 858 (residual TR). Baseline assessment for TR and TR pressure gradient was not associated with outcomes after M-TEER. In contrast, patients with new-onset TR had the highest adjusted risk for the primary outcome, followed by those with residual TR [compared with no TR as a reference, hazard ratio 1.83 (95% confidence interval: 1.39-2.40) for new-onset TR, 1.45 (1.23-1.72) for residual TR, and 0.82 (0.65-1.04) for normalized TR]. Similarly, from baseline to post-procedure, TR pressure gradient changes were associated with subsequent outcomes after M-TEER. New-onset and residual TR incidence was commonly associated with dilated tricuspid annulus diameter and atrial fibrillation.

Conclusions: Post-procedural TR, but not baseline TR, was associated with outcomes after M-TEER. Careful TR assessment after the procedure would provide an optimal management for concomitant significant TR in patients undergoing M-TEER.

Keywords: Mitral regurgitation; Mitral valve; Transcatheter edge-to-edge repair; Tricuspid regurgitation.

Structured Graphical Abstract

Change in tricuspid regurgitation and outcome after mitral transcatheter edge-to-edge repair. Change in tricuspid regurgitation pressure gradient was analysed using a linear mixed model, adjusted for the interaction between the four tricuspid regurgitation categories and visit, with a random intercept and slope per patient. AF, atrial fibrillation; AFL, atrial flutter; CV, cardiovascular; HF, heart failure; M-TEER, mitral transcatheter edge-to-edge repair; TR, tricuspid regurgitation; TRPG, tricuspid regurgitation pressure gradient; TV, tricuspid valve.

Figure 1

Cumulative incidence of each outcome according to tricuspid regurgitation categories. This figure shows the cumulative incidence of each outcome according to tricuspid regurgitation categories. CV, cardiovascular; HF, heart failure; M-TEER, mitral transcatheter edge-to-edge repair; TR, tricuspid regurgitation

Figure 2

Tricuspid regurgitation pressure gradient assessments and adjusted risk of the primary outcome. This figure shows the association between tricuspid regurgitation pressure gradient value and the adjusted risk of cardiovascular death or heart failure hospitalization, adjusted for age, sex, clinical frailty scale, body mass index, New York Heart Association functional classification, diabetes mellitus, systolic blood pressure, atrial fibrillation/flutter, degenerative or functional mitral regurgitation, estimated glomerular filtration rate, left ventricular ejection fraction, significant aortic stenosis, significant aortic regurgitation, and postoperative significant mitral regurgitation. Analyses using the tricuspid regurgitation pressure gradient at 1 month and 1 year were landmark analyses beginning at the 1-month and 1-year post-procedure visits. TRPG, tricuspid regurgitation pressure gradient