Acute impact on right ventricular function following orthotopic transcatheter tricuspid valve replacement. Insights from deformation imaging and non-invasive pressure–volume analysis

Background

Right ventricular (RV) adaptation after transcatheter tricuspid valve replacement (TTVR) remains poorly characterized, particularly following complete tricuspid regurgitation (TR) elimination.

Purpose

To characterize the acute and early RV functional response following orthotopic TTVR with two of the most widely adopted systems (EVOQUE and LuX-Valve Plus), and evaluate its prognostic implications.

Methods

multicenter cohort of consecutive patients undergoing TTVR with EVOQUE (n=49) or LuX-Valve Plus (n=18) systems from 2019 to 2025. Intraprocedural and pre-discharge changes in RV size and function were assessed by core-lab echocardiography.Load-independent metrics of RV contractility (end-systolic elastance, Ees), afterload (arterial elastance, Ea) and RV-pulmonary artery coupling (Ees/Ea) were derived from non-invasive pressure–volume loop analysis. Predictors of all-cause mortality at follow-up were analyzed.

Results

Sixty-seven patients (median age 78 years [IQR: 73-84], 72% female, 76% NYHA ≥III) achieved near-complete TR reduction (grade 5 [IQR 4–5] to 1 [IQR 0–1], p<0.001) with both devices. Baseline RV contractility (Ees) and afterload (Ea) were comparable among both cohorts. Parameters of longitudinal (RV free-wall longitudinal strain, RV-FWLS: -10.8% [95% confidence interval, CI: −8.5 to −12.2], RV global longitudinal strain by −8.7% [95% CI: −6.5 to −10.8] and radial function (RV-fractional area change [RV-FAC]:−13.6% [95% CI: −11.4 to −15.8]) declined intraprocedurally, irrespective of TTVR design. The reduction in RV-FAC was primarily driven by a significant increase in RV-end systolic area (mean absolute increase: 3.6 cm2 [95%CI: 2.4 to 4.8]), consistent with an acute increase in afterload. At discharge, decline in RV function metrics persisted (Figure 1) and 39 (58%) patients fulfilled criteria for severe RV dysfunction according to the criteria proposed in the 2025 ESC/EACTS Guidelines for the Management of Valvular Heart Disease. At a median follow-up of 13.9 months (IQR 7.8–21.9), all-cause mortality was 20.6% and was not associated with device design, early RV functional changes, or load-independent metrics. Patients with baseline global impairment of longitudinal (TAPSE <17 mm and/or RV-FWLS < 23%) and radial (RV-FAC<35%) function exhibited higher mortality (log-rank P=0.001; Figure 2).

Conclusions

TTVR is associated with an acute decline in RV systolic function metrics, regardless of device anchoring mechanisms. Although common, early RV deterioration does not predict mid-term mortality.

Figure 1. Changes in right ventricular longitudinal function assessed by TAPSE (A), RV-FWLS (B), RV-GLS (C). Panel D illustrate changes in RV radial function (RV-FAC).

Figure 2. Kaplan–Meier curves showing all-cause mortality stratified by (A) TTVR device; (B) baseline RV-Ees (dichotomized at the median value), (C) baseline Ees/Ea (dichotomized at the median value) and (D) baseline RV contraction pattern.Figure 1.For image description, please refer to the figure legend and surrounding text.Figure 2.For image description, please refer to the figure legend and surrounding text.