Baseline New York Heart Association class as a prognostic marker and determinant of symptomatic response after tricuspid valve transcatheter edge-to-edge repair: insights from the EuroTR registry
C Wolff, P Sagmeister, L Stolz, J Hausleiter, H Thiele, T Kister, K FenglerAbstract
Background
In patients undergoing tricuspid valve transcatheter edge-to-edge repair (T-TEER), New York Heart Association (NYHA) class is central to patient selection and follow-up assessment. However, real-world data on its prognostic value and determinants of symptomatic response remain limited.
Purpose
To assess the prognostic impact of baseline NYHA class and to identify correlates of NYHA class improvement and deterioration after T-TEER.
Methods
We analysed patients undergoing T-TEER for symptomatic tricuspid regurgitation (TR) in the multicentre, real-world EuroTR registry (European Registry of Transcatheter Repair for Tricuspid Regurgitation). Baseline NYHA class was related to survival and heart failure hospitalisation using Kaplan-Meier analyses. In patients with paired NYHA assessments, changes from baseline to follow-up were evaluated, and predictors of NYHA class improvement and worsening were identified using multivariable logistic regression, including pre-specified covariates: age, sex, body mass index (BMI), left ventricular ejection fraction (LVEF), tricuspid annular plane systolic excursion (TAPSE), TR severity, estimated systolic pulmonary artery pressure (PAPs), log(NT-proBNP), and baseline NYHA class.
Results
In the overall cohort (n=3,434), Kaplan-Meier curves demonstrated stepwise separation by baseline NYHA class for both overall and event-free survival, indicating progressively higher risk with advancing baseline functional limitation (log-rank χ²=121.14 and 98.48, respectively; both p<0.001). In adjusted Cox regression with administrative censoring at 2 years, higher baseline NYHA class independently predicted all-cause mortality (HR 1.78 per 1-class increase; 95% CI 1.50-2.10; p<0.001). Among patients with paired NYHA data (n=1,974), baseline NYHA class was predominantly advanced, with NYHA I/II in 323 patients (16.4%) and NYHA III/IV in 1,651 patients (83.6%). At follow-up, functional status improved substantially, with NYHA I/II observed in 1,173 patients (59.4%) and NYHA III/IV in 801 patients (40.6%). In multivariable analysis of improvement, higher baseline NYHA class was the strongest correlate of improvement (OR 4.76 per NYHA class; 95% CI 3.70-6.12; p<0.001), alongside lower BMI (per 1 kg/m² decrease; OR 1.04; 95% CI 1.02-1.06; p<0.001), higher TAPSE (OR 1.03 per mm; 95% CI 1.00-1.06; p=0.030), and lower log(NT-proBNP) (per 1-log decrease; OR 1.27; 95% CI 1.14-1.43; p<0.001). Worsening was infrequent (n=104) and was associated with higher PAPs (OR 1.03 per mmHg; 95% CI 1.01-1.04; p<0.001) and lower baseline NYHA class (OR 0.17 per class; 95% CI 0.11-0.25; p<0.001).
Conclusion
In the large EuroTR real-world T-TEER cohort, baseline NYHA class is a strong independent predictor of 2-year mortality. While improvement is common, particularly in patients with advanced baseline limitation, worsening is rare and mainly related to higher pulmonary pressures.Kaplan-Meier curvesFor image description, please refer to the figure legend and surrounding text.Alluvial for NYHA class shiftFor image description, please refer to the figure legend and surrounding text.