Evolution and prognostic impact of residual tricuspid regurgitation after transcatheter mitral valve replacement (TMVR)
N Groshenry, M Urena Alcazar, J Farjat Pasos, N Carre, J Mesnier, C Delhomme, A Cailliau, E Brochet, S Mohammadi, G Ducrocq, B Iung, J Rodes Cabau, G SucAbstract
Introduction
Tricuspid regurgitation (TR) is common among patients undergoing transcatheter mitral valve replacement (TMVR). However, its evolution after intervention and the prognostic impact of residual TR remain uncertain.
Purpose
We aimed to assess the evolution of TR after TMVR, evaluate the impact of residual TR on mortality, and identify predictors of TR improvement.
Methods
Patients undergoing TMVR with a balloon-expandable prosthesis in 2 centers were included. Those undergoing concomitant tricuspid percutaneous intervention were excluded. Follow-up was performed at 1, 6, and 12 months, and annually thereafter. At each time point, TR severity was classified as ≤ mild, moderate, or severe. The primary endpoint was all-cause mortality according to residual TR at 30 days. Secondary endpoints were TR evolution at 30 days and 1 year, as well as changes in tricuspid annular diameter, pulmonary artery systolic pressure (PASP), right ventricular dilatation and dysfunction at 30 days.
Results
A total of 268 patients were included. At baseline, 170 (63%) had ≤ mild TR, 51 (19%) had moderate TR, and 47 (18%) had severe TR. The median age was 71 [56-80] years, with 63% women. Most patients (92%) had prior cardiac surgery, and 34% had previous tricuspid intervention. Among them, 185 (69%) underwent valve-in-valve, 49 (18%) valve-in-ring, and 34 (13%) valve-in-mitral annulus calcification procedures. TMVR was associated with a non-significant trend toward TR improvement at 30 days (15% of residual severe TR and 16% of residual moderate TR versus 18% and 19% respectively, at baseline; p = 0.14) with no change at 1 year (p = 0.47). Tricuspid annular diameter remained unchanged (p = 0.60), whereas PASP significantly decreased (53 [42-65] mmHg to 42 [35-50] mmHg; p < 0.01). There were no changes in right ventricular dilatation (p = 0.73) and dysfunction (p = 0.23). After a median follow-up of 2.1 [0.5-4.9] years, 103 deaths occurred, 56% of cardiovascular cause. One- and 5-year survival rates were 93 [89-97]% and 65 [56-75]% in patients with ≤ mild residual TR at 30 days, compared with 84 [71-97]% and 34 [15-53]% in those with moderate TR (p < 0.01 at each time point), and 79 [65-93]% and 35 [14-55]% in those with severe TR (p < 0.01 at each time point). After adjustment for confounders, both moderate and severe residual TR remained independently associated with increased mortality (aHR = 2.05 [1.05-4.02]; p = 0.04 and 2.40 [1.29-4.48]; p < 0.01, respectively). Smaller baseline tricuspid annular diameter was the only predictor of TR improvement at 30 days (aOR = 0.91 [0.84-0.99] per mm; p = 0.03).
Conclusions
Despite a trend toward early improvement, TMVR was not associated with significant reduction in TR severity at 30 days and 1 year. Residual moderate and severe TR at 30 days after TMVR were independently associated with increased mortality during follow-up.TR evolution at 30 days and 1 year after TVMRFor image description, please refer to the figure legend and surrounding text.Survival according to residual TR at 30 daysFor image description, please refer to the figure legend and surrounding text.