The presence of tricuspid regurgitation (TR), either moderate or severe, in patients with heart failure and severe secondary mitral regurgitation (MR) was associated with worse clinical and echocardiographic characteristics as well as clinical outcomes, according to an analysis of the COAPT study published Sept. 7 in the Journal of the American College of Cardiology. Regardless of the presence or absence of TR, outcomes were improved in patients who received the MitraClip vs. guideline-directed medical therapy.

For this analysis, Rebecca T. Hahn, MD, FACC, and colleagues, evaluated data from the 599 (of 614 randomized) patients with core lab evaluable echocardiograms and divided patients by baseline TR severity into two groups: ≤Mild TR (none/trace/mild; n=501) or ≥Moderate TR (moderate/severe; n=98).

Compared with patients with ≤Mild TR, among those with ≥Moderate TR, NYHA class III/IV heart failure and a Society of Thoracic Surgeons score ≥8 were more common, along with anemia, chronic kidney disease and a higher N-terminal pro–B-type natriuretic peptide. Researchers also found the patients with ≥Moderate TR had more severe MR and higher right ventricular systolic pressure.

Among patients treated with GDMT alone, results showed the composite rate of death or heart failure hospitalization (HFH) at two years was higher for those with ≥Moderate TR vs. ≤Mild TR (83.0% vs. 64.3%; hazard ratio [HR, 1.74; 95% confidence interval [CI], 1.24-2.45; p=0.001). For patients treated with MitraClip, the rates of the composite outcome were 48.2% vs. 44.0%, respectively (HR, 1.14; 95% CI, 0.71-0.84; p=0.59). Rates of death or HFH, as well as death and HFH alone, were reduced by MitraClip compared with GDMT, regardless of baseline TR grade.

The authors write, "In the COAPT trial of patients with heart failure and severe secondary MR who remained symptomatic despite maximally tolerated GDMT, the concomitant presence of moderate or severe TR at baseline was associated with more severe MR, higher pulmonary pressures, and worse heart failure signs and symptoms."

They note that although the MitraClip seems to mitigate adverse outcomes associated with baseline TR, "further research is needed to determine whether concomitant or sequential treatment of TR can improve outcomes further."

In an accompanying editorial comment, Yee-Ping Sun, MD, FACC, writes, "Once considered the 'forgotten valve,' it is now clear that tricuspid regurgitation has important prognostic significance, with significant impact on clinical management."

Sun also notes, "The experienced multidisciplinary heart team is now more important than ever as we strive to achieve the results seen in COAPT."

Clinical Topics: Anticoagulation Management, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Valvular Heart Disease, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Echocardiography/Ultrasound, Mitral Regurgitation

Keywords: Tricuspid Valve Insufficiency, Mitral Valve Insufficiency, Natriuretic Peptide, Brain, Blood Pressure, Echocardiography, Heart Failure, Renal Insufficiency, Chronic, Peptide Fragments, Anemia, Surgeons

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