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Pulmonary Hypertension in Tricuspid Regurgitation Patients and TTVR
Study Questions:
What is the role of pulmonary hypertension (PH) in patients with tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve repair (TTVR)?
Methods:
The authors reported the clinical characteristics, diagnosis, and risk stratification of PH in patients with severe TR and its impact on outcomes after TTVR from a cohort of 243 patients who underwent TTVR at two centers in Germany from 2016-2019. PH was identified using two methods: invasive hemodynamics (iPH+, defined as invasive systolic pulmonary artery pressures [PAPs] ≥50 mm Hg) and echocardiography (ePH+). The occurrence of the combined clinical endpoint (death, heart failure hospitalization, and re-intervention) was assessed over a follow-up of 330 (interquartile range, 175–402) days.
Results:
Among a total of 243 patients, invasive systolic PAPs ranged from 19 to 117 mm Hg, with 121 patients (~50%) in the constituted iPH+ group demonstrating a systolic PAP ≥50 mm Hg, and echocardiographic accuracy to detect PH was only 55%. iPH+ patients were at higher preoperative risk (p < 0.01), were more symptomatic (p = 0.01), had higher N-terminal pro-B-type natriuretic peptide levels (p < 0.01), and had more right ventricular (RV) dysfunction (p < 0.01). Procedural TTVR success was similar in iPH+ and iPH- patients (84% vs. 84%, p = 0.99). Afterload corrected RV function (tricuspid annular plane systolic excursion/iPAP ratio) was significantly impaired in iPH+ patients. Mitral regurgitation and TR grades were similar between iPH+/- groups, although iPH+ patients demonstrated a slightly smaller effective regurgitation orifice area but similar coaptation gaps and tenting parameters.
During follow-up, 35% of patients reached the combined clinical endpoint: 45 patients (19%) died, 67 patients (28%) were hospitalized for HF, and nine patients (4%) underwent a re-intervention (6x TTVR, 2x tricuspid surgery, 1x heart transplantation). The discordant diagnosis of iPH+/ePH- carried the highest risk for the combined clinical endpoint (hazard ratio, 3.76; 95% confidence interval, 2.25–6.37; p < 0.01), while iPH+/ePH+ patients had similar survival-free time from the combined endpoint compared to iPH- patients (p = 0.48).
Concomitant transcatheter mitral valve repair was performed in 46% of patients (n = 111). In patients with isolated tricuspid procedure (n = 131), a discordant iPH+/ePH- diagnosis and an impaired afterload corrected RV function (p < 0.01 for both) were independent predictors for the occurrence of the combined endpoint.
Conclusions:
Echocardiographic assessment of PH is of limited diagnostic value. Therefore, outcomes correlated with invasively measured hemodynamics. In fact, those with PH (diagnosed invasively) with a false-negative echocardiogram have the worst prognosis. This concept of RV–PA coupling is independently associated with event-free survival in patients undergoing TTVR.
Perspective:
This study identifies invasively measured pulmonary pressures as a key risk predictor in patients undergoing TTVR. One cannot rely on echocardiography alone to risk stratify these patients. Combining invasive and echocardiographic assessment of PH is essential for risk stratification and patient selection. Overall, TTVR poses a promising therapeutic option even in patients with PH and severe TR; especially if invasive and echocardiographic PH diagnosis is concordant. Future trials will further define the role of this promising therapy.
Clinical Topics: Anticoagulation Management, Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Vascular Medicine, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Pulmonary Hypertension, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Hypertension, Mitral Regurgitation
Keywords: Cardiac Surgical Procedures, Cardiology Interventions, Diagnostic Imaging, Echocardiography, Heart Failure, Heart Valve Diseases, Hypertension, Pulmonary, Mitral Valve Insufficiency, Natriuretic Peptide, Brain, Peptide Fragments, Systole, Tricuspid Valve Insufficiency, Ventricular Dysfunction, Right
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