Does Valve Morphology Impact Outcomes After TEER For TR?

In patients with tricuspid regurgitation (TR) who were highly symptomatic despite optimal medical therapy and with advanced comorbidities, a new study has found that a four-leaflet configuration of the tricuspid valve was associated with a greater risk of TR ≥3+ after transcatheter edge-to-edge repair (TEER). The findings will be presented during ESC Congress 2021 and were published Aug. 23 in JACC: Cardiovascular Interventions.

Atsushi Sugiura, MD, et al., conducted a retrospective analysis of data from the Bonn registry, a prospective, consecutive collection of patient data from the Bonn Heart Center in Germany. They identified consecutive patients with symptomatic TR who had TEER with the MitraClip, TriClip or PASCAL systems between June 2015 and July 2020.

The 145 patients in this analysis were on average 78 years old and most were women (55.2%). At baseline, most had atrial fibrillation (93.8%), normal left ventricular ejection fraction (median 56.8%), dilated right ventricular diameter (53.0 mm) and a functional etiology of TR.

Assessment of the tricuspid morphology was by 2D- and 3D-transesophageal echocardiography. TR severity was evaluated using a 5-grade scheme: 0, none; 1+, mild; 2+, moderate; 3+, severe; 4+, massive; 5+, torrential.

Results showed that about one-third (28.9%) of study patients had a four-leaflet configuration and two-thirds (71.1%) had three-leaflet configuration. The device implantation was successful in most patients (93.8%); no statistical difference was seen between the two groups.

The primary endpoint of residual TR ≥3+ within 30 days was seen more frequently in patients with four-leaflet configuration vs. three-leaflet configuration (38.1% vs. 18.4%; p=0.018). On multivariable analysis, four-leaflet configuration was associated with an increased risk of residual TR ≥3+ (odds ratio, 2.65; 95% confidence interval, 1.15-6.10; p=0.022), independent of baseline TR grade, coaptation gap width and TR jet location.

After one year of follow-up, patients with residual TR ≥3+, compared with patients with residual TR <3+, had a significantly higher incidence of the secondary composite outcome of all-cause mortality or heart failure hospitalization (56.1% vs. 27.7%; p=0.016).

In what the authors say is the first study to investigate the effect of valve morphology in this context, they write that, "Understanding tricuspid-valve anatomy may assist cardiac interventionalists in selecting a device, based on specific pathophysiology of the tricuspid regurgitation observed in an individual." They also note that the echocardiographic parameters of a wide coaptation gap width, TR jet from the posteroseptal or anteroposterior commissures may assist in determining the suitability of edge-to-edge repair.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: ESC Congress, ESC21, Stroke Volume, Tricuspid Valve Insufficiency, Tricuspid Valve, Echocardiography, Transesophageal, Atrial Fibrillation, Ventricular Function, Left, Biometry, Echocardiography, Echocardiography, Three-Dimensional, Heart Failure

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