Impact of Renal and Liver Function on Clinical Outcomes Following Tricuspid Valve Transcatheter Edge-to-Edge Repair

Two-Year Outcomes of Transcatheter Edge-to-Edge Repair for Severe Tricuspid Regurgitation: The TRILUMINATE Pivotal Randomized Controlled Trial

BACKGROUND

One-year outcomes of TRILUMINATE Pivotal (Trial to Evaluate Cardiovascular Outcomes in Patients Treated With the Tricuspid Valve Repair System Pivotal) found that transcatheter edge-to-edge repair (TEER) for the treatment of severe, symptomatic tricuspid regurgitation improved quality of life compared with medical therapy alone with similar rates of mortality and heart failure hospitalization. However, additional follow-up is necessary to determine the prolonged benefits of tricuspid TEER.

METHODS

A total of 572 patients with severe, symptomatic tricuspid regurgitation were randomized to either tricuspid TEER+medical therapy (device group) or medical therapy alone (control). Two-year prespecified end points were recurrent heart failure hospitalization and freedom from all-cause mortality, tricuspid valve surgery, and tricuspid valve intervention after treatment visit, assessed in the intention-to-treat population.

RESULTS

The annualized rate of recurrent heart failure hospitalizations through 2 years was significantly lower with tricuspid TEER compared with control (0.19 event per patient-year versus 0.26 event per patient-year; P=0.02; joint frailty model hazard ratio, 0.72; one-sided upper confidence limit, 0.93; P=0.02). Freedom from all-cause mortality, tricuspid valve surgery, and tricuspid valve intervention through 2 years was significantly higher with tricuspid TEER compared with control (77.6% versus 29.3%; P<0.0001), driven by more tricuspid valve intervention in control patients who crossed over to device treatment (3.8% versus 61.5%). Rates of all-cause mortality (17.9% versus 17.1%) and tricuspid valve surgery (2.3% versus 4.3%) were similar between groups. Moderate or less tricuspid regurgitation was present in 84% at 2 years in the device group.

CONCLUSIONS

At the 2-year follow-up, tricuspid TEER appeared safe, significantly reduced tricuspid regurgitation severity, and decreased rates of heart failure hospitalization compared with medical therapy alone.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03904147.

Unlocking prognostic insights in severe tricuspid regurgitation: impact of right ventricular volumes and function by cardiac magnetic resonance

AIMS

To describe prognostic cut-off values of right ventricular (RV) size and function by cardiac magnetic resonance (CMR) in a multicentre cohort of patients with severe tricuspid regurgitation (TR).

METHODS AND RESULTS

The study enrolled patients with at least severe TR (severe, massive, and torrential) assessed by 2D echocardiography undergoing a contemporary CMR study. The primary endpoint was defined as combined endpoint of all-cause mortality or hospitalization for heart failure (HF) events, and the secondary endpoint was defined as cardiovascular mortality. Three hundred fourteen patients with severe TR were included in this study (70 ± 11 years, 67% female, 79% NYHA I or II). During a median follow-up of 35 months (interquartile range: 12-60), 39% of the patients experienced the combined endpoint. After adjusting for clinical and imaging variables, RV end-diastolic volume (RV-EDV) and RV ejection fraction (RVEF) were independently associated with all-cause mortality and HF (adj HR for RV-EDV: 1.015 [1.012-1.019], P < 0.001; adj HR for RVEF: 0.957 [0.938-0.976], P < 0.001). Thresholds of highest risk were defined by RV-EDV > 150 mL/m² and RVEF < 50%, while intermediate risk was defined by RV-EDV between 100 and 150 mL/m² and RVEF between 50% and 60%. Compared with low-risk groups, adjusted threshold for high-risk (adj HR for RV-EDV > 150 mL/m2: 5.42 [3.20-9.16] and for RVEF < 50%: 2.12 [1.21-3.71]) and intermediate-risk (adj HR for RV-EDV 100-150 mL/m2: 1.72 [1.11-2.64] and for RVEF 50-60%: 1.59 [1.04-2.43]) was significantly associated with impaired outcomes.

CONCLUSION

Thresholds of RV volume and function by CMR stratifying low-intermediate and high-risk of cardiovascular events are defined in a multicentre cohort of patients. Compared with low-risk group, high- and, to a lower extent, intermediate-risk groups are independently associated to HF and all-cause mortality.

Optimizing the management of tricuspid regurgitation: an update on current treatment strategies and perspectives

INTRODUCTION

Tricuspid regurgitation (TR) is a prevalent condition and is independently associated with high morbidity and mortality rates. Despite its prognostic impact, TR remains undertreated, with patients often referred at late stages when medical therapy is ineffective and surgical intervention high risk. Emerging transcatheter therapies offer a promising alternative for safer and effective management of this elderly patient population with numerous comorbidities.

AREAS COVERED

This review highlights recent advances in treatment strategies and future directions for addressing significant TR. The literature search was conducted across the PubMed, Embase, Scopus, and Google Scholar databases. A structured search strategy was developed using 'tricuspid regurgitation' and 'management' or 'treatment' or 'therapy' and 'surgery' or 'tricuspid valve repair' or 'tricuspid valve replacement' or 'transcatheter tricuspid intervention' as MeSH terms and keywords. Selected articles from 2017 to present were critically analyzed for strengths, limitations, and gaps in evidence.

EXPERT OPINION

Enhancing disease awareness, the involvement of multidisciplinary Heart Team and intervening earlier are critical priorities for TR therapies to prevent treatment futility. Improved device designs, more performant imaging techniques, and dedicated research endpoints will help optimizing the management of TR.

Transcatheter Tricuspid Valve Replacement

Transcatheter tricuspid valve replacement (TTVR) has emerged as a promising intervention for the treatment of severe tricuspid regurgitation with complex valve morphology. This consensus document provides a comprehensive overview of the current state of orthotopic TTVR, focusing on patient selection, procedural details, and follow-up care. Clinical outcomes from initial studies and compassionate use cases are discussed, highlighting the effectiveness of TTVR in reducing tricuspid regurgitation, inducing reverse right ventricular remodeling, and enhancing patients' quality of life. This review paper also addresses potential complications and challenges associated with TTVR, such as new-onset conduction disturbances, bleeding complications, and afterload mismatch, and provides expert recommendations for the periprocedural management, anticoagulation strategies, and long-term follow-up. With the commercial approval of the first TTVR system in the United States and Europe, it intends to serve as a reference for clinicians and researchers involved in the evolving field of transcatheter tricuspid valve interventions.