Prediction of Mortality and Heart Failure Hospitalization After Transcatheter Tricuspid Valve Interventions: Validation of TRISCORE

Right heart failure and mortality in patients undergoing transcatheter tricuspid valve interventions

AIMS

To assess the association between right heart failure (RHF) and mortality in patients with severe tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve intervention (TTVI), and to determine whether clinical RHF status reduces the survival benefit of successful versus failed TTVI.

METHODS AND RESULTS

The TriValve International Registry (Transcatheter Tricuspid Valve Therapies) is a multicenter registry collecting data of patients with symptomatic, severe or greater TR undergoing TTVI. The population was stratified according to RHF status defined by the following clinical criteria: history of previous hospitalization for RHF (<1 year) OR presence of signs of RHF (jugular venous distension, ascites, peripheral oedema) OR high dose diuretic (≥125 mg/day of furosemide or equivalent). The outcome of interest was 1-year all-cause death. Among 639 patients included in the TriValve registry, 498 had complete data regarding RHF status. Overall, 54 (10.8 %) patients had no criteria for RHF, 133 (26.7 %) patients fulfilled 1 criterion, 240 (48.2 %) 2 criteria and 71 (14.3 %) 3 criteria. At a median follow-up of 216 days (IQR 49-372 days), cumulative incidence of all-cause death was higher in patients with 2 or 3 RHF criteria versus those with no or 1 RHF criterion (adjusted HR 2.91-95 % CI 1.46-5.83, P = 0.002). However, RHF status did not influence the association between procedural success and all-cause death at 1-year follow-up (p for interaction 0.857).

CONCLUSIONS

In a large real-world population undergoing TTVI for severe TR, the presence of at least 2 RHF clinical criteria was independently associated with an increased risk of 1-year mortality. Procedural success was associated with a lower risk of mortality regardless of RHF status.

Predictive performance of the TRI-SCORE in patients with severe aortic stenosis and concomitant tricuspid regurgitation undergoing TAVR

BACKGROUND

Tricuspid regurgitation (TR) is a common comorbidity in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) and represents a significant predictor of adverse outcomes. Precise risk stratification through clinical scoring systems is vital for tailoring treatment decisions in this patient population.

OBJECTIVES

To assess the applicability of the TRI-SCORE for predicting adverse outcomes in patients with AS and concomitant moderate-to-severe TR undergoing TAVR and to compare its performance with established surgical risk scores like the EuroSCORE II and Society of Thoracic Surgeons score (STS-Score).

METHODS

We conducted a retrospective analysis of 301 patients with severe AS and concomitant TR who underwent TAVR between 2013 and 2022 at the Heart Center Bonn. According to the TRI-SCORE, patients were stratified into a low or intermediate-risk group (TRI-SCORE 0-5) and a high-risk group (TRI-SCORE 6-12). The primary endpoint was 2-year all-cause mortality. Predictive values of the TRI-SCORE were compared to the EuroSCORE II and the STS-Score for both 30-day and 2-year mortality outcomes.

RESULTS

The 2-year mortality rate was significantly higher in the high-risk group compared to the low or intermediate-risk group (TRI-SCORE 6-12: 40.0% vs. TRI-SCORE 0-5: 17.9%; p < 0.001). For predicting 30-day mortality, the EuroSCORE II and the STS-Score demonstrated superior predictive values, with AUCs of 78.4% and 83.0%, respectively, in comparison to the TRI-SCORE, which showed an AUC of 70.0%. Conversely, the TRI-SCORE allowed a better risk prediction with regard to 2-year all-cause mortality, achieving an AUC of 69.7%, superior to the EuroSCORE II (60.6%) and the STS-Score (62.1%).

CONCLUSION

The TRI-SCORE is effective in predicting mid-term mortality in patients with AS and moderate-to-severe TR undergoing TAVR, demonstrating greater robustness than the EuroSCORE II and the STS-Score for this timeframe.

Malnutrition and outcomes in patients with tricuspid regurgitation undergoing transcatheter tricuspid valve repair

AIMS

The impact of malnutrition in patients with tricuspid regurgitation (TR) undergoing tricuspid transcatheter edge-to-edge repair (T-TEER) is not well established. We evaluated the impact of malnutrition among patients with symptomatic TR undergoing T-TEER.

METHODS AND RESULTS

Baseline nutritional status was evaluated using the geriatric nutritional risk index (GNRI), based on serum albumin concentrations and body weight to ideal body weight ratio, among patients with symptomatic TR undergoing T-TEER, enrolled in the multicentre EuroTR registry between March 2016 and February 2024. Malnutrition was defined as GNRI ≤98. The primary outcome of interest was all-cause mortality. A total of 1034 patients were included (mean age 78.4 ± 7.3 years, 47.7% male). Among them, GNRI ≤98 (i.e. malnutrition) was observed in 211 patients (20.4%). Estimated rates of all-cause death at 2 years were 45.9% and 28.2% in patients with and without malnutrition, respectively (log-rank p < 0.001). After multivariable adjustment, malnutrition was independently associated with an increased risk of mortality (adjusted hazard ratio 1.53, 95% confidence interval 1.11-2.10, p = 0.009), also confirmed at inverse probability of treatment weighting-adjusted analysis. As compared to post-procedural residual TR ≥3+, residual TR ≤2+ was associated with a similar lower risk of mortality in patients with and without malnutrition (interaction p = 0.947).

CONCLUSION

In the large, real-world, multicentre EuroTR registry, malnutrition was present in one out of five patients with symptomatic TR undergoing T-TEER and was independently associated with increased mortality. The prognostic benefit of successful T-TEER in reducing mortality was consistently observed in patients with and without malnutrition.

Bibliometric analysis of imaging and treatment strategies for severe tricuspid regurgitation from 2015 to 2023

Background

Severe tricuspid regurgitation is a progressive disease with an unfavourable prognosis. In recent years there have been extraordinary gains in knowledge through both clinical and basic scientific work. We performed a bibliometric analysis on tricuspid regurgitation with a focus on imaging techniques and treatment approaches and to identify scientific milestones and emerging research trends.

Methods

Publications, published between 2015 and 2023 were identified. Study characteristics, impact factors and countries of origin studies were recorded. Heat maps were created to visualise data and to identify leading centers. Most frequently cited publications were recognised as milestones.

Results

We screened 3,519 studies. 368 studies were included, of which 326 were clinical studies. Clinical studies were further subdivided into interventional (n = 138), surgical (n = 115) or studies on imaging modalities (n = 74). We detected an enormous increase in scientific output worldwide, especially in imaging and interventional studies. The United States, Germany and Poland were identified as leading countries in imaging, interventions and preclinical studies respectively.

Conclusions

Our study reflects the global gain in knowledge over the last 9 years. We were able to identify an annually rising number of interventional studies. Imaging studies have also seen a rapid increase, especially since 2020. In recent years, we monitored a decline in surgical studies.

TRIVALVE Score: A Risk Score for Mortality/Hospitalization Prediction in Patients Undergoing Transcatheter Tricuspid Valve Intervention

BACKGROUND

Transcatheter tricuspid valve intervention (TTVI) has been increasingly adopted in recent years for the treatment of patients with tricuspid regurgitation (TR). However, no dedicated risk stratification has been established for patients undergoing TTVI.

OBJECTIVES

The aim of the present study was to propose a dedicated risk score for patients affected by severe TR undergoing TTVI.

METHODS

The score was derived from the TRIVALVE (International Multisite Transcatheter Tricuspid Valve Therapies Registry; NCT03416166) registry, according to data availability. A stepwise model approach was used on predictor variables to develop a scoring system for predicting 12-month mortality or rehospitalization using multivariable logistic regression. Internal discrimination, calibration, and validation were assessed using receiver-operating characteristic curve analysis and bootstrapping with 1,000 resamples.

RESULTS

A total of 483 patients were included in the study, with an overall 12-month mortality or rehospitalization rate of 19% (n = 94). The final risk score, ranging from 0 to 4.5, included the following 5 parameters (adjusted for age and gender): 1) atrial fibrillation at baseline; 2) glomerular filtration rate <30 mL/min; 3) elevated gamma-glutamyl transferase/bilirubin levels; 4) signs of right heart failure; and 5) left ventricular ejection fraction <50%. The bias-corrected area under the receiver-operating characteristic curve was 68% (95% CI: 62%-75%). A cutoff value of 2.5 demonstrated sensitivity of 65.4% and specificity of 60.5% for the outcome.

CONCLUSIONS

The present study proposes a dedicated risk score for patients undergoing TTVI, providing an additional and simple tool for heart teams to select the best therapy for patients affected by severe TR.

Novel interventions on the tricuspid valve: how to consider the pulmonary circulation?

PURPOSE OF REVIEW

This review addresses treatment options for moderate to severe tricuspid valve regurgitation and the importance of right ventricular function and the pulmonary circulation.

RECENT FINDINGS

Several interventional treatment options for severe tricuspid regurgitation have been developed including transcatheter edge-to-edge repair, annuloplasty and valve replacement. So far, transcatheter edge-to-edge repair is most frequently used with procedural success rates of more than 95% and improvements in functional and quality of life parameters for up to 2 years. Right ventricular function as well as pulmonary artery pressure and resistance levels are important outcome predictors. Mean pulmonary artery pressure more than 30 mmHg, transpulmonary gradient more than 17 mmHg and right ventricular to pulmonary artery coupling ratio less than 0.406 indicate poor outcome.

SUMMARY

Despite the remarkable safety of interventional treatment of severe tricuspid regurgitation right ventricular dysfunction and abnormal pulmonary hemodynamics are important determinants of procedural success and clinical outcome.Complete hemodynamic work-up should be an integral part of prerepair assessment although validated data predicting outcome are limited.

The Other Side of the Coin: Transesophageal Echocardiography Complications following Cardiac Surgery and Transcatheter Structural Heart Interventions

Transesophageal echocardiography (TEE) is widely used in cardiac surgery and interventional cardiology and is often an indispensable tool, giving supportive anatomical understanding and smooth guidance in both settings. Despite it being considered safe, fatal complications can commonly occur after a TEE examination in cardiac surgery operating rooms and catheterization laboratories. Currently, there is a lack of awareness of the scale of the problem, as there are only small amounts of data available, mainly derived from the surgical literature. This review summarizes the main predisposing factors for TEE-associated complications (classified as patient and procedure-related) and the main preventive strategies. We aim to apply preventive strategies more broadly, especially to patients at high risk of developing TEE-related serious adverse events.