Prognostic impact of acute kidney injury following tricuspid transcatheter edge-to-edge repair

Background

A considerable risk of acute kidney injury (AKI) following transcatheter interventions without iodinated contrast agents has also been recognized; however, little is known about the incidence and clinical relevance of post-procedural AKI in patients undergoing transcatheter edge-to-edge repair (TEER) for tricuspid regurgitation (TR).

Purpose

This study aimed to investigate the prognostic impact and predictors of post-procedural AKI following TEER for TR.

Methods

We retrospectively analyzed 218 consecutive patients who underwent TEER for TR. Post-procedural AKI was defined as an increase in serum creatinine of ≥0.3 mg/dl within 48 hours or of ≥50% within seven days after the procedure, compared to baseline. Procedural success was defined as at least one grade reduction in TR severity upon discharge. We determined the association between post-procedural AKI and the composite outcome consisting of all-cause mortality and re-hospitalization due to heart failure within one year after the procedure.

Results

Overall, the mean age of the patients was 79±7 years, and 46.3% of the patients were male. Post-procedural AKI occurred in 32 patients (14.7%) (Figure 1). Among baseline characteristics, male sex and an estimated glomerular filtration rate of <60 ml/min/m2 were associated with the occurrence of AKI. In addition, patients without procedural success had a higher incidence of post-procedural AKI (30.4% vs. 1.8%; p=0.024).

Patients with AKI had a higher incidence of in-hospital mortality compared to those without AKI (12.5% vs. 1.1%; p=0.005). Moreover, AKI was associated with the incidence of the composite outcome within one year after TEER for TR (adjusted hazard ratio: 2.06; 95% confidence interval: 1.11–3.84; p=0.023). In addition, our restricted cubic spline curve showed that a post-procedural increase in the creatinine level within seven days after the procedure was associated with a linear trend of the risk of the composite outcome after TEER (Figure 2).

Conclusions

Post-procedural AKI occurred in 14.7% of patients undergoing TEER for TR, despite the absence of iodinated contrast agents, which was associated with worse clinical outcomes. Male sex and CKD at baseline were related to the occurrence of AKI, and the procedural success of TEER was associated with a lower incidence of AKI. Our findings highlight the clinical impact of AKI following TEER for TR and should help with identifying patients at high risk of AKI.

Funding Acknowledgement

Type of funding sources: None.

Effectiveness of transcatheter edge-to-edge repair for atrial secondary mitral regurgitation

Background

Atrial secondary mitral regurgitation (ASMR) is a subtype of SMR that is characterized by normal left ventricular (LV) function, an enlarged left atrium and mitral annulus, and flattened leaflets. This anatomical feature is different from ventricular SMR (VSMR) and might therefore impact the procedural results of transcatheter edge-to-edge repair (TEER). The effectiveness and durability of TEER in patients with ASMR has not yet been well-studied.

Purpose

This study aimed to investigate the effectiveness of TEER and anatomical characteristics related to optimal MR reduction in patients with ASMR.

Methods

We retrospectively analyzed consecutive patients who underwent MitraClip at our institution. ASMR was defined as cases that met all of the following criteria: 1) normal mitral leaflets without organic disorder, 2) LV ejection fraction >50%, and 3) absence of LV enlargement and segmental abnormality. The primary outcome measure was MR reduction to ≤1+, and its predictors were explored in a logistic regression analysis. Leaflet-to-annulus index (LAI) was measured using the mid-esophageal long-axis view in the A2-P2 segment as follows: (anterior leaflet length + posterior leaflet length) / anteroposterior length of the mitral annulus.

Results

Among 415 patients with SMR, 118 patients met the criteria for ASMR (mean age: 80±8 years; male: 39.8%) (Figure 1). Patients with ASMR had a larger mitral annulus diameter, shorter mobile posterior leaflet length, and smaller coaptation depth compared to those with VSMR.

The technical success rate was 90.7%, and the MR reduction to ≤1+ after TEER was achieved in 94 (79.7%) patients with ASMR, which was comparable with VSMR. The in-hospital mortality rate was 2.5%. In multivariable logistic analysis, a large left-atrial (LA) volume index and a low LAI were associated with a lower rate of MR reduction to ≤1+ after TEER for ASMR (odds ratio [OR]: 0.98; 95% confidence interval [CI]: 0.97–0.99, and OR per 0.1 increase: 1.98; 95% CI: 1.13–3.45, respectively). The combined assessment of the LA volume index and LAI stratified the risk of residual MR ≥2+ after TEER (Figure 2).

In addition, the use of a newer generation of the MitraClip systems (NTR/XTR or G4 systems) was associated with a higher rate of MR reduction to ≤1+ compared to older generations (OR: 4.65; 95% CI: 1.67–13.00).

Conclusions

TEER with the MitraClip system achieved a high rate of MR reduction to ≤1+ in patients with ASMR. Furthermore, the new generations of the MitraClip system may provide a more effective reduction in ASMR. Although our findings suggest that TEER with the MitraClip system is a safe and feasible approach in patients with ASMR, the combined assessment of the LA volume index and LAI might be useful to refine the device selection for transcatheter mitral valve treatment in this subgroup of SMR patients.

Funding Acknowledgement

Type of funding sources: None.

Right ventricular ejection fraction assessed by computed tomography in patients undergoing transcatheter tricuspid valve intervention

Background

The role of right-ventricular (RV) function in patients with tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve interventions (TTVI) is poorly understood. Although cardiac computed tomography (CCT) provides elaborate three-dimensional (3D) visualization of the entire anatomy of the RV and theoretically allows to assess the global RV systolic function. Nevertheless, the utility of the functional assessments of the RV using CCT remains unclear in patients undergoing TTVI.

Purpose

This study investigated the association of right-ventricular ejection fraction (RVEF) assessed by CCT with clinical outcome in patients undergoing TTVI.

Methods

We retrospectively assessed 3D-RVEF by using pre-procedural CCT images in patients undergoing TTVI with either edge-to-edge repair or annuloplasty device. RV dysfunction (RVD) was defined as a CT-RVEF <45%. The primary outcome was a composite outcome, consisting of all-cause mortality and hospitalization due to heart failure, within one year after TTVI.

Results

Of 157 patients, 58 (36.9%) presented with CT-RVEF <45%. Patients with CT-RVEF <45% were more likely to be male, to have a previous history of coronary artery disease, and had higher EuroSCORE II and a lower LVEF compared to those with CT-RVEF ≥45%, while the severity of TR was comparable between the groups.

Among the patients with CT-RVEF <45%, acute procedural success was achieved in 93.1%, and in-hospital mortality was 1.7%, which were comparable to those with CT-RVEF ≥45%.

Patients with CT-RVEF <45% had an improvement in New York Heart Association functional class at follow-up compared to baseline; however, CT-RVEF <45% was associated with a higher risk of the composite outcome (adjusted hazard ratio: 3.23; 95% confidence interval: 1.52–6.88; p=0.002) (Figure 1). Furthermore, CT-RVEF had an additional value to stratify the risk of the composite outcome beyond two-dimensional transthoracic echocardiographic (TTE) assessments (Figure 2).

In addition, patients with CT-RVEF <45% exhibited an attenuated association between a reduction in TR to <3+ and a lower incidence of the composite outcome after TTVI compared to those with CT-RVEF ≥45%.

Conclusions

TTVI is safe and feasible regardless of baseline RV function, while RVD, defined as 3D-RVEF <45%, is associated with a higher risk of the composite outcomes within one year after TTVI. Furthermore, our findings suggest that the prognostic benefits of TR reduction might be attenuated in patients with RVD. Given the additional prognostic value of CT-RVEF to the conventional echocardiographic assessments, the assessments of 3D-RVEF with CCT may refine the patient selection for TTVI.

Funding Acknowledgement

Type of funding sources: None.

Impact of leaflet-to-annulus index on residual tricuspid regurgitation following transcatheter edge-to-edge tricuspid valve repair

Introduction

Edge-to-edge transcatheter tricuspid valve repair (TTVR) is a promising treatment option for tricuspid regurgitation (TR), and it is required to identify anatomical parameters to predict the procedural success of TTVR.

Purpose

In this study, we assessed leaflet-to-annulus index (LAI), a simple tool to evaluate the remodeling of tricuspid annulus in relation to the leaflets, and investigated the association of the LAI with residual TR after edge-to-edge TTVR.

Methods

Consecutive 140 patients with symptomatic TR who underwent edge-to-edge TTVR from June 2015 to July 2020 were enrolled. The LAI was calculated using preprocedural transesophageal echocardiography and was defined as follows: (anterior leaflet length + septal leaflet length)/anteroseptal tricuspid annulus diameter (Figure 1). Primary outcome was residual TR ≥3+ at discharge, and patients were allocated into two groups as follows: residual TR ≥3+ and <3+. Secondary outcome was the composite outcome, consisting of all-cause mortality and heart failure hospitalization, within one year after TTVR.

Results

Of the 140 patients, 43 patients had residual TR ≥3+ after TTVR. The patients with residual TR ≥3+ had lower LAI compared to those with residual TR <3+ (1.06±0.10 vs. 1.13±0.09; p=0.001). Multivariable analysis revealed that LAI was associated with residual TR ≥3+ (odds ratio [by 0.1 increase]: 0.57; 95% confidence interval [95% CI]: 0.35–0.94; p=0.02), independently of baseline TR severity, location of TR jet, and coaptation gap size (Table 1). Patients with residual TR ≥3+ had a higher incidence of the composite outcome within one year after TTVR (34.9% vs. 18.6%; log-rank p=0.04) and residual TR ≥3+ was an independent predictor of the composite outcome within one year (hazard ratio: 2.04; 95% CI: 1.01–4.11; p=0.04).

Conclusion

Lower LAI is associated with residual TR ≥3+ after edge-to-edge TTVR, which itself was a significant predictor of the one-year composite outcome. Our findings suggest that LAI is a useful tool to identify patients to be successfully treated with edge-to-edge TTVR.

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

One-year outcome of transcatheter repair of tricuspid regurgitation: comparison edge-to-edge repair versus anuloplasty

 

Tricuspid regurgitation (TR) is found to be associated with increased mortality, morbidity, and impaired quality of life. The interventional tricuspid valve repair techniques are being increasingly performed. We aimed to compare the mid-term outcomes of both methods (Clipping and Banding) in our patient cohort. F

We retrospectively included 60 patients who underwent between January 2016 to March 2018 the transcatheter tricuspid valve edge-to-edge repair or annuloplasty in our center. Follow up (FU) examinations were done 12.6±7.6 months. Comprehensive transthoracic echocardiography inclusively 3D acquisitions were performed before and at FU in all patients. The 3D data were used for strain analysis of left and right ventricles and atriums through a dedicated automated offline program (TomTec).

We retrospectively included 60 patients (75±6.1 years, 40% female) with symptomatic (65% ascites, 95% edema, 100% NYHA>II, 75% liver congestion) severe TR (TR>II, 90% functional) at surgical high risk (EuroSCORE II: 5.2±3.2%). Forty patients underwent transcatheter TV edge-to-edge repair (TTVR, MitraClip, PASCAL), and twenty patients were treated by interventional annuloplasty (Cardioband).

At baseline, the patients underwent edge-to-edge (E2E) repair showed more comorbidities with higher EuroScore II and more decreased functional capacity. Echocardiographical, patients who underwent annuloplasty, presented a more significant coaptation gap with more impaired RV function and more dilated right atrium. In contrast, the E2E group showed to have higher right ventricular systolic pressure. Left ventricular dimensions and functions were comparable between the groups.

Left atrial volume and right atrial pressure were found to be statistically significantly reduced in both groups at FU. RV and RA fractional area change were found to be relevantly improved solely after interventional annuloplasty at FU. Left ventricular end-diastolic pressure significantly increased in the E2E group with relevant reduction of outflow/inflow ratio. Moreover, interventional annuloplasty, as expected, reduces SL diameter more significantly.

Patients showed lower symptoms and better functional capacity 12 months after interventional E2E therapy. Of note, improvement in walking distance was found to be significantly higher in patients who underwent annuloplasty. However, patients were hospitalized significantly more frequently after interventional annuloplasty.

In conclusion, both interventional techniques are safe, feasible, and effective for treatment of tricuspid regurgitation in patients at surgical high risk. Interventional annuloplasty significantly impacts on RV function and geometry, and reduces SL diameter significantly. Patients were found to have decreased symptoms, better functional capacity, as well as fewer rehospitalization 12 months after interventional E2E therapy, although they showed more comorbidities at baseline compared to interventional annuloplasty.

Funding Acknowledgement

Type of funding source: None

43 Echocardiographical analysis of right ventricular function after transcatheter edge-to-edge repair of tricuspid regurgitation

Tricuspid regurgitation (TR) is a frequent valvular heart disease associated with increased mortality and morbidity. RV function is mostly assessed using tricuspid annulus plane systolic excursion (TAPSE), which shows merely systolic RV function and can be influenced by many other pathologies and image quality. Furthermore, the impact of dedicated percutaneous clip treatment of TR on RV global function and clinical outcomes are scarce.

We aim to perform detailed echocardiographical global RV function analysis inclusively speckle tracking of RV before and after transcatheter edge-to-edge repair of TR (TTVR).

We evaluated 50 patients, who underwent between January 2017 to March 2018 TTVR in our center. Apical four chamber images were used to perform strain analysis of RV. The systolic velocity of free RV wall (S´ Vmax) was measured through PW doppler on lateral TV annulus in color tissue Doppler. RV myocardial performance index is a parameter for systolic as well as diastolic ventricle function and can be calculated using ratio between TV closure to opening time and RV ejection time (RVCOT-RVET/RVET), which can be assessed from PW Doppler of lateral TV annulus in color tissue Doppler.

We retrospectively included 40 patients (73 ± 5.6 years, 32% female) with symptomatic (65% ascites, 95% edema, 100% NYHA > II) high grade functional TR at surgical high risk (EuroSCORE II: 7.6%). 95% of all interventions were successfully performed (TR reduction at least I grade).

Our collective shows normal baseline left ventricle (LV) systolic function (Ejection fraction: 60.8 ± 4.6%) with diastolic LV dysfunction and increased LV end systolic pressure (E/E´ ratio: 17.7 ± 6.5). Baseline RV analysis presented impaired RV systolic function (TAPSE: 1.2 ± 3.2 cm, RV-FAC: 25.6 ± 9.8%, S´ Vmax: 5.6 ± 1.2cm/s) with decreased RV global longitudinal strain (RV-GLS: -8.9 ± 4.3). RV myocardial performance index (RV-MPI) was 0.51 ± 0.4 as a parameter for poor global RV function. Baseline echocardiography showed dilation of both atria (Left atrium: 80.5 ± 14.5ml, right atrium: 26.7 ± 7.8cm2) with pronounced right ventricle congestion (dilated vena cava inferior: 25.5 ± 3.4mm without breath modulation, paradoxical intraventricular septum motion, dilated RV: 57.7 ± 14.5cm2). All TR were high grade (PISA: 0.78 ± 0.3cm, VC width: 0.8 ± 0.2cm, EROA: 0.43 ± 0.1cm2, regurgitant volume: 67.1 ± 10.4ml) and functional with mostly anteroseptal (85%) coaptation defect (coaptation defect diameter: .5.7 ± 3.2mm).

The right heart failure symptoms significantly improved three months after the procedure. Patients with severe right heart failure (TAPSE < 1cm) showed more often rehospitalization and limited improvements in symptoms (p = 0.02).

RV function should be more comprehensively evaluated before interventional TR therapy. The patients with already preprocedural severe right heart failure should be more critically discussed. RV-GLS and RV-MPI are strongest independent parameter of clinical outcome after TTVR.