Edge-to-edge mitral valve repair improves concomitant high-grade tricuspid regurgitation

Background

Mitral regurgitation (MR) and tricuspid regurgitation (TR) often occur simultaneously and symptoms of biventricular heart failure can overlap. There is currently no consensus on the management of combined MR and TR.

Purpose

To evaluate the impact of TR on echocardiographic and functional outcome after M-TEER.

Methods

740 patients underwent M-TEER for moderate-to-severe MR at our center from 2010 to 2021. Patients were analyzed according to severity of concomitant TR: low-grade TR (grade ≤ I (trace - mild)), moderate TR (grade II) and high-grade TR (grade III - V (severe - torrential)). After M-TEER, patients were followed up for 12 months and their echocardiographic and functional outcome was evaluated.

Results

Low-grade TR was present in 279 patients (37.7%), moderate TR in 170 patients (23.0%) and high-grade TR in 291 patients (39.3%) at the time of M-TEER procedure. Patients with moderate to high-grade TR had higher morbidity resulting in higher EuroSCORE II and STS-Score. At baseline more patients had MR grade ≥III in the high-grade TR group (92.8% vs. 87.1% in the low-grade TR group; p=0.023).

Procedural success of M-TEER was achieved similarly in all groups (98.2% vs. 97.6% vs. 95.9%, p=0.22). At discharge 87.6% of patients with low-grade TR and 80.9% of patients with high-grade TR had residual MR grade ≤I (p=0.036). Residual MR grade ≥III was present in 6.0% of low-grade TR patients and 10.5% of high-grade TR patients at discharge (p=0.062). 3 months after M-TEER residual MR ≥III increased to 9.4% vs. 13.4% (p=0.23) and after 12 months further increased to 12.3% vs. 15.3%, respectively (p=0.52).

TR grade decreased rapidly and consistently after M-TEER. 3 months after the procedure only 48.0% of high-grade TR patients still had TR grade ≥III (p<0.001). After 12 months this proportion declined to 46.8% (p=0.99).

High-grade TR patients had significantly higher mortality (21.5% vs. 18.2% vs. 11.1%, p=0.003) up to 12 months after M-TEER. However, TR-grade ≥III did not independently predict mortality (HR 1.326, 95% CI 0.623–2.824, p=0.46).

Conclusion

M-TEER patients with concomitant moderate to high-grade TR had higher morbidity at baseline compared to low-grade TR patients. M-TEER was safe and effective in MR reduction independent of concomitant TR severity. However, high-grade TR patients had an increased risk for mortality after M-TEER, but high-grade TR did not independently predict adverse outcome. After M-TEER TR grade decreased rapidly and significantly in the high-grade TR group.

Funding Acknowledgement

Type of funding sources: None.

Severe tricuspid regurgitation worsens prognosis outcome after edge-to-edge mitral valve repair

Introduction

MitraClip has been well established for treatment of severe mitral regurgitation (MR). MR and tricuspid regurgitation (TR) often occur simultaneously and symptoms of biventricular heart failure can overlap. While it has been shown that TR grade regression can be achieved through repair of MR1, presence of moderate to severe TR can increase all-cause mortality after MitraClip2. There is currently no consensus on the management of combined MR and TR. We evaluated the impact of TR on echocardiographic and functional outcome after MitraClip.

Methods

370 patients underwent MitraClip for moderate to severe MR at our center from 2010 to 2018. Patients were dichotomized into low grade TR (grade <I - I (trace - mild)) and high grade TR (grade III - V (severe - torrential)). Moderate TR (grade II) was excluded. After MitraClip for MR, patients were followed up for 12 months and their echocardiographic and functional outcome was evaluated. Use of diuretic drugs throughout 12 month follow-up was registered.

Results

Low grade TR (<I - I) occurred in 225 patients (67.0%), high grade TR (III - V) was present in 111 patients (33.0%). 34 patients (9.2%) with moderate TR (II) were excluded. Patients with high grade TR had an increased morbidity (higher age, worse renal function, higher prevalence of atrial fibrillation, higher levels of natriuretic peptides, increased left atrial and right heart diameters, higher TR gradient). These patients also received significantly higher doses of torasemid (33.5±36.7 mg vs. 21.6±20.9 mg, p=0.003) and furosemid (163.4±155.5 mg vs. 75.8±72.3 mg, p=0.01). Average grade of MR at baseline was similar in both groups (2.9±0.46 vs. 2.8±0.5, p=0.66).

Procedural success of MR repair was achieved similarly in both groups (96.4% vs. 96.9%, p=0.82) and residual MR grade immediately after device implantation was comparable (p=0.61). However, recurrent MR in the high grade TR group increased during follow up, while MR further decreased in the low grade TR group (3 months: 1.24±0.7 vs. 1.16±0.7, p=0.5; 12 months: 1.46±0.93 vs. 1.12±0.61, p=0.04). Accordingly, use of diuretic drugs after 12 months rose in the high grade TR group while it did not change or even decreased in the low grade TR group (torasemid: 40.2±48.4 mg vs. 24.1±30.0 mg, p=0.04; furosemid: 197.5±251.0 mg vs. 67.1±81.8 mg, p=0.22).

Kaplan-Meier-Analysis showed significantly higher mortality (24.9 vs. 14.1%, p=0.01), higher risk for heart failure induced rehospitalisation (25,4 vs. 12,5%, p=0.005) and for major adverse cardiac and cerebrovascular events (MACCE: 42.3 vs. 29.1%, p=0.008) in the high grade TR group after 12 months.

Conclusion

MitraClip patients for MR with concomitant high grade TR (≥ III) had an increased morbidity at baseline compared to low grade TR patients. By MitraClip comparable reduction of MR was achieved. However, during 12 month follow-up in the high grade TR group recurrent MR occurred more often while use of diuretics increased.

Funding Acknowledgement

Type of funding sources: None.