Dannenberg Varius, Koschutnik Matthias, Donà Carolina, Nitsche Christian, Mascherbauer Katharina, Heitzinger Gregor, Halavina Kseniya, Kammerlander Andreas A, Spinka Georg, Winter Max-Paul, Andreas Martin, Mach Markus, Schneider Matthias, Bartunek Anna, Bartko Philipp E, Hengstenberg Christian, Mascherbauer Julia, Goliasch Georg
Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.
Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
Front Cardiovasc Med. 2022 Jun 2;9:891468. doi: 10.3389/fcvm.2022.891468. eCollection 2022.
Severe tricuspid regurgitation (TR) is a common condition promoting right heart failure and is associated with a poor long-term prognosis. Transcatheter tricuspid valve repair (TTVR) emerged as a low-risk alternative to surgical repair techniques. However, patient selection remains controversial, particularly regarding the benefits of TTVR in patients with pulmonary hypertension (PH).
We aimed to investigate the impact of preprocedural invasive hemodynamic assessment and procedural success on right ventricular (RV) remodeling and outcome.
All patients undergoing TTVR with a TR reduction of ≥1 grade without precapillary or combined PH [mean pulmonary artery pressure (mPAP) ≥25 mmHg, mean pulmonary artery Wedge pressure ≤ 15 mmHg, pulmonary vascular resistance ≥3 Wood units] were assigned to the responder group. All patients with a TR reduction of ≥1 grade and precapillary or combined PH were classified as non-responders. Patients with a TR reduction ≥2 grade were directly classified as responders, and patients without TR reduction were directly assigned as non-responders.
A total of 107 patients were enrolled, 75 were classified as responders and 32 as non-responders. We observed evidence of significant RV reverse remodeling in responders with a decrease in RV diameters (-2.9 mm, = 0.001) at a mean follow-up of 229 days (±219 SD) after TTVR. RV function improved in responders [fractional area change (FAC) + 5.7%, < 0.001, RV free wall strain +3.9%, = 0.006], but interestingly further deteriorated in non-responders (FAC -4.5%, = 0.003, RV free wall strain -3.9%, = 0.007). Non-responders had more persistent symptoms than responders (NYHA ≥3, 72% vs. 11% at follow-up). Subsequently, non-response was associated with a poor long-term prognosis in terms of death, heart failure (HF) hospitalization, and re-intervention after 2 years (freedom of death, HF hospitalization, and reintervention at 2 years: 16% vs. 78%, log-rank: < 0.001).
Hemodynamic assessment before TTVR and procedural success are significant factors for patient prognosis. The hemodynamic profiling prior to intervention is an essential component in patient selection for TTVR. The window for edge-to-edge TTVR might be limited, but timely intervention is an important factor for a better outcome and successful right ventricular reverse remodeling.
严重三尖瓣反流（TR）是导致右心衰竭的常见病症，且与不良的长期预后相关。经导管三尖瓣修复术（TTVR）作为外科修复技术的低风险替代方案应运而生。然而，患者选择仍存在争议，尤其是TTVR在肺动脉高压（PH）患者中的获益情况。
我们旨在研究术前有创血流动力学评估及手术成功率对右心室（RV）重塑和预后的影响。
所有接受TTVR且TR降低≥1级、无毛细血管前性或混合性PH（平均肺动脉压[mPAP]≥25 mmHg，平均肺动脉楔压≤15 mmHg，肺血管阻力≥3伍德单位）的患者被分配至反应者组。所有TR降低≥1级且有毛细血管前性或混合性PH的患者被归类为无反应者。TR降低≥2级的患者直接归类为反应者，未出现TR降低的患者直接分配为无反应者。
共纳入107例患者，75例被归类为反应者，32例为无反应者。我们观察到，在TTVR后平均随访229天（±219标准差）时，反应者存在明显的RV逆向重塑证据，RV直径减小（-2.9 mm，P = 0.001）。反应者的RV功能有所改善[面积变化分数（FAC）增加5.7%，P < 0.001，RV游离壁应变增加3.9%，P = 0.006]，但有趣的是，无反应者的RV功能进一步恶化（FAC降低4.5%，P = 0.003，RV游离壁应变降低3.9%，P = 0.007）。无反应者比反应者有更持续的症状（纽约心脏协会功能分级≥3级，随访时分别为72%和11%）。随后，在死亡、心力衰竭（HF）住院和2年后再次干预方面，无反应与不良的长期预后相关（2年时无死亡、HF住院和再次干预的自由度：16%对78%，对数秩检验：P < 0.001）。
TTVR前的血流动力学评估和手术成功率是影响患者预后的重要因素。干预前的血流动力学分析是TTVR患者选择的重要组成部分。缘对缘TTVR的时机可能有限，但及时干预是获得更好预后和成功实现右心室逆向重塑的重要因素。
