Clin Res Cardiol (2021)
DOI DOI https://doi.org/10.1007/s00392-021-01843-w
|A disproportionate elevation in right sided filling pressure in relation to left sided filling pressure predicts outcome after transcatheter mitral valve repair in patients with chronic heart failure|
|R. Osteresch1, K. Diehl1, A. Ben Ammar1, P. Dierks1, S. Rühle1, J. Schmucker1, A. Fach1, H. Wienbergen1, R. Hambrecht1|
|1Bremer Institut für Herz- und Kreislaufforschung (BIHKF), Bremen;|
Background: Although right atrial pressure (RAP) and precapillary wedge pressure (PCWP) are correlated in chronic heart failure (CHF), a disproportionately elevated RAP relative to PCWP occurs in a subset of patients with CHF undergoing transcatheter mitral valve repair (TMVR) for severe mitral regurgitation (MR).
Objective: To assess the prognostic impact of disproportionately increased RAP relative to PCWP (RAP/PCWP ratio) in patients undergoing TMVR.
Methods Consecutive patients with severe MR, CHF and elevated filling pressures (RAP ≥10mmHg and PCWP ≥22mmHg) who underwent TMVR were enrolled and separated into 3 groups according to RAP/PCWP terciles (A: low RAP/PCWP <0.46; B: intermediate RAP/PCWP 0.46-0.55; C: high RAP/PCWP ≥0.55). Primary endpoint was a composite of all-cause mortality and rehospitalization due to CHF during a mean follow-up period of 16±9 months. The impact of RAP/PCWP on prognosis was assessed by receiver operating characteristic (ROC) and Kaplan Meier analysis. Multivariable Cox proportional-hazards regression analysis was used to investigate independent predictors for primary outcome.
Results: 121 patients (A: n=39, B: n=42, C: n=40) at high operative risk (75±9 years, 71.1% male, Logistic Euro-SCORE 20.6±10%) were enrolled. Mean RAP/PCWP was 0.38±0.01 vs. 0.51±0.03 vs. 0.72±0.16; p<0.001. Patients in the high RAP/PCWP group showed significantly higher rates of early rehospitalization for heart failure at 30 days (20.5% vs. 17.5% vs. 5.1%; p=0.03). At long-term follow-up, Kaplan-Meier analysis revealed a significantly lower event free survival for combined primary endpoint in the high RAP/PCWP group (72.2% vs. 63.2% vs. 43.6%; log-rank p=0.041). ROC curve analysis demonstrated that RAP/PCWP was associated with an area under the curve of 0.65 (95% confidence interval (CI) 0.55-0.76; p=0.006). In Cox regression analysis, preexisting NYHA functional class IV (hazard ratio (HR) 2.89; 95% CI 1.79-4.66; p<0.0001), failed clip procedure (HR 3.39; 95% CI 1.85-6.23; p<0.0001) and increased RAP/PCWP ratio (HR 2.91; 95% CI 1.50-5.65; p=0.002) were independent predictors for combined primary endpoint.
Conclusions: A disproportionate increase in right to left ventricular filling pressures is independently associated with worse prognosis in patients undergoing TMVR. Therefore, RAP/PCWP ratio may be helpful in optimal patients selection for TMVR.