Clin Res Cardiol (2021)

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.