Clin Res Cardiol (2022). https://doi.org/10.1007/s00392-022-02002-5

Analysis of patients´ characteristics which were deemed to be unsuitable for transcatheter tricuspid valve treatment
A. Goncharov1, K. Friedrichs2, T. K. Rudolph2, F. Roder2, V. Rudolph1, M. Gercek2
1Allgemeine und Interventionelle Kardiologie/Angiologie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen; 2Klinik für Kardiologie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen;

Background
Recent data show a benefit in clinical outcome in patients with symptomatic tricuspid regurgitation (TR) and high surgical risk undergoing transcatheter tricuspid valve treatment (TTVT). Despite the rapid development of technologies, a relevant proportion of evaluated patients are found to be unsuitable for currently available option of TTVT. Herein we aim to assess the screening failure rates and their reasons in a contemporary routine setting for patients evaluated for TTVT.

Methods
147 patients evaluated for TTVT at our centre between January 2018 and March 2021 were included in the analysis. Echocardiography and cardiac computed tomography (in 76 patients) were applied to assess the tricuspid valve (TV) anatomy. Health status assessment and surgical risk was carried out with the 6-minute walk test and EuroSCORE II.

Results
Median age of the patients was 79.0 years (IQR: 71.0 - 82.0 years). 56% of them were female. The patients presented an at least moderate surgical risk (EuroSCORE II: 7.76 ± 6.91%) and an impaired exercise capacity (median 6-minute-walked distance 240.0 m (IQR: 120.0 - 320.0 m)). All patients were symptomatic (NYHA Class ≥ III) and had at least severe TR.

76 patients (51.7%) were amenable to TTVT while 71 patients (48.3%) were deemed unsuitable because of clinical futility in 26 (17.7%) cases and morphological/technical criteria in 45 (30.6%) cases. Of the latter, 22 cases (14.9%) were treated surgically, while 23 (15.6%) cases had to be continued on conservative therapy. Reasons for clinical futility were precapillary pulmonary hypertension (8.9%), frailty or limitation of prognosis (4.1%), other cardiac disorders that were found during screening (2.7%) and inappropriate echocardiographic window (2.0%).

In the cohort declined due to morphological reasons, overt right ventricle and tricuspid enlargement were the main drivers of rejection. Thus, on multivariate regression analysis, right ventricular basal diameter (p = 0.007, OR 0.93, CI: 0.89 – 0.98), right atrial area (p = 0.016, OR 0.95, CI: 0.92 – 0.99), tricuspid annulus diameter (p = 0.002, OR 0.90, CI: 0.84 – 0.96), coaptation gap (p = 0.023, OR 0.92, CI: 0.86 – 0.99), tethering area (p = 0.004, OR 0.42, CI: 0.24 – 0.76) and coaptation depth (p = 0.005, OR 0.78, CI: 0.66 – 0.93) were identified as independent predictors of rejection for TTVT. 4 (2.7%) patients were declined because of pacemaker lead impingement, 3 (2.0%) patients had no appropriate echocardiographic window.

Computed tomography data confirmed a limiting role of the tricuspid anulus size in the choice of therapeutic strategy. Tricuspid annulus area in diastole (p = 0.026, OR 0.15, CI: 0.03 – 0.80), annulus perimeter in diastole (p = 0.035, OR 0.95, CI: 0.91 – 0.99) and max. diastolic distance (p = 0.042, OR 0.64, CI: 0.41 – 0.98) were also identified as independent predictors of rejection for TTVT.

Conclusions
Geometric dimensions of tricuspid annulus and also the morphology of the leaflets (coaptation gap, tethering area and coaptation depth) seem to have a decisive influence during defining the appropriate treatment strategy in patients with TR and high surgical risk.


https://dgk.org/kongress_programme/jt2022/aP1869.html