Background: Secondary tricuspid regurgitation (TR) is associated with worse patient outcome and patients often present at inhibitive surgical risk. Recently, several catheterbased treatment techniques have emerged, that have proven efficient in reducing TR grade and clinical symptoms of heart failure. Anatomy of the tricuspid valve is highly variable and recently, Hahn et al. proposed a classification scheme for distinguishing tricuspid leaflet morphology involving 2-leaflet, 3-leaflet, 5-leaflet and several 4-leaflet subtypes. Leaflet morphology has been associated with treatment success and outcome in patients undergoing edge-to-edge TR repair, but the impact on direct annuloplasty is unclear.

Methods&Results: We retrospectively analyzed patients who underwent catheter-based direct annuloplasty with the Cardioband system at two German centers (Heart Center Cologne and Bad Oeynhausen) between 2018 and 2021. Leaflet morphology was classified using transesophageal echocardiographic data sets (considering transesophageal and transgastric views). Technical success was defined as device deployment without intraprocedural death and no need for urgent surgery.

We included 86 patients. 35.3% presented with torrential, 29.4% with massive and 35.3% with severe TR. Patients were symptomatic (NYHA class III/IV in 95.3% and 77.9% with prior decompensated heart failure) and already under medical treatment (95.3% were taking loop diuretics). 90% were also suffering from atrial fibrillation and 87.8% from heart failure with preserved ejection fraction. Overall, technical success was 95.3% and TR reduction of at least one grade was achieved in 92.9%. Distribution of leaflet morphology is shown in Figure 1. For further analyses we compared tricuspid leaflet morphologies I and II (“3-leaflet configuration”) with morphologies III and IV (“4-leaflet configuration”). 53.7% of patients presented with a 3-leaflet morphology and 46.3% with a 4-leaflet morphology. Baseline clinical characteristics as well as comorbidities did not differ between 3- and 4-leaflet patients. Baseline echocardiographic variables (i.a. TR grade, EROA, vena contracta, tricuspid annulus diameter) were also similar between groups. Safety endpoints included intervention duration, renal failure, bleeding complications as well as right coronary artery complications and in-hospital death and were also not significantly different. While TR grade distribution at baseline did not reach a significant difference between 3- and 4-leaflet patients (p=0.083), numerically more patients with 4-leaflets presented with torrential TR (48.6% versus 27.3%) and still had residual TR grade >3 at discharge (52.8% vs. 27.3%, p=0.018). Efficacy with TR reduction of >2 grades was similar between 3- and 4-leaflet patients (70.5% of 3-leaflet patients and 66.7% of 4-leaflet patients (p=0.451), Figure 2).