Clin Res Cardiol (2023). https://doi.org/10.1007/s00392-023-02180-w

Atrial functional tricuspid regurgitation: applying a novel definition to patients undergoing percutaneous tricuspid valve annuloplasty

J. von Stein1, P. von Stein2, D. Mehrkens2, C. Iliadis2, M. Gercek3, V. Rudolph3, S. Baldus1, R. Pfister2, M. I. Körber2

1Klinik für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin, Herzzentrum der Universität zu Köln, Köln; 2Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Köln; 3Allgemeine und Interventionelle Kardiologie/Angiologie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen;

Background: Secondary tricuspid regurgitation (TR) is associated with poor prognosis when left untreated. Atrial functional TR (atrial TR) has been recently recognized as a TR entity which can emerge in the absence of left-heart disease or pulmonary hypertension, primarily induced by annular remodeling. A novel echocardiographic-based definition of atrial TR has been published recently (tricuspid valve tenting height ≤10 mm, midventricular right ventricular diameter ≤38 mm and left ventricular ejection fraction ≥50%). Transcatheter tricuspid valve therapies have become an integral part of clinical routine. Among these, the Cardioband direct annuloplasty system obtained CE-Mark in 2019 for treatment of severe symptomatic functional TR. Methods: We retrospectively analyzed consecutive patients that underwent treatment with the Cardioband system in two high-volume centers in Germany (Heart Center Cologne and Bad Oeynhausen) between 2019 and 2022. 145 patients were included, whereof 54 patients had atrial TR according to the above-mentioned definition and 91 patients had non-atrial TR. Results: At baseline, patients with atrial TR had lower risk profiles (EuroSCORE II, P=0.018), lower NTproBNP levels (P=0.004), higher right ventricular fractional area change (P=0.007), lower right ventricular length (P=0.024), lower right atrial area (P<0.001), lower tricuspid annular size (P<0.001), lower effective regurgitation orifice area (P<0.001) and vena contracta width (P<0.001). TR severity at discharge and at 30-day-follow-up was lower in atrial TR compared to non-atrial TR (P=0.005 and P=0.001 respectively) but was significantly reduced in both groups compared to baseline (P<0.001). TR reduction by ≥2 grades was not significantly different between groups (P=0.19). Reduction of vena contracta width compared to baseline was significant in both groups (P<0.0001) without significant difference between groups (P=0.681). NYHA functional class equally improved in both groups after 30 days (P<0.0001) following transcatheter tricuspid valve annuloplasty (TTVA) with no significant difference between groups at 30 days (P=0.22). Estimated Kaplan-Meier 1-year-mortality was 6.4 % and 26.4 % for atrial and non-atrial TR respectively (P=0.027). Conclusion: Patients with atrial TR per definition show less signs of right ventricular remodeling and also present with less severe TR grade. Furthermore, atrial TR was associated with significantly lower 1-year mortality following TTVA, implicating the prognostic relevance of the novel echocardiographic-based definition of atrial TR. Still, patients with non-atrial TR show symptomatic improvement in the same extent compared to patients with atrial TR following TTVA, underscoring the symptomatic benefit of TTVA even in advanced disease progress.

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