Clin Res Cardiol (2023).

Prognostic Impact of Tricuspid Regurgitation Improvement after Transcatheter Mitral Valve Replacement: Results from an International Multicenter Registry
S. Ludwig1, A. Coisne2, W. Ben Ali3, J. Weimann1, B. Köll1, D. Kalbacher4, A. Duncan5, M. Akodad6, A. Scotti7, T. K. Rudolph8, G. Nickenig9, J. Hausleiter10, H. Ruge11, M. Adam12, A. S. Petronio13, N. Dumonteil14, L. Sondergaard15, M. Adamo16, D. Regazzoli17, A. Garatti18, T. Schmidt19, G. Dahle20, M. Taramasso21, T. Walther22, J. Kempfert23, J.-F. Obadia24, O. Chehab25, G. H. L. Tang26, M. Reardon27, N. Fam28, M. Andreas29, D. W. Muller30, P. Denti31, F. Praz32, M. Metra16, H. Reichenspurner33, S. Blankenberg1, A. Latib7, R. S. von Bardeleben34, J. F. Granada35, T. Modine36, L. Conradi33, für die Studiengruppe: CHOICE-MI
1Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg, Hamburg; 2CHU de Lille, Lille, FR; 3Montreal Heart Institute, Montréal, CA; 4Allgemeine und Interventionelle Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg, Hamburg; 5Royal Brompton Hospital, London, UK; 6St. Paul's Hospital, Vancouver, CA; 7Montefiore Medical Center, The Bronx, New York, US; 8Allgemeine und Interventionelle Kardiologie/Angiologie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen; 9Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn; 10Medizinische Klinik und Poliklinik I, LMU Klinikum der Universität München, München; 11Klinik für Herz- und Gefäßchirurgie, Deutsches Herzzentrum München, München; 12Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Köln; 13Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, University of Pisa, Pisa, Italien; 14Clinique Pasteur, Toulouse, FR; 15Rigshospitalet, Kopenhagen, DK; 16Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, IT; 17Humanitas Research Hospital, Mailand, IT; 18San Donato Hospital, Mailand, IT; 19Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Lübeck; 20Rikshopitalet Oslo, Oslo, NO; 21Klinik Hirslanden, Zürich, CH; 22Klinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Frankfurt, Frankfurt am Main; 23Klinik für Herz-, Thorax- und Gefäßchirurgie, Deutsches Herzzentrum Berlin, Berlin; 24Louis Pradel Hospital, Lyon, FR; 25St. Thomas' Hospital, London, UK; 26Mount Sinai Hospital, New York, US; 27Houston Methodist Hospital, Houston, US; 28St. Michael's Hospital, Toronto, CA; 29Medizinische Universität Wien, Wien, AT; 30St. Vincent's Hospital, Sydney, AU; 31San Raffele Hospital, Mailand, IT; 32Inselspital Bern, Bern, CH; 33Klinik und Poliklinik für Herz- und Gefäßchirurgie, Universitäres Herz- und Gefäßzentrum Hamburg, Hamburg; 34Zentrum für Kardiologie im Herz- und Gefäßzentrum, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz; 35Cardiovascular Research Foundation, New York, US; 36CHU de Bordeaux, Bordeaux, FR;

Background: Tricuspid regurgitation (TR) is a common bystander in patients with severe mitral regurgitation (MR). Transcatheter mitral valve replacement (TMVR) using dedicated devices is an alternative therapy for high-risk patients with MR and, by effectively eliminating MR, might also have an impact on TR severity.


Objectives: This study aimed to assess incidence and prognostic value of TR improvement after TMVR using data from an international multicenter registry.


Methods: The CHOICE-MI registry included consecutive patients with symptomatic MR treated with dedicated TMVR devices at 31 international centers. For this study only patients with available echocardiographic data on TR severity were included. TR improvement was defined as a reduction in TR at discharge by at least one grade compared to baseline. Residual MR and NYHA functional class were compared between patients with and without TR improvement. Kaplan-Meier estimates were calculated for the 2-year combined endpoints of all-cause mortality or cardiovascular (CV) mortality and heart failure (HF) hospitalization. Stepwise Cox regression adjusting for age, sex, LVEF, renal function, COPD and atrial fibrillation was applied to assess the prognostic impact of TR improvement. Independent predictors of TR improvement were derived from multivariable analysis.


Results: A total of 255 patients undergoing TMVR (age 76.0 years [IQR 71.0-81.0], 58.4% male, EuroSCORE II 6.2% [3.6, 12.1]) were included. TR severity at baseline was mild in 36.5% (N=93), moderate in 43.1% (N=110), severe in 18.0% (N=46), massive in 2.0% (N=5) and torrential in 0.4% (N=1). Following TMVR, 94 patients (36.9%) showed TR improvement by at least one grade, while TR did not improve in 161 patients (63.1%). Patients with TR improvement were younger than patients without TR improvement (75.0 years [IQR 69.9-79.1] vs. 78.0 years [IQR 73.0-82.0], p=0.0043) and worse right ventricular function (TAPSE 15.0mm [IQR 12.0-19.8] vs. 17.0mm [IQR 14.0-20.0], p=0.015), but there were no differences regarding MR severity, MR mechanism, LVEF and LV volumes. At discharge, MR was completely eliminated in the majority of patients regardless of TR improvement (89.4% vs. 86.1%, p=0.57). At 1-year follow-up, the rate of patients at NYHA class I was higher in patients with TR improvement compared to patients without TR improvement (41.4% vs. 24.1%, p=0.048). At 2 years, lower rates were found in patients with TR improvement for the combined endpoints of all-cause mortality of HF hospitalization (36.6% vs. 52.5%, p=0.067), and CV mortality of HF hospitalization (24.8% vs. 44.6%, p=0.039), compared to patients without TR improvement. After multivariate adjustment, TR improvement was independently associated with lower all-cause mortality or HF hospitalization (HR 0.59, 95%-CI 0.36-0.97, p=0.039) and CV mortality or HF hospitalization (HR 0.55, 95%-CI 0.31-0.99, p=0.046). In multivariable analysis, coronary artery disease (HR 0.52, 95%-CI 0.29-0.92, p=0.026) and TAPSE (HR 0.94, 95%-CI 0.88-0.99, p=0.019) were inversely predictive of TR improvement.


Conclusions: In this large real-world registry, improvement of TR was found in more than one third of patients with MR undergoing TMVR. TR improvement was an independent predictor of lower mortality and HF hospitalization and was associated with superior symptomatic benefit. These results support the need for echocardiographic follow-up of patients with TR after TMVR.