Cardiologists examine how residual TR after transcatheter tricuspid valve repair impacts survival
Moderate-to-severe and severe residual tricuspid regurgitation (TR) after transcatheter tricuspid valve repair (TTV repair) are both associated with much lower survival rates, according to new findings published in JACC: Cardiovascular Interventions.[1]
The study’s authors noted that refining TR grade classification into more categories could help care teams anticipate adverse outcomes in advance and provide better patient care.
“We and others have shown that significant residual TR post–TTV repair is associated with a poor outcome,” wrote first author Julien Dreyfus, MD, PhD, an interventional cardiologist with Centre Cardiologique du Nord in France, and colleagues. “Interestingly, the current three-grade scheme (mild, moderate, and severe) recommended for the assessment of TR severity before and after interventions by the European and North American societies of cardiology contrasts with the four-grade scheme routinely used for mitral regurgitation (mild, mild to moderate, moderate to severe, and severe). We hypothesized that a more granular grading classification, similar to that of mitral regurgitation, may better define the prognosis of patients undergoing TTV interventions.”
Dreyfus et al. explored data from 613 patients who underwent TTV repair in one of 10 different countries. All data came from TRIGISTRY, a retrospective registry focused on adult patients presenting with severe isolated TR on a native valve. While 80% of patients included in the study underwent transcatheter edge-to-edge repair (TEER), the other 20% were treated with annuloplasty.
Overall, no or mild TR was seen in 33% of patients following treatment, moderate TR was seen in 52% and severe was seen in 15%. The two-year adjusted survival rates were 85%, 70% and 44%, respectively.
One of the biggest takeaways from the group’s research was the fact that subdividing patients with moderate TR into two distinct groups—mild to moderate and moderate to severe—the two-year adjusted survival rates were 80% and 55%, respectively.
“A major result of the present study is to highlight the limitations of the current three-grade scheme for the assessment of TR severity,” the authors wrote. “TR severity is a continuum, and it has been suggested to add at the right hand of the spectrum two additional grades: massive and torrential. We show that the left hand of the spectrum also deserves a more precise assessment of the severity of the regurgitation as routinely performed for mitral regurgitation. Indeed, moderate TR encompasses a wide range of TR severity with patients experiencing different outcomes, and subdividing the moderate grade into mild to moderate and moderate to severe as for mitral regurgitation further refined the prognosis of these patients.”
The group also emphasized that clinicians will be tasked with more and more decisions between TTV repair and transcatheter tricuspid valve replacement (TTVR) as time goes on. Improving how patients are evaluated following TTV repair will help cardiologists and other members of the heart team gain a better understanding of just how effective TTV repair is for patients who present with severe TR.
“Balancing safety, efficacy, durability, and predictability of procedural results will be imperative,” they concluded. “Our results underscore the need for directing effort toward technological advancements and operator expertise to optimize the procedural results of TTV repair.”
Another cardiologist’s perspective on residual TR data
Marta Sitges, MD, PhD, a cardiologist with Hospital Clinic of Barcelona, shared her own thoughts on the team’s analysis in a separate commentary piece that was also published in JACC: Cardiovascular Interventions.[2]
“These findings underscore the prognostic importance of effectively eliminating TR,” she wrote. “The authors merit recognition for their efforts to consolidate global experiences, enhancing our understanding of this field.”
However, Sitges added, there were certain limitations to the team’s research. The data was all retrospective, for example, meaning “the impact of residual confounders” need to be considered. Also, grading in TRIGISTRY was reported by each individual site and not independently reviewed.
Sitges also observed that the critical importance of eliminating TR suggests TTVR should be considered in eligible patients.
“The issue of repair vs. replacement is, nonetheless, more nuanced,” she wrote. “Although TV replacement has demonstrated safety and efficacy in eliminating TR, experience from surgical TV replacement suggest that the durability of right sided valves may be hindered by a high occurrence of functional stenosis, thrombosis, and early structural deterioration.”
Ultimately, she concluded, “our efforts should concentrate on repairing patients with TR before they reach an irreparable stage, aiming to achieve optimal results with mild residual TR at most.”
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.