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• W2968320270 abstract "This article refers to ‘Aetiology-based clinical scenarios predict outcomes of transcatheter edge-to-edge tricuspid valve repair of functional tricuspid regurgitation’ by F. Schlotter et al., published in this issue on pages xxx. Tricuspid regurgitation (TR) affects > 1.6 million people in the United States and > 70 million people worldwide.1, 2 Approximately 90% of TR in adults is functional (secondary) due to (i) left-sided heart disease (valve disease or left ventricular dysfunction), (ii) pulmonary arterial hypertension (PAH), (iii) right ventricular (RV) dysfunction/chronic RV volume overload, or (iv) idiopathic [often associated with atrial fibrillation (AF)].3 The majority of patients have trivial or mild TR, which may be non-pathological. However, 1-year mortality increases with increasing severity of TR, reaching 36.1% in patients with severe TR.4 Despite the high prevalence of TR and its association with increased mortality, < 8000 tricuspid valve surgeries are performed annually, and the majority of patients are managed medically in the absence of another indication for cardiac surgery.5 Isolated tricuspid valve surgery accounts for only 20% of tricuspid valve interventions.6 To address this unmet clinical need, several less invasive transcatheter tricuspid valve therapies have emerged as an alternative to surgery in prohibitive- or high-risk patients with symptomatic severe TR.7 The off-label use of the MitraClip system (Abbott Vascular, Santa Clara, CA, USA) is the most commonly performed transcatheter tricuspid valve repair (TTVr) procedure, either for isolated severe TR or combined severe TR and severe mitral regurgitation (MR).8, 9 Several single-centre studies and multicentre registries of patients with severe TR treated with TTVr using the MitraClip system have demonstrated acute procedural success (defined as a 1-grade improvement in TR severity) rates of > 90%.9-12 Even a modest reduction in TR severity was associated with significant improvements in New York Heart Association (NYHA) functional class, 6 min walk distance, and quality of life in these studies. Mortality rates were 2.8%, 16%, and 37.5% at 1, 6, and 12 months, respectively.9-12 However, none of the prior studies have examined the association between aetiology of functional TR and outcomes after TTVr with MitraClip. In this issue of the Journal, Schlotter et al.13 report the procedural outcomes of 159 patients who underwent TTVr for severe functional TR stratified by four aetiology-based clinical scenarios (CS). All patients were in NYHA functional class II to IV and had severe TR according to current echocardiography guidelines based on qualitative (colour flow jet and diameter of the inferior vena cava), semiquantitative [vena contracta, proximal isovelocity surface area (PISA), hepatic vein flow], and quantitative [effective regurgitant orifice area (EROA), regurgitant volume by PISA, right atrial and RV sizes] parameters. Patients with restricted leaflet mobility due to pacemaker or implantable cardioverter-defibrillator leads, EROA > 1.5 cm2, or tricuspid valve coaptation gap > 15 mm were excluded. Using a stepwise approach, the authors categorized patients into four CSs: (i) Dialysis-CS for patients on chronic haemodialysis in whom TR is driven mainly by chronic RV volume overload, (ii) MR-CS for patients not on haemodialysis, with ≥ grade 3 MR (i.e. left-sided valve disease), (iii) PAPs-CS for patients not on haemodialysis and not meeting inclusion criteria for MR-CS, with invasively-determined pulmonary artery systolic pressure ≥ 50 mmHg (i.e. PAH), and (iv) Afib-CS for patients with history of atrial fibrillation/flutter.13 The primary endpoint was a composite of death, heart failure hospitalization, and reintervention. The median follow-up was 248 (interquartile range: 151–368) days. Of 159 patients who underwent TTVr, 11 (6.9%) were categorized into Dialysis-CS, 74 (46.5%) into MR-CS, 30 (18.9%) into PAPs-CS, and 44 (27.7%) into Afib-CS. Procedural success (defined as TR reduction ≥ 1 grade) rate was 88.7%, and was similar between the CSs (P = 0.38).13 Procedural success was associated with decreased rates of the primary endpoint (P < 0.001) and mortality (P = 0.03). In patients with successful TR reduction ≥ 1 grade, PAPs-CS was associated with significantly higher rates of the primary endpoint and heart failure hospitalization, compared with other CSs. On multivariable Cox regression analyses, in addition to procedural success, PAPs-CS was identified as an independent predictor of the primary composite endpoint [hazard ratio (HR) 2.01, 95% confidence interval (CI) 1.21–3.54, P < 0.01] as well as mortality (HR 3.16, 95% CI 1.44–6.91, P < 0.01).13 Mortality rate was highest in Dialysis-CS, and comparable to that in PAPs-CS (33.3% vs. 30.8%). MR-CS and Dialysis-CS had the highest rates of NYHA functional class improvement, whereas MR-CS and Afib-CS had significant gains in the 6 min walk test results.13 This elegant study by Schlotter et al.13 provides invaluable insights into the variable efficacy of TTVr in patients with different aetiologies of severe functional TR, and suggests that an aetiology-based classification system of functional TR may be useful in clinical practice in counselling patients about procedural benefit, as well as in selecting patients for future clinical trials. The findings of this study, although important, are not surprising. Among patients categorized into MR-CS, 93.2% also underwent concomitant transcatheter mitral valve repair (TMVr), thereby addressing the aetiology of functional TR.13 Severe TR is also an independent risk factor for worse outcomes in patients undergoing MitraClip for severe MR.14 Thus, addressing both MR and TR is likely to have an additive beneficial effect in reducing mortality and heart failure hospitalizations.15 On the contrary, TTVr alone does not address the underlying aetiology of severe functional TR in Dialysis-CS or PAPs-CS. Further, patients in Dialysis-CS were much sicker at baseline (median STS score 16.7%).13 Furthermore, severe TR correlates with PAH severity, and is independently associated with increased long-term mortality in patients with PAH, suggesting that the presence of severe TR is a marker of advanced PAH and poor prognosis.16 All these factors may explain the favourable outcomes in patients in MR-CS vs. those in PAPs-CS or Dialysis-CS.13 Idiopathic TR or functional TR caused by AF is a unique entity with a prevalence of 9.2%.17 Prior echocardiography studies have shown that the mechanism of TR in patients with AF involves marked tricuspid annular and RV basal dilatation, but RV length is normal (no conical deformation) and there is no leaflet tethering or tenting.17, 18 On the contrary, TR in patients with PAH is due to RV lengthening and eccentricity (elliptical-shaped right ventricle) resulting in tricuspid leaflet tethering and tenting.18 The implications of these findings in terms of the choice of tricuspid valve therapy (annuloplasty vs. edge-to-edge repair) remain unclear. In the current study by Schlotter et al.13 procedural success rates after TTVr were similar in patients categorized to Afib-CS or PAPs-CS; however, whether differences in outcomes are related to differences in RV reverse modelling following TTVr in these two aetiology-based CSs needs further investigation.19 Despite the limitations of the study including small sample size, potential selection bias, and unmeasured confounding, and the need for confirming the findings in larger, prospective cohorts, the aetiology-based classification system used by Schlotter et al. is an important step forward in our understanding of which group(s) of patients with severe functional TR may benefit the most from TTVr. Future studies should consider reporting outcomes of TTVr in subgroups of patients according to the aetiology of TR. Further investigations are needed to understand the mechanism or reasons underlying the variable benefit of TTVr across different aetiologies of functional TR. Conflict of interest: none declared." @default.
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• W2968320270 date "2019-08-13" @default.
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• W2968320270 title "Transcatheter edge‐to‐edge tricuspid valve repair for functional tricuspid regurgitation: does aetiology matter?" @default.
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• W2968320270 doi "https://doi.org/10.1002/ejhf.1588" @default.
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