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• W3013239960 abstract "This article refers to ‘Nutritional status in tricuspid regurgitation: implications of transcatheter repair’ by C. Besler et al., published in this issue on pages 1826–1836. The presence of significant tricuspid regurgitation (TR) is directly associated with morbidity and mortality,1 and there is a graded association of more severe TR with worse prognosis.2 Previously, it has been speculated that TR was rather a secondary sign than a serious pathology in itself, and the attention was drawn toward the treatment of underlying conditions, e.g. heart valve disease and heart failure.3-5 Recent data have challenged the concept of only targeting the left heart by showing that a reduction of TR, particularly by transcatheter tricuspid valve edge-to-edge repair (TTVR), may reduce mortality and rehospitalization.6 Regrettably, it is unclear how to best define those patients who benefit most from TTVR. This question, however, is of paramount importance as significant TR is a common condition, affecting more than 2% of individuals over the age of 75, and has recently even been referred to as a “public health crisis”.7 In this issue of the Journal, Besler et al.8 present the results of their single-centre experience with TTVR and how procedural success was related to changes in nutritional status at follow-up. Nutritional status before and after treatment was assessed by the Mini Nutritional Assessment (MNA) questionnaire. An MNA score increase of at least 1 point was considered as an improvement. The high prevalence of patients already malnourished (15%) or at risk for malnutrition (79%) prior to the intervention, as well as the reported 6-month mortality of 28% in the overall cohort illustrate the frailty of patients who are currently treated at reference centres for TTVR. Procedural success, defined as a TR reduction of at least one grade at 1-month follow-up was achieved in the majority of patients. Also, MNA scores mostly improved after 1 month, and better scores were associated with better results in quality of life and functional capacity as assessed by 6-min walking distance. Improvements in MNA scores were accompanied by improved serum levels of blood urea nitrogen, cholinesterase, bilirubin, and protein. Unchanged or even declined nutritional status after TTVR was linked to more frequent hospitalizations for heart failure and poorer survival. The authors conclude that the nutritional status can be applied as a new patient-centred marker to judge procedural success and to monitor outcome of TTVR. Instruments such as the MNA might give insights into the complex multi-organ pathophysiological process associated with right heart failure. The vicious cycle initiated by right heart dilatation and severe TR can lead to peripheral oedema, ascites, pleural effusion, cardiac cirrhosis, renal failure, and malnourishment due to chronic congestion of the liver, the kidneys, and the intestine (Figure 1). Previous work has shown a connection between elevated right atrial pressures, increased bowel wall thickness, and cardiac cachexia.9 In heart failure patients, malnourishment is associated with poor physical function and high mortality.10, 11 It is of magnificent importance to define when to intervene in this cascade – and when it is too late. At the same time, a holistic general internal evaluation of these frail patients is mandatory, as TR can also be a secondary finding in renal failure with central volume overload, or in primary liver disease leading to hepatopulmonary syndrome with concomitant pulmonary hypertension. The study by Besler and coworkers8 very elegantly shows that, by relieving the right ventricle through a (modest) reduction in volume overload, significant improvements in exercise capacity and nutritional status in sick and frail patients are achievable. The authors are to be congratulated for their timely and innovative investigation. However, a few issues need consideration. Patients treated with TTVR for isolated severe TR and patients receiving TTVR immediately after transcatheter mitral valve repair (TMVR) due to concomitant TR may suffer from fundamentally different pathologies. Any analysis should therefore be carried out separately. In the present study,8 50% of patients underwent TMVR + TTVR. It has so far not been assessed whether patients undergoing TMVR also benefit with regard to nutritional status. Due to the small size of this cohort, a solid differentiation between patients who underwent TMVR + TTVR and those with only TTVR was not possible. Evaluation of patients receiving a TTVR procedure needs standardization. This applies for pre-, intra-, and postprocedural quantification of TR, right heart size and function, as well as pre-procedural haemodynamic assessment. Some degree of pulmonary hypertension is present in the vast majority of patients presenting with significant TR. It is currently unclear to what extent pulmonary hypertension impacts procedural success and which cut-off limits indicate an increased risk of right heart failure after TTVR. In any case, the presence of significant pulmonary hypertension indicates a poor prognosis and should therefore be known before intervention. The TRILUMINATE study excluded patients with systolic pulmonary artery pressure >60 mmHg as estimated by transthoracic echocardiography (TTE).12 However, especially in patients with severe TR, TTE estimates of systolic pulmonary artery pressure can be false-low due to pressure equalization between the right ventricle and the right atrium, and should not be relied on. Therefore, a complete invasive haemodynamic assessment should always precede TTVR. In addition, thorough pre-interventional echocardiography is mandatory. The size of the coaptation defect as well as valve anatomy determine the interventional strategy. Standardization of TR grading is essential, especially for comparability of TTVR success.13 Available semiquantitative two-dimensional parameters, as well as gradation of right ventricular size and function via TTE all have significant limitations.14 The routine application of three-dimensional echocardiography might be the missing link and should be considered in these patients.15 At this stage, any pooled data on TTVR are of great interest due to the rare data available. However, in future studies it seems inevitable to strictly divide between the different aetiologies of TR to create homogeneous cohorts. Presence and absence of significant pulmonary hypertension needs to be reported. Cohorts with atrial functional and ventricular functional TR as well as with and without concomitant left heart valve disease need to be analysed separately. Tricuspid regurgitation is more than a ‘valve disease’ but a central puzzle piece in the complex vicious cycle of right heart decompensation and failure. It seems that with TTVR cardiology has a new technique at hand to influence the detrimental course of these patients. Patient selection is key, though, and this is where the focus needs to be in the near future. Conflict of interest: none declared." @default.
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• W3013239960 date "2020-03-25" @default.
• W3013239960 modified "2023-09-23" @default.
• W3013239960 title "Improvement in nutritional status – a determinant of successful transcatheter tricuspid valve repair?" @default.
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• W3013239960 doi "https://doi.org/10.1002/ejhf.1794" @default.
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