Clinical Research
Transcatheter Tricuspid Valve Intervention in Patients With Previous Left Valve Surgery

https://doi.org/10.1016/j.cjca.2021.02.010Get rights and content

Abstract

Background

Scarce data exist on patients with previous left valve surgery (PLVS) undergoing transcatheter tricuspid valve intervention (TTVI). This study sought to investigate the procedural and early outcomes in patients with PLVS undergoing TTVI.

Methods

This was a subanalysis of the multicenter TriValve registry including 462 patients, 82 (18%) with PLVS. Data were analyzed according to the presence of PLVS in the overall cohort and in a propensity score–matched population including 51 and 115 patients with and without PLVS, respectively.

Results

Patients with PLVS were younger (72 ± 10 vs 78 ± 9 years; p < 0.01) and more frequently female (67.1% vs 53.2%; P = 0.02). Similar rates of procedural success (PLVS 80.5%; no-PLVS 82.1%; P = 0.73), and 30-day mortality (PLVS 2.4%, no-PLVS 3.4%; P = 0.99) were observed. After matching, there were no significant differences in both all-cause rehospitalisation (PLVS 21.1%, no-PLVS 26.5%; P = 0.60) and all-cause mortality (PLVS 9.8%, no-PLVS 6.7%; P = 0.58). At last follow-up (median 6 [interquartile range 1-12] months after the procedure), most patients (81.8%) in the PLVS group were in NYHA functional class I-II (P = 0.12 vs no-PLVS group), and TR grade was ≤ 2 in 82.6% of patients (P = 0.096 vs no-PVLS group). A poorer right ventricular function and previous heart failure hospitalization determined increased risks of procedural failure and poorer outcomes at follow-up, respectively.

Conclusions

In patients with PLVS, TTVI was associated with high rates of procedural success and low early mortality. However, about one-third of patients required rehospitalisation or died at midterm follow-up. These results would support TTVI as a reasonable alternative to redo surgery in patients with PLVS and suggest the importance of earlier treatment to improve clinical outcomes.

Résumé

Contexte

Les données sont rares sur les patients ayant déjà été traités par une chirurgie valvulaire gauche (CVG) qui subissent une intervention sur la valve tricuspide par cathéter (TTVI, pour transcatheter tricuspid valve intervention). Cette étude visait à évaluer les résultats de la TTVI et les issues précoces chez les patients qui avaient auparavant subi une CVG.

Méthodologie

Il s’agissait d’une sous-analyse du registre multicentrique TriValve comptant 462 patients, dont 82 (18 %) ayant subi une CVG. Les données ont été analysées selon les antécédents de CVG dans la cohorte globale et dans une population appariée par score de propension composée de 51 et de 115 patients ayant et n’ayant pas subi de CVG, respectivement.

Résultats

Les patients ayant subi une CVG étaient plus jeunes (72 ± 10 contre 78 ± 9 ans; p < 0,01) et étaient en majorité de sexe féminin (67,1 % contre 53,2 %; p = 0,02). Des taux similaires d’intervention réussie (CVG antérieure : 80,5 %; sans CVG antérieure : 82,1 %; p = 0,73) et de mortalité à 30 jours (CVG antérieure : 2,4 %; sans CVG antérieure : 3,4 %; p = 0,99) ont été observés. Après appariement, il n’y a pas eu de différences significatives pour ce qui est des nouvelles hospitalisations toutes causes confondues (CVG antérieure : 21,1 %; sans CVG antérieure : 26,5 %; p = 0,60) et de la mortalité toutes causes confondues (CVG antérieure : 9,8 %; sans CVG antérieure : 6,7 %; p = 0,58). Au moment du dernier suivi (médiane de 6 mois [écart interquartile de 1 à 12] après l’intervention), la plupart des patients (81,8 %) du groupe CVG antérieure étaient dans les classes fonctionnelles I-II de la NYHA (p = 0,12 par rapport au groupe sans CVG antérieure) et le degré d'insuffisance tricuspidienne était ≤ 2 chez 82,6 % des patients (p = 0,096 par rapport au groupe sans CVG antérieure). Une moins bonne fonction ventriculaire droite et des antécédents d’hospitalisation pour insuffisance cardiaque déterminaient respectivement le risque d’échec de l’intervention et de piètres résultats au suivi.

Conclusions

Chez les patients ayant déjà subi une CVG, la TTVI a été associée à des taux élevés d’intervention réussie et à un faible taux de mortalité précoce. Toutefois, environ le tiers des patients ont dû être hospitalisés de nouveau ou étaient décédés à mi-parcours du suivi. Ces résultats indiquent que la TTVI serait une option raisonnable pour réopérer les patients ayant déjà subi une CVG, et tendent à démontrer l’importance d’un traitement plus précoce pour améliorer les issues cliniques.

Section snippets

Methods

The design of the TriValve registry has been published elsewhere.12 A total of 25 centers from Europe and North America participated in this registry. The study included patients with TR considered at increased surgical risk and referred for TTVI by each center. Grading of the severity of TR was assessed using a semiquantitative and quantitative assessment, as described previously.12 The transcatheter devices for TTVI included in the registry were: MitraClip (Abbott Vascular, Santa Clara, CA),

Results

A total of 462 patients that underwent TTVI from July 2014 to August 2019, 82 (18%) of them with PLVS, were included in the study. The main baseline and procedural characteristics along with the in-hospital outcomes are presented in Table 1. Patients with PLVS were younger (72 ± 10 years vs 78 ± 9 years, respectively; P < 0.01), more frequently female (67.1% vs 53.2%; P = 0.02), and less frequently presented previous myocardial infarction (3.7% vs 16.9%; P < 0.01). Patients with PLVS less

Discussion

The present study described, for the first time, the baseline characteristics and clinical outcomes of patients with PLVS undergoing TTVI. The main findings can be summarised as follows: 1) PLVS was present in one-fifth of patients undergoing TTVI; 2) patients with PLVS exhibited periprocedural (high procedural success, low in-hospital/30-day mortality) and late (mortality, rehospitalisation) outcomes similar to those without PLVS; 3) in PVLS patients, a poorer right ventricular function (as

Conclusion

In patients with PLVS, TTVI was associated with high rates of procedural success, low early mortality, and improved functional status, with no differences compared with no-PLVS patients. However, about one-third of patients required rehospitalisation or died after a median follow-up of 6 months, with poorer right ventricular function and previous heart failure hospitalisation determining an increased risk. These results would support TTVI as a reasonable alternative to redo surgery in patients

Funding Sources

Dr Rodés-Cabau holds the Research Chair “Fondation Famille Jacques Larivière” for the Development of Structural Heart Disease Interventions. Dr Muntané-Carol was supported by a grant from the Fundación Alfonso Martín Escudero (Madrid, Spain).

Disclosures

Dr Taramasso has served as a consultant for Abbott Vascular, Boston Scientific, 4Tech, and CoreMedic and received speaker honoraria from Edwards Lifesciences. Dr Gavazzoni has served as a consultant for Biotronik. Dr Latib has served on the advisory board for Medtronic and Abbott Vascular, on the Speakers Bureau for Abbott Vascular, on the scientific advisory board for Millipede, and as a consultant for 4Tech, Mitralign, and Millipede. Dr Braun has received speaker honoraria and travel support

References (27)

Cited by (4)

  • Tricuspid valve replacement: The old and the new

    2022, Progress in Cardiovascular Diseases
    Citation Excerpt :

    The most used approach for TTVI is transcatheter repair, with many devices under different phases of investigation, and with 3 of them being recently approved for commercial use in Europe (Triclip, Pascal and Cardioband). Although different studies from real world registries in high-risk population showed feasibility and promising initial results in different clinical settings,44,83–88 there are many patients who do not qualify for repair strategy and who could benefit from a catheter based TVR. Different replacement devices are under clinical and preclinical investigation (Figs. 1 and 2).

  • Potential Candidates for Transcatheter Tricuspid Valve Intervention After Transcatheter Aortic Valve Replacement: Predictors and Prognosis

    2021, JACC: Cardiovascular Interventions
    Citation Excerpt :

    In that study, the TriClip system offered a sustained reduction in TR severity up to 1 year, which translated to clinical improvement in terms of functional status and favorable mortality at 6 months and at 1 year (19,28). These results suggest the potential benefit of TTVI in patients exhibiting symptomatic moderate or greater TR after TAVR, although current evidence is limited in this specific population (29). First, more than 20% of patients were excluded because of inadequate echocardiographic images for the assessment of TR, which may have resulted in some degree of selection bias.

See editorial by Levi et al., pages 949–952 of this issue.

Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT03416166.

See page 1100 for disclosure information.

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