Most Hospitalized Patients with Significant Tricuspid Regurgitation Have Advanced Disease Preventing Transcatheter Tricuspid Valve Intervention

Abstract

ABSTRACTBackgroundMore than moderate tricuspid regurgitation (TR) is associated with high mortality. Surgical tricuspid valve repair and replacements are rarely performed due to high operative mortality risk, mainly attributed to late presentation. Novel transcatheter tricuspid valve intervention (TTVI) devices are being developed as an alternative to surgery. The population of patients presenting to tertiary care centers who can benefit from TTVI has not been well defined. Our objective was to study the characteristics of these patients and to define the sub-population who may be candidates for TTVI.MethodsWe analyzed 12,677 consecutive 2D echocardiograms completed at our tertiary care center between March 2021 and March 2022 and identified 581 inpatients with more than moderate TR. Clinical and echocardiographic data were collected by individual chart review. The 2021 European Society of Cardiology (ESC) guidelines on the management of valvular disease are currently the only guidelines that include TTVI. We used these guidelines to retrospectively assign the 581 patients to medical therapy, surgery, or TTVI treatment.Results470 patients (80.9%) were assigned to medical therapy, 57 (9.8%) were assigned to TTVI, and 54 (9.3%) were assigned to tricuspid valve surgery. Of note, 76.2% (443/581) of patients were precluded from any intervention due to advanced disease or anatomic ineligibility, and only 4.6% (27/581) presented too early for intervention, being both asymptomatic and without RV dilatation.ConclusionOnly 9.8 percent of patients presenting to a tertiary care center with significant TR would be hypothetical candidates for TTVI when these technologies are approved in the United States. Earlier identification and treatment of TR could increase the number of patients who may benefit from interventions including TTVI.CLINICAL PERSPECTIVEWhat is New?Most patients presenting to a tertiary care center with significant TR are too advanced for any intervention and have high in-hospital and late mortality rates.Tertiary care centers planning to offer TTVI should expect that, based on the current ESC guidelines and late presentation of TR, approximately 10% of patients with more than moderate TR will be TTVI candidates.What are the clinical implications?There is a need to improve care for patients with TR through earlier detection and referral for intervention.Future clinical trials with longer follow up will be needed to assess TTVI devices in patients at earlier or even asymptomatic stages of TR when there may be a greater likelihood of improving survival.