Impact of body mass index in patients with tricuspid regurgitation after transcatheter edge-to-edge repair

Clinical Research in Cardiology https://doi.org/10.1007/s00392-023-02312-2 ORIGINAL PAPER Impact of body mass index in patients with tricuspid regurgitation after transcatheter edge‑to‑edge repair Johanna Vogelhuber1 · Tetsu Tenaka1 · Mitsumasa Sudo1 · Atsushi Sugiura1 · Can Öztürk1 · Refik Kavsur1 · Anika Donner1 · Georg Nickenig1 · Sebastian Zimmer1 · Marcel Weber1 · Nihal Wilde1 Received: 1 July 2023 / Accepted: 14 September 2023 © The Author(s) 2023 Abstract Background Obesity and underweight represent classical risk factors for outcome in patients treated for cardiovascular disease. This study describes the impact of different body mass index (BMI) categories on 1-year clinical outcome in patients with tricuspid regurgitation (TR) undergoing transcatheter-edge-to-edge repair (TEER). Methods We analyzed 211 consecutive patients (age 78.3 ± 7.2 years, 55.5% female, median EuroSCORE II 9.6 ± 6.7) with tricuspid regurgitation undergoing TEER from June 2015 until May 2021. Patients were prospectively enrolled in our single center registry and were retrospectively analyzed. Patients were stratified according to body mass index (BMI) into 4 groups: BMI < 20 kg/m2 (underweight), BMI 20.0 to < 25.0 kg/m2 (normal weight), BMI 25.0 to > 30.0 kg/m2 (overweight) and BMI ≥ 30 kg/m2 (obese). Results Kaplan–Meier survival curves demonstrated inferior survival for underweight and obese patients, but comparable outcomes for normal and overweight patients (global log rank test, p < 0.01). Cardiovascular death was significantly higher in underweight patients compared to the other groups (24.1% vs. 7.0% vs. 6.3% vs. 6.4%; p < 0.01). Over all, there were comparable rates of bleeding, stroke and myocardial infarction. Multivariable Cox regression analysis (adjusted for age, gender, coronary artery disease, chronic obstructive pulmonary disease, tricuspid annular plane systolic excursion, left-ventricular ejection fraction) confirmed underweight (HR 3.88; 95% CI 1.64–7.66; p < 0.01) and obesity (HR 3.24; 95% CI 1.37–9.16; p < 0.01) as independent risk factors for 1-year all-cause mortality. Conclusions Compared to normal weight and overweight patients, obesity and underweight patients undergoing TEER display significant higher 1-year all-cause mortality. * Nihal Wilde 1 Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg‑Campus 1, 53127 Bonn, Germany 13 Vol.:(0123456789) Clinical Research in Cardiology Graphical abstract Impact of body mass index in patients with tricuspid regurgitation after transcatheter edge-to-edge repair Severe, symptomatic tricuspid regurgitation, n = 211 TEER One year mortality p < 0.01 Cardiovascular death p < 0.01 11 (37.9%) 8 (11.3%) 6 (9.3%) 14 (29.8%) 7 (24.1%) 5 (7.0%) 4 (6.3%) 3 (6.4%) Normal Weight n = 71 (33.6%) 100% 79.4% 80% 70.5% 60% 63.9% 55.2% Overweight n = 64 (30.33%) Survival Underweight n = 29 (13.7%) Underweight Normal Overweight Obesity Underweight Normal weight Overweight Obesity 40% 20% Obesity n = 47 (22.27%) 100 • Underweight and obese showed increased risk of one year mortality • Underweight and obese showed inferior TR Reduction of ≥ 2 grades after TEER log-rank test p < 0.01 0% 0 Results 200 Follow up days 300 365 Keywords Tricuspid valve disease · Tricuspid regurgitation · Transcatheter edge-to-edge repair · Body mass index Abbreviations LVEF Left-ventricular ejection fraction LV Left ventricle MR Mitral regurgitation NYHA New York Heart Association RVFAC Right-ventricular fractional area change TAPSE Tricuspid annular plane systolic excursion TEER Transcatheter edge-to-edge repair TMVR Transcatheter mitral valve replacement TEE Transesophageal echocardiography TR Tricuspid regurgitation TTE Transthoracic echocardiography BMI Body mass index Introduction Tricuspid regurgitation is a common finding in routine practice as population-based studies showed that the prevalence of tricuspid regurgitation of any grade amounts to > 80% of the population, particularly affecting people at older age and of female gender [1, 2]. Consequently, and with regard to the elderly (> 70 years), a significant TR (moderate) was present in 1.5% of male and 5.6% of female patients, respectively [2]. Thus, clinically relevant TR can be anticipated in approximately 3 Mill. individuals in Europe and 13 1.5 Mill. individuals in the USA [2–4]. Moreover, prevalence of 3 moderate TR in patients with chronic heart failure and reduced left ventricular ejection fraction is even higher with approximately 26% [2, 5, 6]. The importance of TR for prognosis has long been underrated and treatment has subsequently been neglected in accordance with the initial recommendations to handle TR with optimal heart failure therapy [4, 7, 8]. However, numerous studies recently underlined congruently the negative impact of significant TR on morbidity and mortality if left untreated [4, 6, 9–13]. Underweight and obesity are known risk factors for adverse outcome in patients with cardiovascular diseases [14, 15]. With regard to valvulopathies, recent studies showed an increased morbidity and mortality for the overweight and obese patient cohort after transcatheter aortic valve replacement (TAVR) as well as for underweight patients after transcatheter edge-to-edge repair (TEER) for mitral regurgitation, respectively [16, 17]. Concerning the prognostic impact of significant TR for the clinical course, identification and characterization of relevant risk constellations have more recently come to the fore—especially in the light of selecting the suitable treatment strategy for each patient. In terms of patient selection, established scores for left-sided valvulopathies and/or CABG procedures such as STS Score and the EUROScore II are not validated and imprecise concerning accurate risk Clinical Research in Cardiology stratification of tricuspid valve procedures although still recommended for perioperative risk assessment especially in the elderly and high-risk population [18]. Currently, the TRISCORE is most frequently used to assess procedural risk for tricuspid valve procedures as it includes and addresses parameters of right heart failure such as impaired liver function as a result of an increased central venous backlog, daily dosage of diuretics and right heart failure signs [19, 20]. However, parameters such as frailty which are associated with adverse outcome and BMI are not included into this score. While defining frailty still remains vague and without a predefined gold standard, BMI acquisition and interpretation is simple to attain and less faulty. But up to now, little is known regarding the impact of underweight and obesity on the postinterventional course after edge-to-edge repair for significant symptomatic TR. Methods Study population This study was designed as a retrospective analysis of data from the Bonn registry, which is a prospective, consecutive collection of patient data from the H (...truncated)