Tricuspid edge-to-edge repair for tricuspid valve prolapse and flail leaflet: feasibility in comparison to patients with secondary tricuspid regurgitation

European Heart Journal - Cardiovascular Imaging (2024) 25, 365–372 https://doi.org/10.1093/ehjci/jead264 ORIGINAL PAPER Varius Dannenberg 1, Philipp E. Bartko1*, Martin Andreas 2, Anna Bartunek3, Arseniy Goncharov 4, Muhammed Gerçek 4, Kai Friedrichs4, Christian Hengstenberg 1, Volker Rudolph 4*, and Maria Ivannikova4 1 Department for Internal Medicine II, Cardiology, Medical University of Vienna, Vienna, Austria; 2Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria; 3Department of Cardiovascular, Cardiac, Thoracic and Vascular Anesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria; and 4Clinic for General and Interventional Cardiology/ Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany Received 13 July 2023; revised 6 September 2023; accepted 13 October 2023; online publish-ahead-of-print 20 October 2023 Aims Transcatheter tricuspid edge-to-edge repair (T-TEER) has gained widespread use for the treatment of tricuspid regurgita tion (TR) in symptomatic patients with high operative risk. Although secondary TR is the most common pathology, some patients exhibit primary or predominantly primary TR. Characterization of patients with these pathologies in the T-TEER context has not been systematically performed. ................................................................................................................................................... Methods Patients assigned to T-TEER by the interdisciplinary heart team were consecutively recruited in two European centres over and results 4 years. Echocardiographic images were evaluated to distinguish between primary and secondary causes of TR. Both groups were compared concerning procedural results. A total of 339 patients were recruited, 13% with primary TR and 87% with secondary TR. Patients with primary TR had a smaller right ventricle (basal diameter 45 vs. 49 mm, P = 0.004), a better right ventricular function (fractional area change 45 vs. 41%, P = 0.001), a smaller right (28 vs. 34 cm2, P = 0.021) and left (52 vs. 67 mL/m2, P = 0.038) atrium, and a better left ventricular ejection fraction (60 vs. 52%, P = 0.005). The severity of TR was similar in primary and secondary TR at baseline (TR vena contracta width pre-interventional 13 ± 4 vs. 14 ± 5 mm, P = 0.19), and T-TEER significantly reduced TR in both groups (TR vena contracta width post-interventional 4 ± 3 vs. 5 ± 5 mm, P = 0.10). These findings remained stable after propensity score matching. Complications were similar between both groups. ................................................................................................................................................... Conclusion T-TEER confers equally safe and effective reduction of TR in patients with primary and secondary TR. * Corresponding author. E-mail: (P.E.B.); (V.R.) © The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Tricuspid edge-to-edge repair for tricuspid valve prolapse and flail leaflet: feasibility in comparison to patients with secondary tricuspid regurgitation 366 V. Dannenberg et al. Graphical Abstract Keywords tricuspid regurgitation • primary leaflet defects • edge-to-edge repair Introduction Tricuspid regurgitation (TR) is a common disease with high morbidity and mortality.1,2 In an overall cohort, significant TR was detected echocardio graphically in 6% of all patients, of which 92.6% were secondary TR and 7.4% were primary TR.3 Secondary TR can be differentiated according to its underlying condition, resulting from left heart disease, right ventricu lar (RV) disease, pulmonary hypertension, or atrial dilatation.4,5 There are many reasons for primary TR. Common causes are endocarditis, cardiac implantable electronic device (CIED) leads, or rheumatic heart dis ease.4,6,7 Similar to mitral valve prolapse, the tricuspid valve (TV) may also prolapse, resulting in significant TR.8 Current guidelines implemented recommendations for concomitant TV surgery in patients undergoing left heart valve surgery. For isolated TR, recommendations for surgery are generally stronger for primary TR than for secondary TR.9,10 Interventional procedures for transcatheter tricuspid edge-to-edge repair (T-TEER) are increasingly performed and could show promising results in recent studies.11–13 European guidelines implemented a IIb in dication for transcatheter repair for patients with symptomatic severe secondary TR for inoperable patients in experienced heart valve centres. Current guidelines do not recommend interventional therapy in patients with primary TR.9,10 Nevertheless, in clinical routine approved by the multidisciplinary heart team, T-TEER is often performed in inoperable patients with primary TR. These procedures have shown promising re sults in individual cases but have yet to be described in larger cohorts.14 This study focuses on T-TEER in patients with primary TR induced by leaflet defects. The main aims are to elaborate (i) the number of patients with primary leaflet defects in an all-comer cohort of T-TEER patients, (ii) their clinical characteristics compared with patients with secondary TR, and (iii) the feasibility of T-TEER and the post-procedural reduction of TR compared with patients with secondary TR. Methods Study population Patients assigned to T-TEER were recruited at the Medical University of Vienna (Austria) and the Clinic for General and Interventional Cardiology/Angiology at the Heart & Diabetes Center NRW in Bad Oeynhausen (Germany) between September 2018 and December 2022 in a post hoc analysis of a prospective cohort. The multidisciplinary heart team approved each procedure ac cording to current guidelines and careful risk stratification. Pre-procedural Edge-to-edge repair in patients with primary tricuspid regurgitation. TR, tricuspid regurgitation. ................................................................................................................................................... 367 TEER for tricuspid valve prolapse and flail leaflet and peri-procedural echocardiographic images were evaluated, and pa tients were divided into those with secondary TR and those with primary TR. Patients with mixed aetiology were assigned to the respective group according to the predominant TR mechanism. Both groups were analysed, and the results were compared. The Ethics Committee of the Medical University of Vienna (1386/2019) and the Ruhr University Bochum (AZ 2023-1018) approved the study protocol. All patients consented to participate. Echocardiographic assessment Procedural characteristics Transcatheter tricuspid (...truncated)