Prognostic significance and determinants of persistent right atrial pressure elevation following transcatheter tricuspid valve replacement

Background While transcatheter tricuspid valve replacement (TTVR) improves quality of life and reduces heart failure hospitalization (HFH) in patients with symptomatic severe tricuspid regurgitation (TR), a considerable residual risk of cardiovascular events remains. Purpose We sought to evaluate whether estimated right atrial pressure (RAP) assessed by transthoracic echocardiography (TTE) after successful TTVR can stratify the risk of cardiovascular events and to identify the determinants of persistent RAP elevation. Methods A total of 119 consecutive patients underwent TTVR at our institution between 2018 - 2025. After excluding patients who died within 30 days (n = 9) or had unavailable TTE data (n = 2), 108 patients were included in the analysis. RAP was estimated with TTE 30 days after TTVR based on inferior vena cava diameter and collapsibility, classified as 3, 8, 15, and 20 mmHg. Patients were stratified into 2 groups: low RAP (3 or 8 mmHg, n = 47) and high RAP (15 or 20 mmHg, n = 61). Kaplan-Meier analysis with a 30-day landmark was performed for the composite of cardiovascular death or HFH, and event rate were compared using the log-rank test. Logistic regression was also performed to identify baseline predictors of high RAP following TTVR. Results Mean age was 74.8 years, and 57% were female. Patients with high RAP after TTVR was more likely to be male, have ascites, higher TRI-SCORE, higher dose of diuretics, lower albumin and hemoglobin levels, and a greater prevalence of left ventricular ejection fraction (LVEF) < 50%, and basal RV diameter > 49 mm. On right heart catheterization, these patients exhibited higher RAP, higher mean pulmonary artery pressure, and higher post-capillary wedge pressure with lower pulmonary artery pulsatile index (PAPi), compared with those with low RAP after TTVR. The 1-year cumulative incidence of the composite of cardiovascular death or HFH was significantly higher in patients with high RAP compared with those with low RAP (23.9% vs. 6.1%, log rank P = 0.009) (Figure). Even after restricting the analysis to patients with baseline RAP of 15 or 20 mmHg, the results showed a consistent directional trend (19.0% vs. 9.7%, log rank P = 0.19). On multivariable logistic regression, LVEF < 50% (Odds ratio [OR] 5.94), severe RV dilatation (OR 2.65), and lower PAPi (OR 0.62) were significant determinants of high RAP following TTVR. Conclusions More than half of patients had residual elevated RAP 30 days after successful TTVR. Reduced LVEF, severe RV dilatation, and lower PAPi at baseline were associated with residual elevated RAP. Patients with residual elevated RAP experienced significantly higher rates of cardiovascular death or HFH compared with those without residual RAP elevation. These findings may facilitate post-procedural risk stratification and guide therapeutic optimization after TTVR.