Predictors of haemodynamic response to transcatheter tricuspid valve replacement for severe tricuspid regurgitation

Abstract Background Transcatheter tricuspid valve replacement (TTVR) is a novel therapy for symptomatic severe tricuspid regurgitation (TR) in patients unsuitable for conventional surgery or transcatheter edge-to-edge repair. While its safety and efficacy are increasingly reported, there remains a need to evaluate predictors of haemodynamic response and clinical outcomes. Aim The primary outcome was to determine predictors of haemodynamic response (echo derived cardiac index) to TTVR. Secondary outcomes included predictors of safety and efficacy including procedural complications, in-hospital MACCE and length of stay (LOS). Methods This retrospective observational analysis examined consecutive patients undergoing TTVR at a specialist tricuspid referral centre. All patients deemed suitable had cardiac-gated CT, transthoracic (TTE) and transoesophageal echocardiography (TOE); and an early (48hrs) post-TTVR TTE. Baseline characteristics, frailty score, procedural outcomes, in-hospital major adverse cardiovascular and cerebrovascular events (MACCE), and 30-day survival were reported. Favourable haemodynamic response was defined as an improvement in cardiac index (CI). Correlation and regression analyses were performed using baseline characteristics to identify predictors of haemodynamic response, procedural complications, in-hospital MACCE and length of stay. Results Between June and December 2024, 12 patients underwent TTVR. Mean age was 81 (±5) years, 58% were female, and 92% had permanent atrial fibrillation. 100% procedural success with ≤mild TR and mean transvalvular gradient 3.3 mmHg (±1.2). No patients required transfusion, emergency pacing, or conversion to surgery. 30-day survival was 100%. One patient (8%) experienced a transient ischemic attack, and another (8%) required a new permanent pacemaker. All patients were discharged on warfarin, with a median hospital LOS of 14 days (IQR 11-16). Non-invasive right ventricular-pulmonary artery coupling at baseline (tricuspid annular plane systolic excursion/pulmonary artery systolic pressure - TAPSE/PASP) was the strongest predictor of haemodynamic response (increase in CI), r=0.47, β = 1.57, p = 0.04. Elevated baseline frailty score (CHSA) (β = -0.45, p = 0.04) and post-TTVR non-invasively PASP (β = -0.33, p = 0.048) were both predictors of adverse post-procedural events. Furthermore, elevated baseline frailty score had positive correlation with procedural complications (p = 0.02) and hospital LOS (r = 0.51, p = 0.02). Conclusion This study demonstrates the safety and efficacy of TTVR. Important findings were as follows: non-invasive RV-PA coupling is an important predictor of favourable haemodynamic response in this cohort with post procedure elevated PASP a predictor of adverse events post procedure. Baseline frailty remained a key determinant of outcomes and length of stay highlighting its importance of measuring and incorporating frailty in procedural risk stratification.TAPSE/PASP vs CI