Prognostic significance and predictors of worsening functional class after transcatheter edge-to-edge tricuspid valve repair: insights from the TRI-SPA registry

Abstract Background New York Heart Association (NYHA) class trajectory could predict morbidity and mortality in patients with heart failure (HF)(1). Purpose The aim of this study was to evaluate the prognostic significance of worsening functional class in patients undergoing tricuspid transcatheter edge-to-edge repair (T-TEER) and to identify the predictors associated with this outcome. Methods This multicenter registry included patients who underwent T-TEER at 15 Spanish centers between June 2020 and January 2024. Patients were classified into two groups based on changes in their NYHA functional class: the NYHA-worsening (NYHA-w) group, which comprised patients with any baseline NYHA class who progressed to NYHA III or IV one year after the procedure, and the NYHA-improvement (NYHA-i) group, which included the remaining patients. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization (HFH) at 2 years. Secondary endpoints included all-cause mortality and HFH, assessed separately. Results Among the 245 enrolled individuals, 203 (82.9%) were assigned to the NYHA-i, and 42 (17.1%) were assigned to the NYHA-w group. At baseline, patients in the NYHA-w group exhibited more severe symptoms, greater systemic congestion, and a higher burden of comorbidities compared to those in the NYHA-i group, as well as suboptimal results following the intervention. No significant differences were observed in right heart catheterization values prior to the T-TEER procedure. With a median follow-up of 494 days (range: 364–717), patients with worsening NYHA functional class had significantly higher rates of the primary endpoint (40.5% vs. 11.9%; p 0.001, log-rank test), as well as higher rates of all-cause mortality (p = 0.001, log-rank test) and HFH (p = 0.001, log-rank test) when analyzed separately. NYHA worsening was identified as an independent predictor of the primary endpoint in multivariate analysis (Hazard Ratio HR 2.92, 95% Confidence Interval CI 1.10–7.80, p = 0.032). Chronic obstructive pulmonary disease (COPD), more severe heart failure symptoms, the presence of congestive parameters, a history of recurrent HFH, and residual TR ≥ 3+ were identified as predictors of a lack of improvement in NYHA functional class. Conclusions In conclusion, the lack of functional class improvement one year after T-TEER is associated with poor mid-term outcomes. Additionally, factors such as COPD, more severe heart failure, and suboptimal procedural results were identified as predictors of this lack of improvement.Primary endpoint Kaplan-Meier curves