Based on the presentation by Nadira Hamid (Minneapolis Heart Institute Foundation, MN), at PCR London Valves 2024.
Key messages
- Improved quality of life: Treatment of severe tricuspid regurgitation (TR) with the TriClip significantly improves quality of life, independent of right ventricular (RV) size or function
- Reverse RV remodeling: Effective reduction of TR leads to reverse RV remodeling and increased stroke volume
- Therapeutic objective: Obtaining a minimal residual TR or trace (trace/mild) is crucial to optimize clinical benefits
Introduction
The TRILUMINATE study demonstrated at ACC 2023 that transcatheter edge-to-edge repair (TEER) of the tricuspid valve with the TriClip device (Abbott) is superior to medical treatment alone in improving quality of life and reducing hospitalizations for heart failure (HF). At the London Valves 2024 PCR, echocardiographic analysis demonstrated favorable changes in right ventricular remodeling and systolic function after TEER, providing a pathophysiological explanation for the benefits observed in patients.
Study design
Population studied: 285 patients with severe TR treated with TEER in the TRILUMINATE trial.
73% had RV dilation (indexed basal diameter ≥ 24.5 mm) and 25% had moderate to severe RV dysfunction, assessed by TAPSE or FAC.
Evaluation criteria: Reverse RV remodeling, assessed by reduction of end-diastolic diameter (RVEDD). Changes in stroke volume, measured at the RV outflow tract. Reduction in TR grades and impact on quality of life (KCCQ questionnaire).
Follow-up duration: Results analyzed at 1 year.
Results
Quality of life: Treatment with TriClip improved quality of life, even in patients with severe dilatation or advanced RV dysfunction. Gains were greater in patients with significant RV dilation.
Figure 1 : Study endpoint: the impact of right ventricular dilation on quality of life
Reverse RV remodeling: Patients with minimal residual TR (trace/mild) at 1 year had a significant reduction in RVEDD compared to those with severe residual TR. An improvement of at least two grades in TR was associated with maximum reductions in RVEDD.
Figure 2 : Study endpoints: reverse remodeling and residual leak grade
Impact of the VD function: Despite the lack of a clear association between RV dysfunction and HF hospitalizations or mortality, data suggest that reducing TR improves overall RV systolic parameters.
Figure 3 : Study endpoint: the impact of right ventricular systolic function on hospitalization for heart failure and death from all causes
Figure 4 : Study endpoint: the impact of right ventricular dilatation on hospitalization for heart failure and death from all causes.
Conclusion
Treatment of severe TR with TEER and the TriClip device not only improves patients’ quality of life, but also induces significant RV reverse remodeling and increased stroke volume. These data reinforce the idea that the therapeutic goal should be maximal reduction in TR, ideally to trace or minimal levels.
Comments after the session live from London
Importance of reducing TR: Obtaining minimal residual TR seems to be the key objective to promote reverse remodeling and improve clinical parameters.
Dysfonction VD : Although TAPSE and FAC have limitations for assessing RV function, other tools, such as MRI or 3D ultrasound, could better quantify the impact of interventions on the RV.
Perspectives futures : Ancillary studies using advanced modalities, such as RV-pulmonary artery (VD-PA) coupling analysis, could shed more light on the mechanisms underlying the observed benefits.
Practical recommendations: The TriClip may be considered even in patients with significant RV dilation or dysfunction, unlike complete replacement valves, which appear to require more caution in patients with severe RV dysfunction.
This presentation reinforces the idea of a clinical benefit to tricuspid repair, with an improvement in right ventricular function as an intermediate criterion. Many questions are still unanswered, and numerous studies are still necessary for a better understanding, particularly in the timing of intervention.
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