Implications of tricuspid regurgitation and right ventricular volume overload in patients with heart failure with preserved ejection fraction

Abstract

AimsThe aim of this study was to assess the pathophysiological implications of severe tricuspid regurgitation (TR) in patients with heart failure with preserved ejection fraction (HFpEF) by using tricuspid transcatheter edge‐to‐edge repair (T‐TEER) as a model of right ventricular (RV) volume overload relief.Methods and resultsThis prospective interventional single arm trial (NCT04782908) included patients with invasively diagnosed HFpEF. The following parameters were prospectively assessed before and after T‐TEER: left ventricular (LV) diastolic properties by invasive pressure–volume loop recordings; biventricular time–volume curves and function as well as septal curvature by cardiac magnetic resonance imaging; strain analyses for timing of septal motion. Overall, 20 patients (median age 78, interquartile range [IQR] 72–83 years, 65% female) were included. T‐TEER reduced TR by a median of 2 (of 5) grades (IQR 2–1). T‐TEER increased LV stroke volume and LV end‐diastolic volume (LVEDV) (p < 0.001), without increasing LV end‐diastolic pressure (LVEDP) (p = 0.094), consequently diastolic function improved with a reduction in LVEDP/LVEDV (p = 0.001) and a rightward shift of the end‐diastolic pressure–volume relationship. The increase in LVEDV correlated with a decrease in RV end‐diastolic volume (p < 0.001) and LV transmural pressure increased (p = 0.028). Secondary to a decrease in early RV filling, improvements in early LV filling were observed, correlating with an alleviation of leftwards bowing of the septum (p < 0.01, respectively).ConclusionDiastolic LV properties in patients with HFpEF and severe TR are importantly determined by ventricular interaction in the setting of RV volume overload. T‐TEER reduces RV volume overload and improves biventricular interaction and physiology.

Letting go of restraint: Tricuspid valve intervention in heart failure with preserved ejection fraction

“…Furthermore, it lends insight into RV and LV interactions following TR reduction. 9 The findings build upon other early mechanistic descriptions of tricuspid valve (TV) repair and RV remodelling using transcatheter mitral repair devices, 10 but further adds an important characterization of LV function particularly in a population with LV diastolic impairment on baseline haemodynamics. The authors should be commended for their efforts.…”

“…We also do not know if a similar response would occur in HFpEF patients without marked pericardial restraint or more typical HFpEF haemodynamics (Figure 1). Secondly, while the authors note that 60% of patients enrolled at baseline had at least mild pulmonary hypertension with a pulmonary vascular resistance (PVR) >2 Wood units (WU), 9 the median PVR was <3 WU. This suggests that most patients did not have significant RV pressure overload as a cause of their functional TR.…”

“…In this issue of the Journal, Kresoja et al 9 examined physiologic mechanistic response to reduction in TR severity following T-TEER among patients with severe TR and HFpEF. The authors used single-beat LV pressure-volume analysis, cardiac magnetic resonance (CMR) imaging, and two-dimensional transthoracic echocardiography (TTE) to characterize right (RV) and LV pressure-volume relationships and interventricular dependence immediately before and 1 month after T-TEER.…”