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Transcatheter pulmonary valve replacement reduces tricuspid regurgitation for certain patients
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In patients with postoperative right ventricular outflow tract conduit dysfunction and significant baseline tricuspid regurgitation, transcatheter pulmonary valve replacement appears to yield improvements in tricuspid valve function, according to recent findings.
In the study, researchers pooled data from three prospective, multicenter trials of patients (n = 300) who underwent catheterization to implant a transcatheter pulmonary valve (Melody, Medtronic) for RV outflow tract conduit dysfunction. Eligible patients underwent successful valve implantation and had the transcatheter pulmonary valve intact at hospital discharge.
The researchers collected and analyzed echocardiograms from the preprocedural assessment (baseline) period, predischarge and annual follow-up assessments out to 5 years. They evaluated tricuspid regurgitation annulus measurements from echocardiographic data from all three trials and tricuspid valve annulus dimensions from two of the included trials.
The researchers found that, at baseline, 10 (3.3%) patients were free of tricuspid regurgitation, whereas 213 (71%) had mild tricuspid regurgitation, 64 (21.3%) had moderate tricuspid regurgitation and 13 (4.3%) had severe tricuspid regurgitation. There was no difference between trials in the proportion of patients with significant tricuspid regurgitation.
Improvement shown
Of the 76 patients with significant baseline tricuspid regurgitation for whom echocardiographic data at discharge were available, 49 (64.5%) demonstrated acute improvements of one or more grades, and 42 had mild or less tricuspid regurgitation at hospital discharge (P < .001), according to the findings.
Of the 13 patients whose preimplantation tricuspid regurgitation was severe, all but two showed acute improvements after transcatheter pulmonary valve replacement. Improvements were observed in tricuspid regurgitation among patients of all diagnostic classifications, other than those with underlying pulmonary atresia with intact ventricular septum or pulmonary stenosis, the researchers wrote.
Overall, a decrease in tricuspid regurgitation from baseline to discharge was seen in 21% of patients, whereas 3.7% showed increases from no or trivial tricuspid regurgitation to mild tricuspid regurgitation or from mild tricuspid regurgitation to moderate tricuspid regurgitation, according to researchers.
Improvement was more likely in patients with moderate or severe baseline tricuspid regurgitation vs. those without (P < .001), and patients who demonstrated improvement had higher preimplantation RV systolic pressure and more substantial RV pressure reductions vs. those who did not show improvement, the researchers wrote.
At 1 year, 24.2% of patients had a lower grade of tricuspid regurgitation vs. baseline, and significant tricuspid regurgitation was less prevalent vs. at baseline (13.8% vs. 25.7%; P < .001). Patients with moderate or severe tricuspid regurgitation at baseline had shorter post-transcatheter pulmonary valve replacement freedom from RV outflow tract reintervention, according to the results.
More study needed
In a related editorial, Jonathan Beaudoin, MD, of the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, department of medicine, Laval University, Québec, and colleagues wrote that these findings underscore the need for additional studies on the mechanisms and evolution of tricuspid regurgitation after transcatheter pulmonary valve replacement.
“Such studies will benefit from modern development in imaging technologies that allow precise assessment of 3-dimensional geometry of the tricuspid valve annulus and leaflets as well as RV dimensions and function,” Beaudoin and colleagues wrote. “The decision-making process with regard to the indication, type and timing of therapeutic management of concomitant [tricuspid regurgitation] in patients who are candidates for [pulmonary valve replacement] should weigh the likelihood of spontaneous [tricuspid regurgitation] improvement without intervention on the tricuspid valve, the likelihood of successful and durable tricuspid valve annuloplasty, and the surgical risk.” – by Jennifer Byrne
Disclosure: The studies from which the analysis was drawn were funded by Medtronic. Some researchers report financial ties with Medtronic. Please see the full study for a list of all the researchers’ relevant financial disclosures. The editorial writers report no relevant financial disclosures.
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