Outcomes similar for men, women after transcatheter tricuspid valve intervention
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Key takeaways:
- Sex does not impact procedural success or survival outcomes after transcatheter tricuspid valve intervention.
- A new metric with sex-specific cutoff values could better predict 2-year survival after intervention.
Men and women with severe tricuspid regurgitation have similar rates of procedural success and 2-year survival after transcatheter tricuspid valve intervention, despite significant differences in cardiac volumetrics and comorbidities.
“Although female sex is generally recognized as a risk factor for hospital mortality and is, thus, included in surgical risk scores used by interdisciplinary heart teams, no study to date has investigated the impact of sex on survival prediction after transcatheter tricuspid valve intervention,” Volker Rudolph, MD, of the department of general and interventional cardiology at Ruhr University Bochum, Germany, and colleagues wrote in the study background. “Do sex-related differences in the prevalence of comorbidities and the etiology of tricuspid regurgitation affect the procedural success of transcatheter tricuspid valve intervention and, hence, influence survival?”
Image: Adobe Stock
Assessing differences by sex
In a post hoc analysis of prospectively collected data, Rudolph and colleagues assessed clinical characteristics and outcomes of 702 patients with severe tricuspid regurgitation who underwent transcatheter tricuspid valve intervention (TTVI; 55% women; mean age, 78 years; 31.2% with massive tricuspid regurgitation). The primary outcome was all-cause mortality at 2 years.
The findings were published in JACC: Cardiovascular Interventions.
Within the cohort, the overall 2-year survival rate was 67%, with 50% of deaths occurring within 9.72 months after TTVI.
Researchers observed sex-based differences in the underlying etiology of tricuspid regurgitation. Men in the cohort were more often diagnosed with CAD than women (52.9% vs. 35.5%; P = 5.6 x 10-6). The underlying etiology for tricuspid regurgitation in men was predominantly secondary ventricular (64.6% in men vs. 50% in women; P = 1.4 x 10-4), whereas women more often presented with secondary atrial etiology (41.7% in women vs. 24.4% in men; P = 2 x 10-6).
However, when assessing 2-year survival, men and women had similar outcomes, with rates of 69.9% in women vs. 63.7% in men (P = .144). In multivariate regression analysis, dyspnea expressed as NYHA functional class (HR per increasing class = 1.5; 95% CI, 1.1-2; P = .007), tricuspid annulus plane systolic excursion (TAPSE; HR per 1 mm = 0.95; 95% CI, 0.92-0.98; P = .004) and mean pulmonary artery pressure (mPAP; HR per 10 mm Hg = 1.2; 95% CI, 1.1-1.5; P = .008) were independent predictors for 2-year mortality.
“Men and women undergoing TTVI for severe tricuspid regurgitation differ in comorbidities, etiology and volumetric status; yet, procedural success rates and survival following TTVI were similar between sexes,” the researchers wrote. “In fact, our study reveals that male patients tend to have higher mortality rates after TTVI, which can be at least partially attributed to the higher prevalence of CAD and subsequent impairment of left ventricular systolic function and dilatation of left-sided heart chambers as similarly described in patients with secondary mitral regurgitation undergoing transcatheter edge-to-edge repair.”
Researchers found that the prognostic significance of TAPSE and mPAP differed between sexes and assessed right ventricular-pulmonary arterial coupling expressed as TAPSE/mPAP to identify sex-specific thresholds to best predict survival. In those analyses, women with a TAPSE/mPAP ratio less than 0.612 mm/mm Hg displayed a 3.43-fold increased HR for 2-year mortality (P < .001), whereas men with a TAPSE/mPAP ratio less than 0.434 mm/mm Hg displayed a 2.05-fold increased HR for 2-year mortality (P = .001).
“The TAPSE/mPAP ratio is a better predictor for 2-year survival after TTVI than the TAPSE/[systolic]PAP ratio,” the researchers wrote. “Moreover, sex-specific thresholds bear the potential to improve prognostication, guide future timing of intervention, and/or optimize patient selection.”
Validation among all-comers needed
In a related editorial, Georg Nickenig, MD, PhD, and Atsushi Sugiura, MD, PhD, of University Hospital, Bonn, Germany, wrote that, given the inherent selection bias for TTVI, researchers must investigate the value and predictive power of TAPSE/mPAP in an all-comers population with tricuspid regurgitation.
“Only then could this parameter be used in the guidance of patient selection and the timing of intervention,” Nickenig and Sugiura wrote. “Finally, although TAPSE is easily reproducible and the most frequently assessed marker of RV function in clinical practice, this parameter is modestly correlated with RV ejection fraction. Four-dimensional cardiac CT or cardiac MRI for quantifying RV contractility and its response to TTVI should also be investigated according to sex in future studies.”
The authors wrote that further investigations are needed to guide clinicians on how these insights can influence decision-making in clinical practice.
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