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Two recent studies published in JACC: Cardiovascular Interventions focus on improved cardiac remodeling following transcatheter valve replacement (TTVR) and transcatheter valve annuloplasty (TTVA).
The first, a single-center, retrospective, shorter-term TTVR study conducted by Robin Le Ruz, MD, Rebecca T. Hahn, MD, FACC, et al., analyzed 80 TTVR patients (median age, 81; 65% women), 88% of whom had baseline massive/torrential tricuspid regurgitation (TR). The replacements (80% used the EVOQUE system) were a technical success in 90% of patients, and 96% presented with only mild or less TR post implantation.
Results at a median follow up of 40 days showed that TTVR was associated with a reduction in right ventricular (RV) end diastolic volume (EDV; 138.2 mL/m2 to 59.5 mL/m2; p<0.001) and increase in septal curvature and stroke volume, leading to a 65% increase in effective RVEF and 20% increase in RV coupling.
Additionally, this reduction in RVEDV was reciprocal with an increase in left ventricular (LV) EDV (49.6 mL/m2 to 57.9 mL/m2; p=0.001). Greater discordance of these two volumes at baseline, as indicated by an average eccentricity index (aEI) ≥1.25, led to greater reverse remodeling, lower follow-up NT pro-BNP levels and greater symptom improvement.
On the eccentricity index, the study authors write, “Our findings add to the growing literature supporting the use of multi-modality imaging to defining subpopulations of patients that may derive greater benefit from TTVR and by which shared decision-making about device choice could be made.”
In an accompanying editorial comment, Muhammed Gerçek, MD, and Felix Rudolph, MD, add that “Incorporating such imaging biomarkers into next-generation risk models could refine patient selection and predict tolerance to sudden afterload shifts.”
The second, longer-term TTVA study, by Caroline Hasse, MD, et al., followed 156 patients (median age, 79 years; 76% women; 89% with atrial fibrillation) undergoing TTVA for severe TR (27% with massive and 42% with torrential) using the Cardioband system. The procedure was successful in 62% of patients, and 37% still had severe or greater TR at discharge.
Results at a median follow-up of 435 days showed that 71% of patients had a TR reduction ≤2+, and 68% improved in NYHA functional class ≤III (p<0.001 for both) following TTVA. Compared with baseline, right atrial area (36.0 vs. 30.4 cm2), RV length (67.5 vs. 63.7 mm), RV midventricular dimension (42.6 vs. 35.6 mm) and RV basal dimension (47.8 vs. 42.6 mm) were all significantly reduced at follow-up (p<0.001 for all).

Torrential to severe TR reduction still led to remodeling (RV basal diameter, 50 vs. 44 mm; p=0.007) and additionally, right heart remodeling was associated with a decrease in vena contracta width (odds ratio, 1.14; p=0.015).
Hasse, et al., note that in the study, residual TR ≥3 at discharge was associated with an elevated mortality rate compared with TR <3 (26% vs. 13%; p=0.042). “Residual TR therefore must be taken seriously. Close clinical follow-up and the evaluation of further treatment options, such as staged edge-to-edge repair, should be carefully taken into consideration in this vulnerable ‘high-risk-cohort,’” they write.
While “the investigators should be commended for assembling a large cohort of patients treated with a single device and for providing a comprehensive clinical and echocardiographic evaluation,” write David Messika-Zeitoun, MD, PhD; Maurice Enriquez-Sarano, MD, FACC; and Julien Dreyfus, MD, PhD, in an accompanying editorial comment, they add that in addition to residual TR severity – procedural complexity, patient selection and timing of intervention all remain crucial concerns for future work.
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