Left-sided heart failure determines outcomes in patients with severe tricuspid regurgitation undergoing percutaneous repair

Abstract Background Severe tricuspid regurgitation (TR) is frequently associated with left-sided heart failure (HF), and both conditions contribute to a poor prognosis. Transcatheter tricuspid edge-to-edge repair (T-TEER) has emerged as a treatment option for patients with severe TR; however, the influence of left-sided HF on outcomes remains unclear. Purpose This study aimed to evaluate the impact of T-TEER across different left ventricular ejection fraction (LVEF) profiles. Methods Data from the European Registry of Transcatheter Repair for Tricuspid Regurgitation (EuroTR registry) were analyzed to assess the effect of LVEF on 1-year all-cause mortality following T-TEER. Patients were categorized into those with heart failure with reduced ejection fraction (HFrEF, LVEF 50%) and those with preserved LVEF (LVEF ≥50%). The latter group was further stratified based on pulmonary capillary wedge pressure (PCWP) into those with PCWP ≤15 mmHg (isolated right heart failure, iRHF) and those with PCWP 15 mmHg (heart failure with preserved ejection fraction, HFpEF). Results A total of 1,773 patients (mean age 79±7 years, 53% female) were included. Of these, 532 (30%) had HFrEF, while 1,241 (70%) had preserved LVEF. PCWP data were available for 582 patients (47%), with 213 (37%) classified as iRHF and 369 (63%) as HFpEF. Regardless of LVEF, New York Heart Association (NYHA) functional class improved in all groups (p0.001). Patients with HFrEF exhibited higher 1-year mortality compared to those with preserved LVEF (p log-rank=0.008, Figure 1A). Within the preserved LVEF group, HFpEF patients had poorer survival than those with iRHF (p log-rank=0.035, Figure 1B). Residual TR severity ≤II after T-TEER was comparable between HFrEF and HFpEF patients (78% vs. 83%) and highest in the iRHF group (87%, p=0.014). Conclusion The majority of patients undergoing T-TEER present with left-sided HF, with HFpEF being the most prevalent subtype. While functional improvements were observed across all subgroups, outcomes worsened as LVEF declined. Patients with iRHF demonstrated the highest procedural success rates and the lowest 1-year mortality, identifying for the first time a distinct cohort with a favourable response to therapy, warranting further investigation into its underlying pathophysiology.Figure 1A and 1B