Impact of Transcatheter Tricuspid Valve Repair for Severe Tricuspid Regurgitation on Kidney and Liver Function

JACC: CARDIOVASCULAR INTERVENTIONS

VOL.

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ª 2019 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER

Impact of Transcatheter Tricuspid Valve Repair for Severe Tricuspid Regurgitation on Kidney and Liver Function Nicole Karam, MD, PHD,a,b Daniel Braun, MD,a Michael Mehr, MD,a,c Mathias Orban, MD,a,c Thomas J. Stocker, MD,a,c Simon Deseive, MD,a,c Martin Orban, MD,a,c Christian Hagl, MD,c,d Michael Näbauer, MD,a Steffen Massberg, MD,a,c Jörg Hausleiter, MDa,c

ABSTRACT OBJECTIVES The authors sought to determine the impact of transcatheter tricuspid edge-to-edge valve repair (TTVR) of severe tricuspid regurgitation (TR) on kidney and liver functions. BACKGROUND TR leads to impairment in renal and hepatic function, which is associated with worse prognosis. TTVR emerged as a treatment option for patients ineligible for cardiac surgery. However, no study has assessed the impact of TTVR on kidney and liver functions. METHODS All patients treated with TTVR in our center between March 2016 and June 2018 were included. Kidney and liver functions were compared at baseline, 30 days, and 6 months. RESULTS Over the study period, 126 patients were treated for TR (59 isolated TTVR and 67 TMTVR). Among them, 110 (87.3%) survived at 6 months. Among survivors, renal function remained stable, including among patients with moderate-to-severe chronic kidney disease (mean glomerular filtration rate 37.5 ml/min/1.73 m2 at baseline vs. 40.1 ml/ min/1.73 m2 at 6 months; p ¼ 0.39). Regarding liver function, a significant improvement at 6 months was only observed in the alanine transaminase level in the entire cohort (30.7 U/l vs. 24.9 U/l; p < 0.001). Among patients with abnormal baseline liver function, significant reductions in aspartate transaminase (50.5 U/l to 39.9 U/l; p ¼ 0.02) and bilirubin (1.8 mg/dl to 1.5 mg/dl; p ¼ 0.03) were also observed. CONCLUSIONS TR reduction by TTVR is associated with an improvement in liver function, mainly among patients with abnormal liver function at baseline, whereas kidney function remained stable. Accordingly, TTVR is an attractive option especially for patients presenting with severe TR and liver dysfunctions, who are at even higher surgical risk compared with patients who still have normal organ functions. (J Am Coll Cardiol Intv 2019;-:-–-) © 2019 by the American College of Cardiology Foundation.

T

ricuspid regurgitation (TR) is associated with

(3,4). Concurrently, alterations of renal and hepatic

right-heart venous congestion and reduced

functions are associated with a worse prognosis

forward stroke volume, which contributes

among patients presenting with TR and heart

to renal dysfunction among patients with heart fail-

failure (5,6).

ure (1,2), and leads to perturbations in hepatic func-

Conventional tricuspid treatment with cardiac

tion, through the so-called cardiohepatic syndrome

surgery is associated with hemodynamic impairment

From the aMedizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany;

b

European Hospital Georges Pompidou (Cardiology Department) and Paris Cardiovascular Research Center

(INSERMU970), Paris, France; cMunich Heart Alliance, Partner Site German Center for Cardiovascular Disease (DZHK), Munich, Germany; and the dHerzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Munich, Germany. Dr. Karam has received consultant fees from Abbott Vascular. Dr. Braun has received speakers honoraria from Abbott Vascular. Dr. Mehr has received travel grants from Bristol-Myers Squibb. Dr. Näbauer has received speakers honoraria from Abbott Vascular and Edwards Lifesciences. Prof. Hausleiter has received research support and speakers honoraria from Abbott Vascular and Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received February 11, 2019; revised manuscript received April 10, 2019, accepted April 11, 2019.

ISSN 1936-8798/$36.00

https://doi.org/10.1016/j.jcin.2019.04.018

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Kidney and Liver Function After Transcatheter Tricuspid Repair

ABBREVIATIONS

during cardiopulmonary bypass, which might

status, patients in this study were assessed in a

AND ACRONYMS

interfere with interpretation of the early ef-

compensated stable status in a standardized manner,

fect of tricuspid repair on kidney and liver

that is, after diuretic treatment and not in a hyper-

functions.

volemic state.

ALT = alanine transaminase AST = aspartate transaminase CKD = chronic kidney disease Gamma-GT = gammaglutamyl transpeptidase

GFR = glomerular filtration rate

LVEF = left ventricular ejection fraction

MR = mitral regurgitation

Transcatheter

edge-to-edge

tricuspid valve repair (TTVR) for severe TR

The indication for the combined transcatheter

has emerged as a treatment option for pa-

mitral and tricuspid valve repair (TMTVR) was the

tients ineligible for cardiac surgery (7–10).

presence of severe biventricular heart failure attrib-

Improvement in renal function has previ-

uted to severe regurgitation of these valves. In this

ously been described after mitral valve edge-

case, concomitant severe MR was treated in a first

to-edge repair in patients with severe mitral

step, followed by TR treatment.

regurgitation (MR) and chronic kidney dis-

Procedural

technique

has

been

previously

ease (CKD) (11–13). However, no study has

described (17). The edge-to-edge valve repair system

assessed the impact of TTVR, either isolated

was introduced through the right femoral vein to ac-

Association

or in combination with mitral valve repair, on

cess the tricuspid valve. Clip placement was guided

TMTVR = transcatheter mitral

kidney function and liver function.

using a sequential combination of transesophageal

NYHA = New York Heart

We tested the hypothesis that TTVR will

and transgastric multiplane 2-dimensional views, as

TR = tricuspid regurgitation

result in an improvement in kidney and liver

well as multiplane 2-dimensional transthoracic views

TTVR = transcatheter tricuspid

functions at 30 days and 6 months among

for clip steering and leaflet grasping. Pre-procedural

valve repair

patients presenting with severe TR.

diuretic dose was recommended not to be reduced

and tricuspid valve repair

during the first 3 months after the procedure. All pa-

METHODS

tients provided written informed consent.

All patients undergoing tricuspid repair using the edge-to-edge repair technique (MitraClip; Abbott Vascular, Santa Clara, California) between March 2016 and June 2018 at the Munich University Hospital were included in the study. Patients had an initial assessment at baseline, at 30 days, and a 6-month follow-up with blood tests performed at each time point.

STUDIED VARIABLES. Analyzed variables included

demographic characteristics (age and sex), patient history and risk factors (diabetes, hypertension, previous transcatheter mitral valve repair or mitral valve surgery, known coronary artery disease, presence of pacemaker or implantable cardioverter-defibrillator leads), clinical status (STS [Society of Thoracic Surgeons] mortality score, atrial fibrillation, NYHA

PATIENT SELECTION AND PROCEDURAL TECHNIQUE.

functional class, and loop diuretic equivalent dose),

Patient

previously

echocardiographic data (type and severity of TR,

described (14). In brief, patients were referred to

selection

criteria

have

been

severity of MR, and left ventricular ejection fraction

TTVR if they presented with severe right-sided heart

[LVEF]), and procedural data (number of clips

failure (New York Heart Association [NYHA] func-

implanted and TR at discharge). Clinical and echo-

tional class III to IV, peripheral edema, ascites,

cardiographic characteristics were assessed at base-

pleural effusion, jugular vein distension, and/or fa-

line, 30-day, and 6-month follow-up.

tigue) despite optimal medical therapy and were

Technical success was defined as placement of at

deemed inoperable by the heart team. Grading of TR

least 1 clip in the tricuspid valve. Procedural success

was performed using echocardiography according to

was defined as a successful implantation of the clip

American and European guidelines for quantification

device and a post-procedural TR of grade 2þ or less.

of native valves regurgitations. Evaluation of TR

Kidney function was assessed using the serum

comprised coaptation gap width, vena contracta

creatinine

width, TR volume, and effective regurgitant orifice

glomerular filtration rate (GFR). According to the

area according to the proximal isovelocity surface

National Kidney Foundation recommendations, CKD

area method, inferior vena cava width, and presence

was classified as mild (CKD stage 1 or 2 for GFR

of systolic flow reversal in hepatic veins. The syn-

of $60 ml/min/1.73 m2), moderate (CKD stage 3 for

thesis of all available parameters led to a grading of

GFR of 30 to 59 ml/min/1.73 m 2), or severe (CKD stage

TR comprising 4 stages: mild (1þ), moderate (2þ),

4 and 5 for GFR <30 ml/min/1.73 m 2). Patients

severe (3þ), and massive (4þ) (14). The parameters of

requiring renal replacement therapy at baseline were

right ventricular size and function were measured in

excluded from the 30-day kidney function analysis.

and

urea

levels,

and

the

estimated

the apical 4-chamber view according to current

Liver function was assessed using aspartate trans-

guidelines (15,16). Because echocardiographic pa-

aminase (AST), alanine transaminase (ALT), gamma-

rameters are highly dependent on current fluid

glutamyl transpeptidase (Gamma-GT), and bilirubin

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levels. Abnormal values were defined according to international standards. Abnormal AST level was

Karam et al. Kidney and Liver Function After Transcatheter Tricuspid Repair

F I G U R E 1 Evolution of Abnormal Kidney and Liver Function at 6 Months According to

the Type of Procedure

defined by an AST level above 40 U/l, abnormal ALT level by an ALT level above 56 U/l, abnormal GammaGT level by a Gamma-GT level above 48 U/l, and an abnormal bilirubin level by a bilirubin level above 1.2 mg/dl. STATISTICAL ANALYSIS. Variables were described

using means and standard deviations for continuous variables, and counts and proportions for categorical variables. Mean baseline, 30-day, and 6-month values were compared in the global population using the chisquare test, paired Student t-test, or Wilcoxon test, as appropriate. Subgroup analyses were performed with an assessment of the evolution of kidney and liver functions among patients with abnormal baseline tests. Evolution of kidney and renal functions were separately assessed according to whether the patients underwent isolated TTVR or combined TMTVR. All p values were calculated using 2-sided tests, and a significance level of 0.05 was used to declare statistical significance. Statistical analyses were performed using R software version 3.5.1 (R Project for Statistical Computing, Vienna, Austria).

RESULTS Over the study period, 126 patients underwent TTVR for severe TR. Among them, 59 patients (46.8%) underwent isolated TTVR, and 67 patients (53.2%) underwent combined TMTVR (Figure 1). Their mean age was 77.2  9.5 years, and 50.8% were women. Most patients presented with functional TR (88.9%), with a TR grade $3 in 96.0% of cases and a MR grade $3 in 54.3%). Mean LVEF was 50.0  13.4%. NYHA functional class $III was present in 96.8%. Sixteen patients died within 6 months of the procedure, with a median time to death of 57.5 (26.0 to

Significant improvements in liver function were observed in the global population,

72.5) days. They were excluded from the primary

whereas renal function remained unchanged. When taken separately, patients presenting

analysis. Their mean age was 76.2  10.5 years, with

with isolated TTVR or combined TMTVR presented improvements in renal and liver

43.7% men. They presented with functional TR in 14

function, which did not reach the significance threshold, except for AST, among patients undergoing isolated TTVR. The height of the bar corresponds to the mean, and the

cases (87.5%), with a TR grade $3þ and an NYHA

error bars correspond to the standard deviation. AST ¼ aspartate transaminase; GFR ¼

functional class $III in all cases. Their mean LVEF

glomerular filtration rate; TMTVR ¼ transcatheter mitral and tricuspid valve repair;

was 47.6  15.7%. They had undergone simultaneous

TTVR ¼ transcatheter tricuspid valve repair.

mitral repair in 7 cases (43.7%). Their mean GFR was 52.5  25.1 ml/min/1.73 m 2, and 3 patients were on dialysis. They presented abnormal liver function with

except for a higher AST level among patients who

abnormal Gamma-GT (251.8  275.0 U/l) and bilirubin

died before 6 months (43.8 vs. 32.1 U/l; p ¼ 0.03).

(1.8  1.5 mg/dl) levels, whereas mean AST (43.8 

Baseline characteristics of patients who survived

23.7 U/l) and ALT (26.2  30.5 U/l) levels were normal.

until 6 months are presented in Table 1. Overall, 9

There was no difference in kidney and liver function

patients (8.2%) were on dialysis, 70 patients (69.3%)

tests between patients dead and alive at 6 months

presented with moderate-to-severe kidney disease,

3

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Kidney and Liver Function After Transcatheter Tricuspid Repair

T A B L E 1 Baseline Characteristics According to Procedural Type Among Patients Alive at 6 Months

n

Global Population (N ¼ 110)

TTVR (n ¼ 50)

TMTVR (n ¼ 60)

p Value

Demographics Age, yrs Female

110 110

77.4  9.4 57 (51.8)

76.9  11.3 28 (56.0)

77.7  7.4 31 (51.7)

0.67 0.54

Patients’ history Diabetes Hypertension Previous TMVR Previous MVR Known CAD Previous MI Previous PCI Previous CABG Previous PM/ICD

110 110 110 110 110 110 110 110 110

27 (24.5) 96 (87.3) 11 (10.0) 5 (4.5) 56 (50.9) 17 (15.4) 36 (32.7) 20 (18.2) 16 (14.5)

11 (22.0) 46 (92.0) 8 (16.0) 5 (10.0) 25 (50.0) 2 (4.0) 14 (28.0) 9 (18.0) 5 (10.0)

16 (26.7) 50 (83.3) 5 (8.3) 0 (0.0) 31 (51.7) 15 (25.0) 22 (36.7) 11 (18.3) 11 (18.3)

0.73 0.16 0.53 0.99 0.005 0.44 0.99 0.32

Patients’ characteristics STS mortality score NYHA III or IV Atrial fibrillation Loop diuretics dose

110 110 110 108

5.9  6.6 106 (96.4) 96 (87.3) 85.9  103.7

5.7  6.1 49 (98.0) 42 (84.0) 107.7  126.3

6.2  7.1 57 (95.0) 54 (90.0) 68.5  78.2

0.68 0.66 0.51 0.19

Echocardiographic data Functional TR TR $3þ MR $3þ LVEF, %

110 108 108 128

98 (89.1) 106 (96.4) 65 (60.2) 49.7  13.8

43 (86.0) 49 (98.0) 6 (12.5) 53.0  12.3

55 (91.7) 57 (95.0) 60 (100.0) 47.0  14.5

0.20 0.11 <0.001 0.02

Procedural data Number of clips TR #2þ at discharge

110 110

2.1  0.7 99 (90.0)

2.2  0.7 43 (86.0)

2.1  0.7 56 (93.3)

0.60 0.07

Renal function Dialysis GFR, ml/min/1.73 m2 Creatinine, mg/dl Urea, mg/dl

110 110 110 110

9 (8.2) 47.7  23.1 1.7  0.9 80.4  44.3

3 (6.0) 49.6  24.8 1.6  0.8 77.6  40.1

6 (10.0) 46.1  21.6 1.7  0.9 82.7  47.8

0.68 0.57 0.23 0.88

Hepatic function AST, U/l ALT, U/l Bilirubin, mg/dl Gamma-GT, U/l

108 108 100 106

32.1  13.0 24.8  38.6 1.2  0.7 149.8  128.2

32.4  11.9 20.4  10.6 1.2  0.6 158.5  120.1

31.8  13.9 28.5  51.7 1.2  0.7 142.3  135.4

0.35 0.54 0.47 0.31

Values are mean SD or n (%). ALT ¼ alanine transaminase; AST ¼ aspartate transaminase; CABG ¼ coronary artery bypass graft; CAD ¼ coronary artery disease; GFR ¼ glomerular filtration rate; ICD ¼ implantable cardioverter-defibrillator; LVEF ¼ left ventricular ejection fraction; MI ¼ myocardial infarction; MR ¼ mitral regurgitation; MVR ¼ mitral valve replacement/ repair; NYHA ¼ New York Heart Association functional class; PCI ¼ percutaneous coronary intervention; PM ¼ pacemaker; STS ¼ Society of Thoracic Surgeons; TMVR ¼ transcatheter mitral valve repair; TR ¼ tricuspid regurgitation.

and 99 patients (90.0%) presented with abnormal

available for 78 patients (70.9% of survivors), with a

liver function.

median follow-up of 188 (172 to 203) days. Among

PROCEDURAL RESULTS. At least 1 clip was implan-

ted in all patients, with a mean number of clips of 2.1  0.7. A primarily successful procedure with TR reduction to a grade #2þ was achieved in 99 patients (90.0%) (Table 1). Among patients with available data at 6 months (78

them, 67 (85.9%) had a TR grade #2þ. Right ventricular end-systolic and end-diastolic areas decreased over the study period (17.3 to 16.7 cm2; p ¼ 0.03, and 27.6 to 24.7 cm2 ; p ¼ 0.002, respectively). The other values remained stable (Table 2). EVOLUTION OF KIDNEY AND RENAL FUNCTION AT

patients), 54 patients (69.2%) presented with NYHA

6 MONTHS. There was no difference between base-

functional class #II. The diuretic loop equivalent

line and 30-day renal and liver function tests, except

dose remained stable over the study period (67.7 

for a reduction in the bilirubin level (1.2 vs. 1.0 mg/dl;

78.0 mg at baseline vs. 74.7  107.4 mg; p ¼ 0.99).

p ¼ 0.017).

Echocardiographic parameters at 6 months are

Among patients who survived at 6 months, renal

presented in Table 2. At 6 months, TR grade was

function tests remained stable, including among

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Kidney and Liver Function After Transcatheter Tricuspid Repair

T A B L E 2 Evolution of Echocardiographic Parameters Level

T A B L E 3 Evolution of Kidney and Liver Functions at 6 Months

at 6 Months n

Baseline*

6 Months*

p Value

n

Baseline*

6 Months*

p Value

TR $ 3þ

78

75 (96.2)

11 (14.1)

<0.001

Creatinine, mg/dl

74

1.5  0.6

1.8  1.5

0.08

LVEF, %

76

49.9  13.6

50.8  14.2

0.48

Urea, mg/dl

71

80.2  42.2

79.9  43.2

0.89

FAC, %

73

35.3  9.2

36.7  9.1

0.22

GFR <60 ml/min/1.73 m2

TAPSE, mm

73

17.4  4.9

16.4  4.4

0.20

76 50

50.7  21.8 37.5  11.9

49.8  21.9 40.1  17.3

0.45 0.39

74

17.3  7.1

16.7  9.1

0.03

RV end-diastolic area, cm

75

27.6  10.6

24.7  8.1

0.002

AST >40 U/l

RA area, cm2

71

36.5  12.8

35.3  13.8

0.11

74 12

30.9  11.1 50.5  9.5

38.4  46.3 39.2  9.4

0.19 0.02

ALT >56 U/l

76

30.7  11.1

24.9  23.8

<0.001

100.3

38 152.7  162.8 178.4  172.4

RV end-systolic area, cm2 2

Renal function tests†

Liver function tests

1

Values are n (%) or mean  SD. *Paired data. FAC ¼ fractional area change; RA ¼ right atrial; RV ¼ right ventricular; TAPSE ¼ tricuspid annular plane systolic excursion; other abbreviations as in Table 1.

patients with moderate-to-severe CKD (50 patients: mean GFR 37.5 at baseline vs. 40.1 ml/min/1.73 m2 at

Gamma-GT >48 U/l

74 59

145.3  132.6 174.2  133.8

Bilirubin >1.2 mg/dl

64

1.2  0.6

1.1  0.6

0.26

21

1.8  0.7

1.5  0.8

0.03

Values are mean  SD. *Paired data. †Patients requiring renal replacement therapy at baseline were excluded. Abbreviations as in Table 1.

6 months; p ¼ 0.39) (Table 3). Regarding liver function, a significant improvement was only observed in ALT level (30.7 U/l at

(90.0%), and 85.9% of survivors with available

baseline vs. 24.9 U/l at 6 months; p < 0.001). When

follow-up had a TR grade #2 at 6 months, with a

considering patients with abnormal liver function at

persistent improvement in NYHA functional class and

baseline, improvement was also observed in terms of

a reduction in right ventricular dimensions over the

AST and bilirubin, with a reduction in AST level from

study period. Improvements in liver function were

50.5 U/l to 39.9 U/l (p ¼ 0.02), and a reduction in bili-

observed, mainly among patients with abnormal liver

rubin level from 1.8 mg/dl to 1.5 mg/dl (p ¼ 0.03)

function

(Central Illustration). There was no significant decrease

remained stable.

in Gamma-GT levels over the study period (Table 3).

at

baseline,

whereas

kidney

function

TR leads to hemodynamic abnormalities that have been associated with both kidney and renal

ISOLATED TTVR VERSUS SIMULTANEOUS TMTVR.

disease. TR has been associated with decreased for-

Patients undergoing isolated TTVR versus combined

ward stroke volume and kidney perfusion, and with

TMTVR had similar baseline characteristics, except

increased right-sided filling pressure and venous

for lower rates of MR $3þ (12.5% vs. 100%; p < 0.001)

congestion. Similarly, TR leads to an elevation in

and previous myocardial infarction (4.0% vs. 25.0%;

right-sided filling pressures resulting in congestive

p ¼ 0.005), and a higher mean LVEF (53.0% vs. 47.0%;

hepatopathy,

p ¼ 0.02) in the isolated TTVR group. Mean GFR did

pressure, and decreased hepatic blood flow and

through

increased

hepatic

venous

not differ significantly between the 2 groups (49.6 ml/

arterial oxygen saturation (4). Several liver function

min/1.73 m 2 among patients undergoing isolated

tests abnormalities have been described in car-

TTVR vs. 46.1 ml/min/1.73 m 2 among those undergo-

diohepatic syndrome, with a predominant cholestatic

ing TMTVR; p ¼ 0.57). Liver function tests did not

enzyme profile (3,5,18). Bilirubin increase has been

differ between the 2 groups (Table 1).

most often described and is associated with increased

Among patients with abnormal kidney and liver

morbidity and mortality in patients presenting with

functions, there was a numerical improvement in

heart failure (5). It is also associated with worse out-

GFR, AST, and bilirubin in both groups, that only

comes after left ventricular assist device implantation

reached statistical significance with AST in TTVR

and cardiac transplantation (19,20).

(50.2 vs. 36.1 U/l; p ¼ 0.02).

The current availability of TTVR provides a minimally

DISCUSSION

0.86 0.75

invasive

option

for

treating

TR.

A

previous study assessing the impact of transcatheter edge-to-edge mitral valve repair on kidney function

Among 126 patients undergoing TTVR, either isolated

showed an improvement in renal function that was

or combined with mitral repair, 110 (87.3%) survived

mainly observed among patients with moderate to

at 6 months. Procedural success rate was high

severe CKD (GFR <60 ml/min/1.73 m 2) (11). However,

6

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Kidney and Liver Function After Transcatheter Tricuspid Repair

C E NT R AL IL L U ST R AT IO N Evolution of Kidney and Liver Function at 6 Months Among Patients With Abnormal Function at Baseline

GFR, ml/mn/1.73m2 60

AST, U/L 80

P = 0.39

Bilirubin, mg/dl 3

P = 0.02

P = 0.03

60 40

2

40

20

1 20

0

0

0 Baseline

6-Months

Karam, N. et al. J Am Coll Cardiol Intv. 2019;-(-):-–-.

Among patients with abnormal liver and kidney function at baseline, a significant improvement in liver function and a stabilization of renal function at 6 months can be expected after transcatheter tricuspid valve repair for severe tricuspid regurgitation. The height of the bar corresponds to the mean, and the error bars correspond to the standard deviation. AST ¼ aspartate transaminase; GFR ¼ glomerular filtration rate.

no data exist regarding the impact of TTVR on

efficacy of TTVR in achieving steady liver function

kidney and liver function. In our study, despite a

improvement.

stabilization in kidney function, TTVR was not

Chronic kidney and liver dysfunctions are associ-

associated with a significant improvement in kidney

ated with a worse outcome among heart failure pa-

function including those patients presenting with

tients and

moderate-to-severe CKD. Even though the low sam-

tricuspid repair or LVAD implantation (5,6). Mortality

ple size could have led to a lack of power to detect a

rate at 6 months was of 12.7, probably due to the

significant difference in kidney function, stabiliza-

disease severity of the patients included in this study,

tion of kidney function and of diuretics dose can be

who all presented with a prohibitive surgical risk.

considered as a positive outcome among those pa-

This mortality is close to what was found in the in-

tients with severe disease where the spontaneous

ternational TriValve registry that includes patients

disease

undergoing TTVR in 14 centers from Europe and

course

rather

includes

a

progressive

worsening.

among

patients

undergoing

surgical

North America (21). According to our study, TTVR

TTVR was also associated with an early improve-

seems safe, with a symptomatic improvement and a

ment in hepatic function with a reduction in bilirubin

right ventricular reverse remodeling, and might be a

at 1 month, and a further improvement at 6 months as

good option to slow, or potentially reverse, the pro-

shown by the reduction in bilirubin, ALT, and AST

gression of the disease. Indeed, the reduction in right

levels. These findings highlight both the reversibility

ventricular volumes observed in our study might

of TR-associated congestive hepatopathy and the

offer a further advantage beyond the reduction of TR

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Kidney and Liver Function After Transcatheter Tricuspid Repair

per se. Longer follow-up is needed to assess the

presenting with severe TR and kidney or liver dys-

impact of this improvement on right ventricular

functions, who are at even higher surgical risks

function and patients’ clinical status.

compared with patients who still have normal kidney

STUDY LIMITATIONS. Even though this study is the

first to assess the impact of TTVR on kidney and liver functions, several limitations have to be

and liver functions. Larger studies and longer followup are needed to assess the impact of kidney and liver function improvement on patients’ prognosis.

acknowledged. First, despite the relatively large sample size for a TTVR series, the absolute number

ADDRESS FOR CORRESPONDENCE: Prof. Jörg Haus-

of patients included remained low, which probably

leiter, Medizinische Klinik I, Ludwig-Maximilians-

accounted for a lack of power to provide evidence

Universität München, Marchioninistraße 15, Munich,

for significant improvements in liver and kidney

Germany

tests, particularly in subgroup analyses, despite

uni-muenchen.de. Twitter: @nickaram.

81377.

E-mail:

joerg.hausleiter@med.

showing nonsignificant improvements in several laboratory values. Second, we had no laboratory data regarding factor V and albumin levels for the assessment of liver function. However, it has been demonstrated that among patients presenting with cardiohepatic

syndrome,

bilirubin

is

the

most

important prognostic factor (5). Third, several patients were only referred to our center for their intervention, but had their follow-up performed in

PERSPECTIVES WHAT IS KNOWN? Tricuspid regurgitation (TR) leads to impairment in renal and hepatic function, which is associated with a worse prognosis. WHAT IS NEW? TR reduction by transcatheter tricuspid valve repair (TTVR) is associated with an improvement in liver function

their referring centers, leading to an incomplete

and at least a stabilization of kidney function. Accordingly, TTVR

follow-up in those patients.

is an attractive option for patients presenting with severe TR and kidney or liver dysfunctions, who are at even higher surgical risk compared with patients who still have normal kidney and liver

CONCLUSIONS

functions.

TR

reduction

by

TTVR

is

associated

with

an

improvement in liver function, mainly among patients with abnormal liver function at baseline, whereas kidney function remained stable. Accord-

WHAT IS NEXT? Larger studies and longer follow-up are needed to assess the impact of kidney and liver function improvement on patients’ prognosis.

ingly, TTVR is an attractive option for patients

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