Beyond 2-Dimensional Echocardiography: A Novel Multiparametric Assessment of Right Ventricular Dysfunction in Transcatheter Tricuspid Valve Repair

Background: Right ventricular (RV) heart failure as assessed by RV to pulmonary artery coupling (RVPAc) is a prognostic marker in transcatheter tricuspid valve repair (T-TEER). However, quantification of RVPAc components by 2-dimensional (2D) echocardiography in patients with severe tricuspid regurgitation (TR) has significant limitations, and the traditional RVPAc parameter neglects the degree of volume overload/dilatation of the RV, which is another key clinical indicator for right ventricular dysfunction (RVD). Therefore, we aimed to assess RVD by a novel RVPAc parameter, including the 3 important drivers of RVD, for an improved prediction of 1-year mortality after T-TEER. Methods: We analyzed 262 patients undergoing T-TEER with complete 3D RV echocardiography and 1-year follow-up. Results: Increased 3D-RV end diastolic volume (3D-RVEDV: hazard ratio [HR], 1.85; 1.10-3.12; P = 0.020) and impaired RV free-wall longitudinal strain (RVFWLS: HR, 1.73, 1.02-2.92; P = 0.042) predicted 1-year mortality. A novel RVPAc parameter (RVFWLS/[3D-RVEDV∗sPAPinvasive]) including all 3 important drivers for RVD was developed, associating RVPA-uncoupling with a tripled risk for 1-year mortality (HR, 3.19, 1.7-6.0; P < 0.001). The novel RVPAc parameter significantly outperformed the traditional noninvasive RVPAc parameter in 1-year mortality prediction (C-index: 0.68 vs 0.57 for novel vs traditional noninvasive RVPAc; P = 0.027). Conclusions: The novel RVPAc parameter, integrating RV function, volume stress, and pressure stress is a powerful metric for RV failure and a superior predictor for survival post-T-TEER. Clinical Trial Registration: Data is based on the EveryValve Registry (ethical code number: 19-840). No further clinical Trial registration.