Impact of Tricuspid Regurgitation in Mitral V-in-V

The coexistence of mitral regurgitation (MR) and tricuspid regurgitation (TR) presents a therapeutic dilemma. While surgery is often the preferred course of action, it might not be viable, especially in patients with prior CABG, which makes the transcatheter strategy a valid option. 

Even though this might be the solution, some questions remain unanswered. Firstly, it is still unclear what patients will see improved TR after mitral valve treatment; secondly, what the extent and duration of such improvement is still uncertain; thirdly, there are few long term studies (they mostly measure one-year outcomes); and finally, the impact of TR on mortality or hospitalization for cardiac failure has not yet been fully clarified.  

This analysis included 4,938 TR patients receiving mitral Valve-in-Valve (MVIV). 2,107 (42,7%) had trivial or mild TR, 1,792 (36,3%) moderate, and the rest severe or greater TR. 

All patients received MVIV with SAPIEN 3, SAPIEN 3 Ultra or SAPIEN 3 Ultra RESILIA.

Primary end point was all cause mortality at 3 years.

≥ Severe TR patients were older, mostly women, with atrial fibrillation, definite pacemaker, implantable cardioverter-defibrillators (ICDs), kidney function deterioration, worse functional class, prior cardiogenic shock, worse quality of life, elevated BNP, and increased right atrial and pulmonary pressure.

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Procedural success was 97%, with no differences between groups. 

In-hospital mortality was higher among ≥ severe TR patients vs. moderate or trivial/mild TR (4.8% vs. 3.2% vs. 2.2%; P = 0.0005), at one year (18.2% vs. 14.1% vs. 10.7%; P < 0.0001) and at 3 years (39.9% vs. 29.8% vs. 27.2%, respectively).

Because populations were quite heterogeneous, patients were match with propensity score, leaving 951 patients in each group. Primary end point resulted higher among ≥ sever e TR patients vs. moderate or trivial/mild (39.4% vs. 31.3%, P = 0.003 and 39.4% vs. 27.7%, P = 0.005, respectively). There were no differences between trivia/mild TR patients and moderate TR patients. 

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After 30 days, patients were also propensity score matched to compare trivial/mild TR against ≥ severe TR patients, and no differences were found in mortality. 

Improved 30-day TR was associated with lower mortality, vs no change or worsening. 

Conclusion

Residual 30-day severe or greater tricuspid regurgitation that will not improve or progress after MVIV, has been associated with a significant increase of all-cause death at 3 years. These findings highlight the negative impact of severe tricuspid regurgitation in multivalve disease and identify early high risk patients that could benefit from early catheter-based tricuspid interventions. 

Original Title: Tricuspid Regurgitation and 3-Year Mortality After Transseptal Mitral Valve-in-Valve Replacement. 

Reference: Kashish Goel, et al. JACC Cardiovasc Interv. 2025;18:1438–1449.