Invasive Hemodynamics and Risk Stratification in T-TEER: Moving Beyond ESC Thresholds

Background Right heart catheterization (RHC) plays a pivotal role in the preprocedural evaluation of patients considered for transcatheter tricuspid edge-to-edge repair (T-TEER). This study aimed to explore the potential impact of hemodynamic parameters obtained through RHC on patients-centered outcomes. Clinical Trial Registration Information EuroTR registry (European Registry of Transcatheter Repair for Tricuspid Regurgitation; NCT06307262, https://clinicaltrials.gov/study/NCT06307262 ) Methods This study represents a subanalysis from the multicenter EuroTR registry. Patients with invasive hemodynamic data who underwent isolated T-TEER for significant tricuspid regurgitation were included. Outcomes of interest were a composite of 2-year all-cause death or hospitalization for heart failure (HFH) and a patient-centered composite of 6-month all-cause mortality, HFH, New York Heart Association (NYHA) class IV/worsening NYHA class compared to baseline. Secondary outcome included postprocedural New York Heart Association (NYHA) class improvement. Results 711 patients were included in the analysis. Two-year survival free from death and HFH was 63%. Optimal prognostic thresholds identified for death and HFH at 2 years were: mPAP ≥32 mmHg, PCWP ≥20 mmHg, PVR ≥5 WU. The early patient-centered composite outcome occurred in 25% of cases. PCWP ≥20 mmHg was independently associated with an early clinical deterioration (HR 2.77; 95% CI 1.47-5.28; p<0.001) and with 2-year death/HFH (HR 1.75; 95% CI 1.03-3.02; p=0.04). No invasive parameter was associated with residual TR ≥3+. NYHA class improved significantly throughout the follow up (p<0.001), although patients with elevated mPAP (p=0.04) or PCWP (p<0.01) experienced less symptomatic benefit. Conclusion In patients undergoing T-TEER, invasive hemodynamics —especially elevated PCWP— are independently associated with early patient-centered outcomes and late adverse clinical events. Despite overall improvement of the functional status and no impact on residual TR, patients with higher mPAP or PCWP benefit less. These findings support the role of comprehensive RHC in preprocedural risk stratification.