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Impact of Tricuspid Regurgitation on Clinical Outcomes: The COAPT Trial.

by Asch, Federico M; Weissman, Neil J; Medvedofsky, Diego.
Citation: Journal of the American College of Cardiology. 76(11):1305-1314, 2020 Sep 15..Journal: Journal of the American College of Cardiology.Published: ; 2020ISSN: 0735-1097.Full author list: Hahn RT; Asch F; Weissman NJ; Grayburn P; Kar S; Lim S; Ben-Yehuda O; Shahim B; Chen S; Liu M; Redfors B; Medvedofsky D; Puri R; Kapadia S; Sannino A; Lindenfeld J; Abraham WT; Mack MJ; Stone GW.UI/PMID: 32912445.Subject(s): IN PROCESS -- NOT YET INDEXEDInstitution(s): MedStar Heart & Vascular InstituteActivity type: Journal Article.Medline article type(s): Journal ArticleOnline resources: Click here to access online Digital Object Identifier: https://dx.doi.org/10.1016/j.jacc.2020.07.035 (Click here) Abbreviated citation: J Am Coll Cardiol. 76(11):1305-1314, 2020 Sep 15.Local Holdings: Available online from MWHC library: 1995 - present, Available in print through MWHC library:1999-2007.Abstract: BACKGROUND: The presence of tricuspid regurgitation (TR) may affect prognosis in patients with mitral regurgitation (MR).Abstract: OBJECTIVES: This study sought to determine the impact of TR on outcomes in patients with heart failure and severe secondary MR randomized to guideline-directed medical therapy (GDMT) or edge-to-edge repair with the MitraClip in the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial.Abstract: METHODS: A total of 614 patients with symptomatic heart failure with moderate to severe (3+) or severe (4+) secondary MR were randomized to maximally tolerated GDMT plus MitraClip or GDMT alone; 599 had core laboratory evaluable echocardiograms. Patients were divided into 2 groups by baseline TR severity: none/trace/mild TR (<=Mild TR) (n = 501 [83.6%]) and moderate/severe TR (>=Mod TR) (n = 98 [16.4%]). Two-year composite endpoints of death or heart failure hospitalization (HFH) and the individual endpoints were analyzed.Abstract: RESULTS: Patients with >=Mod TR were more likely to be New York Heart Association functional class III/IV (p < 0.0001) and have a Society of Thoracic Surgeons score of >=8 (p < 0.0001), anemia (p = 0.02), chronic kidney disease (p = 0.003), and higher N-terminal pro-B-type natriuretic peptide (p = 0.02) than those with <=Mild TR. Patients with >=Mod TR had more severe MR (p = 0.0005) despite smaller left ventricular volumes (p = 0.005) and higher right ventricular systolic pressure (p < 0.0001). At 2 years, the composite rate of death or HFH was higher in patients with >=Mod TR compared with <=Mild TR treated with GDMT alone (83.0% vs. 64.3%; hazard ratio: 1.74; 95% confidence interval: 1.24 to 2.45; p = 0.001) but not following MitraClip (48.2% vs. 44.0%; hazard ratio: 1.14; 95% confidence interval: 0.71 to 1.84; p = 0.59). Rates of death or HFH, as well as death and HFH alone, were reduced by MitraClip compared with GDMT, irrespective of baseline TR grade (pinteraction = 0.16, 0.29, and 0.21 respectively).Abstract: CONCLUSIONS: Patients with severe secondary MR who also had >=Mod TR had worse clinical and echocardiographic characteristics and worse clinical outcomes compared to those with <=Mild TR. Within the COAPT trial, MitraClip improved outcomes in patients with and without >=Mod TR severity compared with GDMT alone. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [COAPT]; NCT01626079). Copyright (c) 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

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