Significance of Right Ventricular Myocardial Work for Clinical Improvement in Heart Failure with Reduced Ejection Fraction Patients after Transcatheter Edge-To-Edge Repair

Aims: It remains uncertain which patients would benefit the most from transcatheter edge-to-edge repair (TEER). We aim to investigate the relationship between right ventricular function, as assessed by pressure-strain loops (PSL), and post-TEER clinical improvement. Methods and results: A total of 48 heart failure with reduced ejection fraction (HFrEF) patients (68±15 yrs) with moderate-to-severe or severe SMR were enrolled for TEER. Impaired health status (Kansas City Cardiomyopathy Questionnaire Overall Summary Score [KCCQ-OS]) and exercise capacity (6-min walk distance [6MWD]) were evaluated at baseline and during 1-year follow up. Before and right after TEER, myocardial work (MW) metrics were non-invasively evaluated, including global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE). RV GLS, RVGWI, RVGCW, RVGWE were significantly increased after MitraClip treatment (-9.7±3.8%, 452.4±112.5 mmHg%, 596.3±127.5 mmHg% and 85.7±15.6% before vs -12.5±3.5%, 589.4±119.6 mmHg%, 778.8±135.3 mmHg% and 91.2±22.4% after MitraClip treatment, p = 0.025, 0.030, 0.025 and 0.037, respectively). The Kaplan-Meier estimates for survival, freedom from HF hospitalization at 12 months were 95.8% and 89.1%. On multivariable linear regression analysis, RVGWI and RVGCW immediate change was independently associated with KCCQ-OS (RVGWI: 3; = 0.40, P < 0.001; RVGCW: 3; = 0.39, P =0.003), RVGWI, RVGCW and RVGLS immediate change were independently associated with 6MWD improvement (RVGWI: 3; = 0.31, P = 0.029; RVGCW: 3; = 0.30, P = 0.039; RVGLS: 3; = 0.35, P = 0.041). Conclusion: RVMW was significantly increased after MitraClip treatment. And RV reserve function is an important predictor of clinical improvement in HFrEF patients with TEER. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial This is not a clinical trial study. ### Funding Statement Dr. Qinglan Shu received research grants from the Natural Science Foundation of Sichuan Province (2022NSFSC0662); Dr. Qingfeng Zhang received research grants from the Natural Science Foundation of Sichuan Province (2023NSFSC0641) ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: the institutional research and ethical committees of Sichuan Provincial People's Hospital I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data referred to this manuscript are available from the corresponding author (Yi Wang) upon reasonable request.