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RV Function After Surgical and Transcatheter AVR
Study Questions:
What is the differential impact of surgical (SAVR) or transcatheter aortic valve replacement (TAVR) on right ventricular (RV) function, and the impact of RV dysfunction on outcomes?
Methods:
The investigators paired baseline and 30-day core laboratory echocardiograms in 1,376 patients from the PARTNER IIA study. Worsening RV function was defined as decline by at least one grade from baseline to 30 days. The primary outcome was all-cause mortality from 30 days to 2 years. Multivariable logistic regression was performed to assess associations with worsening RV function. Time-to-event curves for 30-day to 2-year mortality were created using the Kaplan–Meier estimates with between-group comparisons using the log-rank test.
Results:
Among 744 patients with TAVR, 62 (8.3%) had worsening RV function, compared with 156 of 632 patients with SAVR (24.7%) (p < 0.0001). In a multivariable model, SAVR (odds ratio [OR], 4.05; 95% confidence interval [CI], 2.55–6.44), a dilated RV (OR, 2.38; 95% CI, 1.37–4.14), and more than mild tricuspid regurgitation (TR) (OR, 2.58; 95% CI, 1.25–5.33) were associated with worsening RV function. There were 169 deaths, and patients with worsening RV function had higher all-cause mortality (hazard ratio [HR], 1.98; 95% CI, 1.40–2.79). This association remained robust after adjusting for clinical and echocardiographic variables. Among patients with worsening RV function, there was no mortality difference between TAVR and SAVR (HR, 1.16; 95% CI, 0.61–2.18). The development of moderate or severe RV dysfunction from baseline normal RV function conferred the worst prognosis (HR, 2.87; 95% CI, 1.40–5.89).
Conclusions:
The authors concluded that after AVR, worsening RV function is more common in patients with baseline RV dilation, more than mild TR, and in patients treated surgically.
Perspective:
This study reports that the odds for worsening RV function were more than four times greater for SAVR compared to TAVR. Worsening RV function was also more common in patients with dilated RVs and at least moderate TR. Furthermore, after adjusting for baseline clinical and echocardiographic parameters, worsening RV function was associated with higher all-cause and cardiovascular mortality. These results may have implications regarding choice of modality (TAVR or SAVR) in intermediate-risk patients and should be discussed by the heart team, but given limitations of the study design, the results should be considered exploratory and need to be validated in prospective studies. In addition, future studies should also assess whether treatment of concomitant TR or myocardial protection strategies can preserve RV function/prevent RV dysfunction after AVR.
Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Diagnostic Imaging, Dilatation, Echocardiography, Heart Valve Diseases, Heart Valve Prosthesis, Secondary Prevention, Transcatheter Aortic Valve Replacement, Tricuspid Valve Insufficiency, Ventricular Function, Right
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