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Tricuspid Regurgitation in Low-Flow Low-Gradient Aortic Stenosis With Reduced LVEF | Journal Scan
Study Questions:
Is there an association between tricuspid regurgitation (TR) severity and mortality among patients with low-flow low-gradient (LF-LG) severe aortic stenosis (AS) with reduced left ventricular ejection fraction (LVEF)?
Methods:
A total of 211 patients (73 ± 10 years of age; 77% men) with LF-LG AS (mean gradient <40 mm Hg and indexed aortic valve area [AVA] ≤0.6 cm2/m2) and reduced LVEF (≤40%) were prospectively enrolled in the TOPAS (True or Pseudo-Severe Aortic Stenosis) study, and 125 (59%) of them underwent aortic valve replacement (AVR) within 3 months following inclusion. The severity of AS was assessed by the projected AVA (AVAproj) at normal flow rate (250 ml/s), as previously described and validated. The severity of TR was graded according to current guidelines.
Results:
Among the 211 patients included in the study, 22 (10%) had no TR, 113 (54%) had mild (grade 1), 50 (24%) mild-to-moderate (grade 2), and 26 (12%) moderate-to-severe (grade 3) or severe (grade 4) TR. During a mean follow-up of 2.4 ± 2.2 years, 104 patients (49%) died. Univariable analysis showed that ≥ grade 2 TR was associated with increased risk of all-cause mortality (hazard ratio [HR], 1.82; 95% confidence interval [CI], 1.22-2.71; p = 0.004) and cardiovascular mortality (HR, 1.85; 95% CI, 1.20-2.83; p = 0.005). After adjustment for age, sex, coronary artery disease, AVAproj, LVEF, stroke volume index, right ventricular dysfunction, mitral regurgitation, and type of treatment (AVR vs. conservative), the presence of ≥ grade 2 TR was an independent predictor of all-cause mortality (HR, 1.88; 95% CI, 1.08-3.23; p = 0.02) and cardiovascular mortality (HR, 1.92; 95% CI, 1.05-3.51; p = 0.03). Furthermore, in patients undergoing AVR, grade 3 or 4 TR was an independent predictor of 30-day mortality compared with either grade 0 or grade 1 TR (odds ratio [OR], 7.24; 95% CI, 1.56-38.2; p = 0.01) or grade 2 TR (OR, 4.70; 95% CI, 1.00-25.90; p = 0.05).
Conclusions:
Among patients with LF-LG AS and reduced LVEF, the presence of moderate-to-severe or severe TR is independently associated with increased risk of all-cause mortality and cardiovascular mortality, regardless of surgical (AVR) or conservative treatment. In patients undergoing AVR, moderate/severe TR was associated with increased 30-day mortality.
Perspective:
Patients with LF-LG severe AS and reduced LVEF have been shown to benefit from AVR, with greater risk of postoperative mortality associated with an absence of LV contractile reserve on preoperative low-dose dobutamine stress echocardiography. In analysis of data from a multicenter study of patients with this condition, the authors found an apparent independent association between ≥3+ TR and all-cause and cardiovascular mortality, regardless of whether the patient underwent AVR. Although it is possible that significant functional TR is an independent risk factor, it is likely that it is a marker of more advanced left- and possibly right-sided heart disease. Whether intervention on TR at the time of AVR affects mortality is still open to question.
Keywords: Aortic Valve, Aortic Valve Stenosis, Coronary Artery Disease, Echocardiography, Stress, Heart Valve Prosthesis, Mitral Valve Insufficiency, Risk, Risk Factors, Stroke Volume, Tricuspid Valve Insufficiency, Ventricular Dysfunction, Right, Ventricular Dysfunction, Left, Heart Failure, Cardiac Surgical Procedures, Mortality, Follow-Up Studies
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