Potential Candidates for Transcatheter Tricuspid Valve Intervention After TAVR

Quick Takes

  • This study set out to determine the prevalence of concomitant tricuspid regurgitation (TR) before and after TAVR, and its effects on outcomes.
  • More than 50% of patients with ≥ moderate TR at baseline had an improvement in TR post-TAVR, while a small proportion of patients (5-7%) had progression of their TR severity post-TAVR.
  • Post-TAVR TR that was severe or massive was associated with a two-fold increased risk of all-cause mortality compared to ≤ mild TR at 1 year.
  • Likewise, the 3% of patients who were eligible for transcatheter tricuspid valve intervention (TTVI) after TAVR had a two-fold increased risk of mortality at 1 year, as well as a higher risk of persistent heart failure symptoms (NYHA class III or IV).
  • This study suggests the need for prospective trials evaluating clinical outcomes following TTVI.

Study Questions:

What is the prevalence of concomitant tricuspid regurgitation (TR) before and after transcatheter aortic valve replacement (TAVR), and how does TR severity and eligibility for a transcatheter tricuspid valve intervention (TTVI) affect outcomes?

Methods:

Consecutive patients at a Swiss academic hospital with severe, symptomatic aortic stenosis were enrolled between 2007–2019 into a prospective TAVR registry. Patients with a history of prior TVI or with inadequate echocardiographic assessment of TR severity both pre- and post-TAVR were excluded. Comprehensive transthoracic echocardiography was performed, and the severity of TR was assessed based on current guidelines, relying predominantly on color flow jet area and vena contracta, with quantitative assessment of regurgitant orifice area when available. Severe TR was further divided into severe (vena contracta >0.7) and massive TR (vena contracta >0.92). Right ventricular (RV) function was assessed using tricuspid annular plane systolic excursion, S’, and fractional area change. After TAVR, patients were considered possible candidates for TTVI based on inclusion criteria of the TRILUMINATE trial (NCT03227757) requiring either moderate TR and New York Heart Association (NYHA) class ≥III, or severe/massive TR and NYHA class >II. None of these patients actually underwent TTVI.

Results:

Of the 2,641 consecutive patients enrolled in the registry, 2,008 met inclusion criteria. Of those, 82.6% had none to mild TR; 12.1% had moderate TR; 2.8% had severe TR; and 2.5% had massive TR at baseline prior to TAVR. More than 50% of patients with ≥ moderate TR at baseline had an improvement in TR post-TAVR, while a small proportion of patients (5-7%) had progression of their TR severity post-TAVR. Unlike TR severity at pre-TAVR, severe or massive TR post-TAVR was associated with a two-fold increased risk of all-cause death at 1 year (hazard ratio [HR], 2.17; 95% confidence interval [CI], 1.1-4.3 and HR, 1.9; 95% CI, 1.03-3.49, respectively), when compared to patients with ≤ mild TR at 1 year post-TAVR. Likewise, the 61 patients (3.1%) who were eligible for TTVI after TAVR had a similar two-fold increased risk of mortality at 1 year (HR, 1.93; 95% CI, 1.15-3.25), and higher risk of persistent heart failure symptoms (NYHA class III or IV) (relative risk, 2.80; 95% CI, 1.78-4.40).

Conclusions:

  • More than 50% of patients with ≥ moderate TR at baseline had an improvement in TR post-TAVR, while a small proportion of patients (5-7%) had progression of their TR severity post-TAVR.
  • Unlike TR severity pre-TAVR, post-TAVR TR that was severe or massive was associated with a two-fold increased risk of all-cause compared to ≤ mild TR at 1 year.
  • Likewise, 3% of patients who were eligible for TTVI after TAVR had a similar two-fold increased risk of mortality at 1 year, as well as a higher risk of persistent heart failure symptoms (NYHA class III or IV).

Perspective:

Current guidelines indicate a Class I, Level of Evidence B recommendation for concomitant tricuspid valve surgery for patients with severe TR undergoing surgical AVR. However, there are no current recommendations for the management of TR in patients undergoing TAVR. Given the rapidly expanding use of TAVR, as well as the evolving ability to perform TTVIs, there is a need for clinical data to help guide optimal treatment strategies for concomitant TR in patients undergoing TAVR. This study suggests that >50% of patients had an improvement in their TR post-TAVR, while only a small portion (5-7%) of patients had progression of their TR. Why this progression occurs is probably driven by alternative mechanisms for the TR, such as underlying pulmonary hypertension and RV dysfunction, which are not reversible following relief of the aortic stenosis. This study nicely sets the stage for further prospective trials studying whether an actual TTVI improves clinical outcomes. However, it should be noted that in this study, the candidacy for TTVI was based only on the degree of TR and NYHA functional class, and not on anatomic suitability for a TTVI, which may limit the pool of patients actually able to undergo such a procedure.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Pulmonary Hypertension, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound

Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Cardiology Interventions, Diagnostic Imaging, Echocardiography, Heart Failure, Heart Valve Diseases, Hypertension, Pulmonary, Risk, Transcatheter Aortic Valve Replacement, Tricuspid Valve Insufficiency


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