title: Prevalence and impact of preoperative moderate/severe tricuspid regurgitation on patients undergoing transcatheter aortic valve replacement.
abstract: OBJECTIVE
  Significant tricuspid regurgitation (TR) is a marker for late-stage myocardial and valvular heart disease. Whether preoperative TR affects clinical outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) has never been investigated. This study sought to identify the impact of moderate and severe TR on outcomes after TAVR.
  
  
  METHODS
  All patients undergoing TAVR from January 2007 to August 2012 at St. Paul's Hospital, Vancouver, Canada, (n = 518) were dichotomized according to the severity of preoperative TR (moderate/severe vs. none/mild). All clinical outcomes were defined according to the valve academic research consortium-2 definitions.
  
  
  RESULTS
  At baseline, moderate or severe TR was reported in 79 patients (15.2%). At 30 days, moderate/severe TR had improved in 12 patients (15.2%), was unchanged in 46 patients (58.3%), and worsened in 7 patients (8.9%). Of those with none/mild TR at baseline, 35 (7.9%) patients had moderate TR at 30-day follow-up. Two-year all-cause (38.4% vs. 20.0%, Log-rank test, P = 0.001) and cardiac mortality (12.9% vs. 4.6%, Log-rank test, P = 0.004) as estimated by Kaplan-Meier analysis were considerably higher in patients with significant TR. However, significant TR did not emerge as independent risk factor for 2-year all-cause mortality (adjusted OR: 1.55, 95% confidence interval (CI): 0.91-2.64, P = 0.105). Pre-specified subgroups showed an interaction between TR and left ventricular systolic function (Pinteraction  = 0.047). Indeed, moderate/severe TR was significantly related to mortality only in patients with left ventricular ejection fraction (LVEF) > 40% (adjusted OR: 2.01, CI: 1.05-3.84, P = 0.036). In patients with LVEF ≤ 40%, TR had no significant impact on all-cause mortality (adjusted OR: 1.04, CI: 0.34-3.16, P = 0.946). No significant interactions were identified regarding patients with perioperative moderate/severe mitral regurgitation (Pinteraction  = 0.829) and patients with baseline systolic pulmonary artery pressure ≥ 60 mm Hg (Pinteraction  = 0.669).
  
  
  CONCLUSIONS
  In patients undergoing TAVR, significant preoperative TR was present in 15% of patients and associated with more comorbidities. Despite being associated with a doubling of mortality rate, after a robust adjustment, significant TR was not an independent predictor of 2-year mortality. However, a significant interaction between TR and left ventricular systolic function was found. The response of TR to TAVR was extremely variable.
authors.affiliation: St. Paul's Hospital, University of British Columbia, Vancouver, Canada.
authors.forename: Marco
authors.initials: M
authors.lastname: Barbanti
authors.forename: Ronald K
authors.initials: RK
authors.lastname: Binder
authors.forename: Danny
authors.initials: D
authors.lastname: Dvir
authors.forename: John
authors.initials: J
authors.lastname: Tan
authors.forename: Melanie
authors.initials: M
authors.lastname: Freeman
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Thompson
authors.forename: Anson
authors.initials: A
authors.lastname: Cheung
authors.forename: David A
authors.initials: DA
authors.lastname: Wood
authors.forename: Jonathon
authors.initials: J
authors.lastname: Leipsic
authors.forename: John G
authors.initials: JG
authors.lastname: Webb
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D001955:British Columbia / Q000453:epidemiology; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D015897:Comorbidity; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D015995:Prevalence; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome; D014261:Tricuspid Valve / Q000503:physiopathology; D014262:Tricuspid Valve Insufficiency / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality / Q000503:physiopathology
keywords: TAVI; transcatheter aortic valve replacement; tricuspid regurgitation