title: Effect of tricuspid regurgitation and the right heart on survival after transcatheter aortic valve replacement: insights from the Placement of Aortic Transcatheter Valves II inoperable cohort.
abstract: BACKGROUND
  Tricuspid regurgitation (TR) and right ventricular (RV) dysfunction adversely affect outcomes in patients with heart failure or mitral valve disease, but their impact on outcomes in patients with aortic stenosis treated with transcatheter aortic valve replacement has not been well characterized.
  
  
  RESULTS
  Among 542 patients with symptomatic aortic stenosis treated in the Placement of Aortic Transcatheter Valves (PARTNER) II trial (inoperable cohort) with a Sapien or Sapien XT valve via a transfemoral approach, baseline TR severity, right atrial and RV size and RV function were evaluated by echocardiography according to established guidelines. One-year mortality was 16.9%, 17.2%, 32.6%, and 61.1% for patients with no/trace (n=167), mild (n=205), moderate (n=117), and severe (n=18) TR, respectively (P<0.001). Increasing severity of RV dysfunction as well as right atrial and RV enlargement were also associated with increased mortality (P<0.001). After multivariable adjustment, severe TR (hazard ratio, 3.20; 95% confidence interval, 1.50-6.82; P=0.003) and moderate TR (hazard ratio, 1.60; 95% confidence interval, 1.02-2.52; P=0.042) remained associated with increased mortality as did right atrial and RV enlargement, but not RV dysfunction. There was an interaction between TR and mitral regurgitation severity (P=0.04); the increased hazard of death associated with moderate/severe TR only occurred in those with no/trace/mild mitral regurgitation.
  
  
  CONCLUSIONS
  In inoperable patients treated with transcatheter aortic valve replacement, moderate or severe TR and right heart enlargement are independently associated with increased 1-year mortality; however, the association between moderate or severe TR and an increased hazard of death was only found in those with minimal mitral regurgitation at baseline. These findings may improve our assessment of anticipated benefit from transcatheter aortic valve replacement and support the need for future studies on TR and the right heart, including whether concomitant treatment of TR in operable but high-risk patients with aortic stenosis is warranted.
  
  
  BACKGROUND
  URL: http://www.clinicaltrials.gov. Unique identifier: NCT01314313.
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.). blindman@dom.wustl.edu.
authors: Brian R
authors: BR
authors: Lindman
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Hersh S
authors: HS
authors: Maniar
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Wael A
authors: WA
authors: Jaber
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Stamatios
authors: S
authors: Lerakis
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Michael J
authors: MJ
authors: Mack
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Rakesh M
authors: RM
authors: Suri
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Vinod H
authors: VH
authors: Thourani
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Vasilis
authors: V
authors: Babaliaros
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Dean J
authors: DJ
authors: Kereiakes
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Brian
authors: B
authors: Whisenant
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: D Craig
authors: DC
authors: Miller
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: E Murat
authors: EM
authors: Tuzcu
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Lars G
authors: LG
authors: Svensson
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Ke
authors: K
authors: Xu
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Darshan
authors: D
authors: Doshi
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Martin B
authors: MB
authors: Leon
authors: From the Washington University School of Medicine, St. Louis, MO (B.R.L., H.S.M., A.Z.); Cleveland Clinic Foundation, OH (W.A.J., E.M.T., L.G.S.); Emory University School of Medicine, Atlanta, GA (S.L., V.H.T., V.B.); Baylor Scott and White Health, Plano, TX (M.J.M.); Mayo Clinic, Rochester, MN (R.M.S.); The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, OH (D.J.K.); Intermountain Heart Center, Murray, UT (B.W.); Stanford University School of Medicine, CA (D.C.M.); Cardiovascular Research Foundation, New York, NY (K.X., M.B.L.); and Columbia University Medical Center/New York Presbyterian Hospital (D.D., M.B.L.).
authors: Alan
authors: A
authors: Zajarias
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000401:mortality / Q000601:surgery*; D015331:Cohort Studies; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000401:mortality*; D016019:Survival Analysis; D065467:Transcatheter Aortic Valve Replacement; D016896:Treatment Outcome; D014262:Tricuspid Valve Insufficiency / Q000209:etiology / Q000401:mortality*; D018497:Ventricular Dysfunction, Right / Q000209:etiology / Q000401:mortality*
keywords: aortic valve stenosis; echocardiography; heart failure; transcatheter aortic valve replacement; tricuspid valve insufficiency