title: The failing right heart: implications and evolution in high-risk patients undergoing transcatheter aortic valve implantation.
abstract: OBJECTIVE
  Right ventricular dysfunction (RVdy) is negatively associated with survival after left heart valve surgery. It is unclear whether RVdy has the same impact in patients undergoing transcatheter aortic valve implantation (TAVI). We sought to evaluate the prognostic impact of different grades of RVdy on TAVI, with and without concomitant left ventricular dysfunction (LVdy), and the possible impact of TAVI on RVdy.
  
  
  RESULTS
  Among 870 consecutive patients with severe symptomatic aortic stenosis undergoing TAVI, 226 patients (26%) presented with a concomitant diagnosis of RVdy. Patients were divided into three groups, Group 1: normal RV systolic function, i.e., tricuspid annular plane systolic excursion (TAPSE) >16 mm (n=644, 74%); Group 2: mild-to-moderate RVdy, i.e., TAPSE 10-16 mm (n=180, 20.6%); Group 3: severe RVdy, i.e., TAPSE <10 mm (n=46, 5.2%). Patients in Groups 1 and 2 showed a similar overall mortality rate at one month (5% vs. 8%, OR 1.1 [0.7-1.55], p=0.2) and at one-year follow-up (15% vs. 19%, HR 1.5 [0.84-2.2], p=0.09), respectively. Compared to Groups 1 and 2, patients in Group 3 showed a significantly higher overall mortality at one month (22%, OR 3.3 [1.8-4.1], p<0.001, and OR 2.1 [1.7-3.1], p=0.02, respectively) as well as at one-year follow-up (45%, HR 2.6 [2.1-3.45], p<0.001, and HR 1.9 [1.5-2.7], p=0.02), respectively. Pulmonary hypertension >60 mmHg (HR 1.5 [1.1-2.2], p=0.03), AF (HR 1.6 [1.1-2.4], p=0.01), creatinine clearance <30 mL/min (HR 1.92 [1.3-2.5], p=0.003), LVEF <30% (HR 1.5 [1.1-2.9], p=0.03), severe RVdy (HR 2.9 [2.7-3.3], p=0.002), severe RV dilation (HR 1.7 [1.2-2.2], p=0.005) and severe biventricular dysfunction (HR 3.9 [2.7-4.1], p=0.002) were independent predictors of one-year mortality. Among survivors, the majority of patients in Groups 2 and 3 experienced a significant improvement in NYHA class.
  
  
  CONCLUSIONS
  Severe RVdy limits the expected benefit of TAVI. In current risk scores right heart failure is not considered. The present study advocates the evaluation of this strong predictor in a more complete pre-procedural work-up.
authors.affiliation: Department of Cardiology, IRCCS Pol San Donato, San Donato Milanese, Milan, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Testa
authors.forename: Azeem
authors.initials: A
authors.lastname: Latib
authors.forename: Federico
authors.initials: F
authors.lastname: De Marco
authors.forename: Marco
authors.initials: M
authors.lastname: De Carlo
authors.forename: Claudia
authors.initials: C
authors.lastname: Fiorina
authors.forename: Marco
authors.initials: M
authors.lastname: Barbanti
authors.forename: Rocco A
authors.initials: RA
authors.lastname: Montone
authors.forename: Mauro
authors.initials: M
authors.lastname: Agnifili
authors.forename: Anna Sonia
authors.initials: AS
authors.lastname: Petronio
authors.forename: Federica
authors.initials: F
authors.lastname: Ettori
authors.forename: Silvio
authors.initials: S
authors.lastname: Klugmann
authors.forename: Corrado
authors.initials: C
authors.lastname: Tamburino
authors.forename: Nedy
authors.initials: N
authors.lastname: Brambilla
authors.forename: Antonio
authors.initials: A
authors.lastname: Colombo
authors.forename: Francesco
authors.initials: F
authors.lastname: Bedogni
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000401:mortality* / Q000601:surgery*; D006328:Cardiac Catheterization / Q000009:adverse effects; D005260:Female; D006333:Heart Failure / Q000209:etiology*; D019918:Heart Valve Prosthesis Implantation / Q000379:methods; D006801:Humans; D006976:Hypertension, Pulmonary / Q000209:etiology; D008297:Male; D012307:Risk Factors; D065467:Transcatheter Aortic Valve Replacement / Q000401:mortality*; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000503:physiopathology; D018497:Ventricular Dysfunction, Right / Q000401:mortality / Q000601:surgery*