Barbanti Marco, Binder Ronald K, Dvir Danny, Tan John, Freeman Melanie, Thompson Christopher R, Cheung Anson, Wood David A, Leipsic Jonathon, Webb John G
St. Paul's Hospital, University of British Columbia, Vancouver, Canada.
Catheter Cardiovasc Interv. 2015 Mar;85(4):677-84. doi: 10.1002/ccd.25512. Epub 2014 Apr 30.
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.
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.
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).
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.
严重三尖瓣反流（TR）是晚期心肌和瓣膜性心脏病的一个标志。术前TR是否会影响经导管主动脉瓣置换术（TAVR）患者的临床结局从未被研究过。本研究旨在确定中度和重度TR对TAVR术后结局的影响。
2007年1月至2012年8月在加拿大温哥华圣保罗医院接受TAVR的所有患者（n = 518）根据术前TR的严重程度（中度/重度与无/轻度）进行二分法分类。所有临床结局均根据瓣膜学术研究联盟-2的定义来界定。
在基线时，79例患者（15.2%）报告有中度或重度TR。在30天时，12例患者（15.2%）的中度/重度TR有所改善，46例患者（58.3%）保持不变，7例患者（8.9%）恶化。在基线时无/轻度TR的患者中，35例（7.9%）患者在30天随访时有中度TR。通过Kaplan-Meier分析估计，有严重TR的患者两年全因死亡率（38.4%对20.0%，对数秩检验，P = 0.001）和心脏死亡率（12.9%对4.6%，对数秩检验，P = 0.004）显著更高。然而，严重TR并未成为两年全因死亡率的独立危险因素（校正比值比：1.55，95%置信区间（CI）：0.91 - 2.64，P = 0.105）。预先设定的亚组显示TR与左心室收缩功能之间存在相互作用（P相互作用 = 0.047）。实际上，中度/重度TR仅在左心室射血分数（LVEF）> 40%的患者中与死亡率显著相关（校正比值比：2.01，CI: 1.05 - 3.84，P = 0.036）。在LVEF≤40%的患者中，TR对全因死亡率无显著影响（校正比值比：1.04，CI: 0.34 - 3.16，P = 0.946）。对于围手术期有中度/重度二尖瓣反流的患者（P相互作用 = 0.829）和基线收缩期肺动脉压≥60 mmHg的患者（P相互作用 = 0.669），未发现显著的相互作用。
在接受TAVR的患者中，15%的患者术前存在严重TR且合并症更多。尽管与死亡率翻倍相关，但经过充分校正后，严重TR并非两年死亡率的独立预测因素。然而，发现TR与左心室收缩功能之间存在显著相互作用。TR对TAVR的反应极其多变。
