Worku Berhane, Valovska Marie-Therese, Elmously Adham, Kampaktsis Polydoros, Castillo Catherine, Wong Shing-Chiu, Salemi Arash
Division of Cardiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY USA.
Innovations (Phila). 2018 May/Jun;13(3):190-199. doi: 10.1097/IMI.0000000000000504.
This study sought to analyze outcomes in patients with moderate-severe tricuspid regurgitation (TR) undergoing transcatheter aortic valve replacement (TAVR). The consequences of uncorrected significant TR in patients undergoing TAVR remain undefined.
Between 2009 and 2014, 369 patients underwent TAVR at our institution, and 58 of these had baseline moderate-severe TR. Preoperative, 30-day, and 1-year transthoracic echocardiograms were analyzed. Predictors of persistent TR at 30 days and survival were assessed.
Fifty-eight patients with baseline moderate-severe TR underwent TAVR. Transcatheter aortic valve replacement resulted in significant reductions in pulmonary artery pressures and TR severity (100% vs 64%; P < 0.001) at 30 days. This was sustained at 1 year and was associated with significant improvements in stroke volume index and New York Heart Association functional class. No changes in right ventricular function or size were noted. The only independent predictor of persistent moderate-severe TR at 30 days was preoperative atrial fibrillation [AF; odds ratio (OR), 4.56; 95% confidence interval, 1.1-18.3; P = 0.033]. Independent predictors of overall long-term survival included AF (OR, 0.41; P = 0.001) and chronic lung disease (OR, 0.47; P = 0.011), but not baseline moderate-severe TR. In patients with baseline moderate-severe TR, persistent moderate-severe TR at 30 days was associated with worsened overall survival (log-rank P = 0.02).
Baseline moderate-severe TR is not uncommon in patients undergoing TAVR, and frequently improves. However, the presence of AF suggests that that TR is likely to persist after TAVR and is also indicative of a poor long-term outcome. Whether redirecting such patients to surgery for concomitant tricuspid valve repair will further improve outcomes requires further study.
本研究旨在分析接受经导管主动脉瓣置换术（TAVR）的中重度三尖瓣反流（TR）患者的治疗结果。TAVR患者中未纠正的严重TR的后果仍不明确。
2009年至2014年期间，369例患者在我院接受了TAVR，其中58例有基线中重度TR。分析术前、30天和1年的经胸超声心动图。评估30天时持续性TR和生存的预测因素。
58例基线中重度TR患者接受了TAVR。经导管主动脉瓣置换术使30天时肺动脉压和TR严重程度显著降低（100%对64%；P<0.001）。这种情况在1年时持续存在，并与每搏量指数和纽约心脏协会功能分级的显著改善相关。未观察到右心室功能或大小的变化。30天时持续性中重度TR的唯一独立预测因素是术前房颤[AF；比值比（OR），4.56；95%置信区间，1.1 - 18.3；P = 0.033]。总体长期生存的独立预测因素包括房颤（OR，0.41；P = 0.001）和慢性肺病（OR，0.47；P = 0.011），但不包括基线中重度TR。在基线中重度TR患者中，30天时持续性中重度TR与总体生存恶化相关（对数秩检验P = 0.02）。
基线中重度TR在接受TAVR的患者中并不少见，且常有所改善。然而，房颤的存在表明TAVR后TR可能持续存在，并且也预示着长期预后不良。将此类患者转向手术进行同期三尖瓣修复是否会进一步改善预后需要进一步研究。
