Department of Cardiovascular Medicine, Knight Cardiovascular Institute Cardiology Clinic, Oregon Health and Science University, Portland, Oregon, USA.
Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA.
JACC Cardiovasc Interv. 2024 Aug 26;17(16):1916-1931. doi: 10.1016/j.jcin.2024.07.005.
Tricuspid regurgitation (TR) is highly prevalent in the transcatheter aortic valve replacement (TAVR) population, but clear management guidelines are lacking.
The aims of this study were to elucidate the prevalence and consequences of severe TR in patients with aortic stenosis undergoing TAVR and to examine the change in TR post-TAVR, including predictors of improvement and its impact on longer term mortality.
Using Centers for Medicare and Medicaid Services-linked TVT (Transcatheter Valve Therapy) Registry data, a propensity-matched analysis was performed among patients undergoing TAVR with baseline mild, moderate, or severe TR. Kaplan-Meier estimates were used to assess the impact of TR on 3-year mortality. Multivariable analysis identified predictors of 30-day TR improvement.
Of the 312,320 included patients, 84% had mild, 13% moderate, and 3% severe TR. In a propensity-matched cohort, severe baseline TR was associated with higher in-hospital mortality (2.5% vs 2.1% for moderate TR and 1.8% for mild TR; P = 0.009), higher 1-year mortality (24% vs 19.6% for moderate TR and 16.6% for mild TR; P < 0.0001), and 3-year mortality (54.2% vs 48.5% for moderate TR and 43.3% for mild TR; P < 0.0001). Among the patients with severe TR at baseline, 76.4% improved to moderate or less TR 30 days after TAVR. Baseline mitral regurgitation moderate or greater, preserved ejection fraction, higher aortic valve gradient, and better kidney function predicted TR improvement after TAVR. However, severe 30-day residual TR was associated with higher 1-year mortality (27.4% vs 18.7% for moderate TR and 16.8% for mild TR; P < 0.0001).
Severe baseline and 30-day residual TR after TAVR are associated with increased mortality up to 3 years. This analysis identifies a higher risk group that could be evaluated for the recently approved tricuspid interventions.
三尖瓣反流（TR）在经导管主动脉瓣置换（TAVR）人群中非常普遍，但缺乏明确的管理指南。
本研究旨在阐明主动脉瓣狭窄患者行 TAVR 后严重 TR 的患病率和后果，并研究 TAVR 后 TR 的变化，包括改善的预测因素及其对长期死亡率的影响。
使用医疗保险和医疗补助服务局（Centers for Medicare and Medicaid Services）联合的 TVT（经导管瓣膜治疗）登记数据，对基线时轻度、中度或重度 TR 的 TAVR 患者进行倾向匹配分析。采用 Kaplan-Meier 估计评估 TR 对 3 年死亡率的影响。多变量分析确定 30 天 TR 改善的预测因素。
在纳入的 312320 例患者中，84%为轻度，13%为中度，3%为重度。在倾向匹配队列中，基线时重度 TR 与更高的院内死亡率相关（重度 TR 为 2.5%，中度 TR 为 2.1%，轻度 TR 为 1.8%；P=0.009），1 年死亡率更高（重度 TR 为 24%，中度 TR 为 19.6%，轻度 TR 为 16.6%；P<0.0001），3 年死亡率也更高（重度 TR 为 54.2%，中度 TR 为 48.5%，轻度 TR 为 43.3%；P<0.0001）。在基线时存在重度 TR 的患者中，76.4%在 TAVR 后 30 天内改善为中度或更轻的 TR。基线二尖瓣反流中度或以上、射血分数保留、较高的主动脉瓣梯度和更好的肾功能预测 TAVR 后 TR 改善。然而，重度 30 天残余 TR 与 1 年死亡率较高相关（重度 TR 为 27.4%，中度 TR 为 18.7%，轻度 TR 为 16.8%；P<0.0001）。
TAVR 后严重的基线和 30 天残余 TR 与 3 年内死亡率增加相关。本分析确定了一个风险较高的群体，可对最近批准的三尖瓣介入治疗进行评估。
