Impact of Tricuspid Regurgitation and Right Ventricular Dysfunction on Outcome of Patients Undergoing Trans-catheter Aortic Valve Replacement

Background: Tricuspid Regurgitation (TR) and Right Ventricular (RV) dysfunction may coexist with aortic stenosis (AS).

Objectives: Assess the association between TR severity and RV function and outcomes following transcatheter aortic valve replacement (TAVR).
Methods: Retrospective analysis of baseline, 6 month clinical and echo parameters, including TR grade, vena contracta, RV size (grade, end-diastolic, end-systolic area, annular diameter), and function (grade, TAPSE, fractional area change [FAC], Tei index), from 519 consecutive TAVR patients.

Results: The prevalence of TR ≥Moderate was 11% (n=59) and it was associated with increased mortality (HR 1.84 [1.09- 2.95]; P=0.02) in non-adjusted analysis, but not when adjusted for TAPSE (P=0.3), or clinical parameters (P=0.2). RV parameters associated with poor outcome included reduced TAPSE (p=0.006], and Tei index (P=0.005). TAPSE was associated with lower survival even when adjusted for TR (P=0.009), and all clinical parameters (P=0.01). TR grade improved in less than half of the patients (P=0.8) six months post TAVR, and was associated with the opposing effects of improved systolic pulmonary pressure (P<0.0001), TAPSE (p=0.02), and FAC (p=0.002), combined with widening of tricuspid annulus (P=0.05), and TR vena contracta (P=0.5). Persistence of ≥Moderate TR 6 months post TAVR was associated with lower survival (P=0.02), even when adjusted for all clinical and RV parameters (P=0.07). Female gender, atrial fibrillation, ≥Moderate TR and ≥Moderate MR at baseline were associated with persistence of ≥Moderate TR late after TAVR.

Conclusions: TR in association with AS is frequently progressive despite TAVR, but is not an independent predictor of outcome, thus should not be considered an obstacle for performance of TAVR. Nevertheless, persistence of ≥moderate TR six months after TAVR is associated with poor outcome. Quantitative (and not just qualitative) assessment of RV function by TAPSE, should be included in the risk stratification of patients before TAVR