Abstract
Aim
The aim of this study was to analyse the predictive value of CTA-determined tricuspid annular dilatation (TAD) on the persistence of tricuspid regurgitation (TR) in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS) and concomitant at least moderate TR.
Methods and results
288 consecutive patients treated with TAVR due to severe AS and concomitant at least moderate TR at baseline were included in the analysis. As cutoff for TAD, the median value of the CTA-determined, to the body surface area-normalized tricuspid annulus diameter (25.2 mm/m2) was used. TAD had no impact on procedural characteristics or outcomes, including procedural death and technical or device failure according to the Valve Academic Research Consortium 3 criteria. However, the primary outcome of the study—TR persistence after TAVR was significantly more frequent in patients with compared to patients without TAD (odds ratio 2.60, 95% confidence interval 1.33–5.16, p < 0.01). Multivariable logistic regression analysis, adjusting for clinical and echocardiographic baseline characteristics, which are known to influence aetiology or severity of TR, confirmed TAD as an independent predictor of TR persistence after TAVR (adjusted odds ratio 2.30, 95% confidence interval 1.20–4.46, p = 0.01). Moreover, 2 year all-cause mortality was significantly higher in patients with persistence or without change of TR compared to patients with TR improvement (log-rank p < 0.01).
Conclusion
In patients undergoing TAVR for severe AS and concomitant at least moderate TR at baseline, TAD is a predictor of TR persistence, which is associated with increased 2-year all-cause mortality.
Graphical abstract
Supplementary Information
The online version contains supplementary material available at 10.1007/s00392-023-02152-0.
Keywords: Tricuspid annular dilatation, Tricuspid regurgitation, Transcatheter aortic valve replacement
Introduction
Moderate or severe tricuspid regurgitation (TR) is observed in more than 25% of patients with severe aortic stenosis (AS). Most frequently, TR is of secondary aetiology and therefore often caused by left-sided heart disease [1, 2]. In patients with severe AS and high surgical risk due to age or comorbidities, transcatheter aortic valve replacement (TAVR) is the preferred treatment option, and concomitant TR is common in these patients [3, 4]. While guidelines recommend concomitant tricuspid valve surgery in patients undergoing left-sided heart surgery and at least moderate TR in the context of tricuspid annular dilatation, the best approach for treatment of TR in TAVR patients remains unknown [5]. Besides, an improvement of TR can be achieved after TAVR due to reduction of pressure overload in more than 50% of cases [6]. However, the persistence of TR after the procedure is associated with increased all-cause mortality [6, 7]. Therefore, it is of importance to identify determinants of TR persistence in patients undergoing TAVR.
Recently, computed tomography angiography (CTA)-determined tricuspid annular dilatation (TAD) proved to be an independent predictor of 2-year all-cause mortality in patients with severe AS undergoing TAVR [8]. The objective of this study was to investigate if CTA-determined TAD among TAVR patients who had at least moderate TR at baseline is associated with the persistence of TR after the procedure. Moreover, the predictive value of TR persistence on the composite of 2-year all-cause mortality in these patients was analysed.
Methods
Study design and population
Consecutive patients with severe AS and at least moderate concomitant TR at baseline who underwent TAVR at Munich University Hospital from April 2013 to December 2019 were included in this study. Patients with a history of previous tricuspid valve intervention or surgery and patients treated with TAVR for severe aortic regurgitation were excluded. Moreover, external preprocedural CTA was a criterion for exclusion to ensure a standardized imaging protocol.
Before TAVR, all patients were assessed by the local heart team, consisting of cardiac surgeons and interventional cardiologists. Data were collected in the context of the EVERY-Valve registry, which was approved by the local ethics committee of the University of Munich (project number 19-840).
Tricuspid annular dilatation
Preprocedural multidetector computed tomography angiography was performed as part of the standard of care in all patients. To identify patients with TAD, the maximum septolateral diameter of the tricuspid annulus was measured and normalized to the body surface area (BSA) as described previously [8]. As cutoff for TAD, the median value of the CTA-determined BSA normalized tricuspid annulus diameter of all included patients was used.
Echocardiographic analysis
Transthoracic echocardiography was performed before and after TAVR in accordance with the European and American guidelines [9, 10]. Moreover, a central in-house core laboratory analysis was carried out to assess echocardiographic parameters. Severity of AS was determined using the continuity equation method. To quantify TR, an integrated approach taking into account visual appearance, biplane vena contracta width, effective regurgitant orifice area (EROA) and regurgitant volume was used whenever possible. For TR grading, a five-grade scheme (mild, moderate, severe, massive, torrential) as proposed by Hahn et al. was applied [11]. TR aggravation was defined as an increase in TR severity and TR persistence as lack of TR improvement of at least one grade in the follow-up compared to the preprocedural echocardiography. Right ventricular function was assessed using tricuspid annular plane systolic excursion (TAPSE) and fractional area change.
TAVR procedure
For all TAVR procedures, local anaesthetics were administered and a femoral access for TAVR implantation was used. Type and size of the prosthesis were selected considering patients’ characteristics and measurements of the aortic valve in preprocedural CTA by the interventional cardiologist. Pre- and/or post-dilatation was performed according to the operator’s discretion [8].
Study endpoints
The primary endpoint of this study was persistence of TR after TAVR and was analysed in patients with available echocardiographic follow-up ≥ 30 days after the procedure. As secondary endpoints, 2-year all-cause mortality, tricuspid valve intervention, changes of echocardiographic parameters as well as functional status after TAVR using the New York Heart Association (NYHA) functional class were recorded.
Moreover, procedural outcomes of all patients with at least moderate TR, such as the composite endpoints technical failure (procedural death, cardiac structural complications, conversion to open surgery, prosthesis dislocation, 2nd valve prosthesis, immediate vascular surgery/intervention) and device failure at 30 days (technical failure, 30-day mortality, elevated mean pressure gradient, paravalvular regurgitation, vascular surgery/intervention) as well as early pacemaker implantation, stroke, bleeding and acute kidney injury according to the Valve Academic Research Consortium 3 were recorded [12].
Statistical analysis
Continuous data are presented as median with interquartile range and categorical variables are expressed as frequencies and percentages. Differences between groups were tested for significance using the Fisher exact test, the Wilcoxon rank sum test or the Wilcoxon signed rank test as appropriate. 2-year all-cause mortality was evaluated using the Kaplan–Meier method and log-rank test. A two-sided p value < 0.05 was considered to indicate statistical significance. All statistical analyses were conducted using R version 4.0.2 (The R Foundation for Statistical Computing, Vienna, Austria).
Results
Study population
306 patients with severe AS and at least moderate concomitant TR, underwent TAVR procedure at Munich University Hospital between April 2013 and December 2019. 17 patients were excluded due to externally acquired preprocedural CTA, and one patient due to history of tricuspid valve surgery. The median value of the CTA-determined BSA normalized tricuspid annulus diameter of the remaining 288 patients was 25.2 mm/m2 and was used as cutoff to stratify patients into patients with (TAD +) and without TAD (TAD-).
Procedural characteristics and outcomes
Regarding procedural characteristics, no differences could be observed between patients with and without TAD. Moreover, TAD had no impact on procedural outcomes, including procedural death (0.0% TAD − vs. 1.4% TAD + , p = 0.50), technical failure (6.9% TAD − vs. 5.6% TAD + , p = 0.81), device failure at 30 days (17.4% TAD − vs. 14.6% TAD + , p = 0.63), stroke (3.5% TAD − vs. 1.4% TAD + , p = 0.45) and bleeding BARC type 3 or 4 (15.3% TAD − vs. 11.1% TAD + , p = 0.38). Procedural characteristics and outcomes stratified by TAD are depicted in Table 1. In addition, all-cause mortality at 30 days was similar in both groups (p = 1.00),
Table 1.
Procedural characteristics and outcomes
| All (n = 288) |
TAD − (n = 144) |
TAD + (n = 144) |
p-value | |
|---|---|---|---|---|
| Procedural characteristics | ||||
| Prosthesis type | p = 0.57 | |||
| Sapien | 209 (72.6) | 104 (72.2) | 105 (72.9) | |
| CoreValve | 35 (12.2) | 16 (11.1) | 19 (13.2) | |
| Accurate Neo | 14 (4.9) | 10 (6.9) | 4 (2.8) | |
| Lotus | 21 (7.3) | 10 (6.9) | 11 (7.6) | |
| Other | 9 (3.1) | 4 (2.8) | 5 (3.5) | |
| Prosthesis size | p = 0.53 | |||
| < 25 mm | 99 (34.4) | 54 (37.5) | 45 (31.3) | |
| 25–28 mm | 110 (38.2) | 54 (37.5) | 56 (38.9) | |
| > 28 mm | 78 (27.1) | 36 (25.0) | 42 (29.2) | |
| Pre-dilatation performed | 201 (69.8) | 104 (72.2) | 97 (67.4) | p = 0.37 |
| Post-dilatation performed | 16 (5.6) | 8 (5.6) | 8 (5.6) | p = 0.79 |
| Procedural outcomes | ||||
| Technical failure | 18 (6.3) | 10 (6.9) | 8 (5.6) | p = 0.81 |
| Procedural death | 2 (0.69) | 0 (0.00) | 1 (1.4) | p = 0.50 |
| Cardiac structural complication | 5 (1.7) | 3 (2.1) | 2 (1.4) | p = 1.00 |
| Conversion to open surgery | 2 (0.7) | 0 (0.0) | 2 (1.4) | p = 0.50 |
| Prosthesis dislocation | 4 (1.4) | 3 (2.1) | 1 (0.7) | p = 0.62 |
| 2nd valve prosthesis | 0 (0.0) | 0 (0.0) | 0 (0.0) | p = 1.00 |
| Immediate vascular surgery/intervention | 10 (3.5) | 5 (3.5) | 5 (3.5) | p = 1.00 |
| Device failure at 30 days | 46 (16.0) | 25 (17.4) | 21 (14.6) | p = 0.63 |
| 30 day mortality | 22 (7.6) | 11 (7.6) | 11 (7.6) | p = 1.00 |
| Aortic regurgitation > 1 + | 10 (3.5) | 6 (4.2) | 4 (2.8) | p = 0.75 |
| Elevated PG mean > 20 mmHg | 4 (1.4) | 3 (2.1) | 1 (0.7) | p = 0.62 |
| Vascular intervention/surgery | 11 (3.8) | 5 (3.5) | 6 (4.2) | p = 1.00 |
| Early pacemaker implantation | 48 (16.7) | 30 (20.8) | 18 (12.5) | p = 0.08 |
| Stroke | 7 (2.4) | 5 (3.5) | 2 (1.4) | p = 0.45 |
| Bleeding BARC type 3 or 4 | 38 (13.2) | 22 (15.3) | 16 (11.1) | p = 0.38 |
| Acute kidney injury stage 3 or 4 | 10 (3.5) | 8 (5.6) | 2 (1.4) | p = 0.10 |
PG pressure gradient, BARC bleeding academic research consortium
Clinical and echocardiographic baseline characteristics
Out of 266 patients, who had survived at least 30 days after TAVR, echocardiographic follow-up ≥ 30 days after the procedure was available for 165 patients (62.0%) (median echocardiography follow-up time 101 days [interquartile range 52–342 days]). Comparing baseline characteristics between patients with and without available echocardiographic follow-up, patients without follow-up were older (82.2 years [IQR 77.5–86.0] patients with follow-up vs. 84.2 years [IQR 80.2–87.7] patients without follow-up, p < 0.01), but had a similar prevalence of comorbidities, including renal impairment, atrial fibrillation or coronary artery disease. Moreover, there was no difference regarding TR severity at baseline (TR grade ≥ 3: 30.3% in patients with vs. 29.3% in patients without follow-up, p = 0.90). Clinical and echocardiographic baseline characteristics comparing patients with and without follow-up are shown in Supplemental Table 1.
In patients with available echocardiographic follow-up, the BSA normalized tricuspid annulus diameter was above the threshold of 25.2 mm/m2 in 85 patients (TAD + group). Concerning clinical baseline characteristics, patients in the TAD + group were older (81.2 years [IQR 76.2–84.5] TAD − vs. 83.2 years [IQR 79.6–86.2] TAD + , p = 0.03) and suffered more often from atrial fibrillation (45.0% TAD − vs. 62.4% TAD + , p = 0.03) and renal impairment (47.5% TAD − vs. 70.6% TAD + , p < 0.01). Clinical baseline characteristics are presented in Table 2. Regarding echocardiographic parameters, severe AS with a median aortic valve orifice area of 0.7 cm2 was present in both groups. Dimensions of the right ventricle (RV) and right atrium (RA) were larger, and baseline TR was more pronounced in the TAD + group (TR grade ≥ 3: 20.0% TAD − vs. 40.0% TAD + , p = 0.05). Echocardiographic baseline characteristics are summarized in Table 3.
Table 2.
Clinical baseline characteristics
| All (n = 165) |
TAD − (n = 80) |
TAD + (n = 85) |
p-value | |
|---|---|---|---|---|
| Clinical characteristics | ||||
| Male gender | 76 (46.1) | 36 (45.0) | 40 (47.1) | p = 0.88 |
| Age (years) | 82.2 (77.5; 86.0) | 81.2 (76.2; 84.5) | 83.2 (79.6; 86.2) | p = 0.03 |
| BMI (kg/m2) | 24.7 (22.5; 27.7) | 26.6 (24.2; 28.8) | 22.9 (21.5; 24.9) | p < 0.01 |
| STS score | 4.8 (3.1; 7.8) | 4.0 (3.0; 7.3) | 5.0 (3.7; 8.5) | p = 0.08 |
| NYHA functional class ≥ III | 153 (93.3) | 76 (95.0) | 77 (91.7) | p = 0.54 |
| Coronary artery disease | 91 (57.6) | 46 (59.7) | 45 (55.6) | p = 0.63 |
| Prior myocardial infarction | 19 (11.7) | 9 (11.3) | 10 (12.0) | p = 1.00 |
| Prior PCI | 42 (25.6) | 19 (23.8) | 23 (27.4) | p = 0.72 |
| Prior CABG | 17 (10.4) | 10 (12.5) | 7 (8.3) | p = 0.45 |
| Pacemaker or ICD | 28 (17.0) | 17 (21.3) | 11 (12.9) | p = 0.21 |
| Atrial fibrillation | 89 (53.4) | 36 (45.0) | 53 (62.4) | p = 0.03 |
| Renal impairment | 98 (59.4) | 38 (47.5) | 60 (70.6) | p < 0.01 |
| Diabetes | 54 (32.7) | 26 (32.5) | 28 (32.9) | p = 1.00 |
| Hypertension | 144 (87.3) | 73 (91.3) | 71 (83.5) | p = 0.16 |
| Smoking | 30 (18.9) | 12 (15.6) | 18 (22.0) | p = 0.32 |
| Hypercholesteremia | 71 (44.4) | 33 (42.9) | 38 (45.8) | p = 0.75 |
| NT-proBNP (pg/ml) | 4040 (2179; 9736) | 2911 (1518; 6265) | 4324 (3234; 10034) | p = 0.09 |
BMI body mass index, STS score society of thoracic surgeons score, NYHA New York Heart Association, PCI percutaneous coronary intervention, CABG coronary artery bypass graft, ICD implantable cardioverter defibrillator, NT-proBNP N-terminal pro b-type natriuretic peptide
Table 3.
Echocardiographic baseline characteristics
| All (n = 165) |
TAD − (n = 80) |
TAD + (n = 85) |
p-value | |
|---|---|---|---|---|
| Echocardiographic parameters | ||||
| LVEF (%) | 53.2 (41.2; 58.6) | 53.1 (40.7; 57.1) | 53.6 (41.6; 59.5) | p = 0.45 |
| PG max aortic valve (mmHg) | 49.8 (38.0; 64.1) | 48.4 (36.3; 62.1) | 49.9 (38.1; 68.10) | p = 0.96 |
| PG mean aortic valve (mmHg) | 29.3 (22.0; 40.2) | 28.6 (21.0; 39.5) | 30.3 (23.0; 40.3) | p = 0.92 |
| V max aortic valve (cm/s) | 348.6 (300.9; 396.8) | 341.0 (300.1; 391.5) | 352.9 (308.5; 404.1) | p = 0.81 |
| Stroke volume index (ml/m2) | 29.9 (24.4;36.9) | 30.2 (24.7; 35.3) | 29.6 (23.9;38.2) | p = 0.79 |
| Aortic valve orifice area (cm2) | 0.7 (0.6; 0.9) | 0.7 (0.6; 0.9) | 0.7 (0.6; 0.8) | p = 0.26 |
| Aortic regurgitation, n (%) | p = 0.33 | |||
| Grade 0 | 24 (14.5) | 15 (18.8) | 9 (10.6) | |
| Grade 1 | 107 (64.8) | 49 (61.3) | 58 (68.2) | |
| Grade 2 | 34 (20.6) | 16 (20.0) | 18 (21.2) | |
| RV area change (%) | 35.3 (30.0; 40.8) | 36.3 (29.0; 40.7) | 35.2 (30.0; 39.9) | p = 0.86 |
| RV diameter at mid/BSA (mm/m2) | 21.1 (18.7; 23.0) | 19.9 (17.7; 22.4) | 21.6 (19.9; 24.3) | p < 0.01 |
| RV diameter at base/BSA (mm/m2) | 27.7 (25.5; 31.3) | 26.1 (24.4; 28.5) | 29.6 (27.1; 32.6) | p < 0.01 |
| Tricuspid annulus diameter/BSA (mm/m2) | 22.0 (19.6; 24.6) | 20.5 (18.5; 22.5) | 23.7 (21.7; 25.6) | p < 0.01 |
| Right atrium/BSA (cm2/m2) | 15.1 (12.6; 19.0) | 13.2 (11.1; 15.5) | 17.2 (14.3; 20.4) | p < 0.01 |
| TAPSE (mm) | 17.0 (13.3; 19.8) | 17.0 (14.0; 19.0) | 17.0 (13.0; 20.0) | p = 0.69 |
| TR vena contracta (mm) | 6.2 (4.9; 8.3) | 5.8 (4.7; 6.7) | 6.5 (5.2; 10.0) | p = 0.01 |
| TR EROA (mm2) | 28.0 (21.0; 43.3) | 26.0 (20.0; 32.0) | 32.0 (21.5; 43.0) | p = 0.08 |
| TR regurgitant volume (ml) | 27.0 (21.0; 37.0) | 25.0 (22.0;31.0) | 29.0 (21.0; 43.0) | p = 0.15 |
| dPmean TV inflow (mmHg) | 1.0 (0.8; 1.4) | 1.0 (0.8; 1.6) | 1.0 (0.8; 1.2) | p = 0.17 |
| RV/RA gradient (mmHg) | 39.5 (28.9; 49.4) | 43.4 (30.0; 49.9) | 36.6 (28.0; 48.3) | p = 0.08 |
| TR severity | p < 0.01 | |||
| 2 | 115 (69.7) | 64 (80.0) | 51 (60.0) | |
| 3 | 39 (23.6) | 15 (18.8) | 24 (28.2) | |
| 4 | 9 (5.5) | 1 (1.3) | 8 (9.4) | |
| 5 | 2 (1.2) | 0 (0.0) | 2 (2.4) | |
| MR severity ≥ 2 | 88 (53.3) | 40 (50.0) | 48 (56.5) | p = 0.44 |
| Vena cava inferior (mm) | 22.0 (17.0; 25.0) | 21.0 (17.0; 24.0) | 22.0 (18.8; 25.0) | p = 0.12 |
| Respiratory variance VCI | 25 (33.8) | 16 (51.6) | 9 (20.9) | p = 0.01 |
LVEF left ventricular ejection fraction, PG pressure gradient, V max maximum velocity, TV tricuspid valve, VCI vena cava inferior
Impact of tricuspid annular dilatation on tricuspid regurgitation
Improvement of TR after TAVR was observed in both groups, with a higher number of patients with TR grade 1 at follow-up in the TAD − group (TR grade 1 at follow-up: 50.0% TAD − vs. 23.5% TAD + , p < 0.01) (Fig. 1). Consistently, improvement of TR of at least one grade was significantly more frequent in patients in the TAD− group (57.0% TAD − vs. 34.1% TAD + , corresponding odds ratio for persistence of TR: 2.60, 95% confidence interval 1.33–5.16, p < 0.01) (Fig. 2A). The median value of the CTA-determined BSA normalized tricuspid annulus diameter was higher in patients with an aggravation or persistence of TR compared to patients with an improvement of TR of one or two grades (26.4 mm/m2 [IQR 23.6–28.7] vs. 23.7 mm/m2 [IQR 22.1–26.9], p < 0.001) (Fig. 2B). Moreover, we performed a multivariable logistic regression analysis with adjustment for clinical and echocardiographic parameters, that are known to influence aetiology or severity of TR, including atrial fibrillation, renal impairment, right ventricular lead, mitral regurgitation, baseline TR severity, RV/RA gradient and right ventricular function using TAPSE. Thus, the predictive value of TAD for TR persistence after TAVR (adjusted odds ratio 2.30, 95% confidence interval 1.20–4.46, p = 0.01) could be confirmed. Consistently, tricuspid valve intervention after TAVR was conducted in 11 patients, all of them in the TAD + group (12.9%).
Fig. 1.
TR at baseline and follow-up according to TAD
Fig. 2.
A Percentage of patients with TR improvement of at least one grade following TAVR stratified for TAD B Tricuspid annulus dimensions according to TR grade change
Concerning echocardiographic parameters, we observed a similar decline of the aortic pressure gradient after TAVR in both groups. Consistent with TR improvement, the reduction of vena contracta width was significantly higher in patients without TAD compared to patients with TAD (− 2.0 mm [IQR − 3.9 to − 0.3] TAD − vs. 0.0 mm [IQR − 2.2–2.0] TAD + , p < 0.01). Moreover, we noted an increase in left ventricular ejection fraction at follow-up compared to baseline in patients in the TAD − group. Echocardiographic parameters at baseline and follow-up as well as delta values are presented in Table 4A–C.
Table 4.
A–C Echocardiographic parameters at baseline and follow-up, (A) TAD −, (B) TAD + , (C) delta values
| A TAD- | Baseline | FU | p-value |
|---|---|---|---|
| LVEF (%) | 50.7 (35.5; 56.2) | 54.5 (41.1; 58.7) | p = 0.03 |
| PG max aortic valve (mmHg) | 45.5 (31.4; 60.9) | 13.9 (10.9; 19.2) | p < 0.01 |
| PG mean aortic valve (mmHg) | 27.0 (18.6; 39.2) | 7.6 (6.0; 10.7) | p < 0.01 |
| RV area change (%) | 35.0 (28.9; 40.2) | 37.8 (28.3; 44.5) | p = 0.20 |
| RV diameter at mid/BSA (mm/m2) | 19.7 (17.7; 22.4) | 19.3 (16.2; 21.0) | p = 0.12 |
| RV diameter at base/BSA (mm/m2) | 26.0 (24.5; 28.1) | 25.8 (24.3; 28.6) | p = 0.88 |
| Tricuspid annulus diameter/BSA (mm/m2) | 21.2 (18.6; 22.5) | 19.9 (17.9; 21.7) | p = 0.25 |
| Right atrium/BSA (cm2/m2) | 13.1 (11.1; 15.7) | 13.2 (11.4; 15.6) | p = 0.97 |
| TAPSE (mm) | 15.0 (13.0; 17.5) | 16.0 (13.0; 20.0) | p = 0.19 |
| TR vena contracta (mm) | 6.1 (4.7; 8.1) | 3.8 (2.5; 6.1) | p < 0.01 |
| TR EROA (mm2) | 31.0 (26.0; 33.0) | 23.0 (20.0; 32.0) | p = 0.19 |
| TR regurgitant volume (ml) | 27.0 (25.0; 27.0) | 21.5 (17.0; 26.3) | p = 0.20 |
| dPmean TV inflow (mmHg) | 1.2 (0.9; 1.8) | 1.1 (0.9; 1.3) | p = 0.25 |
| RV/RA gradient (mmHg) | 40.6 (29.4; 47.7) | 36.5 (28.3; 50.8) | p = 0.76 |
| Vena cava inferior (mm) | 22.0 (17.0; 24.0) | 17.0 (16.0; 24.0) | p = 0.11 |
| B TAD + | Baseline | FU | p-value |
|---|---|---|---|
| LVEF (%) | 51.9 (37.1; 58.4) | 51.5 (43.2; 57.9) | p = 0.40 |
| PG max aortic valve (mmHg) | 47.7 (33.8; 58.1) | 14.8 (10.1; 18.2) | p < 0.01 |
| PG mean aortic valve (mmHg) | 29.8 (20.9; 36.7) | 7.9 (5.4; 9.9) | p < 0.01 |
| RV area change (%) | 35.2 (30.4; 37.5) | 37.0 (31.0; 43.0) | p = 0.17 |
| RV diameter at mid/BSA (mm/m2) | 22.0 (20.1; 24.8) | 20.7 (18.8; 23.7) | p = 0.32 |
| RV diameter at base/BSA (mm/m2) | 30.7 )27.2; 32.8] | 28.8 )26.4; 32.7] | p = 0.15 |
| Tricuspid annulus diameter/BSA (mm/m2) | 24.3 (23.0; 26.2) | 22.5 (20.9; 25.1) | p = 0.01 |
| Right atrium/BSA (cm2/m2) | 17.2 )14.5; 20.3] | 17.1 )13.8; 20.3] | p = 0.11 |
| TAPSE (mm) | 15.0 (12.3; 19.8) | 16.0 (13.0; 19.0) | p = 0.51 |
| TR vena contracta (mm) | 6.3 (5.0; 9.2) | 6.3 )4.4; 10.0] | p = 0.77 |
| TR EROA (mm2) | 31.0 (23.5; 50.0) | 30.0 (21.0; 49.3) | p = 0.56 |
| TR regurgitant volume (ml) | 29.0 (21.0;45.0) | 31.5 (21.3; 40.8) | p = 0.83 |
| dPmean TV inflow (mmHg) | 1.0 (0.7; 1.2) | 1.0 (0.8; 1.4) | p = 0.41 |
| RV/RA gradient (mmHg) | 35.3 (25.5; 45.5) | 32.7 (27.8; 41.6) | p = 0.42 |
| Vena cava inferior (mm) | 21.0 (17.0; 25.0) | 21.0 (18.0; 26.0) | p = 0.93 |
| C | TAD − | TAD + | p value |
|---|---|---|---|
| Δ LVEF (%) | 3.6 (− 1.4; 5.7) | − 0.3 (− 4.8; 6.7) | p = 0.34 |
| Δ PG max aortic valve (mmHg) | − 29.0 (− 42.7; − 20.8) | − 34.2 (− 44.8; − 16.9) | p = 0.93 |
| Δ PG mean aortic valve (mmHg) | − 18.0 (− 31.2; − 10.4) | − 21.5 (− 29.6; − 11.4) | p = 0.59 |
| Δ RV area change (%) | 3.1 (− 3.2; 5.5) | 3.2 (− 7.0; 7.6) | p = 0.74 |
| Δ RV diameter at mid (mm/ m2) | − 0.6 (− 3.6; 1.5) | − 1.2 (− 3.4; 2.3) | p = 0.63 |
| Δ RV diameter at base (mm/ m2) | 0.0 (− 2.4; 3.2) | − 0.7 (− 3.5; 2.0) | p = 0.32 |
| Δ Tricuspid annulus diameter/BSA (mm/m2) | − 0.3 (− 1.9; 1.0) | − 1.2 (− 3.3; 1.1) | p = 0.30 |
| Δ Right atrium (cm2/m2) | 0.5 (− 2.0; 1.4) | − 0.5 (− 3.2; 1.3) | p = 0.29 |
| Δ TAPSE (mm) | 1.0 (− 1.0; 3.0) | − 1.0 (− 3.0; 2.0) | p = 0.13 |
| Δ TR vena contracta (mm) | − 2.0 (− 3.9; − 0.3) | 0.0 (− 2.2; 2.0) | p < 0.01 |
| Δ TR EROA (mm2) | − 7.0 [− 13.0; − 4.0] | − 2.5 (− 11.3; 6.8) | p = 0.28 |
| Δ TR regurgitant volume (ml) | − 8.0 (− 9.8; 1.3) | − 2.0 (− 8.8; 8.8) | p = 0.70 |
| Δ dPmean TV inflow (mmHg) | − 0.2 (− 0.5; 0.3) | 0.0 (− 0.3; 0.3) | p = 0.12 |
| Δ RV/RA gradient (mmHg) | 0.0 (− 12.1; 8.5) | 0.9 (− 9.8; 7.2]) | p = 0.91 |
| Δ Vena cava inferior (mm) | − 2.0 (− 6.0; 2.0) | 0.0 (− 4.0; 3.0) | p = 0.31 |
LVEF left ventricular ejection fraction, PG pressure gradient, TV tricuspid valve
Impact of TR development on survival and functional status
Two-year follow-up information was available in 81.8% of patients. All-cause mortality was significantly lower in patients with improvement of TR compared to patients without change or aggravation of TR (log-rank p < 0.01). The corresponding hazard ratio for 2-year all-cause mortality in patients with TR improvement vs. no change of TR and vs. aggravation was 0.47 (95% confidence interval 0.24 to 0.94) and 0.24 (95% confidence interval 0.11 to 0.54), respectively. Kaplan–Meier curves are shown in Fig. 3. Concerning functional status, improvement of NYHA functional class of at least two grades after the procedure was observed less often in patients with persistence of TR compared to patients with TR improvement (24.4 vs. 46.5%, p = 0.04) (Fig. 4).
Fig. 3.
Survival stratified for development of TR after TAVR
Fig. 4.
NYHA functional status at baseline and follow-up according to TR improvement
Discussion
Our analysis demonstrates that in patients undergoing TAVR for severe AS and at least moderate concomitant TR at baseline, CTA-derived TAD is associated with the persistence of TR after the procedure. Consistently, no patient without TAD required tricuspid valve treatment within the 2 year follow-up period. Besides, TR persistence is associated with increased 2 year all-cause mortality.
While former studies stated an association between significant TR at baseline and all-cause mortality in patients with AS undergoing TAVR, recent analyses demonstrated that TR persistence after the procedure is associated with increased mortality and might therefore be prognostically more relevant than TR severity at baseline [6, 7, 13, 14]. In this study, we could confirm that in TAVR patients with concomitant at least moderate TR at baseline, TR persistence is associated with increased all-cause mortality after 2 years. In addition, improvement of NYHA functional class of at least two grades was observed less often in patients with persistence of TR. A multivariable logistic regression analysis with adjustment for atrial fibrillation, renal impairment, right ventricular lead, mitral regurgitation, baseline TR severity, RV/RA gradient and right ventricular function confirmed that TAD is an independent predictor of TR persistence. Moreover, no difference regarding procedural characteristics and outcomes, including procedural mortality, technical or device failure was found between patients with and without TAD. Hence, an impact of procedural factors on the differences in outcomes seems unlikely.
As the preprocedural CTA is part of the standard of care to evaluate vascular access routes and to enable accurate prosthesis selection, the tricuspid annulus diameter can be obtained easily without further diagnostic effort. In addition, the measurement is less error-prone and with a lower degree of interobserver variability compared to echocardiographic assessment. In transthoracic echocardiography, an optimal acoustic window of the RV in the RV-focused apical four-chamber view is necessary to obtain the dimensions of the tricuspid valve. Therefore, and due to the complex oval and saddle-shaped anatomy of the valve, its maximal diameter is often underestimated in echocardiography. On the contrary, datasets of CT-scans can be angulated precisely in the tricuspid annulus for exact assessment of its dimensions as described previously [8]. Hence, CTA-determined BSA normalized tricuspid annulus diameter can serve as a reliable and easily accessible parameter to predict persistence of TR in patients with severe AS treated with TAVR.
Although concomitant tricuspid valve surgery is recommended in patients undergoing left-sided heart surgery and at least moderate TR in the context of tricuspid annular dilatation, optimal management of TR in TAVR patients remains unknown [5]. Considering the fact that moderate or severe TR can be observed in more than 25% of patients with severe AS and that the number of TAVR procedures will increase due to favorable outcomes in recent studies for asymptomatic or low-risk patients, this question might be even of higher relevance in the future [4, 15–17].
While sufficient literature regarding tricuspid valve intervention for persistent TR after TAVR is scarce, a recently published propensity-matched case–control study could demonstrate a benefit for patients without AS and at least moderate TR. Patients treated with transcatheter tricuspid valve intervention had significantly lower rates of mortality and rehospitalization compared to medically managed patients [18]. Besides, the less invasive nature of transcatheter valve repair and replacement procedures compared to open-heart surgery could facilitate a watch-and-wait strategy. Therefore, TAD could serve not only as a predictor of TR persistence after TAVR, but also as a tool to identify patients in need for intensified post-TAVR echocardiographic and clinical surveillance. In case of TR persistence and lack of symptomatic improvement, these patients might be candidates for transcatheter tricuspid valve interventions. Moreover, since tricuspid valve interventions especially edge-to-edge repair evolved in the last years and gained importance recently, the percentage of patients undergoing these procedures might even be higher in the future and TAD could serve as a tool to identify these patients.
Study limitations
The retrospective nature and the incomplete echocardiographic follow-up are major limitations of this study, as it poses a selection bias. Furthermore, we performed a central core laboratory analysis for the assessment of echocardiographic parameters, but analysis was limited by the available echocardiographic images and especially 3D volumetric data were not routinely recorded.
Conclusions
In patients undergoing TAVR for severe AS with at least moderate concomitant TR, TAD identifies patients with persistence of TR after the procedure, which is associated with increased 2-year all-cause mortality.
Supplementary Information
Below is the link to the electronic supplementary material.
Abbreviations
- AS
Aortic stenosis
- BARC
Bleeding academic research consortium
- BSA
Body surface area
- CTA
Computed tomography angiography
- EROA
Effective regurgitant orifice area
- NYHA
New York Heart Association
- RA
Right atrium
- RV
Right ventricle
- TAD
Tricuspid annular dilatation
- TAPSE
Tricuspid annular plane systolic excursion
- TAVR
Transcatheter aortic valve replacement
- TR
Tricuspid regurgitation
Funding
Open Access funding enabled and organized by Projekt DEAL.
Declarations
Conflict of interest
Simon Deseive and Julius Steffen received speaker honoraria from AstraZeneca. Daniel Braun and Christian Hagl received speaker honoraria from Abbott Vascular and Edwards Lifesciences. Martin Orban received speaker honoraria from Abbott Medical, AstraZeneca, Abiomed, Bayer vital, BIOTRONIK, Bristol-Myers Squibb, CytoSorbents, Daiichi Sankyo Deutschland, Edwards Lifesciences Services, and Sedana Medical. Jörg Hausleiter received research support and speaker honoraria from Abbott Vascular and Edwards Lifesciences. The other authors have no conflicts of interest to declare.
Footnotes
Daniel Braun and Simon Deseive contributed equally to this work.
References
- 1.Généreux P, Pibarot P, Redfors B, et al. Staging classification of aortic stenosis based on the extent of cardiac damage. Eur Heart J. 2017;38:3351–3358. doi: 10.1093/eurheartj/ehx381. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Prihadi EA, Delgado V, Leon MB, et al. Morphologic types of tricuspid regurgitation. JACC: Cardiovasc Imaging. 2019;12:491–499. doi: 10.1016/j.jcmg.2018.09.027. [DOI] [PubMed] [Google Scholar]
- 3.Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2022;43:561–632. doi: 10.1093/eurheartj/ehab395. [DOI] [PubMed] [Google Scholar]
- 4.Khan F, Okuno T, Malebranche D, et al. Transcatheter aortic valve replacement in patients with multivalvular heart disease. JACC: Cardiovasc Interv. 2020;13:1503–1514. doi: 10.1016/j.jcin.2020.03.052. [DOI] [PubMed] [Google Scholar]
- 5.Otto CM, Nishimura RA, Bonow RO, et al. ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American college of cardiology/American heart association joint committee on clinical practice guidelines. Circulation. 2020;2021:143. doi: 10.1161/CIR.0000000000000923. [DOI] [PubMed] [Google Scholar]
- 6.Tomii D, Okuno T, Praz F, et al. Potential candidates for transcatheter tricuspid valve intervention after transcatheter aortic valve replacement. JACC: Cardiovasc Interv. 2021;14:2246–2256. doi: 10.1016/j.jcin.2021.07.030. [DOI] [PubMed] [Google Scholar]
- 7.Yoshida J, Ikenaga H, Hayashi A, et al. Predictors and outcomes of persistent tricuspid regurgitation after transcatheter aortic valve implantation. Am J Cardiol. 2019;124:772–780. doi: 10.1016/j.amjcard.2019.05.066. [DOI] [PubMed] [Google Scholar]
- 8.Deseive S, Steffen J, Beckmann M, et al. CT-determined tricuspid annular dilatation is associated with increased 2-year mortality in TAVR patients. JACC: Cardiovasc Interv. 2020;13:2497–2507. doi: 10.1016/j.jcin.2020.06.027. [DOI] [PubMed] [Google Scholar]
- 9.Baumgartner H, Hung J, Bermejo J, et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European association of cardiovascular imaging and the American society of echocardiography. J Am Soc Echocardiogr. 2017;30:372–392. doi: 10.1016/j.echo.2017.02.009. [DOI] [PubMed] [Google Scholar]
- 10.Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American society of echocardiography and the European association of cardiovascular imaging. J Am Soc Echocardiogr. 2015;28:1–39.e14. doi: 10.1016/j.echo.2014.10.003. [DOI] [PubMed] [Google Scholar]
- 11.Hahn RT, Zamorano JL. The need for a new tricuspid regurgitation grading scheme. Eur Heart J Cardiovasc Imaging. 2017;18:1342–1343. doi: 10.1093/ehjci/jex139. [DOI] [PubMed] [Google Scholar]
- 12.Généreux P, Piazza N, Alu MC, et al. Valve academic research consortium 3: updated endpoint definitions for aortic valve clinical research. J Am Coll Cardiol. 2021;77:2717–2746. doi: 10.1016/j.jacc.2021.02.038. [DOI] [PubMed] [Google Scholar]
- 13.Takagi H, Hari Y, Kawai N, et al. Impact of concurrent tricuspid regurgitation on mortality after transcatheter aortic-valve implantation. Catheter Cardiovasc Interv. 2019;93:946–953. doi: 10.1002/ccd.27948. [DOI] [PubMed] [Google Scholar]
- 14.Worku B, Valovska M-T, Elmously A, et al. Predictors of persistent tricuspid regurgitation after transcatheter aortic valve replacement in patients with baseline tricuspid regurgitation. Innovations (Phila) 2018;13:190–199. doi: 10.1097/imi.0000000000000504. [DOI] [PubMed] [Google Scholar]
- 15.Mack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med. 2019;380:1695–1705. doi: 10.1056/NEJMoa1814052. [DOI] [PubMed] [Google Scholar]
- 16.Popma JJ, Deeb GM, Yakubov SJ, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med. 2019;380:1706–1715. doi: 10.1056/NEJMoa1816885. [DOI] [PubMed] [Google Scholar]
- 17.Banovic M, Putnik S, Penicka M, et al. Aortic valve replacement versus conservative treatment in asymptomatic severe aortic stenosis: the AVATAR trial. Circulation. 2022;145:648–658. doi: 10.1161/CIRCULATIONAHA.121.057639. [DOI] [PubMed] [Google Scholar]
- 18.Taramasso M, Benfari G, van der Bijl P, et al. Transcatheter versus medical treatment of patients with symptomatic severe tricuspid regurgitation. J Am Coll Cardiol. 2019;74:2998–3008. doi: 10.1016/j.jacc.2019.09.028. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.