TAVR patients with moderate or greater TR may face increased risks
A considerable number of patients who undergo transcatheter aortic valve replacement (TAVR) present with moderate to severe tricuspid regurgitation (TR). According to a new data published in the Journal of the American Heart Association, those patients may face a significantly higher risk of death or heart failure readmission than patients with less than moderate TR.[1]
“TAVR is approved for the treatment of severe aortic stenosis (AS) across the entire risk spectrum,” wrote first author James A. Brown, MD, a researcher with the department of cardiothoracic surgery at the University of Pittsburgh, and colleagues. “Although left‐sided echocardiographic parameters have been extensively shown to predict TAVR outcomes, some recent data suggest that right‐sided parameters may also be associated with post‐TAVR outcomes … The impact of preoperative TR after TAVR remains poorly characterized with mixed findings.”
Brown et al. tracked data from more than 2,000 patients who underwent TAVR for severe AS at a single high-volume facility from November 2012 to December 2021. Patients were excluded if imaging data from the time of their TAVR for one year following treatment were not available. The median follow-up period was 3.3 years.
Overall, moderate or greater TR at the time of treatment was seen in 13.4% of patients. These patients were more likely to require a permanent pacemaker after TAVR. Mild and moderate paravalvular leak were also more common in this group, and their post-TAVR ejection fraction was lower.
At one year, survival was 96.6% for patients with less than moderate TR at the time of TAVR and 93% for patients with moderate or greater TR. At five years, meanwhile, survival was 59.1% for patients with less than moderate TR at the time of TAVR and 43.1% for patients with moderate or greater TR. Heart failure readmissions were also significantly more common in patients who presented with moderate or greater TR, further suggesting that these patients may experience worse outcomes.
Another big takeaway from the team’s research was how TAVR appears to impact TR levels. One year after TAVR, for example, 8.1% of patients with less than moderate TR at baseline had gone on to develop new moderate or greater TR. Also, 62.1% of patients with moderate or greater TR at baseline experienced notable improvements in TR after being treated with TAVR.
Older patients as well as women and those who presented with peripheral artery disease were more likely to develop new or moderate or greater TR after TAVR.
“Poor outcomes after TAVR for patients with significant TR is likely due to the fact that these patients have more advanced sequelae of severe AS,” the authors wrote. “However, it should be noted that, when considering open heart surgery, guidelines suggest that tricuspid valve (TV) surgery should be performed at the time of left‐sided valve surgery because it does not appreciably increase operative risk and because it allows for positive right ventricular remodeling, reduces heart failure readmissions, and optimizes survival. Admittedly, the data supporting these guidelines are predominantly derived from mitral valve surgery. However, the enhancement of outcomes by adding a TV intervention to left‐sided valve surgery suggests that TR is not simply a surrogate marker of advanced disease but also signifies an additional actionable target.”
Significant TR, the group added, is something care teams must keep in mind when considering treatment plans for patients with severe AS.
“Even though more data are needed to establish guidelines for managing mixed aortic stenosis and TR, these findings ought to inform decision making by the multidisciplinary heart valve team when considering double valve surgery versus successive percutaneous interventions,” they concluded.
Brown and colleagues did note that their study had certain limitations, including the fact that it only focused on patients treated at a single facility. In addition, the facility’s experience with TAVR and other transcatheter treatments was evolving over the course of this analysis.
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Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.