Impact of right ventricular size and function on survival following transcatheter aortic valve replacement

Prognostic Value of a New Right Ventricular-to-Pulmonary Artery Coupling Parameter Using Right Ventricular Longitudinal Shortening Fraction in Patients Undergoing Transcatheter Aortic Valve Replacement: A Prospective Echocardiography Study

Introduction: Right-ventricular-to-pulmonary artery (RV-PA) coupling, measured as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP), has emerged as a predictor factor in patients undergoing transcatheter aortic valvular replacement (TAVR). Right ventricular longitudinal shortening fraction (RV-LSF) outperformed TAPSE as a prognostic parameter in several diseases. We aimed to compare the prognostic ability of two RV-PA coupling parameters (TAPSE/PASP and the RV-LSF/PASP ratio) in identifying MACE occurrences. Method: A prospective and single-center study involving 197 patients who underwent TAVR was conducted. MACE (heart failure, myocardial infarction, stroke, and death within six months) constituted the primary outcome. ROC curve analysis determined cutoff values for RV-PA ratios. Multivariable Cox regression analysis explored the association between RV-PA ratios and MACE. Results: Forty-six patients (23%) experienced the primary outcome. No significant difference in ROC curve analysis was found (RV-LSF/PASP with AUC = 0.67, 95%CI = [0.58-0.77] vs. TAPSE/PASP with AUC = 0.62, 95%CI = [0.49-0.69]; p = 0.16). RV-LSF/PASP < 0.30%.mmHg-1 was independently associated with the primary outcome. The 6-month cumulative risk of MACE was 59% (95%CI = [38-74]) for patients with RV-LSF/PASP < 0.30%.mmHg-1 and 17% (95%CI = [12-23]) for those with RV-LSF/PASP ≥ 0.30%.mmHg-1; (p < 0.0001). Conclusions: In a contemporary cohort of patients undergoing TAVR, RV-PA uncoupling defined by an RV-LSF/PASP < 0.30%.mmHg-1 was associated with MACE at 6 months.

Prosthesis choice for tricuspid valve replacement: Comparison of clinical and echocardiographic outcomes

OBJECTIVES

There is limited evidence evaluating valve function and right heart remodeling after tricuspid valve replacement (TVR), as well as whether the choice of prosthesis has an impact on these outcomes.

METHODS

We reviewed 1043 consecutive adult patients who underwent first-time TVR; 33% had previous aortic and/or mitral valve operations. Severe tricuspid valve regurgitation (TR) was the indication for surgery in 94% patients. A mechanical valve was used in 149 (14%) patients and a bioprosthetic valve in 894 (86%). Concomitant major cardiac procedures were performed in 57% of patients.

RESULTS

The median age of the cohort was 68.8 (range, 25-94) years, and 57% were female. Overall survival at 5 and 10 years was 50% and 31%, respectively. Adjusted survival and cumulative incidence of reoperation after TVR were similar in patients with bioprosthetic and mechanical valves. Overall, right ventricular (RV) function and dilation improved postoperatively with the estimated proportion of patients with moderate or greater RV systolic dysfunction/dilatation decreasing by around 20% at 3 years follow-up. After adjusting for preoperative degree of dysfunction/dilatation, valve type had no effect on late improvement in RV function and dilation. Bioprosthetic TVR was associated with greater rates of recurrence of moderate or greater TR over late follow-up. Overall, a slight decline in tricuspid valve gradients was observed over time.

CONCLUSIONS

Mechanical and bioprosthetic valves provide comparable survival, incidence of reoperation, and recovery of RV systolic function and size after TVR. Bioprosthetic valves develop significant TR over time, and mechanical valves may have an advantage for younger patients and those needing anticoagulation.

Impact of chronic obstructive pulmonary disease on right ventricular function and remodeling after aortic valve replacement

BACKGROUND

Both chronic obstructive pulmonary disease (COPD) and right ventricular (RV) dysfunction are common factors that have been associated with poor prognosis after aortic valve replacement (AVR). Since there is still uncertainty about the impact of COPD on RV function and dilatation in patients undergoing AVR, we sought to explore RV function and remodeling in the presence and absence of COPD as well as their prognostic implications.

METHODS

Patients who received surgical or transcatheter AVR due to severe AS were screened for COPD. Demographic and clinical data were collected at baseline while echocardiographic measurements were performed at baseline and 1 year after AVR. The study end-point was all-cause mortality.

RESULTS

In total 275 patients were included, with 90 (33%) patients having COPD. At 1-year follow-up, mild worsening of tricuspid annular planar systolic excursion and RV dilatation were observed in patients without COPD, while there were significant improvements in RV longitudinal strain, RV wall thickness but dilatation of RV outflow tract distal dimension in the COPD group compared to the baseline. On multivariable analysis, the presence of COPD provided significant incremental prognostic value over RV dysfunction and remodeling.

CONCLUSIONS

At 1-year after AVR, RV function and dimensions mildly deteriorated in non-COPD group whereas COPD group received significant benefit of AVR in terms of RV function and hypertrophy. COPD was independently associated with >2-fold all-cause mortality and had incremental prognostic value over RV dysfunction and remodeling.

Multidetector CT-derived tricuspid annulus measurements predict tricuspid regurgitation reduction after transcatheter aortic valve replacement

AIM

To use multidetector row computed tomography (MDCT)-derived tricuspid annulus (TA) measurements to identify predictors for tricuspid regurgitation (TR) reduction after transcatheter aortic valve replacement (TAVR), and to investigate the impact of TR change on prognosis.

MATERIALS AND METHODS

A retrospective, single-centre study was conducted on consecutive patients who underwent TAVR with concomitant baseline mild or more severe TR from April 2012 to April 2022. TA parameters were measured using MDCT.

RESULTS

The study comprised 266 patients (mean age 74.2 ± 7.6 years, 147 men) and 45.1% had more than one grade of TR reduction at follow-up. Independent predictors of TR reduction at follow-up were distance between TA centroid and antero-septal commissure (odd ratio [OR] 0.776; 95% confidence interval [CI]: 0.672-0.896, p=0.001), baseline TR of moderate or worse (OR 4.599; 95% CI: 2.193-9.648, p<0.001), systolic pulmonary artery pressure (OR 1.018; 95% CI: 1.002-1.035, p=0.027), age (OR 0.955; 95% CI: 0.920-0.993, p=0.019), and pre-existing atrial fibrillation (OR 0.209; 95% CI: 0.101-0.433, p<0.001). Patients without TR reduction had higher rates of rehospitalisation (hazard ratio [HR] 0.642; 95% CI: 0.413-0.998, p=0.049).

CONCLUSIONS

The MDCT-derived TA parameter was predictive of TR reduction after TAVR. Persistent TR after TAVR was associated with higher rates of rehospitalisation.

Impact of atrial fibrillation on outcomes in asymptomatic severe aortic stenosis: a propensity-matched analysis

Background

Atrial fibrillation (AF) portends poor prognosis in patients with aortic stenosis (AS).

Objectives

This study aimed to study the association of AF vs. sinus rhythm (SR) with outcomes in asymptomatic severe AS during routine clinical practice.

Methods

We identified 909 asymptomatic patients from 3,208 consecutive patients with aortic valve area ≤1.0 cm² and left ventricular ejection fraction ≥50% at a tertiary academic center. Patients were grouped by rhythm at the time of transthoracic echocardiogram [SR: 820/909 (90%) and AF: 89/909 (10%)]. Propensity-matched analyses (2 SR:1 AF) matching 174 SR to 89 AF patients by age, sex, and clinical comorbidities were used to compare outcomes.

Results

In the propensity-matched cohort, median age (82 ± 8 vs. 81 ± 9 years, p = 0.31), sex distribution (male 58% vs. 52%, p = 0.30), and Charlson comorbidity index (4.0 vs. 3.0, p = 0.26) were not different in AF vs. SR. Median follow-up duration was 2.6 (IQR: 1.0-4.4) years. The 1-year rate of aortic valve replacement (AVR) was not different (AF: 32% vs. SR: 37%, p = 0.31). All-cause mortality was higher in AF [hazard ratio (HR): 1.68 (1.13-2.50), p = 0.009]. Independent predictors of mortality were age [HR: 1.92 (1.40-2.62), p < 0.001], Charlson comorbidity index [1.09 (1.03-1.15), p = 0.002], aortic valve peak velocity [HR: 1.87 (1.20-2.94), p = 0.006], stroke volume index [HR: 0.75 (0.60-0.93), p = 0.01], moderate or more mitral regurgitation [HR: 2.97 (1.43-6.19), p = 0.004], right ventricular systolic dysfunction [HR: 2.39 (1.29-4.43), p = 0.006], and time-dependent AVR [HR: 0.36 (0.19-0.65), p = 0.0008]. There was no significant interaction of AVR and rhythm (p = 0.57).

Conclusions

Lower forward flow, right ventricular systolic dysfunction, and mitral regurgitation identified increased risk of subsequent mortality in asymptomatic patients with AF and AS. Additional studies of risk stratification of asymptomatic AS in AF vs. SR are needed.

Right ventricle to pulmonary artery coupling after transcatheter aortic valve implantation-Determinant factors and prognostic impact

Introduction

Right ventricular (RV) dysfunction and pulmonary hypertension (PH) have been previously associated with unfavorable outcomes in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI), but little is known about the effect of right ventricle (RV) to pulmonary artery (PA) coupling. Our study aimed to evaluate the determinant factors and the prognostic value of RV-PA coupling in patients undergoing TAVI.

Methods

One hundred sixty consecutive patients with severe AS were prospectively enrolled, between September 2018 and May 2020. They underwent a comprehensive echocardiogram before and 30 days after TAVI, including speckle tracking echocardiography (STE) for myocardial deformation analysis of the left ventricle (LV), left atrium (LA), and RV function. Complete data on myocardial deformation was available in 132 patients (76.6 ± 7.5 years, 52.5% men) who formed the final study population. The ratio of RV free wall longitudinal strain (RV-FWLS) to PA systolic pressure (PASP) was used as an estimate of RV-PA coupling. Patients were analyzed according to baseline RV-FWLS/PASP cut-off point, determined through time-dependent ROC curve analysis, as follows: normal RV-PA coupling group (RV-FWLS/PASP ≥0.63, n = 65) and impaired RV-PA coupling group (RV-FWLS/PASP < 0.63, n = 67).

Results

A significant improvement of RV-PA coupling was observed early after TAVI (0.75 ± 0.3 vs. 0.64 ± 0.3 before TAVI, p < 0.001), mainly due to PASP decrease (p < 0.001). LA global longitudinal strain (LA-GLS) is an independent predictor of RV-PA coupling impairment before and after TAVI (OR = 0.837, p < 0.001, OR = 0.848, p < 0.001, respectively), while RV diameter is an independent predictor of persistent RV-PA coupling impairment after TAVI (OR = 1.174, p = 0.002). Impaired RV-PA coupling was associated with a worse survival rate (66.3% vs. 94.9%, p-value < 0.001) and emerged as an independent predictor of mortality (HR = 5.97, CI = 1.44-24.8, p = 0.014) and of the composite endpoint of death and rehospitalization (HR = 4.14, CI = 1.37-12.5, p = 0.012).

Conclusion

Our results confirm that relief of aortic valve obstruction has beneficial effects on the baseline RV-PA coupling, and they occur early after TAVI. Despite significant improvement in LV, LA, and RV function after TAVI, RV-PA coupling remains impaired in some patients, it is mainly related to persistent pulmonary hypertension and is associated with adverse outcomes.

The Association of Severe Tricuspid Regurgitation with Poor Survival is Modified by Right Ventricular Pressure and Function

Contemporary data on the independent association of severe TR with excess mortality is warranted.

OBJECTIVES

Describe the contemporary outcome of severe TR patients and identify its modifiers.

METHODS

Consecutive echocardiographic reports linked to clinical data of the largest medical center in Israel (2007-2019). The primary outcome was all-cause mortality. Cox regression and propensity score matching models were applied.

RESULTS

Final cohort included 97,096 patients. Mild, moderate, and severe TR was documented in 27,147(28%), 2,844(3%) and 1,805 (2%) patients, respectively. During a median follow-up of 5 years [IQR 2-8], 22,170 (23%) patients died. Kaplan-Meier survival analysis demonstrated an increased risk of death with an increasing degree of TR (p Log-rank <.001). Propensity score matching of 1,265 patients with severe TR and their matched controls showed that compared with non-severe TR, patients with severe TR were 17% more likely to die (95% 1.05-1.29 p = .003). The association of severe TR with survival was dependent on estimated right ventricular (RV) pressure, with a more pronounced effect among patients with estimated systolic pressure ≤ 40 mmHg (HR of 2.12 vs. 1.04, p for interaction < .001). A Landmark sub-analysis of 17,967 patients demonstrated that RV function deterioration on a follow-up echocardiographic exam modified the association of severe TR with survival. It was more significant among patients with preserved and stable RV function (p for interaction = 0.035).

CONCLUSIONS

The outcome of severe TR is modified by RV pressure and function. Once RV function deteriorates, differences in the outcome of patients with and without severe TR are less pronounced.

Evaluating the effect of multivalvular disease on mortality after transcatheter aortic valve replacement for aortic stenosis: a meta-analysis and systematic review

Aims: To determine the prognosis of multivalvular disease in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Methods: Patients undergoing TAVR for aortic stenosis with covariate-adjusted risk of mortality associated with concomitant valve disease (mitral regurgitation [MR], mitral stenosis [MS] or tricuspid regurgitation [TR]) were included. Results: Moderate-to-severe MR was associated with increased mortality at 30 days (hazard ratio [HR]: 1.60; 95% CI: 1.11-2.30; p = 0.01) and 1 year (HR: 1.87; 95% CI: 1.22-2.87; p = 0.004). The presence of all-grade MS did not impact 30-day or 1-year mortality (HR, 30 days: 1.60; 95% CI: 0.71-3.63; p = 0.26; and HR, 1 year: 1.90; 95% CI: 0.98-3.69; p = 0.06); however, an increased risk of 1-year mortality (HR: 1.67; 95% CI: 1.03-2.70; p = 0.04) was observed with severe MS compared with no MS. Moderate-to-severe TR had a higher risk of all-cause mortality at 1 year (HR: 1.49; 95% CI: 1.24-1.78; p < 0.001) compared with no or mild TR. Conclusion: Moderate-to-severe MR or TR, and severe MS, significantly increase mid-term mortality after TAVR.

Pre-Procedural Right Ventricular Longitudinal Strain and Post-Procedural Tricuspid Regurgitation Predict Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI)

Background: Right ventricular (RV) dysfunction has been linked to worse outcomes in patients undergoing TAVI. Assessment of RV function is challenging due to its complex morphology. RV longitudinal strain (LS) assessed by speckle-tracking echocardiography (STE) is a novel measure that may overcome most of the limitations of conventional echocardiographic parameters of RV function. The aim of current study was to assess the prognostic value of RV LS in patients undergoing TAVI and to assess echocardiographic predictors of long-term mortality. Methods and results: A retrospective analysis of all consecutive patients who underwent TAVI at our hospital between 1 January 2015 and 1 June 2016. Indication for TAVI was approved by a local heart-team. Echocardiographic data at baseline and after TAVI were re-analyzed and RV LS was measured in all patients with adequate image quality. A total of 229 patients were included in our study (mean age 83.8 ± 5 years, 62% women, mean EuroSCORE II 5.7 ± 5%). All-cause mortality occurred in 17.3% over a mean follow-up of 929 ± 373 days. In multivariate analysis, only baseline average RV free-wall LS (HR 1.05, 95% CI (1.01 to 1.10), p = 0.049) and more than mild tricuspid valve regurgitation (TR) after TAVI (HR 4.39, 95% CI (2.22 to 8.70), p < 0.001) independently increased the risk of all-cause mortality at long- term follow-up (2.5 years), while conventional echocardiographic parameters of RV function did not predict mortality. Conclusion: Pre-procedural RV LS and post-procedural tricuspid regurgitation significantly predicted long-term all-cause mortality in patients undergoing TAVI while conventional echocardiographic parameters of RV function failed in predicting long-term outcome. RV longitudinal strain by STE should be considered in the routine echocardiographic assessments of patients with severe AS.

Incidence, Predictive Factors, and Prognostic Impact of Right Ventricular Dysfunction Before Transcatheter Aortic Valve Implantation

Right ventricular dysfunction (RVD) is considered to be a late marker of aortic stenosis. However, there is a lack of consensus regarding the incidence, prognostic impact, and evolution of RVD in patients treated with transcatheter aortic valve implantation (TAVI). All patients treated with TAVI for severe aortic stenosis were included in a prospective single-center database. Patients who had a quantitative assessment of right ventricular (RV) function including tricuspid annular plane systolic excursion (TAPSE) and/or Doppler tissue imaging-derived tricuspid lateral annular systolic velocity (S' wave) measurements were eligible for this study. RVD was defined as TAPSE <17 mm or S' <9.5 cm/s if TAPSE was not available. Between 2014 and 2019, 503 patients with RV function assessment were included. The incidence of RVD before TAVI was 18.7%. Predictors of RVD were diabetes (p = 0.03), atrial fibrillation (p = 0.001), impaired left ventricular ejection fraction (p <0.0001), left ventricular dilatation (p = 0.007), and previous cardiac surgery (p = 0.002). Long-term survival was worse in patients with RVD before TAVI compared with those without RVD (hazard ratio 1.97, 95% confidence interval 1.1 to 3.4, p = 0.01). One year after TAVI, 58.7% of patients with baseline RVD had normal RV function and had similar outcomes as compared with those without RVD at baseline. In contrast, patients with persistent RVD had the worst prognosis. In conclusion, RVD is not rare and has a deleterious prognostic impact in patients treated with TAVI. Recovery of normal RV function is frequent after TAVI, whereas persistence of RVD is associated with poor outcomes.

Prognostic implication of right ventricular dysfunction and tricuspid regurgitation following transcatheter aortic valve replacement

OBJECTIVES

Right ventricular (RV) dysfunction and tricuspid regurgitation (TR) are associated with adverse outcomes in severe aortic stenosis (AS) patients. Our aim was to evaluate the association between ≥moderate TR and RV dysfunction on long-term mortality following transcatheter aortic valve replacement (TAVR).

METHODS

A retrospective analysis of the Israeli multicenter TAVR registry among 4,344 consecutive patients, with all-cause mortality as the main outcome measure.

RESULTS

Echocardiographic assessment of TR grade and RV dysfunction was available for 3,733 and 1,850 patients, of whom ≥moderate TR and RV dysfunction was noted for 478(13%) and 78(4%), respectively. The mean follow-up time was 2.9 ± 2.3 years. In univariate models, ≥Moderate TR and ≥moderate RV dysfunction were associated with increased long-term mortality (HR 1.45, 95% CI 1.24-1.69, p < .001 and HR 1.73, 95% CI 1.21-2.47, p = 0.003, respectively). These finding did not remained significant after adjusting to echocardiographic parameters. A subset of patients with no improvement in RV function had the highest long-term mortality risk (HR 3.3, 95% CI 1.95-5.7, p < .001).

CONCLUSION

When adjusted to multiple echocardiographic characteristics baseline ≥Moderate TR and ≥moderate RV dysfunction were not associated with long-term mortality following TAVR. Persistent RV dysfunction following TAVR was associated with the highest risk for mortality.

The Right Ventricle in the Trans-Catheter Era: A Perspective for Planning Interventions

Dysfunction of the right ventricle (RV) is common in patients with advanced left-sided valve disease and the significant impact of RV dysfunction on both short and long-term outcome is well established. However, considerations of RV function are largely absent in current management guidelines for valve disease and cardiac procedural risk models. As the indications and use of trans-catheter therapies rapidly expand for patients with acquired valvular disease, it is critical for clinicians to understand and consider RV function when making decisions for these patients. This review summarizes contemporary data on the assessment of RV function, the prognostic importance of baseline RV dysfunction on surgical and transcatheter procedures for acquired left-sided valvular disease, and the relative impact of these interventions on RV function. Baseline RV dysfunction is a powerful predictor of poor short- and long-term outcome after any therapeutic intervention for acquired left-sided cardiac valve disease. Surgical intervention for aortic or mitral valve disease is associated with a significant but transient decline in RV function, whereas trans-catheter procedures generally do not appear to have detrimental effects on either longitudinal or global RV function. Guidelines for therapy in patents with acquired left-sided valvular disease should account for RV dysfunction. Whereas surgical intervention in these patients leads to a predictable decline in RV function, trans-catheter therapies largely do not appear to have this effect. Further study is needed to determine the impact of these findings on current practice.

Heart failure following transcatheter aortic valve replacement

Introduction: Over the past decade, the number of transcatheter aortic valve replacement (TAVR) procedures has increased exponentially. Despite major improvements in both device and successes, the rate of hospital readmission after TAVR remains high, with heart failure (HF) decompensation being one of the most important causes.Areas covered: This review provides an overview of the current status of HF following TAVR, including details about its incidence, clinical impact, contributing factors, and current and future treatment perspectives.Expert opinion: HF decompensation has been identified as the most common cause of rehospitalization following TAVR, and it has been associated with a negative prognosis. Multiple preexisting factors including low flow status, cardiac amyloidosis, myocardial fibrosis, multivalvular disease, pulmonary hypertension, coronary artery disease, and atrial fibrillation have been associated with an increased risk of HF events. Also, multiple post-procedural factors like the occurrence of significant paravalvular leaks, severe prosthesis-patient mismatch, and conduction disturbances have also contributed to increase this risk . Thus, reducing HF events in TAVR recipients would require a multifactorial and multidisciplinary effort including the optimization of the medical treatment and close follow-up and treatment of residual or concomitant valvular disease and conduction disturbance issues. Future studies in this challenging group of patients are warranted.

Right ventricular function and outcome in patients undergoing transcatheter aortic valve replacement

AIMS

Right ventricular dysfunction (RVD) on echocardiography has been shown to predict outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). However, a comparison with the gold standard, RV ejection fraction (EF) on cardiovascular magnetic resonance (CMR), has never been performed.

METHODS AND RESULTS

Consecutive patients scheduled for TAVR underwent echocardiography and CMR. RV fractional area change (FAC), tricuspid annular plane systolic excursion, RV free-lateral-wall tissue Doppler (S'), and strain were assessed on echocardiography, and RVEF on CMR. Patients were prospectively followed. Adjusted regression analyses were used to report the strength of association per 1-SD decline for each RV function parameter with (i) N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels, (ii) prolonged in-hospital stay (>14 days), and (iii) a composite of heart failure hospitalization and death. Two hundred and four patients (80.9 ± 6.6 y/o; 51% female; EuroSCORE-II: 6.3 ± 5.1%) were included. At a cross-sectional level, all RV function parameters were associated with NT-proBNP levels, but only FAC and RVEF were significantly associated with a prolonged in-hospital stay [adjusted odds ratio 1.86, 95% confidence interval (CI) 1.07-3.21; P = 0.027 and 2.29, 95% CI 1.43-3.67; P = 0.001, respectively]. A total of 56 events occurred during follow-up (mean 13.7 ± 9.5 months). After adjustment for the EuroSCORE-II, only RVEF was significantly associated with the composite endpoint (adjusted hazard ratio 1.70, 95% CI 1.32-2.20; P < 0.001).

CONCLUSION

RVD as defined by echocardiography is associated with an advanced disease state but fails to predict outcomes after adjustment for pre-existing clinical risk factors in TAVR patients. In contrast, RVEF on CMR is independently associated with heart failure hospitalization and death.

The cardiothoracic ratio: a neglected preoperative risk-stratified method for patients with rheumatic heart disease undergoing valve replacement surgery

OBJECTIVES

It is common for patients with rheumatic heart disease to have an enlarged heart. We investigated the prognostic value of cardiothoracic ratio (CTR) in patients with rheumatic heart disease undergoing valve replacement surgery.

METHODS

A total of 1772 patients were divided into 4 groups based on the quartiles of preoperative CTR: <0.56 (n = 349), 0.56-0.61 (n = 488), 0.61-0.66 (n = 449) and ≥0.66 (n = 486). The CTR was measured from postero-anterior chest radiographs. We then investigated the association between the CTR and adverse outcomes.

RESULTS

In-hospital mortality was 4.0% (71/1772). Analyses of receiver operating characteristic curves showed that, at a cut-off of 0.6, the CTR exhibited 66.2% sensitivity and 64.0% specificity for detecting in-hospital death (area under curve 0.671, P < 0.001). The prevalence of in-hospital death was 7.1% in males with a CTR >0.6, which was significantly higher in males without a CTR. A similar result was observed in females (1.9 vs 5.1%, P = 0.004). Multivariable regression showed that a CTR >0.6 was an independent predictor of in-hospital (odds ratio 2.36, P = 0.005) and 1-year mortality (hazard ratio 2.06, P = 0.006). Kaplan-Meier curves, for the cumulative rate of 1-year mortality among groups, indicated that the risk of death was increased if the CTR >0.6 (log-rank 16.36, P < 0.001).

CONCLUSIONS

CTR, as a simple and reproducible indicator, was identified as a prognostic factor for predicting poor outcomes in patients with rheumatic heart disease undergoing valve replacement surgery.

Effect of Transcatheter Aortic Valve Replacement on Right Ventricular-Pulmonary Artery Coupling

OBJECTIVES

The aim of this study was to test the hypothesis that the acute left ventricular (LV) unloading effect of transcatheter aortic valve replacement (TAVR) would improve right ventricular (RV) function and RV-pulmonary artery (PA) coupling in patients with severe aortic stenosis (AS).

BACKGROUND

RV dysfunction is an ominous prognostic marker in patients undergoing TAVR, suggesting that relief of obstruction might be less beneficial in this cohort. However, the left ventricle and right ventricle influence each other through ventricular interaction, which could lead to improved RV function through LV unloading.

METHODS

Prospective invasive hemodynamic measurements with simultaneous echocardiography were performed in symptomatic patients with severe AS before and immediately after TAVR.

RESULTS

Forty-four patients (mean age 81 ± 8 years, 27% women) with severe AS underwent TAVR. At baseline, right atrial, PA mean (27 ± 7 mm Hg), and pulmonary capillary wedge (16 ± 4 mm Hg) pressures were mildly elevated, with a low normal cardiac index (2.3 l/min/m²). Pulmonary vascular resistance was mildly elevated (222 ± 133 dynes · s/cm⁵) and PA compliance mildly reduced (3.4 ± 01.4 ml/mm Hg). Following TAVR, aortic valve area increased (from 0.8 ± 0.3 to 2.7 ± 1.1 cm²; p < 0.001) with a reduction in mean aortic gradient (from 37 ± 11 to 7 ± 4 mm Hg; p < 0.001) and an increase in cardiac index (from 2.3 ± 0.5 to 2.5 ± 0.6 l/min/m²; p = 0.03). LV stroke work, end-systolic wall stress, and systolic ejection period decreased by 23% to 27% (p < 0.001 for all), indicating substantial LV unloading. RV stroke work (from 16 ± 7 to 18 ± 7 mm Hg · ml; p = 0.04) and tricuspid annular systolic velocities (from 9.5 ± 2.0 to 10.4 ± 3.5 cm/s; p = 0.01) increased, along with a decrease in PVR (194 ± 113 dynes · s/cm⁵; p = 0.03), indicating improvement in RV-PA coupling. Increased RV stroke work following TAVR directly correlated with the magnitude of increase in aortic valve area (r = 0.58; p < 0.001).

CONCLUSIONS

Acute relief in obstruction to LV ejection with TAVR is associated with improvements in RV function and RV-PA coupling. These findings provide new insights into the potential benefits of LV unloading with TAVR on RV dysfunction in patients with severe AS.

Impact of right ventricular volumes on the outcomes of TAVR: a volumetric analysis of preprocedural computed tomography

AIMS

The aim of this study was to assess the prognostic implications of increased right ventricle volume index (RVVI) using cardiac-gated computed tomography angiography (CCTA) data among patients undergoing transcatheter valve replacement (TAVR).

METHODS AND RESULTS

CCTA of 323 patients who underwent TAVR at Stanford University Medical Center (CA, USA) and Tel Aviv Medical Center (Israel) between 2013 and 2016 was analysed by an automatic four-chamber volumetric software and grouped into quartiles according to RVVI. Higher one-year mortality rates were noted for the upper quartiles - 5%, 4.9%, 8.6%, and 16% (p=0.039), in Q1 <59 ml/m2, Q2 59-69 ml/m2, Q3 69-86 ml/m2, and Q4 >86 ml/m2, respectively. However, the differences were not significant after propensity score adjustments. Sub-analyses of Q1 demonstrated an escalating risk for one-year mortality in concordance to RVVI: HR 2.28, HR 2.76, and HR 4.7, for the upper 25th, 15th, and 5th percentiles, respectively (p<0.05 for all comparisons). After propensity score adjustments for clinical and echocardiographic characteristics, only the upper 5th percentiles (RVVI >120 ml/m2) retained statistical significance (HR 2.82, 95% CI: 1.02-7.78, p=0.045). Notably, 68.7% of patients from this group were considered low-intermediate risk for surgery.

CONCLUSIONS

Cardiac volumetric data by CCTA performed for procedural planning may help to predict outcome in patients undergoing TAVR.

Prognostic Assessment of Right Ventricular Systolic Dysfunction on Post-Transcatheter Aortic Valve Replacement Short-Term Outcomes: Systematic Review and Meta-Analysis

Background Right ventricular systolic dysfunction (RVSD) is a known risk factor for adverse outcome in surgical aortic valve replacement. Transcatheter aortic valve replacement (TAVR), on the other hand, has been shown to be either beneficial or have no effect on right ventricular systolic function. However, the prognostic significance of RVSD on TAVR has not been clearly determined. We conducted a systematic review and meta-analysis to define the impact of RVSD on outcomes in terms of 1-year mortality in patients with severe aortic stenosis undergoing TAVR. Methods and Results An extensive literature review was performed, with an aim to identify clinical studies that focused on the prognosis and short-term mortality of patients with severe symptomatic aortic stenosis who underwent TAVR. A total of 3166 patients from 8 selected studies were included. RVSD, as assessed with tricuspid annular plane systolic excursion, fractional area change or ejection fraction, was found to be a predictor of adverse procedural outcome after TAVR (hazard ratio, 1.31; 95% CI, 1.1-1.55; P=0.002). Overall, we found that RVSD did affect post-TAVR prognosis in 1-year mortality rate. Conclusions Patients with severe, symptomatic aortic stenosis and concomitant severe RVSD have a poor 1-year post-TAVR prognosis when compared with patients without RVSD. Right ventricular dilation and severe tricuspid regurgitation were associated with increased 1-year morality post-TAVR and should be considered as independent risk factors. Further evaluations of long-term morbidity, mortality, as well as sustained improvement in functional class and symptoms need to be conducted to determine the long-term effects.

Implications of Concomitant Tricuspid Regurgitation in Patients Undergoing Transcatheter Aortic Valve Replacement for Degenerated Surgical Aortic Bioprosthesis: Insights From the PARTNER 2 Aortic Valve-in-Valve Registry

OBJECTIVES

The aim of this study was to assess the implications of concomitant tricuspid regurgitation (TR) in patients undergoing valve-in-valve (VIV) transcatheter aortic valve replacement.

BACKGROUND

Patients undergoing VIV transcatheter aortic valve replacement with concomitant TR may have worse outcomes, and optimal management remains undetermined.

METHODS

The multicenter PARTNER 2 (Placement of Aortic Transcatheter Valves) VIV trial enrolled patients with symptomatic degenerated surgical aortic bioprostheses who were at high risk for reoperation. Outcomes were assessed between patients with mild or no TR versus moderate or severe TR.

RESULTS

A total of 237 patients underwent VIV procedures (mean age 78.7 ± 10.8 years, mean Society of Thoracic Surgeons score 9.1 ± 4.8%). In this cohort, 162 patients (68.4%) had mild or no TR, and 75 patients (31.6%) had moderate or severe TR. Although there was no difference in New York Heart Association functional class III or IV symptomatic status (89.3% vs. 91.4%; p = 0.62) or moderate or severe right ventricular dysfunction (9.4% vs. 16.9%; p = 0.11), patients with moderate or severe TR were more likely to be at high surgical risk, with a Society of Thoracic Surgeons score of >8 (62.7% vs 46.9%; p = 0.02). There was no difference in a composite endpoint of death and rehospitalization between moderate or severe TR and mild or no TR, either at 30 days (10.7% vs. 9.9%; p = 0.85) or at 1-year follow-up (24.1% vs. 23.2%; p = 0.80). There was a significant reduction in overall moderate or severe TR from baseline at 30 days (31.1% vs. 21.1%; p = 0.002), which was sustained at 1-year follow-up (38.0% vs. 22.8%; p = 0.004).

CONCLUSIONS

Despite higher predicted surgical risk, the presence of TR was not a predictor of long-term outcomes. Importantly, there was significant reduction in TR severity at both short- and long-term follow-up. In selected patients undergoing VIV transcatheter aortic valve replacement, it may be appropriate to conservatively manage concomitant TR.

Assessing Right Ventricular Function in the Perioperative Setting, Part I: Echo-Based Measurements

This article reviews transesophageal echocardiography-based assessment of perioperative right ventricular function and failure, including catheter-based methods, three-dimensional echocardiography, and their combination to make pressure-volume loops. It outlines right ventricular pathophysiology, multiple assessment methods, and their relationship to analogous transthoracic echocardiogram measurements. technologies used and developed for transthoracic or left ventricular assessment show significant limitations when applied to transesophageal assessment of the right ventricle. The article provides an overview of right ventricular assessment modalities that can be used in transesophageal echocardiography. Ultimately, clinicians must know limitations of measurements, synthesize information, and assess it in the clinical context.

Lack of Increased Cardiovascular Risk due to Functional Tricuspid Regurgitation in Patients with Left-Sided Heart Disease

BACKGROUND

Significant tricuspid regurgitation (TR) is associated with higher risk for adverse cardiovascular outcomes. Left-sided heart disease (LHD) is a potentially important confounder of this association because it is strongly linked to both TR and clinical outcome.

METHODS

We studied 5,886 patients who were followed for a period of 10 years after the index echocardiographic examination. The relationship between TR severity and the end point of admission for heart failure or cardiovascular mortality was analyzed using competing risk analysis, Cox model, and propensity score matching.

RESULTS

Higher TR grade was associated with markers of LHD including left ventricular systolic dysfunction, valvular heart disease ≥ moderate, left atrial enlargement, and pulmonary hypertension (all P < .001). There was a significant interaction between TR and the presence of LHD with regard to the end point of heart failure in the competing risks model (P = .01) and the combined end point of heart failure and cardiovascular mortality (P = .02). In both models, moderate/severe TR was associated with higher risk for heart failure (hazard ratio [HR] = 3.10; 95% CI, 1.41-6.84; P = .005) and the combined end point of heart failure or cardiovascular mortality (HR = 2.75; 95% CI, 1.33-5.63, P = .006) only in patients without LHD. Propensity score matching yielded 350 patient pairs, of which 88% had LHD. The HR for heart failure or cardiovascular mortality at 10 years was 0.78 (95% CI, 0.56-1.08; P = .14) in the moderate/severe TR group as compared with the trivial/mild TR.

CONCLUSIONS

Moderate or severe functional TR portends an increased risk for heart failure and cardiovascular mortality only when isolated, without concomitant LHD.

Baseline significant tricuspid regurgitation is associated with higher mortality in transcatheter aortic valve replacement: systemic review and meta-analysis

INTRODUCTION

Significant tricuspid regurgitation is a well recognized indicator of right ventricular dysfunction. Recent studies have shown that significant tricuspid regurgitation is potentially associated with increased mortality in patients with severe aortic stenosis who underwent transcatheter aortic valve replacement (TAVR). However, data remained sparse and inconclusive. Thus, we performed a systematic review and meta-analysis of the literature to assess the association between significant tricuspid regurgitation and mortality in post TAVR patients.

HYPOTHESIS

Significant tricuspid regurgitation is predictive for higher mortality in patients undergoing TAVR.

METHODS

We comprehensively searched the databases of MEDLINE and EMBASE from inception to October 2018. Included studies were published observational studies that reported multivariate analysis of the effects of significant tricuspid regurgitation on all-cause mortality among patients undergoing TAVR. Data from each study were combined utilizing the random-effects, generic inverse variance method of DerSimonian and Laird to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Nine cohort studies from August 2011 to May 2018 consisting of 27 614 patients with severe aortic stenosis undergoing TAVR (6255 with and 21 359 without significant tricuspid regurgitation) were included in this meta-analysis. The presence of significant tricuspid regurgitation was associated with higher all-cause mortality (pooled OR = 2.26, 95% CI: 1.45-3.52, P < 0.001). We found that all-cause mortality remained statistically substantial in all subgroups (30-day all-cause mortality: OR = 2.05, 95% CI: 1.20-3.49, P = 0.009; midterm all-cause mortality: OR = 9.67, 95% CI: 2.44-38.31, P = 0.001; and long-term all-cause mortality: OR = 1.48, 95% CI: 1.19-1.85, P < 0.001). Funnel plots and Egger's regression asymmetry test were performed and showed no publication bias.

CONCLUSION

Significant tricuspid regurgitation increased risk of mortality by up to two-fold among patients with severe aortic stenosis undergoing TAVR. Our study suggests that significant tricuspid regurgitation should be considered a component of risk stratification tools.

Predictors of early mortality after transcatheter aortic valve implantation

Objectives

To investigate whether preoperative echocardiographic evaluation of ventricular function, especially right ventricular systolic and diastolic parameters including speckle-tracking analysis, could aid in the prediction of 30-day mortality after transcatheter aortic valve implantation (TAVI) in patients with aortic stenosis.

Methods

This is a prospective observational cohort study including 227 patients accepted for TAVI at the University Hospital of North Norway and Oslo University Hospital from February 2010 through June 2013. All patients underwent preoperative transthoracic echocardiography with retrospective speckle-tracking analysis. Primary endpoint was all-cause 30-day mortality.

Results

All-cause 30-day mortality was 8.7 % (n = 19). Independent predictors of 30-day mortality were systolic pulmonary arterial pressure (SPAP) > 60 mm Hg (HR: 7.7, 95% CI: 1.90 to 31.3), heart failure (HR: 2.9, 95% CI: 1.1 to 7.78), transapical access (HR: 3.8, 95% CI: 1.3 to 11.2), peripheral artery disease (HR: 6.0, 95% CI: 2.0 to 18.0) and body mass index (HR: 0.73, 95% CI: 0.61 to 0.87). C-statistic for the model generated was 0.91 (95% CI: 0.85 to 0.98). Besides elevated SPAP, no other echocardiographic measurements were found to be an independent predictor of early mortality.

Conclusion

Except for elevated systolic pulmonary artery pressure, our data suggests that clinical rather than echocardiographic parameters are useful predictors of 30-day mortality after TAVI.

Impact of tricuspid regurgitation and right ventricular dysfunction on outcomes after transcatheter aortic valve replacement: A systematic review and meta-analysis

Far less attention has been paid to the prognostic effect of right-side heart disease on outcomes after transcatheter aortic valve replacement (TAVR) when compared with the left side. Therefore, we performed a systematic review and meta-analysis on the impact of tricuspid regurgitation (TR) and right ventricular (RV) dysfunction on outcomes after TAVR. We hypothesized that TR and RV dysfunction may have a deleterious effect on outcomes after TAVR. Article revealing the prognostic effect of TR and RV dysfunction on outcomes after TAVR were being integrated. Random or fixed effect model was adopted in accordance with the heterogeneity. There were nine studies with a total of 6466 patients enrolled after a comprehensive literature search of the MEDLINE/PubMed, EMBASE, ISI Web of Science, and Cochrane databases. The overall analysis revealed that moderate or severe TR at baseline increased all-cause mortality after TAVR (HR = 1.79, CI 95% 1.52-2.11, P < 0.001). Both baseline RV dysfunction (HR = 1.53, CI 95% 1.27-1.83, P < 0.001) and presence of RV dilation (HR = 1.83, CI 95% 1.47-2.27, P < 0.001) were associated with all-cause mortality. Both baseline moderate or severe TR and RV dysfunction worsen prognosis after TAVR and careful assessment of right heart function should be done for clinical decision by the heart team before the TAVR procedure.

Impact of concurrent tricuspid regurgitation on mortality after transcatheter aortic-valve implantation

OBJECTIVES

To determine whether concomitant tricuspid regurgitation (TR) is associated with increased mortality in patients with severe aortic stenosis (AS) undergoing transcatheter aortic-valve implantation (TAVI), we performed a meta-analysis of currently available studies.

METHODS

MEDLINE and EMBASE were searched through May 2018. We included comparative or cohort studies enrolling patients with AS undergoing TAVI and reporting early (in-hospital or 30-day) and late (including early) all-cause mortality in patients stratified by baseline TR grade. An odds ratio (OR) of early mortality and a hazard ratio (HR) of late mortality with its 95% CI for significant versus non-significant (typically, ≥moderate versus <moderate) TR was extracted. Study-specific estimates were combined in the random-effects model.

RESULTS

Our search identified 12 eligible studies enrolling a total of 41,485 TAVI patients. The meta-analysis for early mortality combining 3 ORs demonstrated a significant 1.80-fold increase in mortality with significant TR (OR, 1.80; 95% CI, 1.01 to 3.19; P = 0.05). The primary meta-analysis for midterm (6-month to 30-month) mortality combining all the 12 HRs/ORs indicated a significant 1.96-fold increase in mortality (HR/OR, 1.96; 95% CI, 1.35 to 2.85; P = 0.0004). The secondary meta-analysis for midterm mortality combining 7 homogeneous HRs (adjusted HRs for ≥moderate versus <moderate TR) showed a significant 2.25-fold increase in mortality (HR, 2.25; 95% CI, 1.20-4.24; P = 0.01).

CONCLUSIONS

Concurrent significant (typically, ≥moderate) TR is associated with an approximately two-fold increase in both early and midterm all-cause mortality in patients with AS undergoing TAVI.

The Right Heart-Pulmonary Circulation Unit and Left Heart Valve Disease

Valvular heart disease (VHD) is frequently accompanied by pulmonary hypertension (PH). In asymptomatic patients, PH is rare, although the exact prevalence is unknown and mainly stems from the severity of the VHD and the presence of diastolic dysfunction. PH can also be depicted during exercise echocardiography. PH either at rest or during exercise is also a powerful determinant of outcome and is independently associated with reduced survival, regardless of the severity of the underlying valvular pathology. Therefore, because PH is a marker of poor prognosis, assessment of PH in VHD is crucial for risk stratification and management of patients with VHD.

Predictors of Persistent Tricuspid Regurgitation after Transcatheter Aortic Valve Replacement in Patients with Baseline Tricuspid Regurgitation

Objective

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.

Methods

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.

Results

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).

Conclusions

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.

Multimodality Imaging of the Right Ventricle

OPINION STATEMENT

Right ventricular (RV) structure and function is clinically important in a wide range of conditions. While conventional echocardiography (echo) methods are widely used, its limitations in RV assessment due its complex geometry are well recognized. New applications of traditional echo methods as well as emerging echo techniques including 3-dimensional (3D) echo and speckle tracking strain have the potential to overcome limitations of conventional echo, though widespread clinical use remains to be seen. Volumetric methods using cardiac magnetic resonance (CMR) and computed tomography (CT) provide accurate assessment of RV function without geometric assumptions. In addition, tissue characterization imaging for myocardial scar and fat using CMR and CT provides important information regarding the RV beyond structure and function alone and has clinical applications for diagnosis and prognosis in a broad range of pathologies. Limitations also exist for these two advanced modalities including availability and patient suitability for CMR and need for contrast and radiation exposure for CT. The complementary role of each modality for the RV as well as emerging evidence for the use of each imaging method in diagnosis and management of RV pathologies is outlined in this study.

Stunning and Right Ventricular Dysfunction Is Induced by Coronary Balloon Occlusion and Rapid Pacing in Humans: Insights From Right Ventricular Conductance Catheter Studies

Background

We sought to determine whether right ventricular stunning could be detected after supply (during coronary balloon occlusion [BO]) and supply/demand ischemia (induced by rapid pacing [RP] during transcatheter aortic valve replacement) in humans.

Methods and Results

Ten subjects with single‐vessel right coronary artery disease undergoing percutaneous coronary intervention with normal ventricular function were studied in the BO group. Ten subjects undergoing transfemoral transcatheter aortic valve replacement were studied in the RP group. In both, a conductance catheter was placed into the right ventricle, and pressure volume loops were recorded at baseline and for intervals over 15 minutes after a low‐pressure BO for 1 minute or a cumulative duration of RP for up to 1 minute. Ischemia‐induced diastolic dysfunction was seen 1 minute after RP (end‐diastolic pressure [mm Hg]: 8.1±4.2 versus 12.1±4.1, P<0.001) and BO (end‐diastolic pressure [mm Hg]: 8.1±4.0 versus 8.7±4.0, P=0.03). Impairment of systolic and diastolic function after BO remained at 15‐minutes recovery (ejection fraction [%]: 55.7±9.0 versus 47.8±6.3, P<0.01; end‐diastolic pressure [mm Hg]: 8.1±4.0 versus 9.2±3.9, P<0.01). Persistent diastolic dysfunction was also evident in the RP group at 15‐minutes recovery (end‐diastolic pressure [mm Hg]: 8.1±4.1 versus 9.9±4.4, P=0.03) and there was also sustained impairment of load‐independent indices of systolic function at 15 minutes after RP (end‐systolic elastance and ventriculo‐arterial coupling [mm Hg/mL]: 1.25±0.31 versus 0.85±0.43, P<0.01).

Conclusions

RP and right coronary artery balloon occlusion both cause ischemic right ventricular dysfunction with stunning observed later during the procedure. This may have intraoperative implications in patients without right ventricular functional reserve.

Echocardiographic follow-up after transcatheter aortic valve replacement

The use of transcatheter aortic valve replacement (TAVR) for high-risk patients with aortic stenosis has rapidly increased during the past years. Accordingly, more and more patients are referred for a follow-up echocardiographic study after TAVR. However, the echocardiographic evaluation of patients who underwent TAVR places specific demands on echocardiographers. Furthermore, TAVR may be associated with new types of complications, which are frequently unrecognized or underestimated due to lack of familiarity with the normal and pathological appearance of TAVR. Therefore, this review summarizes the echocardiographic parameters describing the structural and functional status of bioprostheses used in TAVR, procedures taking into account their peculiar hemodynamics. We also describe the strengths and the limitations of echocardiography and of other imaging modalities in detecting long-term complications of TAVR (eg, infective endocarditis, thrombosis). The aim of this review was to serve as a guide for a structured echocardiographic follow-up of TAVR patients, as well as for the echocardiographic diagnosis of the procedure-associated complications.