Tricuspid regurgitation worsening after transcatheter or surgical aortic valve replacement

Background

Tricuspid regurgitation (TR) often occurs concomitantly with severe aortic stenosis. Post-operative worsening of tricuspid regurgitation has been observed after surgical and transcatheter aortic valve replacement (SAVR, TAVR) [1,2].

Purpose

Pre-procedural severe tricuspid regurgitation has been shown to be a predictor of all-cause mortality in patients undergoing transcatheter aortic valve replacement (TAVR) [3,4]. However, little is known about the incidence of worsening tricuspid regurgitation after SAVR and TAVR and the impact on post-procedural outcomes. This study aims to evaluate, characterize and compare the incidence of worsening TR after TAVR and SAVR.

Methods

Retrospective single-center study of patients undergoing Transcatheter and Surgical Aortic Valve Replacement for severe aortic stenosis between 2014 and 2020. Incidence of tricuspid regurgitation was noted on echocardiogram at baseline and 1 year after TAVR or SAVR. This study enrolled 430 patients in the TAVR group and 237 patients in the SAVR group. The SAVR group only included patients who underwent isolated SAVR without any other valve intervention. Patients with severe TR at baseline were excluded from the study. Progression of TR severity was defined as deterioration by at least 1 grade of severity compared to baseline on echocardiography. Multivariable logistic regression analysis was performed to identify associations with worsening TR.

Results

Mean age of TAVR patients was higher than the SAVR patients (79±9 vs 68±12 years, p<0.0001). TAVR patients also had a significantly higher EuroSCORE than the SAVR patients (8.0±7 vs 3.5±4, p<0.0001). TAVR group was more likely to have atrial fibrillation than the SAVR group (34% vs 24%, p=0.006). Baseline right ventricular dysfunction and right ventricular enlargement were significantly higher in the TAVR group compared to the SAVR group [9% vs 4%, (p=0.009) and 10% vs 6%, (p=0.04), respectively]. Progression of TR severity occurred in 21.8% (94/430) of TAVR patients and 31.2% (74/237) of SAVR patients. Majority of these patients progressed from absent TR to mild TR [13.2% (57) in TAVR group vs 19.8% (47) in SAVR group (p=0.02)]. 6.3% (27) of patients in the TAVR group and 8.8% (21) of patients in the SAVR group had mild to moderate worsening of TR (p=0.22). 1.63% (7) in the TAVR group and 2.1% (5) in the SAVR group had progression from moderate to severe TR (p=0.65). On multivariable analysis, SAVR (Odds ratio, 2.46 [CI, 1.6–3.7]) and age (Odds ratio, 1.03 [CI, 1.03–1.05]) were associated with worsening TR severity.

Conclusions

In this retrospective observational study, SAVR and age were found to be associated with worsening tricuspid regurgitation. Majority of these patients progressed from absent TR to mild TR after SAVR. Further studies are necessary to determine long term outcomes of worsening tricuspid regurgitation after TAVR and SAVR.

Funding Acknowledgement

Type of funding sources: None.

The current epidemiology of SIDS in Ireland

This paper examines some epidemiological factors associated with SIDS to give a general profile of SIDS cases occurring in Ireland between the years 1993 to 1997. There has been a dramatic decrease in the incidence of the Sudden Infant Death Syndrome (SIDS) in the Republic of Ireland in the last decade from an average rate of 2.2/1000 live-births in the 1980s to 0.8/1000 live-births in the years 1993-1997, a decrease of 100 deaths a year. The fall in the SIDS rate has been seen in many countries and is felt to be associated with Reduce The Risks (RTR) of SIDS campaigns and the avoidance of the prone sleeping position. The use of the prone sleep position averaged at 6% of children being put prone in the years 1993-1997 but the prone position has progressively decreased from 13% of children being put prone in 1994 to only 2% in 1997. The profile of the Irish SIDS cases is similar to that of SIDS cases in other countries following similar RTR campaigns with a male predominance, the characteristic clustering of deaths in the first six months of life and the majority of cases (75%) occuring in the night sleep period. The loss of the seasonal variation of the time of death is also shown and factors such as lower socio-economic status, unemployment and medical card eligibility were seen in higher proportions in SIDS families than in the general population. A high percentage of SIDS mothers smoked (73%). Higher smoking rates were seen among younger and single mothers and smoking rates were inversely related to educational level and socioeconomic grouping. An urgent question that needs to be addressed is how socioeconomic disadvantage increases the SIDS risk and what factors influence socioeconomically disadvantaged families to adopt life style and parenting practices such as smoking that influence their children's health.

Sudden infant death syndrome--are parents getting the message?

BACKGROUND

Factors that place an infant at increased risk of sudden infant death include the prone sleep position, overheating and parental smoking, while practices such as bottle-feeding, co-sleeping and the use of pacifiers remain controversial. Major publicity campaigns have been undertaken, which have included the distribution of printed material and extensive media coverage.

AIMS

To examine if Irish parents follow the currently recommended childcare guidelines to reduce the risk of sudden infant death and to examine factors that may have impact on their acceptance.

METHODS

A random selection of 197 infants from the Birth Register of the Eastern Health Board. Parents were interviewed and a semi-structured survey questionnaire was completed.

RESULTS

Forty one per cent of infants are still placed on their side to sleep, an inherently unstable position. First time parents are more likely to place their infants on their backs. Over 60% of infants are exposed to one or more adults smoking in the home despite parental knowledge of its association with sudden infant death syndrome (SIDS). Sixty eight per cent of infants are overwrapped at night and parental understanding of what constitutes overwrapping is poor. Thirteen per cent of infants regularly co-sleep with their parents and 20% of these parents smoke. Pacifier use is common.

CONCLUSION

Future programmes should target first time parents, should provide clear information regarding appropriate infant thermal environment, and should ensure regular updating of medical personnel so that they can instruct families on best current practice. Smoking remains a significant health issue with an impact on sudden infant death.

A national model of care service for professionals dealing with sudden infant death

Sudden Infant Death Syndrome (SIDS) is any death occurring in an infant or young child which is unexpected by history and in which a thorough post mortem examination fails to demonstrate an adequate cause of death. The National Sudden Infant Death Register collects information on all sudden unexpected deaths in infants and young children occurring in Ireland. In this study, a comparison was made between parent's experience of professional services in the aftermath of their child's death both before and after the implementation of a National Model of Care for professionals in 1995. In addition, a random sample of 105 professionals were surveyed about their knowledge of the Model of Care services. Results were grouped according to the parental experience of the emergency services, the hospital services, the community services and the bereavement support services offered to parents. Prior to the implementation of the Model of Care Service (MOC) (1992-1994), 14 per cent of families stated that they did not find the Gardai helpful. After the Model of Care, only 7 per cent of parents expressed such dissatisfaction. Prior to the MOC, only 3 per cent of Gardai provided families with an information booklet on sudden infant death but afterwards, 23 per cent of Gardai did so. After the MOC families were more likely to have been given the opportunity to hold their infant, were given more privacy and were offered more keepsakes of their infant. Only 46 per cent of families were offered momentos of their baby prior to the MOC as compared to 84 per cent after the implementation of the MOC. They were also more likely to perceive the ancillary services such as the Gardai in a more positive light, where 22 per cent of Gardai offered the family the ISIDA support booklet compared to a previous 3 per cent. Over 50 per cent of parents were provided with a special room in the hospital following the MOC as opposed to a previous 48 per cent. Twenty-one per cent of parents prior to the MOC described the conditions in the hospital as awful, poor or fair, however 31 per cent of parents stated this after the MOC. While there have been improvements in certain areas, there still remains considerable variation in the quality of service provided to all parents. Specifically, we need to address the fact that 16 per cent of parents still report a difficulty in obtaining post-mortem information. Almost 40 per cent said they had little input into how their child was dressed or laid out at this highly emotive time. Over one-third of parents stated they were concerned about how few of their primary health providers, namely general practitioners and public health nurses called to visit them in the aftermath of this tragic event.

Reduce the risk of cot death guidelines. The effect of a revised intervention programme. National Sudden Infant Death Register, Dublin

In March 1992 the 'Reduce the Risk of Cot Death' guidelines were launched in the Republic of Ireland. In response to epidemiological surveys conducted in 1993 and 1994 these guidelines were revised in November 1995 and a new leaflet was distributed. The study set out to compare parents interviewed in 1994 (n = 153) and 1996 (n = 132) to determine their source of information on the guidelines and the extent of parental change in infant care practice as recommended in these guidelines. In both time periods the media was the most frequent source of information with 63% (n = 97) of respondents having received advice from the media in 1994 compared to 55% (n = 72) in 1996. However a significant number of parents especially young (64%) and new (58%) mothers were uninterested or unable to access the relevant health care literature indicating a group needing a tailored educational package in the future. Medical sources especially Public Health Nurses ranked second in delivering information at 47% (n = 72) in 1994 vs 46% (n = 60) in 1996 while other sources such as family and friends were the least frequent sources of information. In 1996 more respondents (59%; n = 78) put their children to sleep on their back than in 1994 (35%; n = 54) but they used heat more frequently at night [73% (n = 96) in 1996 vs 57% (n = 87) in 1994]. There was no significant difference in the percentage of parents smoking [29% (n = 45) vs 33% (n = 43)], the uptake of breast feeding [40% (n = 61) vs 49% (n = 64)] and the way parents clothed their children [60% (n = 92) vs 58% (n = 77) used more than ten tog] between 1994 and 1996. Although in 1996 the message to reduce the risks of cot death was more specific and direct, it seems to have had less effect on further changing parents' practices. However, the overall effect of the two education programmes has been successful in yielding a low percentage (2%; n = 2) of babies sleeping prone in 1996). Smoking remains the major modifiable risk factor for SIDS in Ireland.

The hospital in-patient enquiry scheme: a study of data accuracy and capture

In order to measure the coverage and accuracy of the Hospital In-patient Enquiry Scheme data in a large acute hospital in Dublin, 793 patient charts were selected randomly from all the discharges in 1990. The capture rate was 56%. Whether a diagnosis was captured for the Hospital In-patient Enquiry Scheme depended partly upon geographical factors within the hospital and partly upon the nature of the diagnosis. "Non-capture" was not random and was particularly likely to occur where the case was complex, e.g. oncology, HIV infection. The coding accuracy of primary diagnoses was 59% and the completeness of recording of secondary diagnoses was 56%. Both were significantly associated with the presence in the hospital chart of discharge summaries and with the clarity and source of written diagnoses. The factors that affected accuracy were not the same as those affecting the capture rate.