Potential Candidates for Transcatheter Tricuspid Valve Intervention After Transcatheter Aortic Valve Replacement

Tomii, Daijiro; Okuno, Taishi; Praz, Fabien; Heg, Dik; Wild, Mirjam G.; Lanz, Jonas; Stortecky, Stefan; Reineke, David; Windecker, Stephan; Pilgrim, Thomas

doi:10.1016/j.jcin.2021.07.030

Cited by 27 publications

(18 citation statements)

References 32 publications

(51 reference statements)

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“…It is well established that severe TR in patients undergoing TAVR is associated with poor prognosis9 11 12; however, it is difficult to determine whether TR itself causally drives mortality or whether it simply serves as a marker for PH and right ventricular decompensation 13. A recent study identified 3.4% of patients with TAVR as potential candidates for transcatheter tricuspid valve interventions (TTVIs),14 but larger prospective studies are mandatory to address the question where TR is a clinically meaningful target and where it represents an epiphenomenon 15. This differentiation is important because successful TTVI and concomitant reduction of regurgitant blood flow to the low-pressure right atrium acutely force the right ventricle to eject blood into the high-pressure pulmonary circulation.…”

Section: Discussionmentioning

confidence: 99%

Artificial intelligence-enabled phenotyping of patients with severe aortic stenosis: on the recovery of extra-aortic valve cardiac damage after transcatheter aortic valve replacement

et al. 2022

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ObjectiveA novel artificial intelligence-based phenotyping approach to stratify patients with severe aortic stenosis (AS) prior to transcatheter aortic valve replacement (TAVR) has been proposed, based on echocardiographic and haemodynamic data. This study aimed to analyse the recovery of extra-aortic valve cardiac damage in accordance with this novel stratification system following TAVR.MethodsThe proposed phenotyping approach was previously established employing data from 366 patients with severe AS from a bicentric registry. For this consecutive study, echocardiographic follow-up data, obtained on day 147±75.1 after TAVR, were available from 247 patients (67.5%).ResultsCorrection of severe AS by TAVR significantly reduced the proportion of patients suffering from concurrent severe mitral regurgitation (from 9.29% to 3.64%, p value: 0.0015). Moreover, pulmonary artery pressures were ameliorated (estimated systolic pulmonary artery pressure: from 47.2±15.8 to 43.3±15.1 mm Hg, p value: 0.0079). However, right heart dysfunction as well as the proportion of patients with severe tricuspid regurgitation remained unchanged. Clusters with persistent right heart dysfunction ultimately displayed 2-year survival rates of 69.2% (95% CI 56.6% to 84.7%) and 74.6% (95% CI 65.9% to 84.4%), which were significantly lower compared with clusters with little or no persistent cardiopulmonary impairment (88.3% (95% CI 83.3% to 93.5%) and 85.5% (95% CI 77.1% to 94.8%)).ConclusionsThis phenotyping approach preprocedurally identifies patients with severe AS, who will not recover from extra-aortic valve cardiac damage following TAVR and whose survival is therefore significantly reduced. Importantly, not the degree of pulmonary hypertension at initial presentation, but the irreversibility of right heart dysfunction determines prognosis.

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Section: Discussionmentioning

confidence: 99%

Artificial intelligence-enabled phenotyping of patients with severe aortic stenosis: on the recovery of extra-aortic valve cardiac damage after transcatheter aortic valve replacement

et al. 2022

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“…Right ventricular dysfunction and TR are mainly associated with impaired LVEF, increased LV mass, and increased left atrial volume in patients undergoing TAVI, reflecting the long‐standing elevated LV pressure due to severe AS 11,59 . The presence of RV systolic dysfunction (RVSD) and moderate to severe TR are ~35% and 20% in patients undergoing TAVI, 60,61 respectively. Reports from the Swiss TAVI registry have demonstrated that normalized RV function and reduced TR were found in more than half of the patients who underwent TAVI 60,62 .…”

Section: Clinical Factors Associated With Heart Failure Hospitalizati...mentioning

confidence: 99%

“…The presence of RV systolic dysfunction (RVSD) and moderate to severe TR are ~35% and 20% in patients undergoing TAVI, 60,61 respectively. Reports from the Swiss TAVI registry have demonstrated that normalized RV function and reduced TR were found in more than half of the patients who underwent TAVI 60,62 . In a meta‐analysis of 3166 patients, RVSD, RV dilatation, and severe TR at baseline were independent risk factors of 1 year mortality after TAVI 61 .…”

Section: Clinical Factors Associated With Heart Failure Hospitalizati...mentioning

confidence: 99%

“…In a meta‐analysis of 3166 patients, RVSD, RV dilatation, and severe TR at baseline were independent risk factors of 1 year mortality after TAVI 61 . Although TAVI is likely to improve RV function and TR, worsening RV function and residual TR appeared in a small proportion of post‐TAVI patients and were associated with mortality and HF symptoms 60,63 . Thus, a stepwise approach from aortic to tricuspid valves could be considered with TAVI, mitral transcatheter edge‐to‐edge repair, and transcatheter tricuspid intervention in high‐risk patients with mixed valvular heart disease, 64 reassessing cardiac remodelling and the improvement of valve dysfunction after each intervention, given the complex nature of their condition.…”

Section: Clinical Factors Associated With Heart Failure Hospitalizati...mentioning

confidence: 99%

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Determinants and treatments of heart failure after transcatheter aortic valve implantation: moving up a notch

et al. 2023

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Transcatheter aortic valve implantation (TAVI) has become an alternative to surgical aortic valve replacement for patients with symptomatic severe aortic stenosis in elderly and comorbid population. Significant improvement in heart function has been observed in patients undergoing TAVI, but numerous patients are readmitted to hospital for heart failure (HF). Moreover, repeat HF hospitalization is strongly associated with an adverse prognosis and increases the financial burden of health care. Although studies have identified pre-existing and post-procedural factors that contribute to HF hospitalization after TAVI, there is a paucity of data regarding optimal post-procedural pharmacological treatments. This review aims to provide an overview of the current understanding of mechanisms, determinants, and potential treatments of HF following TAVI. We first review the pathophysiology of left ventricular (LV) remodelling, coronary microcirculation disorder, and endothelial dysfunction in patients with aortic stenosis and then examine the impact of TAVI on these conditions. We then present evidence of various factors and complications that may interplay with LV remodelling and contribute to HF events after TAVI. Next, we describe the triggers and predictors of early and late HF rehospitalizations following TAVI. Lastly, we discuss the potential of conventional pharmacological treatments, including renin-angiotensin blockers, beta-blockers, and diuretics in TAVI patients. The paper explores the potential of newer drugs, including sodium-glucose co-transporter 2 inhibitors, anti-inflammatory drugs, and ion supplementation. Comprehensive knowledge in this field may aid in recognizing successful existing therapies, developing effective new treatments, and establishing dedicated patient care strategies during follow-up after TAVI.

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“… 5 , 6 The once triggered and later self‐sustaining vicious circle of volume overload and increased wall stress of the right ventricle, detrimental remodeling including tricuspid annulus dilatation and papillary muscle displacement, and further worsening of TR, could be interrupted by transcatheter tricuspid valve intervention (TTVI). 7 …”

mentioning

confidence: 99%

Epiphenomenon or Prognostically Relevant Interventional Target? A Novel Proportionality Framework for Severe Tricuspid Regurgitation

Fortmeier

Lachmann

Unterhuber

et al. 2023

JAHA

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Background Tricuspid regurgitation (TR) frequently develops in patients with long‐standing pulmonary hypertension, and both pathologies are associated with increased morbidity and mortality. This study aimed to improve prognostic assessment in patients with severe TR undergoing transcatheter tricuspid valve intervention (TTVI) by relating the extent of TR to pulmonary artery pressures. Methods and Results In this multicenter study, we included 533 patients undergoing TTVI for moderate‐to‐severe or severe TR. The proportionality framework was based on the ratio of tricuspid valve effective regurgitant orifice area to mean pulmonary artery pressure. An optimal threshold for tricuspid valve effective regurgitant orifice area/mean pulmonary artery pressure ratio was derived on 353 patients with regard to 2‐year all‐cause mortality and externally validated on 180 patients. Patients with a tricuspid valve effective regurgitant orifice area/mean pulmonary artery pressure ratio ≤1.25 mm 2 /mm Hg (defining proportionate TR) featured significantly lower 2‐year survival rates after TTVI than patients with disproportionate TR (56.6% versus 69.6%; P =0.005). In contrast with patients with disproportionate TR (n=398), patients with proportionate TR (n=135) showed more pronounced mPAP levels (37.9±9.06 mm Hg versus 27.9±8.17 mm Hg; P <2.2×10 −16 ) and more severely impaired right ventricular function (tricuspid annular plane systolic excursion: 16.0±4.11 versus 17.0±4.64 mm; P =0.012). Moreover, tricuspid valve effective regurgitant orifice area was smaller in patients with proportionate TR when compared with disproportionate TR (0.350±0.105 cm 2 versus 0.770±0.432 cm 2 ; P <2.2×10 −16 ). Importantly, proportionate TR remained a significant predictor for 2‐year mortality after adjusting for demographic and clinical variables (hazard ratio, 1.7; P =0.006). Conclusions The proposed proportionality framework promises to improve future risk stratification and clinical decision‐making by identifying patients who benefit the most from TTVI (disproportionate TR). As a next step, randomized controlled studies with a conservative treatment arm are needed to quantify the net benefit of TTVI in patients with proportionate TR.

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Potential Candidates for Transcatheter Tricuspid Valve Intervention After Transcatheter Aortic Valve Replacement

Cited by 27 publications

References 32 publications

Artificial intelligence-enabled phenotyping of patients with severe aortic stenosis: on the recovery of extra-aortic valve cardiac damage after transcatheter aortic valve replacement

Artificial intelligence-enabled phenotyping of patients with severe aortic stenosis: on the recovery of extra-aortic valve cardiac damage after transcatheter aortic valve replacement

Determinants and treatments of heart failure after transcatheter aortic valve implantation: moving up a notch

Epiphenomenon or Prognostically Relevant Interventional Target? A Novel Proportionality Framework for Severe Tricuspid Regurgitation

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