背景:三尖瓣反流(TR)在经导管主动脉瓣置换术(TAVR)人群中非常普遍,但是缺乏明确的管理指南。
目的:本研究的目的是阐明严重TR在接受TAVR的主动脉瓣狭窄患者中的患病率和后果,并检查TAVR后TR的变化。包括改善的预测因素及其对长期死亡率的影响。
方法:使用与医疗保险和医疗补助服务中心相关的TVT(经导管瓣膜治疗)注册数据,在基线轻度接受TAVR的患者中进行了倾向匹配分析,中度,或严重的TR。Kaplan-Meier估计用于评估TR对3年死亡率的影响。多变量分析确定了30天TR改善的预测因素。
结果:在312,320名患者中,84%有轻度,13%中等,和3%的严重TR。在一个倾向匹配的队列中,重度基线TR与较高的住院死亡率相关(中度TR为2.5%vs2.1%,轻度TR为1.8%;P=0.009),1年死亡率较高(中度TR为24%vs19.6%,轻度TR为16.6%;P<0.0001),3年死亡率(中度TR为54.2%vs48.5%,轻度TR为43.3%;P<0.0001)。在基线时患有严重TR的患者中,TAVR后30天,76.4%改善至中度或更少TR。基线二尖瓣返流中度或更高,保留的射血分数,较高的主动脉瓣梯度,和更好的肾功能预测了TAVR后TR的改善。然而,严重的30天残余TR与较高的1年死亡率相关(中度TR为27.4%vs18.7%,轻度TR为16.8%;P<0.0001).
结论:严重的基线和TAVR后30天的残余TR与高达3年的死亡率增加相关。该分析确定了一个较高的风险组,可以对最近批准的三尖瓣干预措施进行评估。
BACKGROUND: Tricuspid regurgitation (TR) is highly prevalent in the transcatheter aortic valve replacement (TAVR) population, but clear management guidelines are lacking.
OBJECTIVE: The aims of this study were to elucidate the prevalence and consequences of severe TR in patients with aortic stenosis undergoing TAVR and to examine the change in TR post-TAVR, including predictors of improvement and its impact on longer term mortality.
METHODS: Using Centers for Medicare and Medicaid Services-linked TVT (Transcatheter Valve Therapy) Registry data, a propensity-matched analysis was performed among patients undergoing TAVR with baseline mild, moderate, or severe TR. Kaplan-Meier estimates were used to assess the impact of TR on 3-year mortality. Multivariable analysis identified predictors of 30-day TR improvement.
RESULTS: Of the 312,320 included patients, 84% had mild, 13% moderate, and 3% severe TR. In a propensity-matched cohort, severe baseline TR was associated with higher in-hospital mortality (2.5% vs 2.1% for moderate TR and 1.8% for mild TR; P = 0.009), higher 1-year mortality (24% vs 19.6% for moderate TR and 16.6% for mild TR; P < 0.0001), and 3-year mortality (54.2% vs 48.5% for moderate TR and 43.3% for mild TR; P < 0.0001). Among the patients with severe TR at baseline, 76.4% improved to moderate or less TR 30 days after TAVR. Baseline mitral regurgitation moderate or greater, preserved ejection fraction, higher aortic valve gradient, and better kidney function predicted TR improvement after TAVR. However, severe 30-day residual TR was associated with higher 1-year mortality (27.4% vs 18.7% for moderate TR and 16.8% for mild TR; P < 0.0001).
CONCLUSIONS: Severe baseline and 30-day residual TR after TAVR are associated with increased mortality up to 3 years. This analysis identifies a higher risk group that could be evaluated for the recently approved tricuspid interventions.