Functional Tricuspid Regurgitation Is An Independent Predictor Of Mortality And Morbidity In Patients With Aortic Stenosis Undergoing Valve Replacement

Background: In patients with severe aortic stenosis (AS), pulmonary hypertension (PHT) and right ventricular (RV) dysfunction are predictors of adverse events. PHT and RV dysfunction can lead to progressive functional tricuspid regurgitation (FTR), which has an under-appreciated yet potentially devastating course. We describe the impact of FTR in patients with severe AS undergoing aortic valve replacement (AVR). Methods: We identified consecutive patients with severe AS who underwent AVR in 2009 and 2010. We excluded those with concomitant mitral or tricuspid valve replacement, organic tricuspid valve pathology, and those without an available echocardiogram (echo) within 3 months of surgery. A panel of quantitative echo parameters was measured according to American Society of Echocardiography guidelines. Clinical variables were extracted from the Society of Thoracic Surgeons (STS) database. The outcomes of interest were postoperative STS-composite mortality or major morbidity, and all-cause mortality over a mean follow-up of 1.8 years. Results: Of 207 patients studied, 21 (10.1%) had moderate-to-severe FTR. Moderate-to-severe FTR was associated with higher pulmonary artery systolic pressure (58 vs. 38 mmHg, P<0.001), worse RV myocardial performance index (0.57 vs. 0.42, P=0.003), lower RV fractional area change (38% vs. 47%, P=0.004), lower LVEF (48% vs. 58%, P=0.002), and higher left atrial volume index (56 vs. 42 cm2/m2, P<0.001), but not with aortic valve area (0.71 vs. 0.71 cm 2 , P=0.82) or peak aortic velocity (4.3 vs. 4.4 m/s, P=0.62). Patients with FTR were more likely to suffer postoperative in-hospital mortality or major morbidity (48% vs. 23%, P=0.02) and long-term mortality (17% vs. 9%, P=0.004). When echo parameters were entered in a multivariable model, optimal predictors of all-cause mortality were: FTR (HR 3.46, 95% CI 1.26, 9.49) and restrictive diastolic filling (HR 3.07, 95% CI 1.16, 8.11). Results were similar when adjusted for clinical covariates including chronic lung disease. Conclusion: In the setting of AVR, moderate-to-severe FTR is an independent predictor of postoperative mortality and major morbidity. FTR is prevalent in AS patients with PHT and poor right or left ventricular function.