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Baseline significant tricuspid regurgitation is associated with higher mortality in transcatheter aortic valve replacement

systemic review and meta-analysis

Prasitlumkum, Naruta; Kittipibul, Veraprapasb; Tokavanich, Nithic; Kewcharoen, Jakrina; Rattanawong, Pattaraa,d; Angsubhakorn, Natthapone; Mao, Michael A.f; Gillaspie, Erin A.g; Cheungpasitporn, Wisith

Journal of Cardiovascular Medicine: July 2019 - Volume 20 - Issue 7 - p 477–486
doi: 10.2459/JCM.0000000000000807
Research articles: Interventional cardiology. Structural heart disease

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.

aDepartment of Internal Medicine, University of Hawaii Internal Medicine Residency Program, Honolulu, Hawaii

bDepartment of Internal Medicine, Jackson Memorial Hospital Internal Medicine Residency Program, Miami, Florida, USA

cDepartment of Cardiology, Chulalongkorn University

dFaculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

eDepartment of Medicine, University of Minnesota, Minneapolis

fDivision of Internal Medicine, Mayo Clinic, Rochester, Minnesota

gDepartment of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee

hDepartment of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA

Correspondence to Narut Prasitlumkum, MD, University of Hawaii Internal Medicine Residency Program, 1356 Lusitana Street, Honolulu, HI 96813, USA Tel: +1 808 859 3848; e-mail:

Received 27 December, 2018

Revised 19 March, 2019

Accepted 31 March, 2019

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