Bach Y, Abrahamyan L, Lee DS, Dharma C, Day J, Parker JD, Benson L, Osten M, Horlick E.Can J Cardiol. 2022 Mar;38(3):330-337. doi: 10.1016/j.cjca.2021.12.012. Epub 2021 Dec 30.PMID: 34974138
Take Home Points:
- In patients undergoing transcatheter secundum ASD closure, the pre-procedural presence of moderate or greater tricuspid regurgitation is associated with higher rates of all-cause mortality, hospitalization for either heart failure or atrial fibrillation, and new-onset heart failure and atrial fibrillation
- Exploratory analysis is suggestive of similar outcomes in a smaller subset of patients with persisting moderate or greater tricuspid regurgitation (as compared to those with reduction in tricuspid regurgitation severity to mild or less) following ASD closure
- Patients with persistent significant tricuspid regurgitation post ASD closure may need closer surveillance in their long-term follow up to allow earlier identification of cardiac morbidity and appropriate intervention to reduce mortality.
Commentary by Dr. Timothy (Melbourne, Australia), section editor of ACHD Journal Watch:
The presence of moderate to severe tricuspid regurgitation (TR) has been reported in 27 – 55 % of patients with ostium secundum atrial septal defect at the time of transcatheter ASD closure. Post-closure cardiovascular adverse event rates have been reported to be significantly higher in such patients after up to 45 months follow-up. This study aimed to compare the impact of moderate to severe TR on short and long-term outcomes following ASD closure, and to compare long-term outcomes between patients with postprocedural improved and persistent TR.
A retrospective single-centre cohort study of consecutive adult patients undergoing transcatheter ASD closure between 1998 and 2016 was performed at Toronto General Hospital. Exclusion criteria included the presence of additional left-to-right sided cardiac shunts, Ebstein anomaly, previous tricuspid valve surgery, and those without a baseline echocardiography report. Two patient groups were defined according to the presence of (1) mild or no TR (< moderate TR) and (2) moderate, moderate to severe, or severe TR (≥ moderate TR). Patients with baseline ≥ moderate TR were further stratified to either improved or persistent TR groups post-procedure.
Data from electronic medical records and paper charts were reviewed. Echocardiographic images were reassessed by a cardiac sonographer for evaluation of interobserver variability in TR grade. Follow-up period for acute outcomes was 30 days commencing the day of index discharge.
Appropriate statistical methodology was employed using SAS statistical software.
Figure 1 (below) outlines the patient cohort included in the study. Mean patient age was 48 ± 16 years, and 69% were female. The group with ≥ moderate TR were significantly older and more likely to present with a history of AF, HT, coronary disease, hypertension, diabetes, pulmonary hypertension, and COPD.
No difference in acute procedural or short-term (30 day) outcomes was observed between groups. Median follow-up for the 949 patients was 10.9 years. Unadjusted analysis found significantly higher all-cause mortality and new onset or hospitalization for heart failure/atrial fibrillation in the ≥ moderate TR group, while rates of cardiac surgeries or interventions were low and similar in both groups. After adjusting for age, sex, AF, coronary disease, heart failure, hypertension, diabetes, COPD, and Charlson comorbidity index, patients with baseline ≥ moderate TR continued to have a higher risk of all-cause mortality (adjusted hazard ratio 1.69, 95 % confidence interval 1.08-2.62; P = 0.02).
In the smaller subset of patients analysed for improved vs. persistent TR post ASD closure (n = 119), 61 % had improved to mild or less TR on follow-up echocardiography (median follow-up of 4 months, IQR 3-20 months), while the remaining 39% had persistent (≥ moderate) TR. The unadjusted exploratory analysis found patients with persistent TR to have significantly higher rates of new-onset heart failure, new-onset AF, composite hospitalisations for HF or AF, and overall mortality than patients with improved TR. Unadjusted cumulative incidence of all-cause mortality in the persistent TR cohort was also significantly higher than the improved TR cohort (P = 0.003). Due to the small sample size, adjusted survival analyses were not performed.
Data from this study complements other studies in regard to morbidity and mortality, as well as the degree of reduction in TR severity following ASD closure. There are a number of limitations, including the retrospective nature, small cohort included in the exploratory evaluation of long-term outcomes, and the non-standardised and early timing of post-procedure TR assessment. Nonetheless the findings place a spotlight on tricuspid regurgitation and the potential need for closer surveillance of those with persistent TR following transcatheter ASD closure.