Severe aortic stenosis (AS) is a frequent and potentially severe disease if left untreated. Despite the widespread adoption of surgical aortic valve replacement (SAVR) and more recently transcatheter aortic valve implantation (TAVI), mortality rates in the mid- to long-term follow-up remain relatively high, especially for higher-risk patients. ^, Yet, transfemoral TAVI became the dominant approach for patients with age > 70 years, enabling a significant reduction in the all-cause and cardiac mortality rates with respect to SAVR, even though the prognosis of a certain subgroup of patients is still jeopardized. Therefore, prior studies in the TAVI field have focused on helping in risk stratifying such patients. For instance, Genereux et al. ^, have shown that the extent of cardiac damage among patients with AS undergoing TAVI could play an important role. Accordingly, a stepwise impact in the mortality at follow-up was demonstrated when patients with AS also had left chamber involvement, with or without mitral regurgitation, followed by pulmonary hypertension, with or without tricuspid regurgitation (TR), and finally with right ventricle dysfunction. Of note, the last two stages (with moderate or severe TR and right ventricle dysfunction) represent the highest mortality rate, up to 20% at 1 year. Apart from TR grade, there is controversy on whether the changes in TR grade in the follow-up might also affect the clinical outcomes.

In this journal issue, Erbano et al. evaluated the association between TR and mortality in a systematic review and meta-analysis of patients with AS undergoing TAVI and further assessed the changes in TR severity post-TAVI and its relationship with short and mid-term mortality. The primary endpoint was defined as the incidence of all-cause mortality according to TR grade at baseline. Secondary endpoints included cardiac mortality and heart failure hospitalization. The authors included 24 studies and more than 45.000 patients, whose mean age was 81.7±8.5 years; 52% were female, with a mean Society of Thoracic Surgeons (STS) score of 8.2±6.0. Approximately 22% of patients had moderate or severe TR at baseline. After a mean follow-up of 1.2 years, pooled analysis of 14 studies revealed that higher grades of TR were associated with a worse prognosis. Severe TR was associated with an 83% increased mortality compared to no/mild TR in the short-term and 56% in the mid-term. In the pooled analysis, the persistence of moderate/severe TR grades, after a mean follow-up of 21 months post-TAVI, was also associated with a 2-fold increase in all-cause mortality.

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