Comprehensive Right-Sided Assessment for Transcatheter Aortic Valve Replacement Risk Stratification: Time for a Change

Transcatheter aortic valve replacement (TAVR) has been a breakthrough therapeutic advance in the treatment of patients with symptomatic severe aortic stenosis (AS). The continued expansion of this procedure has facilitated access for many patients who previously would have not been considered for further intervention given their high surgical risk. Over the past decade, several clinical and echocardiographic parameters have emerged as important markers in risk stratification, beyond the traditional assessment with Society of Thoracic Surgeons Predictive Risk of Mortality. In the TAVR literature, most of the focus has been on the left ventricle and its response to pressure overload. Parameters such as left ventricular ejection fraction (LVEF), stroke volume index, valve area, and gradients remain important to understand disease severity and the timing of TAVR intervention. 1 Less attention, however, has been given to the right heart and to pulmonary vascular indices. Specifically, the presence and severity of tricuspid regurgitation (TR), the severity and etiology of pulmonary hypertension (PH), and right ventricular (RV) size and function have not been consistently measured or reported. As we will discuss, all those markers will better delineate the hemodynamic stage of the disease process and improve risk stratification of these patients.