Prognostic Value of the Tricuspid Regurgitation Impact on Outcomes (TRIO) Score in Patients Undergoing Transcatheter Aortic Valve Implantation

Abstract

Background:

Prognosis assessments for transcatheter aortic valve implantation (TAVI) patients remain challenging, particularly as the indications for TAVI expand to lower-risk patients. This study assessed the prognostic value of the tricuspid regurgitation impact on outcomes (TRIO) score in patients after TAVI.

Methods:

This single-center study included 530 consecutive patients who underwent TAVI. Patients with a TRIO score >4 were compared to those with a score ≤4. The primary outcome was all-cause mortality, while secondary outcomes included complications defined by the Valve Academic Research Consortium 2 (VARC-2) criteria and major adverse cardiovascular events (MACEs), including mortality, stroke, and heart failure rehospitalization.

Results:

Over a mean follow-up period of 22 months, patients with a TRIO score >4 had significantly higher rates of mortality (11.5% vs. 3.1%, p < 0.001) and MACEs (14.9% vs. 3.6%, p < 0.001). Multivariable Cox regression analysis identified a TRIO score >4 as an independent risk factor for all-cause mortality (hazard ratio (HR): 2.41, 95% confidence interval (CI): 1.08–5.37, p = 0.032) and MACEs (HR: 2.78, 95% CI: 1.34–5.75, p = 0.006). Patients with a higher TRIO score also had significantly higher rates of stroke (3.1% vs. 0.5%, p = 0.028), acute kidney injury (10.1% vs. 4.3%, p = 0.011), and MACEs (14.9% vs. 3.6%, p < 0.001) within 30 days after TAVI.

Conclusions:

The TRIO score was associated with all-cause mortality and MACEs in patients after a TAVI. The TRIO score could serve as a convenient tool for risk stratification in clinical practice, aiding in identifying high-risk patients.

Graphical abstract

Keywords

transcatheter aortic valve implantation / TRIO score / mortality / major adverse cardiovascular events

1. Introduction

Over the past decade, the indications for transcatheter aortic valve implantation (TAVI) have expanded from targeting high-risk patients to encompassing the entire risk spectrum for individuals with aortic stenosis (AS) [1]. Following recent extensions to younger and low-risk patients with a longer life expectancy [2], selecting appropriate TAVI candidates and accurately stratifying their risk remains challenging. Traditional risk assessment tools, such as the Society for Thoracic Surgery Predictive Risk of Mortality [3] and the logistic European System for Cardiac Operative Risk Evaluation [4], were originally developed to assess the risks associated with conventional cardiac surgery rather than a TAVI. Subsequently, concise and accurate tools that can specifically discriminate prognosis following TAVI remain limited.

Concomitant tricuspid regurgitation is common in patients undergoing a TAVI and has been associated with poorer outcomes [5, 6, 7]. The tricuspid regurgitation impact on outcomes (TRIO) score was developed to assess mortality risk in patients with tricuspid regurgitation, incorporating variables such as demographics, laboratory parameters, and echocardiographic findings [8]. However, utilizing the TRIO score in risk stratification for patients undergoing TAVI remains uncertain.

This study evaluated the prognostic value of the TRIO score in patients after a TAVI. We hypothesized that the TRIO score could effectively identify high-risk patients with a greater likelihood of adverse outcomes following a TAVI.

2. Methods

2.1 Study Design

We conducted a retrospective analysis of patients who underwent a TAVI between January 2016 and December 2022 at Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, China. The current study enrolled patients who underwent TAVI between January 2016 and December 2022. No exclusion criteria were applied. A TAVI was performed in patients with symptomatic severe AS using a standard approach. Patients received either self-expandable or balloon-expandable valves via transfemoral, trans-carotid, trans-subclavian, or transapical routes under general or local anesthesia, as determined by individual heart teams based on multidetector computed tomography. All patients were followed up with at 1 month, 6 months, and annually until July 2023. This study was approved by the Research Ethics Committee of Guangdong Provincial People’s Hospital (No. GDREC2019384H), and informed consent was obtained from all participants.

2.2 Clinical Variables

Demographic, laboratory, and echocardiographic data were collected before the TAVI. The TRIO score comprises eight weighted variables [8]: age (70 years, 0 points; 70–79 years, 1 point; \ge80 years, 2 points), sex (female, 0 points; male, 1 point), renal function (creatinine 2 mg/dL, 0 points; creatinine \ge2 mg/dL, 2 points), congestive heart failure (no, 0 points; yes, 2 points), lung disease (no, 0 points; yes, 2 points), aspartate aminotransferase (40 U/L, 0 points; \ge40 U/L, 1 point), heart rate (90 beats/min, 0 points; \ge90 beats/min, 1 point), and severe tricuspid regurgitation (no, 0 points; yes, 1 point) [8]. The study population was categorized into low (\le median) and high (> median) TRIO score groups.

2.3 Clinical Outcomes

The primary endpoint was all-cause mortality at the latest follow-up after the index procedure. Secondary endpoints included complications at 30 days, as defined by the Valve Academic Research Consortium-3 criteria [9]. Major adverse cardiovascular events (MACEs) were defined as a composite of mortality, stroke, and heart failure rehospitalization at 30 days and the latest follow-up.

2.4 Statistical Analysis

Continuous variables are presented as the mean \pm standard deviation or median with interquartile range (IQR), depending on variable distribution, and compared using Student’s t-test or the Mann–Whitney U test, respectively. Categorical variables are expressed as percentages and compared using the chi-squared test or Fisher’s exact test, as appropriate. Multiple imputations were used for missing values.

Univariable and multivariable logistic regression models were utilized to evaluate the association between TRIO scores and 30-day outcomes, with odds ratios (ORs) and 95% confidence interval (CI) reported. Survival curves were constructed using the Kaplan–Meier method, and differences were analyzed using the log-rank test. Multivariable Cox proportional hazard regression was used to assess the association of TRIO scores with all-cause mortality at the latest follow-up, with hazard ratios (HRs) and 95% CI provided. Patients who received a TAVI within 30 days were excluded from the survival analysis. Variables with a p-value 0.2 in the univariable regression analysis were included in multivariable models. A two-tailed p-value 0.05 was considered statistically significant. All statistical analyses were performed using SPSS version 26.0 (SPSS Inc., Chicago, IL, USA).

3. Results

3.1 Baseline Characteristics

A total of 530 consecutive patients who underwent a TAVI were included in the study. The baseline characteristics are summarized in Table 1. The median age was 73 years (IQR: 68–76), and 306 patients (57.7%) were male. A total of 31 patients had chronic lung disease, and 504 patients presented with congestive heart failure. The median Society of Thoracic Surgeons (STS) score was 2.39% (IQR: 1.48–4.11%).

The distribution of TRIO scores is shown in Fig. 1. The median TRIO score in the cohort was 4 points, with 159 patients categorized as having a high TRIO score (>4 points) and 371 patients as having a low TRIO score (\le4 points).

The clinical and echocardiographic characteristics based on the TRIO scores are presented in Table 1. Patients with a high TRIO score were generally older and predominantly male. A higher prevalence of peripheral artery disease, chronic lung disease, atrial fibrillation, previous cardiac valve surgery, and congestive heart failure was observed in the high TRIO score group compared to the low TRIO score group. Additionally, these patients exhibited worse liver and renal functions and faster heart rates, alongside higher surgical risks.

In terms of echocardiographic findings, patients with a high TRIO score had a greater incidence of aortic regurgitation (> mild), mitral regurgitation (> mild), tricuspid regurgitation (> mild), and pulmonary hypertension (> mild) compared to the low TRIO score group. Moreover, patients with a high TRIO score had significantly decreased left ventricular ejection fractions, lower mean gradients, and reduced peak velocities.

The procedural details are shown in Table 2. Transfemoral access was the preferred approach in most procedures, and one patient received a procedure through transapical access. Pre-implantation balloon valvuloplasty was performed in 490 patients (92.5%), and post-implantation balloon valvuloplasty was performed in 220 patients (41.6%). Concomitant percutaneous coronary intervention was conducted in 52 patients (9.8%), and 47 (8.9%) underwent TAVI-in-TAVI, whereby more than one valve prosthesis was implanted during the index procedure. There were no significant differences in procedural characteristics between the high and low TRIO score groups.

3.2 Clinical Outcomes

The clinical outcomes based on the TRIO scores are presented in Table 3. At 30 days, the overall mortality rate was 4.3%, the rate of stroke was 1.3%, the incidence of acute kidney injury (AKI) was 6%, pacemaker implantation was required in 6.4%, and new-onset atrial fibrillation was observed in 9.1% of the patients. No MACEs occurred in the patients who received a transapical transcatheter aortic valve replacement (TAVR) during the follow-up period. Patients with high TRIO scores had a slightly higher mortality rate compared to the low TRIO score group, although this difference was not statistically significant (6.9% vs. 3.2%, p = 0.056). However, patients with high TRIO scores had significantly higher rates of stroke, AKI, and MACEs compared to those with low TRIO scores (3.1% vs. 0.5%, p = 0.028; 10.1% vs. 4.3%, p = 0.011; and 11.9% vs. 4.0%, p = 0.001, respectively).

A total of 507 patients survived beyond 30 days after the procedure and completed at least one follow-up visit. The mean follow-up period was 22 months (95% CI: 20–23 months). Kaplan–Meier survival estimates for all-cause mortality (Fig. 2A) and MACEs (Fig. 2B) are shown. Patients with high TRIO scores had significantly higher cumulative all-cause mortality (p 0.001) and MACEs (p 0.001) compared to those with low TRIO scores. Crude HRs for all-cause mortality and MACEs were 3.87 (95% CI: 1.81–8.26, p 0.001) and 4.25 (95% CI: 2.14–8.44, p 0.001), respectively.

After adjusting for baseline confounders, the high TRIO score remained a strong independent predictor of all-cause mortality and MACEs. The adjusted HR for all-cause mortality was 3.87 (95% CI: 1.81–8.26, p 0.001) (Table 4), and for MACEs, it was 2.78 (95% CI: 1.34–5.75, p = 0.006) (Table 5). Cumulative risk curves for all-cause mortality and MACEs are shown in Fig. 2C,D, respectively.

The TRIO and STS scores demonstrated excellent discrimination in predicting mortality and MACEs. Furthermore, the effects of these scores on predicting mortality and MACEs were comparable (Fig. 3). Although the STS score had a slightly higher area under the curve (AUC) in predicting 30-day mortality, no statistical differences were observed (TRIO vs. STS = 0.699 vs. 0.758, p = 0.246).

4. Discussion

This single-center retrospective study evaluated the prognostic impact of the TRIO scores in 530 patients who underwent a TAVI. The main findings of our study were as follows: (1) the rates of all-cause mortality and MACEs were significantly higher in patients with high TRIO scores. (2) the TRIO score was independently associated with all-cause mortality and MACEs in patients who had undergone a TAVI.

To our knowledge, this was the first study to assess the prognostic value of the TRIO score in patients who had received a TAVI. Predictors of poor outcomes following a TAVI included severe lung disease, chronic kidney disease, frailty, left ventricular dysfunction, pulmonary hypertension, and severe mitral regurgitation [10]. Capodanno et al. [11] developed the OBSERVANT risk score, which includes seven factors: renal dysfunction, pre-operative state, New York Heart Association (NYHA) functional class, pulmonary artery hypertension, diabetes, previous balloon aortic valvuloplasty, and left ventricular ejection fraction. These factors are readily available in clinical practice; however, the OBSERVANT score specifically predicts 30-day mortality rather than long-term outcomes. In a retrospective analysis of 530 patients, Hermiller et al. [12] devised a risk score based on albumin levels, Charlson comorbidity index, home oxygen use, and STS score to predict both early and late mortality risk after a TAVI. While this score incorporates frailty and nutritional status, essential aspects of patient prognosis, such information may not always be routinely collected. Additionally, reliance on the STS score, which can be time-consuming, limits the widespread applicability of the Hermiller et al. [12] devised score in everyday practice.

Neither of these risk scores incorporates parameters of right ventricular function, liver function, or lung function, which are increasingly recognized as crucial predictors of outcomes in patients following a TAVI. The TRIO score was originally developed and validated to predict mortality risk in patients with tricuspid regurgitation and pulmonary hypertension [8, 13]. Since many patients undergoing a TAVI also present with concomitant tricuspid regurgitation and pulmonary hypertension, conditions strongly linked to increased mortality risk [14, 15, 16], we sought to extend these findings to a TAVI cohort. Our results demonstrated that the TRIO score exhibited excellent discrimination for predicting all-cause mortality, independent of tricuspid regurgitation or pulmonary hypertension status. We also compared the effect of the TRIO score to the STS score in predicting all-cause mortality and MACEs and observed no difference. However, the TRIO score was more convenient and concise than the STS score, while the STS score was more time-consuming. Our study established its prognostic value and highlighted the significant association between a high TRIO score and worse clinical outcomes. The TRIO score remained a predictor of all-cause mortality after adjusting for confounding factors, including comorbidities, renal function, and cardiac function.

Right ventricular dysfunction (RVD) is considered a late marker of left-sided heart disease and is reported in approximately 25% of AS patients [17, 18, 19]. Several studies have investigated the prognostic impact of RVD in AS patients, yielding conflicting results [20, 21, 22]. Echocardiographic assessments of right ventricular function typically include tricuspid annular plane systolic excursion, the S’ wave, right ventricular size, and fractional area change. Although the TRIO score does not explicitly incorporate these parameters, it does include tricuspid regurgitation, which serves as a surrogate marker for the progression of RVD and right-sided heart failure. Significant tricuspid regurgitation has been associated with poorer outcomes, particularly in patients with significant tricuspid valve dysfunction [8]. RVD and tricuspid regurgitation contribute to chronic systemic venous congestion, which can lead to end-organ damage, including liver dysfunction and elevated serum aspartate transaminase levels [23]. Thus, the TRIO score partially reflects right-sided heart function and has been shown to predict a worse prognosis for patients after a TAVI.

Our study also demonstrated a correlation between a higher TRIO score and an increased risk of stroke within 30 days following a TAVI. Stroke is a particularly concerning complication of the TAVI, and the TRIO score may help identify patients at an elevated risk who could benefit from cerebral embolic protection devices. These devices have shown promise in reducing stroke incidence [24]; however, a recent randomized controlled trial reported no significant effect on the overall incidence of periprocedural stroke [25]. Therefore, careful patient selection is critical, and the TRIO score may provide a valuable reference for determining appropriate candidates for embolic protection devices.

AKI is another common complication following a TAVI, with reported prevalence rates ranging from 3.4% to 57%, primarily in older people and high-risk populations [26]. Moreover, the development of AKI after a TAVI is associated with increased short- and long-term mortality [27, 28]. In our study, patients with a higher TRIO score were more likely to develop AKI following a TAVI, which could be attributed to several factors included in the TRIO score, such as advanced age, baseline renal dysfunction, lung disease, and heart failure—all of which have been previously identified as risk factors for AKI after a TAVI [26, 29]. Consequently, patients with elevated TRIO scores may benefit from targeted medical interventions to optimize heart failure management and lung function prior to a TAVI.

5. Limitations

Several limitations of this study must be acknowledged. First, this was a retrospective analysis of patients from a single center, which may limit the generalizability of our findings. However, the study reflected the “real-world” daily TAVI practices. Second, the sample size of our cohort was relatively small, and the results should be validated in larger, multicenter cohorts.

6. Conclusions

In conclusion, our study demonstrated that a higher TRIO score is significantly associated with an increased risk of all-cause mortality and MACEs in aortic stenosis patients after a TAVI. These results propose that the TRIO score may serve as a simple and effective prognostic marker in patients after a TAVI. Thus, advanced therapeutic interventions for patients with high TRIO scores could improve clinical outcomes.

Availability of Data and Materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

References

[1] Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal. 2022; 43: 561–632. https://doi.org/10.1093/eurheartj/ehab395.

[2] Rahhab Z, El Faquir N, Tchetche D, Delgado V, Kodali S, Mara Vollema E, et al. Expanding the indications for transcatheter aortic valve implantation. Nature Reviews. Cardiology. 2020; 17: 75–84. https://doi.org/10.1038/s41569-019-0254-6.

[3] O’Brien SM, Shahian DM, Filardo G, Ferraris VA, Haan CK, Rich JB, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2–isolated valve surgery. The Annals of Thoracic Surgery. 2009; 88: S23–S42. https://doi.org/10.1016/j.athoracsur.2009.05.056.

[4] Nashef SAM, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR, et al. EuroSCORE II. European Journal of Cardio-thoracic Surgery: Official Journal of the European Association for Cardio-thoracic Surgery. 2012; 41: 734–744; discussion 744–745. https://doi.org/10.1093/ejcts/ezs043.

[5] Schwartz LA, Rozenbaum Z, Ghantous E, Kramarz J, Biner S, Ghermezi M, et al. Impact of Right Ventricular Dysfunction and Tricuspid Regurgitation on Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement. Journal of the American Society of Echocardiography. 2017; 30: 36–46. https://doi.org/10.1016/j.echo.2016.08.016.

[6] Shamekhi J, Sugiura A, Tabata N, Al-Kassou B, Weber M, Sedaghat A, et al. Impact of Tricuspid Regurgitation in Patients Undergoing Transcatheter Aortic Valve Replacement. JACC. Cardiovascular Interventions. 2020; 13: 1135–1137. https://doi.org/10.1016/j.jcin.2019.09.045.

[7] Tomii D, Okuno T, Praz F, Heg D, Wild MG, Lanz J, et al. Potential Candidates for Transcatheter Tricuspid Valve Intervention After Transcatheter Aortic Valve Replacement: Predictors and Prognosis. JACC. Cardiovascular Interventions. 2021; 14: 2246–2256. https://doi.org/10.1016/j.jcin.2021.07.030.

[8] Lara-Breitinger KM, Scott CG, Nkomo VT, Pellikka PA, Kane GC, Chaliki HP, et al. Tricuspid Regurgitation Impact on Outcomes (TRIO): A Simple Clinical Risk Score. Mayo Clinic Proceedings. 2022; 97: 1449–1461. https://doi.org/10.1016/j.mayocp.2022.05.015.

[9] VARC-3 WRITING COMMITTEE:, Généreux P, Piazza N, Alu MC, Nazif T, Hahn RT, et al. Valve Academic Research Consortium 3: Updated Endpoint Definitions for Aortic Valve Clinical Research. Journal of the American College of Cardiology. 2021; 77: 2717–2746. https://doi.org/10.1016/j.jacc.2021.02.038.

[10] Puri R, Iung B, Cohen DJ, Rodés-Cabau J. TAVI or No TAVI: identifying patients unlikely to benefit from transcatheter aortic valve implantation. European Heart Journal. 2016; 37: 2217–2225. https://doi.org/10.1093/eurheartj/ehv756.

[11] Capodanno D, Barbanti M, Tamburino C, D’Errigo P, Ranucci M, Santoro G, et al. A simple risk tool (the OBSERVANT score) for prediction of 30-day mortality after transcatheter aortic valve replacement. The American Journal of Cardiology. 2014; 113: 1851–1858. https://doi.org/10.1016/j.amjcard.2014.03.014.

[12] Hermiller JB, Jr, Yakubov SJ, Reardon MJ, Deeb GM, Adams DH, Afilalo J, et al. Predicting Early and Late Mortality After Transcatheter Aortic Valve Replacement. Journal of the American College of Cardiology. 2016; 68: 343–352. https://doi.org/10.1016/j.jacc.2016.04.057.

[13] Alabdaljabar MS, Naser JA, Kane CJ, Lara-Breitinger KM, Anand V, Pislaru C, et al. Tricuspid Regurgitation Impact on Outcomes Score for Risk Stratification in Patients With Pulmonary Hypertension. Journal of the American Society of Echocardiography. 2023; 36: 1213–1215. https://doi.org/10.1016/j.echo.2023.07.005.

[14] Prasitlumkum N, Kittipibul V, Tokavanich N, Kewcharoen J, Rattanawong P, Angsubhakorn N, et al. Baseline significant tricuspid regurgitation is associated with higher mortality in transcatheter aortic valve replacement: systemic review and meta-analysis. Journal of Cardiovascular Medicine. 2019; 20: 477–486. https://doi.org/10.2459/JCM.0000000000000807.

[15] Rozenbaum Z, Granot Y, Steinvil A, Banai S, Finkelstein A, Ben-Gal Y, et al. Aortic Stenosis with Severe Tricuspid Regurgitation: Comparative Study between Conservative Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement Combined With Tricuspid Repair. Journal of the American Society of Echocardiography. 2018; 31: 1101–1108. https://doi.org/10.1016/j.echo.2018.07.002.

[16] Alushi B, Beckhoff F, Leistner D, Franz M, Reinthaler M, Stähli BE, et al. Pulmonary Hypertension in Patients With Severe Aortic Stenosis: Prognostic Impact After Transcatheter Aortic Valve Replacement: Pulmonary Hypertension in Patients Undergoing TAVR. JACC. Cardiovascular Imaging. 2019; 12: 591–601. https://doi.org/10.1016/j.jcmg.2018.02.015.

[17] Galli E, Guirette Y, Feneon D, Daudin M, Fournet M, Leguerrier A, et al. Prevalence and prognostic value of right ventricular dysfunction in severe aortic stenosis. European Heart Journal. Cardiovascular Imaging. 2015; 16: 531–538. https://doi.org/10.1093/ehjci/jeu290.

[18] Lindsay AC, Harron K, Jabbour RJ, Kanyal R, Snow TM, Sawhney P, et al. Prevalence and Prognostic Significance of Right Ventricular Systolic Dysfunction in Patients Undergoing Transcatheter Aortic Valve Implantation. Circulation. Cardiovascular Interventions. 2016; 9: e003486. https://doi.org/10.1161/CIRCINTERVENTIONS.115.003486.

[19] Bohbot Y, Guignant P, Rusinaru D, Kubala M, Maréchaux S, Tribouilloy C. Impact of Right Ventricular Systolic Dysfunction on Outcome in Aortic Stenosis. Circulation. Cardiovascular Imaging. 2020; 13: e009802. https://doi.org/10.1161/CIRCIMAGING.119.009802.

[20] Ren B, Spitzer E, Geleijnse ML, Zijlstra F, de Jaegere PPT, Van Mieghem NM, et al. Right ventricular systolic function in patients undergoing transcatheter aortic valve implantation: A systematic review and meta-analysis. International Journal of Cardiology. 2018; 257: 40–45. https://doi.org/10.1016/j.ijcard.2018.01.117.

[21] Asami M, Stortecky S, Praz F, Lanz J, Räber L, Franzone A, et al. Prognostic Value of Right Ventricular Dysfunction on Clinical Outcomes After Transcatheter Aortic Valve Replacement. JACC. Cardiovascular Imaging. 2019; 12: 577–587. https://doi.org/10.1016/j.jcmg.2017.12.015.

[22] Koifman E, Didier R, Patel N, Jerusalem Z, Kiramijyan S, Ben-Dor I, et al. Impact of right ventricular function on outcome of severe aortic stenosis patients undergoing transcatheter aortic valve replacement. American Heart Journal. 2017; 184: 141–147. https://doi.org/10.1016/j.ahj.2016.09.018.

[23] Stolz L, Kirchner M, Steffen J, Doldi PM, Braun D, Weckbach LT, et al. Cardio-hepatic syndrome in patients undergoing transcatheter aortic valve replacement. Clinical Research in Cardiology. 2023; 112: 1427–1435. https://doi.org/10.1007/s00392-023-02245-w.

[24] Zahid S, Ullah W, Zia Khan M, Faisal Uddin M, Rai D, Abbas S, et al. Cerebral Embolic Protection during Transcatheter Aortic Valve Implantation: Updated Systematic Review and Meta-Analysis. Current Problems in Cardiology. 2023; 48: 101127. https://doi.org/10.1016/j.cpcardiol.2022.101127.

[25] Kapadia SR, Makkar R, Leon M, Abdel-Wahab M, Waggoner T, Massberg S, et al. Cerebral Embolic Protection during Transcatheter Aortic-Valve Replacement. The New England Journal of Medicine. 2022; 387: 1253–1263. https://doi.org/10.1056/NEJMoa2204961.

[26] Zaleska-Kociecka M, Dabrowski M, Stepinska J. Acute kidney injury after transcatheter aortic valve replacement in the elderly: outcomes and risk management. Clinical Interventions in Aging. 2019; 14: 195–201. https://doi.org/10.2147/CIA.S149916.

[27] Kliuk-Ben Bassat O, Finkelstein A, Bazan S, Halkin A, Herz I, Salzer Gotler D, et al. Acute kidney injury after transcatheter aortic valve implantation and mortality risk-long-term follow-up. Nephrology, Dialysis, Transplantation. 2020; 35: 433–438. https://doi.org/10.1093/ndt/gfy264.

[28] Ram P, Mezue K, Pressman G, Rangaswami J. Acute kidney injury post-transcatheter aortic valve replacement. Clinical Cardiology. 2017; 40: 1357–1362. https://doi.org/10.1002/clc.22820.

[29] Oguri A, Yamamoto M, Mouillet G, Gilard M, Laskar M, Eltchaninoff H, et al. Impact of chronic kidney disease on the outcomes of transcatheter aortic valve implantation: results from the FRANCE 2 registry. EuroIntervention. 2015; 10: e1–9. https://doi.org/10.4244/EIJV10I9A183.

Funding

National Nature Science Foundation of China(82070478)

Guangdong Provincial Clinical Research Center for Cardiovascular disease(2020B1111170011)

Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention(Y0120220151)