Tricuspid Valve Regurgitation and Endomyocardial Biopsy After Orthotopic Heart Transplantation

Objective: Tricuspid valve regurgitation (TR) after heart transplantation (HTx) has been reported to be caused by endomyocardial biopsy (EMB), acute cellular rejection (ACR), or atrial anastomosis. We performed a prospective study of this problem among our HTx cohort. Methods: From 1988 to 2006, we performed 274 HTx. Excluding cases within 1 year (2006), there were 178 patients in whom we had records of EMB dates, ACR grades (International Society for Heart and Lung Transplantation [ISHLT], 1990), echocardiography-measured TR, and time-to-TR. Statistical analyses were performed using nonparametric comparisons, Spearman correlation, Kaplan-Meier time to failure curves, and Cox regression model. Results: All 178 patients underwent a biatrial anastomosis and underwent 2631 EMB (median, 15 times per patient; range, 0-42). The median follow-up duration was 66 months (range 2 days-194 months). Up to December 31, 2006, there were 47 patients (47/178 = 26.4%) who developed moderate-to-severe TR, which differed significantly from the prevalence rate (24/39 = 61.5%) reported by another cardiac team (P = .001) that performed bicaval anastomoses in half of the cases (20/39 = 51%). Our 1-, 3-, and 10-year Kaplan-Meier incidence rates of remarkable TR were 14.7% (10.2%-20.8%), 19.4% (14.2%-26.2%), and 36.3% (27.2%-47.3%), respectively. A positive correlation was shown between each patient's EMB times and ACR but not TR grades, in terms of mean, maximum, or minimum over time (all P < .001 for null hypothesis of noncorrelation). Each patient's EMB times and number of definite ACRs (≥ISHLT grade II) did not differ significantly between the two groups of remarkable versus nonremarkable TR. Remarkable TR was negatively predicted by each patient's EMB times (hazard ratio = 0.93; P = .010) but not by the ACR grades or the numbers of definite ACRs. Conclusion: Our cohort demonstrated that biatrial anastomosis, ACR, or EMB were not associated with the risk of remarkable TR. The protective effect of EMB on remarkable TR needs further investigation.