Annular Dilatation Research Articles

Relationship between duration of atrial fibrillation and right heart structure remodeling as assessed by 3-dimensional transesophageal echocardiography

BackgroundTricuspid valve (TV) remodeling occurs in patients with atrial fibrillation (AF); however, the affecting factor related to TV remodeling in AF remains to be elucidated. We sought to explore whether the AF persistence itself affects right heart remodeling. MethodsA total of 372 lone AF patients (234 paroxysmal AF [paroxAF] and 138 persistent AF [persAF]) who underwent 3-dimensional transesophageal echocardiography (3D-TEE) was retrospectively reviewed. The duration from first-detected episode of AF to the TEE exam date was defined as AF duration. ResultsPersAF patients had a larger TV area index (625.4 vs 719.0 mm2/m2; P < 0.001) and a higher right atrium area-to-right ventricle end-systolic area ratio (RA/RVESA ratio, 1.7 vs 1.9; P = 0.005) than paroxAF patients. The prevalence of AF-tricuspid regurgitation was higher in persAF than in paroxAF patients (1.3% vs 12.3%; P < 0.001). In persAF patients, AF duration was moderately correlated with TV diameter and 3D-TEE-derived TV annular area but not in paroxAF. On multivariable analysis, AF duration was independently associated with TV annular dilatation even after adjustment for RA/RVESA ratio and tricuspid regurgitation severity (β 0.37 [95% CI: 0.77–1.81]; P < 0.001). Additionally, AF duration with cutoff values of 20 months for predicting TV annular dilatation and 37 months for predicting RA/RVESA ratio > 2.1 had both high diagnostic accuracies among persAF patients (both P < 0.01). ConclusionsAF duration itself is independently associated with right heart remodeling in persAF but not in paroxAF, such as TV annular dilatation and predominant RA remodeling which may lead to subsequent TR progression and adverse outcomes.

Truncal valve repair in an adolescent with severe annular dilatation

Approximately 20% of patients with truncus arteriosus might need a truncal valve procedure within 20 years after anatomical repair due to regurgitation. These patients commonly develop valve regurgitation due to root dilatation with a sufficient amount of good quality valvular tissue. Thus, the reduction of the truncal annulus is the single most important factor to achieve durable repair, especially in patients in whom the Ross procedure is not an option.

Imaging for the assessment of the arrhythmogenic potential of mitral valve prolapse.

Mitral valve prolapse (MVP) is the most common valve disease in the western world and recently emerged as a possible substrate for sudden cardiac death (SCD). It is estimated an annual risk of sudden cardiac death of 0.2 to 1.9% mostly caused by complex ventricular arrhythmias (VA). Several mechanisms have been recognized as potentially responsible for arrhythmia onset in MVP, resulting from the combination of morpho-functional abnormality of the mitral valve, structural substrates (regional myocardial hypertrophy, fibrosis, Purkinje fibers activity, inflammation), and mechanical stretch. Echocardiography plays a central role in MVP diagnosis and assessment of severity of regurgitation. Several abnormalities detectable by echocardiography can be prognostic for the occurrence of VA, from morphological alteration including leaflet redundancy and thickness, mitral annular dilatation, and mitral annulus disjunction (MAD), to motion abnormalities detectable with "Pickelhaube" sign. Additionally, speckle-tracking echocardiography may identify MVP patients at higher risk for VA by detection of increased mechanical dispersion. On the other hand, cardiac magnetic resonance (CMR) has the capability to provide a comprehensive risk stratification combining the identification of morphological and motion alteration with the detection of myocardial replacement and interstitial fibrosis, making CMR an ideal method for arrhythmia risk stratification in patients with MVP. Finally, recent studies have suggested a potential role in risk stratification of new techniques such as hybrid PET-MR and late contrast enhancement CT. The purpose of this review is to provide an overview of the mitral valve prolapse syndrome with a focus on the role of imaging in arrhythmic risk stratification. CLINICAL RELEVANCE STATEMENT: Mitral valve prolapse is the most frequent valve condition potentially associated with arrhythmias. Imaging has a central role in the identification of anatomical, functional, mechanical, and structural alterations potentially associated with a higher risk of developing complex ventricular arrhythmia and sudden cardiac death. KEY POINTS: • Mitral valve prolapse is a common valve disease potentially associated with complex ventricular arrhythmia and sudden cardiac death. • The mechanism of arrhythmogenesis in mitral valve prolapse is complex and multifactorial, due to the interplay among multiple conditions including valve morphological alteration, mechanical stretch, myocardial structure remodeling with fibrosis, and inflammation. • Cardiac imaging, especially echocardiography and cardiac magnetic resonance, is crucial in the identification of several features associated with the potential risk of serious cardiac events. In particular, cardiac magnetic resonance has the advantage of being able to detect myocardial fibrosis which is currently the strongest prognosticator.

An ex-vivo and in-vitro dynamic simulator for surgical and transcatheter mitral valve interventions

PurposeMinimally invasive mitral valve surgery (MIMVS) and transcatheter edge-to-edge repair (TEER) are complex procedures used to treat mitral valve (MV) pathologies, but with limited training opportunities available. To enable training, a realistic hemodynamic environment is needed. In this work we aimed to develop and validate a simulator that enables investigation of MV pathologies and their repair by MIMVS and TEER in a hemodynamic setting.MethodsDifferent MVs were installed in the simulator, and pressure, flow, and transesophageal echocardiographic measurements were obtained. To confirm the simulator’s physiological range, we first installed a biological prosthetic, a mechanical prosthetic, and a competent excised porcine MV. Subsequently, we inserted two porcine MVs—one with induced chordae tendineae rupture and the other with a dilated annulus, along with a patient-specific silicone valve extracted from echocardiography with bi-leaflet prolapse. Finally, TEER and MIMVS procedures were conducted by experts to repair the MVs.ResultsSystolic pressures, cardiac outputs, and regurgitations volumes (RVol) with competent MVs were 119 ± 1 mmHg, 4.78 ± 0.16 l min−1, and 5 ± 3 ml respectively, and thus within the physiological range. In contrast, the pathological MVs displayed increased RVols. MIMVS and TEER resulted in a decrease in RVols and mitigated the severity of mitral regurgitation.ConclusionEx-vivo modelling of MV pathologies and repair procedures using the described simulator realistically replicated physiological in-vivo conditions. Furthermore, we showed the feasibility of performing MIMVS and TEER at the simulator, also at patient-specific level, thus providing new clinical perspectives in terms of training modalities and personalized planning.

Epidemiology and prognostic relevance of morphofunctional classification of secondary mitral regurgitation

Abstract Background Mitral regurgitation has traditionally been divided into organic and functional (FMR) due to its different etiology and prognosis. However, FMR is not a homogeneous entity, and may be secondary to annular dilation, ventricular dilation and dysfunction, or posterior leaflet restriction. Purpose Our aim is to assess the epidemiology of these FMR subtypes and their prognostic impact. Methods Patients with FMR from our center who underwent three-dimensional transesophageal echocardiography (3D-TEE) between 2016 and 2020 were retrospectively evaluated. Patients with at least moderate FMR, effective regurgitant orifice (ERO) by 3D-TEE &amp;gt;0.2 cm2 were selected. They were classified according to the predominant mechanism: type 1 or ventricular dysfunction, type 2 or posterior leaflet restriction, and type 3 or annular dilation. 3D-TEE and the closest transthoracic study variables, as well as baseline demographic and clinical characteristics and evolution events, were obtained and statistical analysis was performed according to FMR types. Results 112 patients were included (66.1% male, mean age 72.3 years). 54.5% had previous hospitalization for heart failure and 53.6% had a history of ischemic heart disease. The most frequently identified FMR mechanism was type 1 (61.6%), followed by type 3 (23.2%) and type 2 (15.2%). There were significant differences in epidemiological factors and echocardiographic parameters (Table) between groups. During follow-up, 43.8% died, received a heart transplant or LVAD and 44.6% had any hospitalization for heart failure. There were no significant differences between FMR types in relation to total mortality (p=0.28), mortality due to heart failure (p=0.13), total hospitalizations (p=0.73), or hospitalization for heart failure (p=0.12). Valvular intervention was performed in 54 patients (48.2%), 33 of them percutaneously with a clip, with no differences in FMR subtypes. Conclusions FMR is a heterogeneous entity and different morphotypes with different epidemiology and etiology can be identified. Despite the different mechanism, all subgroups presented a similar unfavorable prognosis and similar intervention rates.

Prognostic value of three-dimensional regurgitant orifice determination in functional mitral regurgitation

Abstract Background Functional mitral regurgitation (FMR) evaluation using effective regurgitant orifice (ERO) by echocardiography remains controversial. Given the morphology of regurgitant jets in FMR, determination of ERO using three-dimensional transesophageal echocardiography (3D-TEE) may be more accurate. However, a clear threshold for this parameter has not been defined. Purpose Our aim is to evaluate the prognostic value of 3D-ERO in FMR. Methods All patients with at least moderate FMR who underwent 3D-TEE in a tertiary center between 2016 and 2020 were retrospectively selected. Echocardiographic variables by transthoracic and transesophageal, as well as demographic and clinical history variables, were collected. A combined event of urgent hospital admission or death was considered. Variables statistically associated with the event were included in multivariate analysis. Results 112 patients (74 men (66.1%), mean age 72.3±10.9 years) were finally included. The most frequent etiology of FMR was ventricular dysfunction (61.6%), followed by annular dilation (23.2%) and posterior leaflet restriction (15.2%). The mean 3D-ERO was 0.53±0.25 cm2 and mean ejection fraction was 40.7±14.2%. At diagnosis, 49 patients (43.8%) were not receiving diuretics, 63 (56.2%) had atrial fibrillation/flutter, 60.3% permanent. FMR was treated in 54 patients (48.2%), 61,1% percutaneously. During a follow-up of 36 [14-54] months, 50 (44,6%) patients were urgently hospitalized (mean 1.9±2.8 admissions) and 49 (43,8%) died, received a heart transplant or LVAD. 3D-ERO was significantly associated with the occurrence of the event (0.55 vs 0.41; p=0.02). Additionally, 3D-ERO was associated with mitral intervention (0.58 vs 0.47 cm2; p=0.01) and had a trend towards death from any cause (0.56 vs 0.5 cm2; p=0.098). The prognostic capacity of 3D-ERO for the combined event was determined using an ROC curve (Figure). An AUC of 0.67 (95% CI 0.55-0.8; p=0.01) and an optimal cutoff value of 0.45 cm2 (sensitivity 0.62, specificity 0.73) were obtained. In univariate analysis, the combined event was also associated with age (73.9 vs. 65.6 years; p=0.01), diabetes (40 vs. 13.6%; p=0.02), chronic kidney disease (42.7 vs. 13.6%; p=0.01), ischemic heart disease (59.6 vs 31,8%, p=0.02) and daily furosemide dose (39.7 vs. 13.6 mg; p&amp;lt;0.01). In multivariate analysis of the event, age, daily furosemide dose, ischemic heart disease and 3D-ERO were included in the final predictive model (Table). Conclusions In patients with FMR, 3D-ERO was significantly associated with the occurrence of events during follow-up, with an optimal prognostic performance cutoff point of 0.45 cm2. Furthermore, it was an independent predictor of mitral intervention and included among the predictors of urgent hospital admission or death. Therefore, 3D-ERO may be useful in risk stratification of FMR.

Characterizing patients ineligible for mitral valve intervention: Phenotypic clustering sub-analysis from the CHOICE-MI Registry

Abstract Background/Introduction Transcatheter mitral valve replacement (TMVR) is emerging as a therapeutic option for surgcal high-risk patients with mitral regurgitation (MR). However, a large proportion of these patients are still rejected due to clinical or anatomical reasons. The majority of these patients remain ineligible for any mitral valve (MV) intervention and continue medical treatment. Phenotypic characterization of these patients may assist in the identification of the anatomical challenges and drive future innovation efforts as well as assist in the risk stratification process of these patients. Purpose To characterize patients ineligible for TMVR and other MV interventions from a large international registry using an unsupervised phenotypic clustering approach integrating clinical, echocardiographic and computed tomography data to unveil differences between phenogroups. Methods Between 2014 and 2022, the CHOICE-MI registry included 984 patients undergoing screening for TMVR at 33 international sites. For this study, only patients with screening failure resulting in medical therapy alone were included. Patients receiving transcatheter or surgical treatment were excluded (Figure 1). A cluster analysis using K-means algorithm was performed on baseline clinical and imaging variables, and predictors of all-cause mortality within these clusters were assessed. Results Among 284 patients (77.4±8.82 years, 56.0% female, EuroSCORE II 6.6±5.8%) considered ineligible for any MV intervention, two clinically distinct phenogroups (PG) were identified using unsupervised hierarchical clustering of principal components (Figure 2): (PG1) Elderly women with primary MR, high left ventricular (LV) ejection fraction, and annular calcification (N=173, 60.9%); (PG2) Patients with secondary or mixed MR, LV and annular dilation, and high prevalence of comorbidities (N=111, 39.1%). There were no differences regarding Kaplan-Meier estimated 1-year all-cause mortality (PG1 vs. PG2, 21.4% vs. 23.4%, p=0.89) and 1-year cardiovascular mortality (10.4% vs. 13.5%, p=0.53). Predictors of mortality were albumin, renal function, extracardiac arteriopathy for PG1, and albumin, coronary artery disease, and prior myocardial infarction for PG2. Conclusions Using cluster analysis, this study identified two major subgroups among patients ineligible for mitral interventions with profound differences in clinical and anatomical profiles, and predictors of outcome. The combination of elderly women with primary MR, preserved LV ejection fraction and annular calcification was the most common phenogroup among patients rejected for mitral intervention. Identifying these factors may drive technological evolution to address unmet clinical and technical needs.

Right heart remodeling and outcomes of patients with tricuspid regurgitation

Abstract Background Albeit long neglected, significant (at least moderate, ≥ 2+) tricuspid regurgitation (TR) is currently known to be associated with increased mortality, and has thus become a relevant therapeutic target [1-3]. Recent and somewhat preliminary evidence has shown, however, that different subtypes of TR might respond differently to current therapeutic options [4-5]. In fact, secondary TR, rather than being a single entity, can develop because of either right ventricular (RV) remodelling (i.e functional TR) or tricuspid annulus (TA) dilation secondary to right atrial (RA) dilation (i.e isolated TR). Purpose The aim of this meta-analysis was to study the association between right heart remodeling and long-term all-cause mortality in a population of patients with significant TR, independent of the treatment option. Methods MEDLINE, ISI Web of Science, and SCOPUS databases were searched for studies published up to July 2022. Studies reporting data on at least one echocardiographic RV anatomic and/or functional parameter and outcome in patients with significant TR were included. This study was designed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) requirements. The primary endpoint was long-term all-cause mortality. Results Out of 3152 studies, a total of 14 were included in the final analytic synthesis, enrolling 4394 subjects. The median follow-up was 33 [24–51] months. Overall, long-term all-cause mortality was 31% (95% confidence interval [CI]: 20-41%, p = &amp;lt;0.001; Figure 1); however, a significant difference was noted in the medical subgroup vs. the surgery subgroup (43% [32-53%] vs 11% [20-41%]). By means of a meta-regression analysis, a significant and inverse relation was found between tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (RV-FAC) and mortality (11 studies enrolling 3551 subjects, coefficient -0.063 [-0.111 to -0.014], p = 0.011; 9 studies, 2975 subjects, coefficient -0.044 [-0.059 to -0.029], p &amp;lt; 0.001, respectively; Figure 2A and 2B), whereas a significant and concordant relation was found between TA dimension, RA area and mortality (7 studies, 2986 subjects, coefficient 0.003 [0.002 to 0.005], p &amp;lt; 0.001; 6 studies, 1920 subjects, coefficient -0.019 [-0.025 to -0.013], p &amp;lt; 0.001, respectively; Figure 2C and 2D). Conclusions The higher mortality associated with right ventricular dysfunction and reduced mortality with increasing right atrial dilatation suggest a better prognostic outcome for isolated TR than functional TR. Careful assessment of right heart anatomy and function is warranted, as it might foster the identification of different subtypes of TR with unique prognoses.Forest plot all-cause mortalityResult of the meta-regression analysis

Moderate functional mitral regurgitation: difference between atrial and ventricular mechanism of the regurgitation

Abstract Background/Introduction In severe functional mitral regurgitation (MR), further distinction of the mechanism of MR in atrial functional MR (aFMR) and ventricular functional MR (vFMR) has shown prognostic importance. However, no data are available on moderate functional MR, whose characteristics and prognosis are largely unknown. Purpose To assess clinical and echocardiographic characteristics of patients with moderate aFMR and vFMR and their potential difference in outcome. Methods Patients with moderate functional MR were retrospectively included. aFMR was defined as isolated mitral annulus dilatation in combination with preserved left ventricular ejection fraction (LVEF≥50%) without ischemic heart disease or LV dilatation. Patients were classified as vFMR when LVEF was reduced, LV was dilated and/or wall motion abnormalities were present. Mitral valve intervention and all-cause mortality were used as combined endpoint. Results In total 474 patients with moderate functional MR (mean age 67 ±12, 57% male) were evaluated, of which 136 (29%) had aFMR and 338 (71%) had vFMR as underlying mechanism. Among the clinical variables, patients with aFMR had more atrial fibrillation (77% vs. 35%; p&amp;lt;0.001), were less symptomatic (NYHA class ≥ III: 6% vs. 18%; p&amp;lt;0.001) and had better renal function (eGFR 73 ±23 ml/min/1,73m2 vs. 65 ±23 ml/min/1,73m2; p=0.005) as compared to vFMR. In the vFMR group, 49% of patients had ischemic heart disease. Among the echocardiographic variables, as expected in aFMR, LVEF was higher (42 ±14% vs. 55 ±13%; p&amp;lt;0.001), while LV volumes (LV end-diastolic volume index 55 ±13 mL/m2 vs. 82 ±38 mL/m2; p&amp;lt;0.001) and E/E’ ratio were smaller (10 ±4 vs. 15 ±4; p&amp;lt;0.001) as compared to vFMR. However left atrial (LA) volume index was similar between both groups (43 ±14 mL/m2 vs. 41 ±18 mL/m2; p=0.271). For the echocardiographic measures of the right heart, significant difference was observed only for TAPSE which was higher for the aFMR group (22 ±4mm vs. 20 ±5mm; p&amp;lt;0.001). During a median follow-up of 74 months [IQR: 46.8-107.0], 132 (30%) patients died and 30 (6%) underwent mitral valve intervention. Event-free survival analysis for the combined endpoint was significantly better for aFMR patients (Figure 1). Based on significant variables from the univariable Cox regression analysis, multivariable Cox regression analysis showed that the mechanism of functional MR (with aFMR being protective as compared to vFMR), age, male gender, impaired renal function, NYHA class, severe LA dilatation and TAPSE were independently associated with the combined endpoint (Table 1). Conclusion In patients with moderate functional MR, aFMR is independently associated with better event-free survival as compared to vFMR. Therefore, clear identification of the mechanism of MR implies a better risk stratification and may be helpful for the management of patients with moderate MR.

Abstract 17063: Pericardial Patch Augmentation of the Anterior and Posterior Tricuspid Leaflets Relieves Leaflet Tethering and Improves Coaptation in an Acute Porcine Model

Background: Tricuspid annuloplasty is generally effective in treating functional tricuspid regurgitation (TR), but patients with severe annular dilation or leaflet tethering have a high risk of recurrence. Hypothesis: We hypothesized that anterior and posterior patch augmentation (APA) of the tricuspid valve (TV) would reduce leaflet tethering, improve coaptation, and effectively treat TR. Methods: We evaluated APA repair in an acute porcine model. The TV was accessed via a right thoracotomy and cardiopulmonary bypass (CPB) was initiated with bicaval venous and ascending aortic cannulation. The anterior and posterior TV leaflets were separated from the annulus, and a 1.5 cm wide partial reverse frustum-shaped pericardial patch was implanted. 3D transepicardial echocardiography was used to image the TV pre- and post-implantation. Geometric measurements were assessed using Tomtec and compared with paired t-tests. Results: APA repair was performed in five pigs (weight 60-80 kg). All animals were weaned from CPB in sinus rhythm. TR was trace or absent in all cases after APA repair. There were no changes in pressure gradient (0.5 vs 0.5, p&gt;0.9) or annular area (11.2 vs 10.1 cm 2 , p=0.19). APA repair was associated with a decreased tenting height and angle of the anterior (height: 9.0 vs 4.6 mm, p=0.03; angle: 20.9° vs 16.1°, p=0.04) and posterior (height: 9.8 vs 5.5 mm, p=0.03; angle: 28.1° vs 21.8°, p=0.03) leaflets. Central coaptation length increased in all leaflets (septal: 3.8 vs 6.6 mm, p=0.04, anterior: 4.7 vs 12.7 mm, p&lt;0.01, posterior: 4.5 vs 13.2 mm, p&lt;0.01). Conclusions: APA repair was feasible, safe, reduced leaflet tenting, and improved coaptation. This novel repair method shows promise for patients with severe annular dilation or leaflet tethering who otherwise have a high risk of recurrence with annuloplasty alone. Furthermore, by avoiding suture placement near the conduction system, it may reduce the risk of post-operative conduction abnormalities.

Abstract 14699: Effects of Papillary Muscle Approximation and Annuloplasty Ring Sizing for Functional Mitral Regurgitation Repair in Enlarged Ventricles

Introduction: Our recent large animal study showed that papillary muscle approximation (PMA) repairs functional mitral regurgitation (FMR) and increases valve coaptation in enlarged left ventricles without negatively affecting ventricular function. However, since PMA does not reduce mitral annular dilation, addition of annuloplasty ring might be beneficial for such repair. In this study, we used computational modeling to investigate the benefit of the addition of annuloplasty to PMA and the effects of ring sizing on FMR repair in enlarged ventricles. Methods: 3D echo images were obtained in 3 pigs with heart failure, enlarged ventricles, and FMR. Each echo dataset was segmented, and computational model of the mitral valve was developed. To mimic PMA repair, the papillary muscles were drawn together in diastole. A true-sized annuloplasty ring of 40 mm and two downsized-rings of 38 mm and 36 mm were then added to each model. Leaflet closure was simulated and mitral valve geometry and biomechanics in peak systole were evaluated ( Fig A-B ). Results: On average, compared to pre-repair, PMA increased coaptation area by 30.6%, while the addition of annuloplasty increased this area by 85.1% with 40 mm, 138.1% with 38 mm, and 190.6% with 36 mm ring. Tenting area was reduced by 45.8% after PMA, 64.1% with the addition of 40 mm ring, 70.6% with 38 mm, and 76.5% with 36 mm ring. PMA reduced tension forces in chordae by 19.8%, while adding true-sized ring reduced forces by 16.4%. Annular downsizing allowed to reduce chordal forces by 31.2% with 38 mm, and 43.0% with 36 mm ring. Peak leaflet stress was observed on the P2 cusp, and PMA reduced it by 26.9%. True-sized ring reduced peak stress by only 10.7%, while 38 mm ring by 29.9%, and 36 mm by 43.7% ( Fig C ). Conclusions: Addition of true-sized ring to PMA further improved systolic valve geometry but not biomechanical parameters. Annular downsizing added to PMA was more beneficial for FMR repair, as it improved both mitral valve geometry and biomechanics.

Abstract 17823: Impact of the Type of Tricuspid Annuloplasty Ring Concomitant With Mitral Annuloplasty on Atrial Arrhythmia Behaviour and Pacemaker Implantation Rate, Fact or Fancy

Background: Tricuspid valve repair has been advocated in patients undergoing mitral valve surgery who have not only preoperative severe TR but also for tricuspid annular dilatation (TAD) of &gt;40 mm. We sought to analyze the impact of the type of tricuspid annuloplasty ring on the atrial arrhythmia behavior and the incidence of permanent pacemaker implantations in patients undergoing mitral valve annuloplasty. Methods: We performed a retrospective review of 408 patients underwent combined tricuspid and mitral valve annuloplasty in our institution between the years 2007 and 2014.Patients were 68,8 ± 10,7 years old, 67% male, 33% female. A total of 325 patients met the inclusion criteria; 201 received three-dimensional (3D) rigid ring (group 1) and 124 received ring annuloplasty with flexible bands (group2). The distribution of the preoperative and perioperative variables was similar. Results: There was no statistical difference in the incidence of high-grade heart conduction disorders lasting more than 3 days postoperatively (13.4% in group 1 and 12.9% in group 2; P = 0.89). Likewise, there was no difference in the incidence of postoperative atrial fibrillation between the two groups (41.2% in group 1 and 37.1% in group 2; P = 0.45). On the other hand, there was statistical difference in the incidence of permanent pacemaker implantation between the two groups (12.9% in group 1 and 25.8% in group 2; P = 0.003). Likewise, there was difference in the incidence of sick sinus syndrome between the two groups (0.01% in group 1 and 16.1% in group 2; P &lt; 0.00001). Conclusion: The need for permanent pacemaker implantation and the incidence of sick sinus syndrom may be increased after the use of flexible tricuspid annuloplasty ring in the setting of mitral valve surgery.Moreover, the present study found no association between the use of Flexible tricuspid annuloplasty ring and a higher incidence of postoperative atrial fibrillation or high-grade heart conduction disorders.Further large-scale randomized controlled studies are needed to elucidate the Impact of the type of tricuspid annuloplasty ring.

Mitral valve repair using leaflet expansion and subpartial annuloplasty in children

ObjectiveMitral valve reconstruction in the pediatric population is a challenge due to the frequent combination of annular dilatation and leaflet restriction and the need for growth. We present a novel strategy using leaflet expansion and subpartial annuloplasty with polytetrafluoroethylene reinforcement. MethodsFrom January 2014 through May 2021, 11 children aged 5 months to 14 years (median, 24 months) underwent elective mitral valve repair due to severe mitral valve regurgitation. The mitral valve abnormalities included congenital malformations (n = 7), postoperative leakage following commissurotomy (n = 1), and functional mitral valve regurgitation due to dilated cardiomyopathy (n = 3). Surgery consisted of leaflet expansions with autologous, untreated pericardium and subpartial annuloplasty with polytetrafluoroethylene reinforcement. ResultsAll children survived their surgeries with uneventful postoperative courses, except for 1 patient who needed an early reoperation to resolve a functional stenosis due to a spinnaker phenomenon. At discharge, mean gradient was 3.5 ± 3.9 mm Hg, with trivial mitral regurgitation in 9 patients (82%). All patients were alive and asymptomatic during the median follow-up of 3 years (range, 1-7 years). Their echocardiographic data showed a mean transmitral gradient of 4.4 ± 1.7 mm Hg and remained unchanged. Residual mitral valve regurgitation was trivial or mild in 9 patients (82%) and moderate in 2 patients (18%). ConclusionsLeaflet expansion with autologous pericardium and subpartial annuloplasty with polytetrafluoroethylene reinforcement for mitral regurgitation in the pediatric population gives stable and satisfactory results both early and at intermediate follow-up, permitting growth of the mitral valve.

Internal circular suture annuloplasty for aortic valve repair.

Stabilizing the aorto-ventricular junction is integral in aortic valve repair. We report our technique of internal circular suture annuloplasty. We used a continuous horizontal mattress suture of a single thick expanded polytetrafluoroethylene suture (CV-3). We put 4 stitches per sinus, so the suture was below the cusp attachment line at the nadirs and passed through the interleaflet triangle at the upper aorto-ventricular junction level. The suture was reinforced with pericardial pledgets on both sides of each commissure. We used this technique in 12 patients. The diameter of aorto-ventricular junction was reduced from 25 ± 2mm to 22 ± 1mm (n = 11) and was 22 ± 1mm at the latest follow-up (4-74months, median 41, n = 10). In 2 patients with large aorto-ventricular junction (27mm or more), expected annular reduction was not achieved. Our modified technique is simple and seems durable. It may be useful for mild annular dilatation.

Impact of chronic obstructive pulmonary disease on right ventricular function and remodeling after aortic valve replacement

BackgroundBoth chronic obstructive pulmonary disease (COPD) and right ventricular (RV) dysfunction are common factors that have been associated with poor prognosis after aortic valve replacement (AVR). Since there is still uncertainty about the impact of COPD on RV function and dilatation in patients undergoing AVR, we sought to explore RV function and remodeling in the presence and absence of COPD as well as their prognostic implications. MethodsPatients who received surgical or transcatheter AVR due to severe AS were screened for COPD. Demographic and clinical data were collected at baseline while echocardiographic measurements were performed at baseline and 1 year after AVR. The study end-point was all-cause mortality. ResultsIn total 275 patients were included, with 90 (33%) patients having COPD. At 1-year follow-up, mild worsening of tricuspid annular planar systolic excursion and RV dilatation were observed in patients without COPD, while there were significant improvements in RV longitudinal strain, RV wall thickness but dilatation of RV outflow tract distal dimension in the COPD group compared to the baseline. On multivariable analysis, the presence of COPD provided significant incremental prognostic value over RV dysfunction and remodeling. ConclusionsAt 1-year after AVR, RV function and dimensions mildly deteriorated in non-COPD group whereas COPD group received significant benefit of AVR in terms of RV function and hypertrophy. COPD was independently associated with >2-fold all-cause mortality and had incremental prognostic value over RV dysfunction and remodeling.

Failure of Tricuspid Annuloplasty for Functional Tricuspid Regurgitation: Impact of Patient's Body Size

Tricuspid repair is recommended for significant functional tricuspid regurgitation (FTR) or tricuspid annulus (TA) dilation, based on TA >40mm or >21mm/m². The concordance between both TA dimensions related to the patient's body size has not been investigated. Patients who underwent rigid ring tricuspid annuloplasty for FTR between 2009 and 2017 were included. Assuming equality between both TA diameter criteria, patients were divided per body surface area (BSA): group 1=BSA ≤1.9m² and group 2=BSA >1.9m². The primary outcome was TR recurrence at 5years. Tricuspid annuloplasty was performed in 186 patients (group 1: 130 patients [69.9%]; group 2: 56 patients [30.1%]). Group 1 comprised more female (70.8% to 23.2%, p <0.001) and older patients (77.1 ± 9.3 years; 74.2 ± 8.2 years, p=0.048). Group 1 had a smaller absolute TA diameter (group 1: 45.3 ± 5.2mm; group 2: 48.2 ± 5.6mm, p <0.001), whereas the indexed TA size was inversely higher (group 1: 26.3 ± 3.4mm/m²; group 2: 24.2 ± 2.7mm/m², p <0.001). The tenting height was comparable (group 1: 7.8 ± 3.0mm; group 2: 8.0 ± 2.7mm, p=0.714). The median ring size was 30 (interquartile range 28 to 32) and 32 (interquartile range 30 to 34) for groups 1 and 2, respectively (p <0.001). TR recurrence at 5years was noticed in 20.2% and 6.5% of group 1 and 2 (p=0.035). Indexed TA diameter (hazard ratio 1.43, 95% confidence interval 1.10 to 1.87, p=0.008) and tenting height (hazard ratio 5.52, 95% confidence interval 1.87 to 14.57, p=0.002) were independent predictors of TR recurrence. In conclusion, when the absolute TA diameter is used as the primary criterion, smaller patients are at a higher risk for TR recurrence by having a proportionally larger TA at the time of repair. An individualized approach guided by patient's body size might be more appropriate to indicate FTR correction to adjust for the annuloplasty sizing method.

Study of mitral valve remodling in patients with atrial functional mitral valve regurgitation using three-dimensional echocardiography

Abstract Background The global burden of atrial fibrillation (AF) is enormous for healthcare systems. AF is typically classified into five distinct patterns depending on the onset, progression, and resolution of AF episodes, first diagnosed AF, paroxysmal AF, persistent AF, long-standing persistent AF&amp; permanent AF. Atrial structural remodeling or exacerbation of atrial cardiomyopathy are generally defining features of the transition from paroxysmal to non-paroxysmal AF. The duration of rhythm monitoring and the presence of a substrate are both important factors in determining the rate of AF development. In the existence of a structurally normal valve, functional MR develops when there is a mismatch between the tethering forces exerted by the heart &amp; the closing forces exerted by the heart. In the context of functional MR annular dilation alone, can constitute a separate etiology of MR (atrial functional MR). TEE provides supplementary imaging, particularly if TTE windows are technically challenging, making it a useful tool even if TTE is the primary technique for assessing and quantifying mitral valve disease. 3DE data sets can be acquired from either TTE or TEE approach, allowing real-time visualization of the cardiac structures, it is superior to 2DE in quantification of cardiac chamber volumes and function, assessment of the mechanisms and severity of heart valve diseases, evaluation of cardiac complex anatomy. Aim of the work To study mitral valve apparatus remodeling in patients with atrial functional mitral valve regurgitation using three-dimensional echocardiography. Methods This study included a total of 30 patients with diagnosis of atrial fibrillation divided in to two groups, 15 patients having no/ mild mitral regurgitation while 15 patients having moderate/severe mitral regurgitation, they were subjected to 2D and 3D TEE echocardiographic assessment of MR degree, LA volumes, mitral leaflets and mitral annulus parameters. Results There was statistically significant difference between the two groups as regard the posterior leaflet area as larger area was estimated in (Mod/severe MR) group compared to (No/ mild MR) group, with mean posterior leaflet area in group I was (8.96 ± 2.60) and (7.30 ± 2.17) in group II with (P value = 0.029) as well as there was statistically significant difference between the two groups as regard total leaflet area/Mitral annular area ratio as smaller ratio was estimated in (Mod/severe MR) group as compared to (No/mild MR) group, with the mean total leaflet area /mitral annular area ratio in group I was (1.22 ± 0.04) and (1.26 ± 0.04) in group II with (P value = 0.008). Conclusion Isolated annular dilatation can cause significant functional atrial mitral regurgitation while mitral leaflet area increases in AF as the annulus dilates, but this adaptation may plateau at larger annular areas, with the resulting leaflet deficiency causing functional atrial mitral regurgitation. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Transcatheter Tricuspid Valve Replacement: Case Selection, Technical Considerations, and Procedural Planning.

Tricuspid regurgitation (TR) is a highly prevalent valve disorder in the US, with prevalence increasing with age. Without treatment, severe TR carries a poor prognosis. Tricuspid valve (TV) surgery is recommended for patients with severe TR undergoing left-sided valve surgery. Transcatheter TV repair or transcatheter TV replacement are potential options for patients who are not surgical candidates. A few small studies have demonstrated the feasibility and efficacy of transcatheter TV repair in patients with severe symptomatic TR. Careful patient selection by assessing tricuspid valve anatomy, right ventricular and pulmonary hemodynamics, candidacy for anticoagulation, comorbid conditions, and frailty is key to procedural success. Transcatheter TV repair can be performed via the transjugular or transfemoral access, and requires a large-caliber sheath (up to 45 Fr) and delivery system, particularly with dilated tricuspid annulus due to right ventricular enlargement. Multimodality imaging is essential for diagnosing TR severity, defining valve anatomy, and comprehensive functional assessment of the tricuspid valve, right atrium, and right ventricle. Several prosthetic valves, including the EVOQUE system, NaviGate system, Intrepid valve, and Cardiovalve, are currently being investigated in clinical trials.

Left ventricle endomyocardial fibrosis: a case report

BackgroundEndomyocardial fibrosis is a grim disease. It is the most common restrictive cardiomyopathy worldwide, but the exact etiology and pathogenesis both remain unknown. Endomyocardial fibrosis is recurrently associated with chronic eosinophilia and probable dietary, environmental, and infectious factors, which contribute not only to the onset of the disease (an inflammatory process) but also to its progression and maintenance (endomyocardial damage and scar formation). The trademark of the disease is the fibrotic obliteration of the affected ventricle. The combination of such processes produces focal or diffuse endocardial thickening and fibrosis, which leads to restrictive physiology. Endomyocardial fibrosis affects the apices of the right and the left ventricle in around 50% of cases and most often extends to the posterior leaflet of the mitral valve. Sometimes it involves the papillary muscle and chordae tendineae, causing atrioventricular valve dysfunction. The fibrosis does not affect extracardiac organs. This cardiomyopathy is most recurrent in tropical areas of the world.Case presentationA 67-year-old Black male with past medical history of schistosomiasis infection in childhood presented with progressive dyspnea, lower extremity edema, and weakness for 2 years. He was diagnosed with endomyocardial fibrosis. The echocardiogram showed an increased thickness in the septum (17 mm) and free left ventricular wall (15 mm), obliteration of the left ventricular apex and inflow tract, and mitral valve regurgitation. Cardiac magnetic resonance imaging revealed apical left ventricle wall thickening with left ventricular apical obliteration associated with enlargement of the respective atrium. Delayed enhancement imaging showed endomyocardium enhancement involving left ventricular apex, mitral valve regurgitation due to annulus dilation, and a thrombus at left ventricular apex. He underwent open heart surgery with mitral valve replacement, endocardial decortication, endomyocardiectomy, and two-vessel coronary artery bypass grafting as preoperative coronary angiogram showed mild right coronary artery and proximal left anterior descending artery severe lesions. Postoperative course was uncomplicated, and he was discharged successfully from the hospital. Six months after surgery, he was New York Heart Association functional class I.ConclusionThe purpose of this case report is to illustrate the aspects of endomyocardial fibrosis by reporting a case of this entity. In conclusion, progress in imaging techniques and treatment in a reference institution for cardiac diseases contribute to earlier diagnosis and survival in patients with endomyocardial fibrosis.

Procedural success of transcatheter annuloplasty in ventricular and atrial functional tricuspid regurgitation.

Transcatheter annuloplasty is meant to target annular dilatation and is therefore mainly applied in functional tricuspid regurgitation (TR). Due to recent recognition of varying disease pathophysiology and differentiation of ventricular and atrial functional TR (VFTR and AFTR), comparative data regarding procedural success for both disease entities are required. In this consecutively enrolled observational cohort study, 65 patients undergoing transcatheter annuloplasty with a Cardioband® device were divided into VFTR (n = 35, 53.8%) and AFTR (n = 30, 46.2%). Procedural success was assessed by comparing changes in annulus dilatation, vena contracta (VC) width, effective regurgitation orifice area (EROA), as well as reduction in TR severity. Overall, improvement of TR by at least two grades was achieved in 59 patients (90.8%), and improvement of TR by at least three grades was realised in 32 patients (49.2%). Residual TR of ≤2 was observed in 52 patients (80.0%). No significant differences in annulus diameter reduction [VFTR: 11 mm (9-13) vs. AFTR: 12 mm (9-16), p = 0.210], VC reduction [12 mm (8-14) vs. 12 mm (7-14), p = 0.868], and EROA reduction [0.62 cm2 (0.45-1.10) vs. 0.54 cm2 (0.40-0.70), p = 0.204] were reported. Improvement by at least two grades [27 (90.0%) vs. 32 (91.4%), p = 1.0] and three grades [14 (46.7%) vs. 18 (51.4%), p = 0.805] was similar in VFTR and AFTR, respectively. No significant difference in the accomplishment of TR grade of ≤2 [21 (70.0%) vs. 31 (88.6%), p = 0.118] was noted. According to our results from a real-world scenario, transcatheter annuloplasty with the Cardioband® device may be applied in both VFTR and AFTR with evidence of significant procedural TR reduction.