Annular Dilatation Research Articles

Phẫu thuật nội soi điều trị bệnh lý van ba lá tại Trung tâm Tim mạch, Bệnh viện E

Background. Tricuspid regurgitation is one of the most common heart valve diseases, affecting 65-85% of the population. Primary tricuspid regurgitation has causes in the tricuspid valve including rheumatic, degenerative, congenital, infectious, etc. Secondary tricuspid regurgitation is more common, associated with right ventricular dysfunction, dilated annulus. valves, often secondary to left-sided valve disease (especially mitral valve disease), atrial fibrillation, and pulmonary hypertension. Traditional sternal open surgery has the advantage of being spacious and convenient for technical manipulations, but the method still has many traumas and risks of sternum inflammation. Endoscopic surgery avoids opening the sternum with the advantages of minimizing trauma, eliminating sternitis, being more aesthetic is becoming a trend and is increasingly applied in cardiovascular surgery.
 Aims: Evaluation of early and medium-term results of endoscopic surgery for tricuspid valve disease at cardiovascular center, E Hospital
 Method. Cross-sectional descriptive study, data were collected retrospectively and prospectively
 Result. From January 2020 to December 2021, we studied 42 patients undergoing endoscopic surgery for tricuspid valve disease, including 13 men (31%), 29 women (69%). Average age is 53.98±12.51 years. The number of patients with tricuspid valve repair and mitral valve replacement surgery was 34 patients, the number of patients with tricuspid valve repair after mitral valve replacement surgery was 4 patients, there were 2 patients with severe tricuspid regurgitation due to infective endocarditis . There was 1 patient with tricuspid valve repair combined with atrial septal defect patching. Immediately after surgery, the proportion of patients with no regurgitation or mild regurgitation of the tricuspid valve was 35 patients (83.3%), moderate regurgitation had 6 patients (14.3%), severe regurgitation had 1 patient (2.4%) ), 41 patients (97.6%) were discharged from hospital, 1 patient (2.4%) died early after surgery. The longest follow-up time was 17 months, the shortest was 6 months, the results were no longer tricuspid regurgitation or mild regurgitation in 37 patients (90.2%), moderate regurgitation in 4 patients (9.8%), there aren’t patients with severe regurgitation of the tricuspid valve or late death.
 Conclusion. Endoscopic surgery for the treatment of tricuspid valve disease has good results, aesthetics, few complications.

Predictors of long term tricuspid regurgitation after pulmonary valve replacement: a single center study on the cohort of significant preoperative tricuspid regurgitation

Abstract Background Almost one-third of repaired tetralogy of Fallot (TOF) and pulmonary stenosis (PS) patients referred for pulmonary valve replacement (PVR) have at least moderate tricuspid regurgitation (TR). Predictors of long term TR in this population are not well defined and the role of Tricuspid Annuloplasty (TA) in addition to PVR in this setting is controversial. Purpose Patients with preoperative severe TR or moderate TR with dilated tricuspid annulus (>40mm) undergo TA at the time of PVR as per protocol in our instititution. The aim of this observational study was to evaluate the long term results of this approach and to identify predictors of significant TR at the end of follow-up. Material and methods We retrospectively reviewed 35 repaired TOF and PS patients who underwent surgical PVR with (n=17, group 1) or without (n=18, group 2) TA in a single tertiary hospital between June-2009 and June-2021. Pre- and postoperative echocardiographic and cardiac magnetic resonance data were assessed for TR severity and right ventricle size and systolic function. Baseline and clinical follow up data were collected. Uni- and multivariable tests were used to analyze predictors of at least moderate TR after PVR. Results Mean age at PVR and baseline image parameters were comparable between groups, except for TR grade (p 0.006), tricuspid annulus size (p 0.018) and right ventricle outflow tract diameter (p 0.04) which were greater in group 1. TA did not confer and increased risk of surgical and peroperative complications. Intensive care unit (p 0.94) and total hospital admission days (p 0.59) did not differ among groups. At one year, TR grade significantly improved regardless of TA. At the end of follow-up (5.29±2.9 years), the degree of TR increased in both groups with no differences between groups (p 0.38) (see table 1). In univariable analysis, two independent predictors of at least moderate TR at end of follow-up were identified; mixed TR mechanism (OR 12.5, p 0.006) and severe preoperative TR grade (OR 10.21, p 0.003). Mixed TR mechanism (OR 15.78, p 0.01) and a right ventricle ejection fraction below 45% (OR 1.47, p 0.01) were identified as risk factors of significant TR in multivariable analysis (see Table 2). Conclusions TA seems a reasonable approach at the time of PVR in patients with severe TR or moderate TR with dilated annulus. Mixed TR mechanism and a worse right ventricular function have been identified as independent predictors factors of long term significant postoperative TR in our study cohort. Funding Acknowledgement Type of funding sources: None.

Echocardiography and computed tomography predictors of successful transcatheter direct annuloplasty for mitral regurgitation

Abstract Background Secondary mitral regurgitation (SMR) is associated with adverse outcomes and the optimal treatment modality remains challenging due to extensive variety in the pathology of SMR. Percutaneous direct annuloplasty using the Cardioband system emerged as a promising treatment in selected patients. However, success predictors of this intervention and their association with prognosis remain unclear. Purpose To investigate the role of echocardiographic and computed tomography (CT) data in patients with SMR undergoing percutaneous direct annuloplasty. Methods We retrospectively analyzed patients who underwent catheter-based direct annuloplasty with the Cardioband system for SMR at five tertiary centres in Germany and Switzerland between 2013 and 2020. Patients with procedural success (defined as postprocedural MR grade ≤2+) were compared to those with MR >2+ with respect to baseline echocardiographic data and outcome. Results We included 130 patients (median age 75.5 [71–79], 37% female). Most patients were severely symptomatic (NYHA class III/IV 86.9%), had a median EF of 39 (29–52) with an ischaemic etiology in 39%. Procedural success was achieved in 68%. Procedural time was 178.5 (147.5–214.5) minutes. Patients with and without procedural success differed significantly in measures of MR severity (defined as postprocedural SMR severity (grade, vena contracta (VC), effective regurgitation orifice area and regurgitation volume), annular dilatation (leaflet length, LA sphericity index at end-systole and CT-derived intercommissural distance) and leaflet tethering (tenting area, regurgitation jet direction). In multivariable analysis of echocardiographic parameters including significant measures of annular dilatation and leaflet tethering, predictors of procedural treatment success were tenting area (OR 0.54; 95% CI 0.33–0.98 per mm2, p=0.016) and central regurgitation jet direction (OR 2.96; 95% CI 1.06–8.25, p=0.038). After adding CT data in the multivariable model, intercommissural distance proved to be the most significant predictor (OR 0.96; 0.92–0.99, p=0.009), whereas VC was the only echo predictor (OR 0.84; 0.73–0.98, p=0.03). NYHA class III/IV at last follow up was significantly different between groups, with 34.1% vs. 55.2% of patients with vs. without procedural success, respectively (p=0.04). The combined endpoint of mortality or reintervention at 1 year was significantly lower in patients with procedural success (27% vs. 63%, p=0.002), whereas the association of procedural success with 1-year mortality was of borderline significance (13% vs. 32%, p=0.05). Conclusion Two thirds of patients undergoing transcatheter direct annuloplasty for SMR had procedural success. Careful patient selection by assessment of mitral valve anatomy is helpful to predict procedural success, which translates into less symptom burden and better clinical outcome. Funding Acknowledgement Type of funding sources: None.

Mitral annulus strain by 3D echo reveals regional annular dysfunction in Barlow's disease

Abstract Background Barlow's disease (BD) provides both diagnostic and therapeutic challenges. Annular dilation is typically seen in BD, however, data on regional deformation is lacking. Purpose We hypothesized that mitral annulus dilates non-homogenously during ventricular systole in BD. A method to calculate annular regional strain was developed and applied in a subset of BD patients and healthy controls. Methods Ten patients with BD and late systolic mitral regurgitation and nine healthy controls were studied. For each subject, the mitral annulus was segmented throughout the cardiac cycle using 3D echocardiography. Twelve evenly distributed geometrical points were annotated along the annular perimeter, enabling the creation of periodic degree-3 spline curves parameterized by arc length at each discrete time-frame. The motion of the mitral annulus was then acquired by assuming that heterogeneity in annular strain is small and finding the point-wise map that minimized the total displacement between the consecutive curves. Then, the end-diastolic annular curve was divided into 200 evenly distributed points around the annular perimeter, and the point-wise mapping was implemented to create a continuous movement of the discretized annulus throughout the cycle. Annular strain was then calculated for each individual line segment. The method presented herein is validated by comparing the strain between sonomicrometric crystals in pigs and the method described above. The timescale was normalized from ED (end-diastole) to mitral valve opening for each individual. The regional strains of the annulus were calculated with the ED configuration as reference. Results Hemodynamic data are presented in Table 1. In BD annulus area increased from 16.6±3.2 to 21.7±4.2 cm2 at end-diastole and peak systole, respectively (p<0.001). In controls, annulus area at end-diastole and end-systole was 9.6±2.2 cm2 and 9.2±1.8 cm2, respectively (NS). Figure 1 demonstrates non-homogenous regional strain at peak systole, with the most severe deformation in the posteromedial region. In healthy controls, peak systolic strain was similar in all segments. Conclusions In the present study, we have applied a novel non-invasive method to demonstrate non-homogenous deformation of the mitral annulus in Barlow patients. On average, the most severe deformation was seen in the posteromedial region. This finding may reveal further insight into the mechanisms of late systolic mitral regurgitation in BD as well as the design of annuloplasty in the future. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Trond Mohn Foundation

CT-determined tricuspid annular dilatation is associated with persistence of tricuspid regurgitation after transcatheter aortic valve replacement

Abstract Introduction Moderate or severe tricuspid regurgitation (TR) can be observed in 11% to 27% of patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). Even though in most patients an improvement of TR can be achieved after TAVR, the persistence of severe or massive TR after the procedure is associated with increased all-cause mortality. Purpose The aim of this study was to investigate if tricuspid annular dilatation (TAD) measured in pre-procedural CT among TAVR patients who had at least moderate TR at baseline could serve as a predictor for the persistence of TR. Moreover, the predictive value of TR persistence on the composite of 2-year mortality or tricuspid valve intervention was analysed. Methods We examined 151 patients with severe AS and at least moderate concomitant TR at baseline, who were treated with TAVR from April 2013 to December 2019. TR persistence was defined as the same or a higher grade of TR in the follow-up echocardiography at least 30 days after the procedure compared to preprocedural TR grade. To identify patients with TAD, the maximum septolateral diameter of the tricuspid annulus was measured in pre-procedural cardiac computed tomography images and normalized to the body surface area. Results The median value of 25.5 mm/m2 was determined as cut-off value for TAD. Out of 151 patients with moderate or more TR before TAVR, 75 patients (49.7%) were above the threshold of 25.5 mm/m2. Improvement of TR after TAVR of at least one grade was significantly more frequent in patients without TAD than with TAD (59% vs. 32%, corresponding odds ratio for persistence of TR: 3.06, 95% confidence interval: 1.50–6.35, p=0.001) (Figure 1A). Multivariable logistic regression analysis with adjustment for baseline TR severity confirmed that the predictive value of TAD for TR persistence after TAVR was irrespective of baseline TR (adjusted odds ratio: 2.79, 95% confidence interval: 1.42–5.59, p=0.003). Tricuspid valve intervention was conducted in 11 patients with TAD after TAVR (14.6%) and in no patients without TAD. Accordingly, at 2-years, tricuspid valve intervention-free survival was lowest among patients with TAD and persistent TR (Figure 1B). Conclusion Our analysis demonstrates for the first time that in patients undergoing TAVR for severe AS and at least moderate concomitant TR, CT-derived TAD is associated with persistence of TR after the procedure. Furthermore, TR persistence is associated with an adverse outcome. Funding Acknowledgement Type of funding sources: None.

MECHANISTIC CLASSIFICATION AND OUTCOMES OF ISOLATED AORTIC REGURGITATION IN A CONTEMPORARY COHORT OF PATIENTS

MECHANISTIC CLASSIFICATION AND OUTCOMES OF ISOLATED AORTIC REGURGITATION IN A CONTEMPORARY COHORT OF PATIENTS

Medical Therapy for Functional Mitral Regurgitation

Functional mitral regurgitation (FMR) can be broadly categorized into 2 main groups: ventricular and atrial, which often coexist. The former is secondary to left ventricular remodeling usually in the setting of heart failure with reduced ejection fraction or less frequently due to ischemic papillary muscle remodeling. Atrial FMR develops due to atrial and annular dilatation related to atrial fibrillation/flutter or from increased atrial pressures in the setting of heart failure with preserved ejection fraction. Guideline-directed medical therapy is the first step and prevails as the mainstay in the treatment of FMR. In this review, we address the medical therapeutic options for FMR management and highlight a targeted approach for each FMR category. We further address important clinical and echocardiographic characteristics to aid in determining when medical therapy is expected to have a low yield and an appropriate window for effective interventional approaches exists.

Impact of the degree of tricuspid valve tethering on the early outcome of tricuspid valve repair with the De-Vega technique

Background: Functional tricuspid regurgitation (TR) is usually caused by leaflet tethering, and annuloplasty is usually recommended to repair annulus dilatation. This work aimed to evaluate the impact of the degree of the tricuspid valve (TV) tethering on the early outcome of tricuspid valve repair with the De-Vega technique.
 Methods: This prospective study included 50 patients with De-Vega tricuspid valve repair. Patients were divided into two groups; Group A (n= 25) included patients with tricuspid valve tethering of 8 mm or less, and Group B (n= 25) included patients with tricuspid valve tethering distance of more than 8 mm.
 Results: The mean age of Group A was 46.1 ±3.5 years compared to 49.6 ±7 years in Group B. There were significant differences in postoperative ejection fraction (48.7 ±12.5 vs. 39.1 ±9.4 %, P= 0.003), TV tethering distance (0.6 ±0.2 vs. 1.1 ±0.4 cm, P <0.001), and area (1.1 ±0.5 vs. 2.6 ±0.9 cm2; P<0.001), and right ventricle fractional area (32.2± 7.9 vs. 25.4 ±9.7 cm2, P= 0.008) in Group A vs. B, respectively. There were no differences in postoperative complications, ICU, and hospital stay between groups.
 Conclusion: Residual tricuspid regurgitation after De-Vega annuloplasty could be related to TV tethering distance. Increased TV tethering distance could be associated with reduced postoperative ejection fraction.

Outcomes of valve-sparing surgery in heritable aortic disorders: results from the AVIATOR registry.

Root reimplantation has been the favoured approach for patients with heritable aortic disorder requiring valve-sparring root replacement. In the past few years, root remodelling with annuloplasty has emerged as an alternative to root reimplantation in the general population. The aim of this study was to examine the late outcomes of patients with heritable aortic disorder undergoing valve-sparring root replacement and compare different techniques. Using the AVIATOR registry (Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry), data were collected from 5 North American and European centres. Patients were divided into 4 groups according to the technique of valve-sparing used (root reimplantation, root remodelling with ring annuloplasty, root remodelling with suture annuloplasty and root remodelling alone). The primary endpoints were freedom from aortic regurgitation (AR) ≥2 and freedom from reintervention on the aortic valve. Secondary endpoints were survival and changes in annular dimensions over time. A total of 237 patients were included in the study (reimplantation = 100, remodelling + ring annuloplasty = 76, remodelling + suture annuloplasty = 34, remodelling alone = 27). The majority of patients had Marfan syndrome (83%). Preoperative AR ≥2 was present in 41% of the patients. Operative mortality was 0.4% (n = 1). No differences were found between techniques in terms of postoperative AR ≥2 (P = 0.58), reintervention (P = 0.52) and survival (P = 0.59). Changes in aortic annulus dimension were significantly different at 10 years (P < 0.05), a difference that started to emerge 4 years after surgery. Overall, valve-sparring root replacement is a safe and durable procedure in patients with heritable aortic disorder. Nevertheless, root remodelling alone is associated with late annular dilatation. The addition of an annuloplasty, however, results in similar freedom from AR, reintervention, survival and changes in annulus size compared to reimplantation.

One ring to rule them all

When valve-sparing root replacement was introduced, it soon became an attractive option for children and adolescents presenting with aortic root aneurysm due to disorders of connective tissue. In this young patient population, a Bentall procedure with a mechanical valve and life-long anticoagulation seemed a particularly uninviting option. At that time, many surgeons chose to perform a remodelling procedure as it was thought to be simpler in execution. While the initial results were very promising, patients soon started to come back with aortic valve regurgitation (AR) due to annular dilatation. This prompted many surgeons to adopt the reimplantation technique as the method of choice for young patients with disorders of connective tissue. In the current edition of the Journal, Chauvette et al. [1] report results from the AVIATOR registry that encompasses a large number of patients who underwent valve-sparing root replacement using different techniques. This article conveys several important messages: (i) Valve-sparing root replacement is safe. There was only 1 perioperative death resulting in a 0.4% mortality. (ii) Supporting the aortic anulus is key. As long as the aortic anulus is supported, it does not matter whether a reimplantation or a remodelling technique is performed. (iii) Valve-sparing root replacement in young patients with disorders of connective tissue is a durable procedure—but not as durable as we had hoped for. The authors report 22% of AR ≥2 after 10 years. While this is in line with previously reported results in patients with Marfan syndrome, it is underwhelming to note that the median time to develop AR ≥2 was <3 years. Given the vast experience of participating centres that have contributed to this study, mistakes in strategy and surgical technique seem unlikely to explain this rather high incidence of aortic valve regurgitation after such a short period of time. This raises the important question how we can identify those patients who will develop aortic regurgitation over time? Is it just bad luck or are there anatomical factors that predispose patients for failing valve-sparing root replacements that we have not yet identified?

Finite element analysis of mitral valve annuloplasty in Barlow’s disease

Barlow’s Disease affects the entire mitral valve apparatus causing mitral regurgitation. Standard annuloplasty procedures lead to an average of 55% annular area reduction of the end diastolic pre-operative annular area in Barlow’s diseased valves. Following annular reduction, mitral valvuloplasty may be needed, usually with special focus on the posterior leaflet. An in silico pipeline to perform annuloplasty by utilizing the pre- and -postoperative 3D echocardiographic recordings was developed. Our objective was to test the hypothesis that annuloplasty ring sizes based on a percentage (10%–25%) decrease of the pre-operative annular area at end diastole can result in sufficient coaptation area for the selected Barlow’s diseased patient. The patient specific mitral valve geometry and finite element model were created from echocardiography recordings. The post-operative echocardiography was used to obtain the artificial ring geometry and displacements, and the motion of the papillary muscles after surgery. These were used as boundary conditions in our annuloplasty finite element analyses. Then, the segmented annuloplasty ring was scaled up to represent a 10%, 20% and 25% reduction of the pre-operative end diastolic annular area and implanted to the end diastolic pre-operative finite element model. The pre-operative contact area decrease was shown to be dependent on the annular dilation at late systole. Constraining the mitral valve from dilating excessively can be sufficient to achieve proper coaptation throughout systole. The finite element analyses show that the selected Barlow’s diseased patient may benefit from an annuloplasty ring with moderate annular reduction alone.

Mitral Annular Elasticity Determines Severity of Regurgitation in Barlow’s Mitral Valve Disease

Barlow's mitral valve disease with late systolic mitral regurgitation provides diagnostic and therapeutic challenges. The mechanisms of the regurgitation are still unclear. We hypothesized that the onset and the severity of late systolic regurgitation are determined by annulus dynamics and the mechanical stresses imposed by the left ventricle. Ten patients with Barlow's mitral valve disease and mitral annulus disjunction (MAD) were compared with 10 healthy controls. Resting blood pressure was measured, and transthoracic three-dimensional echocardiography was analyzed using a holographic display that allows tracking and measurements of mitral annulus surface area (ASA) throughout the cardiac cycle. A novel annulus elastance index (dASA/dP) was calculated between aortic valve opening and onset of mitral regurgitation. Severity of MAD was quantified as the disjunction index (mm × degree). Leaflet coaptation area was calculated using a finite element model. Peak systolic ASAs in controls and patients were 9.3±0.6 and 21.1±3.1cm², respectively (P&lt;.001). In patients, the ASA increased rapidly during left ventricular ejection, and onset of mitral regurgitation coincided closely with peak upslope of annulus area change (dASA/dt). The finite element model showed a close association between rapid annulus displacement and coaptation area deficit in Barlow's mitral valve disease. Systolic annulus elastance index (0.058±0.036cm²/mm Hg) correlated strongly with disjunction index (r=0.91, P&lt;.0001). Moreover, regurgitation volume showed a positive correlation with systolic blood pressure (r=0.80, P&lt;.01). The present pilot study supports the hypothesis that annulus dilatation may accentuate mitral valve regurgitation in patients with Barlow's mitral valve disease. A novel annulus elastance index may predict the severity of mitral valve regurgitation in selected patients.

Histology of the tricuspid valve annulus and right atrioventricular muscle distance.

OBJECTIVESHistologically, the mitral valve annulus comprises a collection of collagen fibres. However, the existence of collagen fibres in the tricuspid valve annulus has not been elucidated. Our goal was to clarify the histology of the tricuspid annulus.METHODSFifty human hearts without heart disease that were autopsied at Osaka City University Hospital between January 2009 and December 2017 were examined. The tricuspid valve was sectioned at 12 sites around the annulus, and the atrioventricular junction distance was measured.RESULTSNone of the tricuspid valve annulus samples had a continuous aggregation of collagen fibres that could be called an annulus. The interventricular space between the right atria and ventricles was composed of adipose tissue only on the anterosuperior and inferior sides, and no adipose tissue was found on the septal side. Comparing the atrioventricular muscle distance of the anterosuperior and inferior sides, the distance at the inferior side was statistically significantly larger than that of the anterosuperior side in 47 cases (P < 0.0001).CONCLUSIONSThere was no continuous circumferential aggregation of collagen fibres in the right atrioventricular junction. The distance between the right atrial and ventricular myocardium was greater at the inferior side than that at the anterosuperior side, which might lead to more inferior annular dilation versus anterosuperior dilation. These anatomical features will be fundamental for future discussions of the suturing method used in prosthetic ring annuloplasty for tricuspid regurgitation.

Atrial Mitral and Tricuspid Regurgitation: Sex Matters. A Call for Action to Unravel the Differences Between Women and Men.

Atrial functional regurgitation is caused by atrioventricular annulus dilation, with normal leaflets and ventricular dimensions and function within the normal range. Its occurrence, in both mitral and tricuspid valves, implies a worse prognosis due to the hemodynamic derangement they produce, but also constitutes a marker of greater comorbidity and more advanced disease. Predisposing conditions for these heart valve dysfunctions are mainly atrial fibrillation and heart failure with preserved ejection fraction. However, other factors like female sex also may be involved and influence their incidence, especially for atrial tricuspid regurgitation. In the present review, we analyze sex differences in the reported prevalence of atrial mitral and tricuspid regurgitation, and suggest possible mechanisms involved. Finally, we underline potential therapeutic and preventive strategies to reduce the burden of these heart valve disorders and discuss research gaps.

Leaflet-to-annulus index and residual tricuspid regurgitation following tricuspid transcatheter edge-to-edge repair.

A mismatch between tricuspid leaflet size and annular dilation is one of the morphological features tied to the development of tricuspid regurgitation (TR). We assessed the association of the leaflet-to-annulus index (LAI) with residual TR after transcatheter edge-to-edge repair (TEER). Consecutive patients who underwent TEER for TR were enrolled. Significant residual TR was defined as a post-procedural TR ≥3+, and patients were divided into two groups according to the amount of residual TR. The LAI was retrospectively calculated using procedural transoesophageal echocardiography and was defined as follows: (anterior leaflet length+septal leaflet length)/septolateral tricuspid annulus diameter. Of 140 patients, 43 patients had residual TR ≥3+ after TEER. The patients with residual TR ≥3+ had a lower LAI compared to those with residual TR <3+ (1.04±0.10 vs 1.13±0.09; p=0.001). In multivariable analysis, the LAI was associated with residual TR ≥3+ (odds ratio [OR] [per 0.1 increase]: 0.57; 95% confidence interval [95% CI]: 0.35-0.94; p=0.02), independent of baseline TR severity or coaptation gap size. Patients with residual TR ≥3+ had a higher incidence of the composite outcome, consisting of all-cause mortality and heart failure hospitalisation within one year after TEER (47.1% vs 26.6%, p=0.02). Residual TR ≥3+ was an independent predictor of the composite outcome within one year (hazard ratio: 2.04; 95% CI: 1.01-4.11; p=0.04). The leaflet-to-annulus mismatch (i.e., LAI) is associated with residual TR ≥3+ after TEER for TR. A detailed echocardiographic analysis of the tricuspid valve will be conducive to identifing suitable subjects for TEER.

P219 IS DISPROPORTIONALITY ENOUGH TO IDENTIFY CANDIDATES FOR PERCUTANEOUS MITRAL VALVE REPAIR? A CLINICAL CASE

Abstract Functional mitral regurgitation (FMR) is defined as regurgitation with structurally normal leaflets secondary to the distortion of the LV in the context of dilated cardiopathy. The conflicting results emerged from the MITRA–FR and COAPT trials have raised a new interest in the individuation of “primary–like” components of MR. In this scenario, a binary classification in proportionate and disproportionate FMR has been proposed by Garland et al. When the MR is completely due to LV remodeling, they observed a linear relationship between ERO and LVEDV, defining a proportionate FMR; on the other side, when the ERO is superior to the expected one, the FMR is considered as disproportionate, and it may benefit from TEER on top of GMDT. However, the Garland’s model may not explain the full complexity of MV apparatus and FMR. We present the case of a 75–years–old woman diagnosed with dilated cardiopathy of ischemic origin, known since 2008. In 2021 she started receiving multiple hospitalizations for acute decompensation of HF with dyspnoea and symptoms of hypoperfusion, such as AKI on top of CKD and hypotension. The TOE showed a severe LV dysfunction and a moderate dilation of the left ventricle (EF 19%, LVEDVi 90 ml/m2), with a severe FMR secondary to annular dilation and retraction with tethering of the posterior leaflet (MR ERO 0,27 cm2, VC 0,67 cm, RV 45 ml). In order to improve symptoms she underwent TEER with implantation of one Edwards Pascal device at the level of A2–P2, with good results and a mild residual MR. Basing on the Garland’s model our patient would have been classified as proportionate FMR, with no benefit from TEER. However, removing MR component from the heart disease, she improved her stroke volume and her systolic function, allowing a better peripheral perfusion, as showed by an increase in renal function and in arterial pressure during follow–up, which allowed an introduction ad up–titration of Sacubitril/Valsartan, impossible before TEER. At the same time TEER decreased pulmonary pressures improving dyspnoea and functional status (she was NYHA II–III at the 6 month follow–up). In conclusion, the binary model of proportionality has the strength of being easy–to–use and of easily recognizing a primary–like MR that can benefit from TEER; however, proportionate FMR probably includes different pathophysiological mechanisms of disease, requiring an ultra stratification to better identify cases where TEER may increase survival.

C14 A PROMISING SURGICAL TECHNIQUE IN PATIENTS WITH ATRIAL FUNCTIONAL MITRAL REGURGITATION: HYPER–DOWN–SIZING ANNULOPLASTY

Abstract Objective Atrial functional mitral valve regurgitation is a less common form of functional mitral regurgitation with normal leaflet motion and morphology, preserved dimension and function of left ventricle, associated with atrial fibrillation ad/or left atrial dilatation. Several factors are involved into the etiology, such as mitral annular dilation and insufficient leaflet remodeling, atriogenic leaflet tethering, loss of annular saddle shape and contractility, changes in heart rate. Methods Eleven consecutive patients with atrial functional mitral regurgitation, mean age 65 ± 12 years, normal left ventricle dimension and ejection fraction greater than 50% underwent mitral valve repair via right mini–thoracotomy in case of isolated mitral and tricuspid valve surgery or via median sternotomy in case of combined procedures. Concomitant procedures include tricuspid valve repair in 1 patient and coronary artery bypass in 5 patients. All patients presented an increased dimension of left atrium (mean left atrial volume: 90 ± 23 ml); mitral annular dimension was investigated with trans–esophageal echocardiography before operation. In all patients was implanted a downsized complete rigid annuloplasty ring with asymmetrical design of two sizes smaller respect to measured intercommissural distance. Clinical outcomes of patients and echocardiographic findings related to mitral regurgitation recurrence and left ventricle function were followed in the time. Results At discharge, any patient present a residual mitral regurgitation greater than mild, mean trans–mitral gradient was 2.5 ±2.1 mmHg. During the follow–up period of 24 ± 5 months, the New York Heart Association functional class significantly improved from 2.5 ± 0.4 to 1.5 ± 2.1. In three patients occurred cardiac rhythm disturbances requiring hospital stay, only one patient developed a greater than mild mitral regurgitation, reoperation was not becessary in any case. Left atrial volume decreased from 90 ± 23 ml to 58 ± 30 ml. Conclusions Mitral annuloplasty with downsized ring is a safe and effective procedure in patient with atrial functional mitral regurgitation in the same way of patient with functional mitral regurgitation due to ventricular dilation and tethering. The comforting clinical and echocardiographic outcome in our small group of patient encourage future studies in this particular group of patients.

Tricuspid Annulus Dilation in Patients With Combined Functional Tricuspid Regurgitation and Left-Heart Valvular Disease: Does Septal Annulus Not Dilate?

BackgroundThis study aimed to investigate the course of tricuspid annulus dilation in functional tricuspid regurgitation with varied severities by direct intraoperative assessment.MethodsA total of 317 patients who underwent left heart surgery and concomitant tricuspid repair were divided into three groups according to the severity of the functional tricuspid regurgitation (mild, moderate and severe). Demographic and echocardiographic data were collected. The length of each tricuspid annulus segment was measured intraoperatively. The risk factors for preoperative severe functional tricuspid regurgitation and its postoperative recurrence were identified, and the impact of each tricuspid annulus segment on postoperative recurrence was compared.ResultsIn the course of tricuspid annulus dilation, the posterior annulus dilated 17% (group 1: 33.31 ± 6.94 mm vs. group 2: 35.56 ± 7.63 vs. group 3: 38.98 ± 8.70, p < 0.01), the anterior annulus dilated 13.4% (group 1: 36.71 ± 6.30 mm vs. group 2: 38.21 ± 8.35 vs. group 3: 41.63 ± 9.20, p < 0.01), and the septal annulus dilated 11.4% (group 1: 38.11 ± 5.28 mm vs. group 2: 39.76 ± 6.90 vs. group 3: 42.46 ± 7.50, p < 0.01). Tricuspid annulus circumference index (p < 0.01) independently correlated with preoperative severe tricuspid regurgitation and postoperative recurrence. When patients were grouped based on the length of each segment, the septal annulus demonstrated significantly higher sensitivity (p < 0.001) to postoperative recurrence than the anterior (p = 0.085) or posterior annulus (p = 0.262).ConclusionsThis study revealed that each segment of tricuspid annulus could dilate in functional tricuspid regurgitation and highlighted the potential benefits of septal annulus plication in tricuspid annuloplasty, which may aid in the development of a methodology for prosthetic ring annuloplasty.

Multimodality Evaluation of Aortic Insufficiency and Aortitis in Rheumatologic Diseases.

Aortic insufficiency is commonly observed in rheumatologic diseases such as ankylosing spondylitis, systemic lupus erythematosus, antiphospholipid syndrome, Behçet's disease, granulomatosis with polyangiitis, and Takayasu arteritis. Aortic insufficiency with an underlying rheumatologic disease may be caused by a primary valve pathology (leaflet destruction, prolapse or restriction), annular dilatation due to associated aortitis or a combination of both. Early recognition of characteristic valve and aorta morphology on cardiac imaging has both diagnostic and prognostic importance. Currently, echocardiography remains the primary diagnostic tool for aortic insufficiency. Complementary use of computed tomography, cardiac magnetic resonance imaging and positron emission tomography in these systemic conditions may augment the assessment of underlying mechanism, disease severity and identification of relevant non-valvular/extracardiac pathology. We aim to review common rheumatologic diseases associated with aortic insufficiency and describe their imaging findings that have been reported in the literature.

Efficacy of a Novel Posterior Leaflet Repair Device to Treat Secondary Mitral Regurgitation Using an Ex Vivo Heart Model

Mitral regurgitation is one of the most prevalent valvular disorders. It has numerous etiologies grouped as primary typically because of underlying degenerative leaflet disease, or secondary mitral regurgitation (SMR), most commonly because of geometrical distortion of the left ventricle (LV) impacting the functional integrity of the valvular apparatus.1 Specifically for SMR, LV dilation and dysfunction lead to papillary muscle displacement, annular dilation, and apical tethering of the leaflets with restricted mobility, predominantly affecting the posterior leaflet.