Degree Of Regurgitation Research Articles

Changes in valvular regurgitation in mid-term follow-up of children with first attack acute rheumatic fever: first evaluation after the updated Jones criteria

In present study, we aimed to evaluate the changes in valvular regurgitations in mid-term follow-up of children with first attack acute rheumatic fever diagnosed after updated Jones criteria. The medical records of the children diagnosed with acute rheumatic fever between June 2015 and November 2018 were evaluated retrospectively. When compared to the findings during diagnosis, the changes in the degree of valvular regurgitation in the last visit were coded as same, regressed, or disappeared. A total of 50 children were diagnosed with the first attack of acute rheumatic fever between the noted dates. Nine patients (18%) could be diagnosed depending on the new criteria. Eight patients did not have carditis, and 35 patients (49 valves) could be followed for a median follow-up period of 11.7 ± 3.3 months. In our study, the valvar lesions continued in 82% of patients with clinical carditis at the end of the first year and the degree of valvular regurgitation decreased in 39% of them. Despite this, in a significantly higher (p = 0.031) ratio of patients with silent carditis (41%), valvar lesions disappeared in the same follow-up period. In 18.4% of the involved valves, regurgitation regressed to physiological level. Updated Jones criteria make it possible to diagnose a significant number of patients, and the ratio of complete recovery among patients with silent carditis is significantly higher. Also, it can be speculated that the normal children in whom a physiological mitral regurgitation is detected should be followed in terms of rheumatic heart disease.

Determinants of changes in pulmonary artery pressure in patients with severe aortic stenosis treated by transcatheter aortic valve implantation

Background Elevated pulmonary artery pressure (PAP) in patients with severe aortic stenosis (AS) is a strong predictor of adverse prognosis. This study sought to assess the relation between PAP and clinical and echocardiographic parameters in elderly patients with severe AS, as well as to identify the determinants of the change in PAP after transcatheter aortic valve implantation (TAVI). Methods The study included 170 subjects (age 81 ± 7 years, 45% men) with symptomatic severe AS who were treated by TAVI. They underwent a clinical evaluation and a transthoracic echocardiography before the TAVI procedure and 6 months after. Results In a multivariable analysis, the independent predictors for baseline PAP were the body mass index (BMI) (β = 0.21, p = .006), COPD GOLD class (β = 0.20; p = .009), the E/e′ ratio (β = 0.20; p = .02) and the degree of aortic regurgitation (β = 0.20; p = .01). After TAVI, there was significantly less (51% vs. 29%, p<.0001) pulmonary hypertension, defined as a tricuspid regurgitation velocity ≥2.8 m/s. The baseline variables related to an improvement in PAP were the tricuspid regurgitation velocity (p = .0001) and the E/e′ (p = .005). From the parameters potentially modified with TAVI, the only independent predictor of PAP variation was the change in the E/e′ ratio (β = 0.23; p = .01). Conclusions Independent predictors for baseline PAP in elderly patients with symptomatic AS were the BMI, GOLD class, the aortic regurgitation and the E/e′ ratio. The baseline predictors for a change in PAP 6 months after TAVI were the baseline PAP and E/e′, with only the change in the E/e′ ratio being correlated to the change in PAP.

Right ventricular end-systolic remodeling index in the assessment of pediatric pulmonary arterial hypertension. The European Pediatric Pulmonary Vascular Disease Network (EPPVDN).

Echocardiographic determination of the right ventricular end-systolic remodeling index (RVES RI) has clinical value for the assessment of pulmonary hypertension (PH) in adults. We aim to determine RVES RI values in pediatric PH and to correlate RVES RI data with echocardiographic variables and NYHA functional class (FC). Prospective echocardiography study in 49 children with PH. The 49 matched control subjects were chosen from 123 healthy children used to construct pediatric normal reference values. The associations with invasive hemodynamic variables were also investigated in a validation cohort of 12 PH children and matched controls. RVES RI was increased in children with PH vs. healthy controls (1.45 ± 0.16 vs. 1.16 ± 0.06; p < 0.01; confirmed in the validation cohort). RVES RI was associated with invasive hemodynamic variables, i.e. the mean pulmonary artery pressure. RVES RI values increased with worsening NYHA-FC. The highest RVES RI values were observed in PH children with NYHA FC 3 (1.60 ± 0.12). RVES RI is a useful indicator of RV remodeling and dilation in the setting of increased RV pressure load, especially when the degree of regurgitation of the tricuspid and pulmonary valves is insufficient to numerically estimate RV systolic pressure and mPAP, due to incomplete Doppler envelopes.

Combined Valve Operations in the Aortic and Mitral Positions With or Without Added Tricuspid Valve Repair

There is limited clinical evidence on when to address tricuspid regurgitation in patients with aortic and mitral valve disease requiring surgical intervention. In this study, we aimed to investigate the potential added value of performing a tricuspid valve repair concomitantly in patients requiring double valve surgery (DVS) of the aortic and mitral valves. We reviewed 223 cases of multivalve surgery from 2011 to 2016. In this single-institution series, 190 underwent DVS in aortic and mitral positions and 33 had triple valve surgery in aortic, mitral, and tricuspid positions. Preoperative and postoperative echocardiograms were evaluated to determine changes in valve function. A logistic regression model was performed to assess relationship of patient comorbidities and type of valve operations to perioperative adverse events. Mid-term survival was similar between the 2 groups (P = 0.541). Compared to DVS, TVS was not associated with an increased risk of perioperative adverse events, including need for pacemaker or mortality on multivariable analysis. Within the DVS subgroup, 19.8% of patients experienced improvement in tricuspid valve function with decrease in the degree of tricuspid regurgitation within a 6-month postoperative follow-up. Our study indicates that repairing the tricuspid valve while addressing the aortic and mitral valves does not pose significant additional risk. The observed improvement of the degree of tricuspid regurgitation without tricuspid operation suggests the need to further define subpopulations of patients with multivalvular disease.

P989 Speckle tracking echocardiography for assessment of baseline myocardial dysfunction and remodelling following tricuspid valve surgery in adults with Ebsteins anomaly

Abstract Funding Acknowledgements Swedish Heart-Lung Foundation, Swedish Society of Medicine, Swedish Heart Association, Skåne University Hospital, Region Skåne, and Lund University Background Ebstein’s anomaly (EA) is due to failure of tricuspid valve (TV) delamination and often associated with RV myopathy. Conventional echocardiographic measurements of systolic ventricular function such as LV EF, and tricuspid annular plane systolic excursion/fractional area change (TAPSE/FAC) are load dependent and may therefore not reflect true myocardial function. Speckle tracking echocardiography (STE) evaluates more subtle myocardial deformation globally and on a regional level. Due to being load independent STE may be the most appropriate way to determine myocardial effects of EA intervention for which data in adults are limited. Purpose We aimed to study biventricular myocardial function before and after tricuspid valve repair/replacement (TVR) in adults with EA with both STE-derived peak systolic global and regional longitudinal strain (GLS; RLS) and conventional echocardiography. Methods A retrospective study of 18 EA patients (55.6% women), who underwent surgical TV repair/replacement (3/15; age at operation: 39 ± 12y) between 2005-2017 was performed. 2D longitudinal strain and conventional assessment of LV and RV function were assessed pre-TVR, and at 1- and 2-years post-TVR. LV and right ventricular (RV) segments were graded for STE assessment feasibility (0-3: no visualisation-optimal). Segments scored 0 were excluded from the strain analysis. Biventricular GLS and RLS were measured by semi-automated tracking. Results Compared to pre-TVR, LVEF improved after TVR at 1 year (Table 1, p = 0.03), but this was not sustained and returned to baseline after 2 years. TAPSE declined 1-year post-TVR with no further change after 2 years (Table 1). RVFAC did not differ pre- and post-TVR. LV GLS and RLS were low pre-TVR without amelioration at 1 or 2 years after TVR (Table 1). RV GLS deteriorated from pre-TVR to 1-year post-TVR with only minor amelioration after 2 years (p = 0.03). RV RLS showed a decrease at basal and mid free wall 1-year post-TVR, and at basal free wall, the mid free wall and the mid septum after 2 years (Table 1). Only, one segment improved in RLS from 1 to 2-year post-TVR (p = 0.03). Least feasible segments were LV apical lateral (both pre- and post-TVR), RV mid (pre-TVR and 1y post-TVR) and apical free wall (pre-TVR, 1y and 2y post-TVR) (all, median score 1). Conclusions In adult patients with EA, LV GLS was reduced before and unchanged after surgery despite preserved EF, and LVEF initially improved but returned to baseline values with time. Although TV surgery reduced the degree of TV regurgitation and RV size, it might have unmasked a potential RV myocardial disease. Both RV longitudinal strain and TAPSE were reduced 1 and 2 years post-TVR with limited recovery of RV longitudinal strain, but not of TAPSE, between 1 and 2 years post-TVR. Speckle tracking echocardiography (STE) is a feasible and a sensitive, load independent method in detecting biventricular myocardial dysfunction and time course of remodelling after surgery. Abstract P989 Table 1

P679 Subpulmonary left ventricular dysfunction is associated with severity of heart failure in patients with systemic right ventricle

Abstract Background Dysfunction of systemic right ventricle (SRV) in patients with congenitally corrected transposition of great arteries (ccTGA) or simple transposition (TGA) is commonly associated with exercise intolerance, heart failure and death. However, the relevance of subpulmonary left ventricular (LV) function in these settings is unknown. Purpose To examine the relation between severity of heart failure and echocardiographic parameters of subpulmonary LV size and function in patients with SRV. Methods We identified all patients with SRV from our digital echocardiographic database between 2014 and 2018. The size and function of SRV and subpulmonary LV were assessed in the most recent examination. Clinical data were collected from electronic patient records. Results We included 157 patients with SRV, median age 40.6 [33.1; 46.8] years, 57% male. 133 (85%) patients had NYHA functional class 1-2 and 24 (15%) NYHA class 3-4. Patients with NYHA class 3-4 were older, had larger SRV and subpulmonary LV with poorer function and higher BNP level (Table, Figure A). LV fractional area change (FAC) had higher sensitivity and specificity in differentiation of patients with severe heart failure than SRV FAC (Figurel B) with LV FAC cut-off value &amp;lt;39.2% showing the highest accuracy in prediction of NYHA class 3-4 (Se 83% and Sp 88%) and 86% Sp in predicting BNP &amp;gt; 100 ng/l. LV end-diastolic diameter and area, MAPSE and FAC significantly correlated with BNP level (p &amp;lt; 0.0001; p = 0.001; p = 0.007; and p = 0.0002, respectively). In Multivariate Cox regression analysis LV FAC and RV FAC were the only independent associates of NYHA class 3-4 (HR 0.69 [95%CI 0.55-0.86], p = 0.001 and HR 0.71 [95%CI 0.55-0.93], p = 0.012, respectively), while age, degree of tricuspid regurgitation and BNP were not. Conclusions Subpulmonary LV dysfunction is strongly associated with NYHA class 3-4 heart failure in patients with SRV. LV FAC is more accurate than SRV FAC in predicting heart failure symptoms. Subpulmonary LV should be accurately assessed in all SRV patients and be taken into account in clinical decision making and timing for interventions. Characteristics of 157 patients with SRV Parameter NYHA Class 1-2 (N = 133) NYHA Class 3-4 (N = 24) P value Age, years 39.1 (31.9; 45.7) 46.5 (43.9; 58.1) &amp;lt;0.0001 RV EDAi, cm2/m2 17.4 (15.2; 20.1) 21.8 (17.5; 25.6) 0.0002 RV FAC, % 29.5 (23; 35) 22 (20; 27) &amp;lt;0.0001 LV EDAi, cm2/m2 12.0 (10.1; 14.1) 16.4 (11.6; 19.1) 0.0008 Reduced LV function by eyeballing 3 (2%) 18 (75%) &amp;lt;0.0001 BNP, ng/l 66 (35; 109) 356 (196; 512) &amp;lt;0.0001 Data presented as median (25th; 75th percentiles) Abstract P679 Figure.

P1754 Regional left ventricular longitudinal myocardial dysfunction in mitral valve prolapse could be primary

Abstract Background Regional left ventricular dysfunction in patients with mitral valve prolapse (MVP) and normal ejection fraction has been described by different Authors, and recent data point to a dysfunction (prevalently longitudinal strain) of the myocardium of the LV base secondary to dilatation of the mitral annulus. Purpose To investigate degree and extent of regional LV dysfunction and its mechanisms in patients with MVP, severe regurgitation and normal global systolic function, compared to patients with equivalent degree of regurgitation but functional etiology (FMR). Methods Speckle-tracking echocardiography was performed in 30 controls (N), and in severe primary (MVP, n= 50) or functional (FMR, n= 20) mitral regurgitation, to measure global, regional and segmental longitudinal peak systolic strain (LPSS, %), and time delay of peak maximum strain (TTPd, ms, calculated as time to peak maximum strain - time of aortic valve closure). Maximum and minimum mitral annulus diameters and area were measured with 3D echo. We also evaluated as recommended: LV end-diastolic volume index (EDVi, ml/m2), ejection fraction (EF, %), and left atrial end-systolic volume index (LAESVi, ml/m2) with 2D echo; LV stroke volume index, and non-invasive pulmonary systolic (PSP, mmHg) and diastolic pressures (PDP), mmHg) with Doppler echo. Results Age, heart rate, BSA and systolic blood pressure were similar between groups. Atrial fibrillation was present in 34% of MVP and 71% of FMR patients. LV EF was normal in MVP and reduced in FMR (43 ± 14 % vs N, p&amp;lt;.001). LV EDVi (MVP: 77 ± 20 ml/m2; FMR: 107 ± 35, both p&amp;lt;.001 vs N) and LAESVi (MVP: 91 ± 26 ml/m2; FMR: 80 ± 30, both p&amp;lt;.001 vs N) were similarly increased (volume overload) in MVP and FMR, as were PSP (MVP: 42 ± 23 ml/m2; FMR: 52 ± 25, both p&amp;lt;.001 vs N) and PDP (MVP: 16 ± 6 ml/m2; MVP: 15 ± 5, both p&amp;lt;.001 vs N). In FMR, LPSS was reduced globally (-12.8 ± 3.3, p&amp;lt;.001 vs N and MVP) and similarly at LV base, papillary and apical levels. In contrast, in MVP global (-19.4 ± 3.7%) and apical (-23.4 ± 4.5%) LPSS were normal, whereas LV base (-12.3 ± 5.8%, p=.003 vs N) and papillary (-17.1 ± 4%, p=.024 vs N) LPSS were reduced; further, LPSS reduction was localized to the anterior (-16 ± 4, p=.028 vs N), lateral (-17 ± 5, p=.006 vs N) and posterior (-16 ± 6, p=.007 vs N) segments, and was associated with an increased TTPd in the same segments in MVP but not in FMR patients. At multivariate analysis, degree and localisation of regional myocardial dysfunction in patients with MVP was not related to the prolapsing scallop, dimension of the mitral annulus, degree of volume overload or pulmonary pressures, or stroke volume index. Conclusions In patients with MVP, severe regurgitation and normal EF, there is a specific dysfunction pattern of regional LV longitudinal function which appears to be primary and not dependent on the degree of preload increase, mitral annulus dilatation, or localization of the prolapsing scallop.

P827 Left atrial contractile function is the main correlate of atrial fibrillation in patients with hypertrophic cardiomyopathy

Abstract Background Given the negative impact of atrial fibrillation (AF) in patients (pts) with hypertrophic cardiomyopathy (HCM), finding new and better predictors of AF is clinically important, especially for patients considered at low or intermediate risk based on current recommendations (i.e. left atrial diameter, LAD &amp;lt;45 mm). Purpose To assess the relationship between left atrial (LA) remodelling (size and function) and the presence of paroxysmal AF in HCM patients with and without increased LAD. Methods A comprehensive echocardiogram was performed in 110 consecutive pts (52 ± 17 years, 50 men) with HCM, in sinus rhythm. Indexed LA volume (LAVi), maximum left ventricular wall thickness (LVWT), LV ejection fraction, E/e’ ratio were determined. Global longitudinal LV strain (GLS) and LA strain parameters (LAɛ, SSr, ASr) were assessed by speckle tracking echocardiography. Patients were divided into two groups according to the presence (30 pts) or absence (80 pts) of documented paroxysmal AF (24/48 h ambulatory ECG recordings) Results Patients with AF were older than pts without AF (p &amp;lt; 0.001). LAD, LAVi, E/e’ were significantly higher, while LAɛ, ESr, ASr were significantly lower in pts with AF compared to pts without AF (p &amp;lt; 0.05 for all). There were no significant differences between pts with and without AF regarding: gender, LVWT, GLS, the presence and severity of LV outflow tract obstruction (p &amp;gt; 0.05 for all). The correlates of AF in the whole HCM study population were: age (OR = 1.05, p = 0.001), ASr (OR = 10.1, p &amp;lt; 0.001), LAVi (OR = 1.03, p = 0.004), LAD (OR = 1.2, p = 0.001), E/e’(OR = 1.05, p = 0.02) and mitral regurgitation degree (OR = 1.6, p = 0.04). ASr had the best area under the curve (AUC: 0.74) with a cutoff of -0.88 s-1 for identifying HCM patients with AF (sensitivity: 80%, specificity: 65%). At multivariable logistic regression analysis, age, LAVi and ASr emerged as the only independent correlates of AF. 14 of the 71 patients with a LAD &amp;lt; 45 mm had paroxysmal AF. In this selected population, pts with AF were older (p = 0.001), had higher values for E/e’ (p = 0.04) and lower values for ASr (p = 0.02) than pts without AF. Moreover, in this subgroup of pts, at multivariable logistic regression analysis, ASr correlated with AF independently of age, LA dimensions, LV hypertrophy or E/e’ (OR = 10.008, 95% CI 1.297-77.219, p = 0.02). Conclusions In pts with HCM, age, LAVi and ASr, were independently related to the presence of AF, while LAD was not. Moreover, in the subgroup of HCM pts with LAD &amp;lt; 45 mm, ASr (reflecting LA contractile function) was the only LA remodelling parameter correlated with the presence of AF. The assessment of LA volume and function can provide further insights into the risk stratification of pts with HCM, especially in pts considered at lower risk for AF based on the assessment of classical risk parameters, such as LAD.

Pressure drop mapping using 4D flow MRI in patients with bicuspid aortic valve disease: A novel marker of valvular obstruction

BackgroundThe influence of complex bicuspid aortic valve (BAV) flow patterns on net intraluminal aortic pressure, both among patients with and without significant aortic stenosis, is unknown. Pressure drop (PD), as estimated by 4D Flow MRI, can quantify pre- vs post-valvular pressure at multiple levels simultaneously. MethodsIn this prospective clinical study, 32 patients with BAV with varying degrees of aortic stenosis and regurgitation and 11 healthy subjects were enrolled. 4D flow MRI was processed and analyzed at 9 pre-defined thoracic aortic levels. PD was calculated at each plane relative to a reference located within the left ventricular outflow tract. Conventional 2D phase-contrast imaging was used as reference of hemodynamic obstruction. PD was compared between healthy subjects versus BAV patients using Kruskal-Wallis H test and Mann-Whitney U. Correlation studies were conducted using Spearman's rank-order correlation. ResultsBoth BAV patients and healthy subjects showed progressive elevation in PD from the aortic root to the distal descending thoracic aorta. However, BAV patients showed higher PD than healthy subjects (p ≤ 0.01) at all analysis planes. Patients with moderate-severe aortic stenosis (n = 5) by 2D phase-contrast (peak PG > 40 mm Hg) showed higher PD than those without in the descending aortic segments (p ≤ 0.005). A correlation (r = 0.88, p < 0.05) was observed between PD at the distal descending thoracic aorta and peak trans-valvular velocity measured by 2D phase-contrast MRI. ConclusionWe demonstrated that PD with 4D flow MRI is clinically feasible in BAV patients and provides an additional physiologic description of valve-related hemodynamic obstruction.

The Analysis of Long-Term Results and Quality of Life in Patients with Massive Pulmonary Embolism in the Course of Treatment with Thrombolytic and Anticoagulant Drugs

RelevanceChronic post-embolic pulmonary hypertension (CPEPH) is a complication of pulmonary thromboembolism found almost in every 10th patient. A special risk group consists of patients with a moderately high risk of pulmonary embolism associated death according to stratification of the probability of early death of the European Society of Cardiology. The development of this condition is potentially preventable with timely and adequate therapy in these patients. We have improved the approach to the treatment of pulmonary embolism patients, which allows indications for thrombolytic therapy to be clarified and expanded. The aim of the study is to evaluate its effectiveness in the long-term period, as well as analyze the qualities of life of patients with massive pulmonary embolism, who underwent thrombolytic and anticoagulant therapy.Material and methodsThe treatment, as well as the analysis of long-term results and quality of life of 71 patients aged 29 to 88 years with diagnosed pulmonary embolism with a moderately high risk of early death were performed. All patients underwent general clinical and biochemical blood tests, D-dimer, ECG, echocardiography, ultrasound of the lower extremities veins, CT angiopulmonography. We registered the dynamics of echocardiographic symptoms of the right heart overload over 6 months (right ventricle size, pulmonary hypertension, the degree of tricuspid regurgitation), and assessed the quality of life based on a survey with the establishment of the appearance of shortness of breath, tachycardia, hospitalizations for heart failure during the study period. Depending on the type of therapy, the patients were divided into two groups: 38 patients with thrombolytic therapy and 33 patients with anticoagulant therapy. Subsequently, their comparative analysis was carried out.Results and conclusionIn patients with pulmonary embolism of moderately high risk of early death, who underwent thrombolytic therapy, chronic postembolic pulmonary hypertension developed 2.9 times less and a higher quality of life retained in these patients than in patients treated with anticoagulant drugs.

Left ventricular function after correction of mitral regurgitation: Impact of the clipping approach.

Functional mitral regurgitation (FMR) is associated with poor outcome in systolic heart failure (HF) patients. Percutaneous edge-to-edge mitral valve repair (PMVR) in Mitra-Fr study failed to prove any beneficial effect over optimal medical treatment (OMT) but win in COAPT study. Nevertheless, little is known about the effect of PMVR on LV performance and mechanics in HF patients with severe secondary MR. Thirty-seven patients with severe FMR undergoing PMVR were included and compared (according to indices of LV myocardial function and the relationship between LV-size and the degree of regurgitation) to nineteen patients with FMR treated by OMT. Both groups were clinically comparable. At 6-month follow-up, cardiac index such as LV global constructive work (GCW) improved significantly in both groups (1.86 vs 2.13L/min/m2 , P=.02, 1.73 vs 2.28L/min/m2 P=.002 and 977 vs 1101mmHg.%, P=.003, 967 vs 1110mmHg.%, P=.002 for PMVR and OMT groups, respectively) whereas left ventricular (LV) end-systolic volume index, LV ejection fraction, and global longitudinal strain were not different. Receiver operating characteristics in PMVR with LVEF≤35% subgroup analysis demonstrated that global work index (GWI) had the best ability to identify patients with worse evolution (AUC=0.882; P=.009), confirmed by univariable logistic regression, particularly for patients with GWI<482mmHg.%. Echocardiographic characteristics at 6-month follow-up are not different when compare PMVR and OMT for HF patients with severe FMR. A low global work index might be a tool for discouraging the implantation of clips for this indication.

A Methodology to Assess Subregional Geometric Complexity for Tetralogy of Fallot Patients

Abstract During surgical repair of tetralogy of fallot (TOF), pulmonary valve preservation (preservative repair) has demonstrated improved long-term outcomes compared to repairs that incise into the valve annulus (nonpreservative repair). Given the influence of geometry on hemodynamics, the success of preservative repair may be linked to the suitability of the preoperative patient geometry. However, the specific patient anatomies that may be predisposed to successful preservative repair are unknown due to significant interpatient variability in right ventricular outflow tract (RVOT) and pulmonary artery geometries, as well as the limitations in current methods of subregional geometric analysis. As a first step toward understanding the link between geometry and hemodynamics in TOF patients at a subregion level, we characterize the TOF geometry from the right ventricular infundibulum (INF) to the left and right pulmonary arteries. Our process consists of segmentation of magnetic resonance (MR) images and analysis of cross-sectional slices of the geometries along the centerlines. For the INF, main, left, and right pulmonary arteries individually, we quantify geometric parameters important in determining hemodynamic characteristics such as flow separation and recirculation, which can influence the degree of regurgitation. Specifically, we calculate the diameter along the subregion length, the average diameter, length, and tortuosity for each segment, as well as the bifurcation, left pulmonary artery (LPA) and right pulmonary artery (RPA) branch angles. This approach enables direct geometric comparisons within and among patients and allows for observation of the range in anatomic presentation. We have applied this approach to a dataset of 11 postoperative TOF patients, repaired with both preservative and nonpreservative surgical techniques.

DeVega versus ring annuloplasty in severe functional tricuspid insufficiency and their impact on the right ventricle

Background: Functional tricuspid valve regurgitation secondary to left-sided valve disease is common. DeVega repair is simple, but residual regurgitation with subsequent impairment of the right ventricular function is a concern. This study aims to compare tricuspid valve repair using DeVega vs. ring annuloplasty and their impact on the right ventricle in the early postoperative period and after six months.&#x0D; Methods: This is a prospective cohort study of 51 patients with rheumatic heart disease who underwent tricuspid valve repair for secondary severe tricuspid regurgitation. Patients were divided into two groups: group A; DeVega repair (n=34) and group B; ring annuloplasty repair (n=17). Patients were assessed clinically and by echocardiography before discharge and after six months for the degree of tricuspid regurgitation, right ventricular diameter and tricuspid annular plane systolic excursion (TAPSE).&#x0D; Results: Preoperative echocardiographic assessment showed no difference in left ventricular end-systolic diameter, end-diastolic diameter, ejection fraction and right ventricular diameter, however; group A had significantly better preoperative right ventricular function measured by TAPSE (1.96 ± 0.27 vs1.75 ± 0.31 cm; p=0.02). Group B had significantly longer cardiopulmonary bypass time (127.65 ± 13.56 vs. 111.74 ± 18.74 minutes; p= 0.003) and ischemic time (99.06 ± 11.80 vs. 87.15 ± 16.01 minutes; p= 0.009). Pre-discharge, there was no statistically significant difference in the degree of tricuspid regurgitation, but the right ventricular diameter was significantly lower in group B (2.66 ± 0.41 and 2.40 ± 0.48 cm; p=0.049). After six months of follow up, the degree of tricuspid regurgitation (p= 0.029) and the right ventricular diameter were significantly lower in the ring annuloplasty group (2.56 ± 0.39 and 2.29 ± 0.44 cm; p=0.029). Although there was a statistically significant difference in preoperative TAPSE, this difference disappeared after six months.&#x0D; Conclusion: Both DeVega and ring annuloplasty techniques were effective in the early postoperative period, ring annuloplasty was associated with lesser residual regurgitation and better right ventricular remodeling in severe functional tricuspid regurgitation than DeVega procedure after 6-months of follow up.

P918Tricuspid regurgitation in patients undergoing transcatheter aortic valve implantation

Abstract Background Transcatheter aortic valve implantation (TAVI) has become the treatment of choice in elderly patients with severe aortic stenosis and increased surgical risk. A significant number of these elderly patients have concomitant tricuspid valve regurgitation. The impact on outcome, however, is still matter of debate. Objectives In this prospective observational study, we investigated the impact of concomitant tricuspid regurgitation (TR) on outcome in patients undergoing transcatheter aortic valve implantation. Methods Between February 2008 and May 2018, 1411 patients with severe symptomatic aortic stenosis and increased operative risk underwent TAVI at the Heart Center Bonn and participated in this study, after written informed consent was obtained. Before TAVI procedure, all patients underwent a careful cardiac evaluation and interdisciplinary discussion within the local, institutional Heart Team. The pre-interventional 3D echocardiography was used to determine the degree of tricuspid valve regurgitation. According to the severity of TR, patients were divided into two groups; patients with TR &lt; II and patients with moderate to severe TR ≥ II andcompared regarding rates of mortality after 1 year of follow-up between the two groups. Results Out of 1411 TAVI patients, 802 (56.8%) had tricuspid regurgitation &lt; II, 610 (43.2%) patients suffered from tricuspid regurgitation ≥ II. The mean age of our study population was 81.1 (±6.5). The baseline characteristics did not differ significantly between the two groups, such as extracardiac arteriopathy (TR &lt; II: 44% vs TR ≥ II: 41.6%; p=0.37), diabetes (TR &lt; II: 27.5% vs TR ≥ II: 27.7%; p=0.92) or arterial hypertension (TR &lt; II: 91% vs TR ≥ II: 93.2%; p=0.64). However, patients with concomitant TR ≥ II had significantly more often NYHA class IV (TR &lt; II: 5.0% vs TR ≥ II: 15.4%; p&lt;0.001) and a higher logistic EuroSCORE (TR &lt; II: 12.9 (8.8/21.2) vs TR ≥ II: 20.6 (13.1/33.4); p&lt;0.001). Additionally, patients with a TR ≥ II had significantly more often a concomitant mitral regurgitation ≥ II (TR &lt; II: 43.3% vs TR ≥ II: 60.4%; p&lt;0.001). Comparing rates of mortality, we found a significant association between the degree of tricuspid regurgitation and 1-year mortality in patients undergoing TAVI (TR &lt; II: 85 (10.6%) vs. TR ≥ II: 136 (22.3%); p&lt;0.001), as presented in Figure 1. Figure 1 Conclusion Moderate to severe tricuspid valve regurgitation is associated with higher rates of mortality in patients undergoing transcatheter aortic valve implantation. Our results are hypothesis-generating and it has to be elucidated whether the severity of TR is only a surrogate for more advanced stage of aortic stenosis or whether it is causative so that mortality could be reduced by its treatment. Acknowledgement/Funding None

P1778Changes in size of ascending aorta in patients with bicuspid aortic valves

Abstract Introduction It is well known that bicuspid aortic valve (BAV) is associated with premature valve dysfunction and ascending aorta dilation. However, limited data still exists regarding the rate of growth of the ascending aorta and the risk factors associated with it in these patients. Methods We analyzed prospectively baseline characteristics and echocardiographic data from 192 adult patients with BAV followed in an Adult Congenital Heart Disease Unit from 2007 until 2018. The exclusion criteria were: patient's without at least 2 echocardiographic examinations &gt;6 months apart, and patients with aortic valve and/or ascending aorta surgery at baseline o at follow up (except aortic coarctation). Following the ASE guidelines two cardiologists experts in echocardiography made all the studies at baseline and follow-up where they measured the aortic root and ascending aortic diameters, as well as typified the aortic valve and analyzed the degree of stenosis (AS) and regurgitation (AR). Statistical analysis was performed using Stata 13.1, and a p value of ≤0.05 was considered significant. Results 97 patients were finally included (70 male, mean age 37.56±18.9 years). 66 patients had type A BAV (68.04%), 21 type B (21.7%), 2 type C (2.06%) and 7 unicuspid (7.22%). 19 patients had hypertension (19.59%) and 9 had a corrected aortic coarctation. In baseline echocardiogram, 20 had aortic stenosis ≥ moderate (20.6%) and 38 regurgitation ≥ grade II (39.18%). Mean diameter of ascending aorta was 35.78mm ± 6.73. With a mean follow-up time of 50.53±27.05 months, mean rate of diameter progression was 0.76 mm/year at the proximal ascending aorta (95% CI 0.6 to 1.2). Progression was significantly higher in patients with moderate or severe aortic stenosis (0.65 vs. 1.17 mm/year, p=0.021). Age, sex, hypertension, AR and high baseline diameters (≥40mm or ≥45mm) were not associated with progression. In a direct comparison between the two more frequent forms of BAV, Type A and Type B, rate of diameter progression was significantly higher in Type B (0.61 vs. 1.05 mm/year, p=0.044). In a multivariate analysis, none of the variables statistically associated to major progression were found to be predictors of growth of the ascending aorta. Conclussions In our population of BAV patients, mean rate of diameter progression at the proximal ascending aorta was 0.76 mm/year. Moderate-severe AS, and having type B BAV were associated, but not predictors, of higher growth rates.

P3440Can pre-operative echocardiography predict RV failure post-LVAD implantation in children?

Abstract Background One of the most frequent complications of left ventricular assist device (LVAD) implantation is the development of right ventricular (RV) failure, which occurs in 10%-40% of patients. It is, therefore, essential to identify which LVAD candidates are at risk for RV failure and will require additional RV mechanical support with a biventricular assist device (BiVAD). However, the echocardiographic assessment of the RV is challenging due to its complex geometry and marked load dependence of its function indices. To our knowledge, there is no published evidence regarding which specific RV echocardiographic parameters should inform this decision in the paediatric population. Aims We sought to determine which pre-operative RV echocardiographic parameters best correlate with the need for a BiVAD, as opposed to LVAD alone, in a paediatric population undergoing VAD insertion at a tertiary care institution. Methods Retrospective review of the pre-operative echocardiograms of children (&lt;18 years) with dilated cardiomyopathy undergoing elective VAD implantation at our institution, from November 2007 to December 2018. Preoperative quantitative and qualitative RV echocardiographic parameters described in the literature to be associated with RV failure after LVAD implantation in adults were collected. Moreover, qualitative RV function was independently assessed by three echocardiographers, blinded to the outcome of the patients. Results 89 patients were included, 39 (43.8%) males, median age = 1.7 years (IQR = 6.9), median weight = 11.6 kg (IQR = 13.8). 49 (55.1%) patients had an LVAD implanted, whereas 40 (44.9%) were deemed to need biventricular support. 45 (50.6%) patients received an EXCOR Berlin Heart, 16 (18%) a HeartWare HVAD and 28 (31.4%) a Levitronix Centrimag device. Requirement of BiVAD support was significantly more common in patients with moderate to severe RV impairment, as per expert assessment (OR = 2.864; 95% CI: 1.188–6.903, p=0.018), and tricuspid regurgitation &gt; grade III (OR = 3.154; 95% CI: 1.124–8.850, p=0.025). All the other parameters collected – tricuspid annular plane systolic excursion (TAPSE), tricuspid regurgitant jet velocity, tricuspid regurgitation duration corrected for heart rate, RV tissue Doppler indices, RV fractional area change, and RV/LV diameter ratio– were not significantly different among groups. Conclusions In our paediatric population, expert assessment of RV function and degree of tricuspid regurgitation were strong predictors of RV failure among patients undergoing LVAD implantation, allowing for pre-emptive RVAD implantation and improving patient outcomes.

Ring, Band or Suture in Tricuspid Annuloplasty for Functional Tricuspid Regurgitation; Which is Better and More Durable?

In this study, we evaluate different annuloplasty modalities to repair functional tricuspid regurgitation. Between January 2011 and January 2017, 200 patients with moderate or greater functional tricuspid regurgitation received tricuspid valve repair as part of primary surgeries on the left side of their cardiac valves. Of these, 39 patients received rings (Group A), 84 patients received bands (Group B), and 77 patients received suture annuloplasty (Group C). Two patients from Group C were operated on again, during the primary hospital stay due to severe symptomatic tricuspid regurgitation. The degrees of early postoperative tricuspid regurgitation - mean vena contracta and mean jet area - significantly were higher in Group C. During a mean follow-up period of 26 ± 12.6 months, 5 patients within Group C (6.85%) and one patient in Group B (1.3%) were operated on again with tricuspid valve replacement due to severe symptomatic tricuspid incompetence. Also during follow up, mean degrees of tricuspid regurgitation, mean vena contracta, and mean jet areas significantly were higher in Group C. Patients who received rings followed by band annuloplasty had better early and late results with lower recurrence rates than those who received suture annuloplasty.

Prediction of biventricular repair by echocardiography in borderline ventricle

Objective:In recent years, attempting the biventricular pathway or biventricular conversions in patients with borderline ventricle has become a hot topic. However, inappropriate pursuit of biventricular repair in borderline candidates will lead to adverse clinical outcomes. Therefore, it is important to accurately assess the degree of ventricular development before operation and whether it can tolerate biventricular repair. This review evaluated ventricular development using echocardiography for a better prediction of biventricular repair in borderline ventricle.Data sources:Articles from January 1, 1990 to April 1, 2019 on biventricular repair in borderline ventricle were accessed from PubMed, using keywords including “borderline ventricle,” “congenital heart disease,” “CHD,” “echocardiography,” and “biventricular repair.”Study selection:Original articles and critical reviews relevant to the review's theme were selected.Results:Borderline left ventricle (LV): (1) Critical aortic stenosis: the Rhodes score, Congenital Heart Surgeons Society regression equation and another new scoring system was proposed to predict the feasibility of biventricular repair. (2) Aortic arch hypoplasia: the LV size and the diameter of aortic and mitral valve (MV) annulus should be taken into considerations for biventricular repair. (3) Right-dominant unbalanced atrioventricular septal defect (AVSD): atrioventricular valve index (AVVI), left ventricular inflow index (LVII), and right ventricle (RV)/LV inflow angle were the echocardiographic indices for biventricular repair. Borderline RV: (1) pulmonary atresia/intact ventricular septum (PA/IVS): the diameter z-score of tricuspid valve (TV) annulus, ratio of TV to MV diameter, RV inlet length z-score, RV area z-score, RV development index, and RV-TV index, etc. Less objective but more practical description is to classify the RV as tripartite, bipartite, and unipartite. The presence or absence of RV sinusoids, RV dependent coronary circulation, and the degree of tricuspid regurgitation should also be noted. (2) Left-dominant unbalanced AVSD: AVVI, LV, and RV volumes, whether apex forming ventricles were the echocardiographic indices for biventricular repair.Conclusions:Although the evaluation of echocardiography cannot guarantee the success of biventricular repair surgery, echocardiography can still provide relatively valuable basis for surgical decision making.

Clinical Experience of Aortic Valve Surgery in Patients With Aortitis Disease.

To investigate single center's clinical experiences of aortic valve surgery for aortitis patients. From January 2010 to December 2018, 15 patients with aortitis disease were treated in our center. Among them, there were 7 males and 8 females with an average age of 48.5 ± 13.9 (29-76) years. Six patients were diagnosed as giant cell arteritis, 2 as Takayasu arteritis (Arteritis Group, N = 8) and 7 as Behcet's disease (BD Group, N = 7). Aortic valve surgery includes valvuloplasty, valve replacement, and root replacement (Bentall procedure). There were 15 cases with 19 operations, 8 cases in the Arteritis Group received 8 operations while 7 cases in the BD Group received 11 operations, including 4 redo operations. Preoperative patients' aortic valve regurgitation degree, diameter of ascending aorta and left ventricular ejection fraction were similar between the two groups. The type of aortic valve surgery also was no different. Cardiopulmonary bypass time of the BD Group seemed longer than the Arteritis Group but no different, the same as clamp time. Mechanical ventilation time is longer in the BD Group. The morbidity and mortality were similar, but the BD Group had significantly higher incidence of redo operations because of postoperative paravalvular leak or valve insufficiency (Arteritis Group versus BD Group, 0% versus 57.1%, P = .026). Clinical diagnosis and management of aortic valve patients with arteritis require comprehensive considerations. For aortitis patients with aortic valve surgery, special surgical techniques can be used to reduce the risk of prosthetic valve detachment.

Follow-Up After CatheterAblation of Papillary Muscles and Valve Cusps.

The goal of this study was to determine the impact of catheter ablation in the region of papillary muscles (PMs) and valvular cusps (VC) on mitral, tricuspid, or aortic valve function. Ventricular arrhythmias arising from PMs and VCs often require extensive catheter ablation. Little is known regarding the risk of valve dysfunction after radiofrequency catheter ablation of such arrhythmias. A retrospective analysis was completed for 149 PM and VC VT/premature ventricular contraction (PVC) ablations from 2008 to 2018 at our institution. Patient and procedural details were collected for VT and PVC ablation cases involving PMs and VCs with available echocardiographic data pre-ablation and post-ablation (within 6months). Degree of valvular regurgitation (VR) was graded from 0 (none) to 4 (severe), and significant valvular dysfunction was defined as a 2+ change in VR. Of 149 radiofrequency catheter ablation cases, there were 84 (56%) aortic valve cusp ablations, 60 (40%) left ventricular PM ablations, and 5 (3%) right ventricular PM ablations. There were no statistically significant differences between pre-ablation and post-ablation VR severity (p=0.33). No patients had a 2+ grade change in VR severity when pre-ablation and post-ablation echocardiograms were compared. There were no significant sequelae requiring intervention in the post-ablation period. On follow-up of 36 ± 9months, for those with a change in VR, the severity had improved to baseline or remained stable. Despite often-times extensive ablation on and around valvular networks, risk of longstanding or permanent valvular dysfunction after VT/PVC ablation is rare.