Effective Regurgitant Orifice Area Research Articles

Color Doppler Splay in Mitral Regurgitation: Hemodynamic Correlates and Outcomes in a Clinical Cohort

Recently, an artifactual horizontal extension of the color Doppler signal was described in patients with mitral regurgitation (MR), called color Doppler splay (CDS). This side-lobe artifact was shown to be associated with concealed and significant MR. In the present study, the authors assessed the prognostic significance of CDS and its hemodynamic correlates. Consecutive patients with primary and secondary MR underwent comprehensive transthoracic echocardiography. Machine settings were fixed for all patients. MR severity was assessed using an integrated approach, as advocated in current international guidelines. The presence of CDS and CDS width and duration were assessed. The outcome measures included the incidence of major adverse cardiac events (a composite of cardiovascular mortality, hospitalization for decompensated heart failure, mitral valve surgery, or percutaneous mitral intervention). One hundred twenty-seven of 469 patients (27%) with MR demonstrated CDS. The presence of CDS was associated with worse MR, and CDS width correlated with effective regurgitant orifice area, regurgitant volume, and vena contracta width. Mitral annular or leaflet calcification was inversely associated with the presence of CDS. Patients with CDS experienced worse event-free survival. For CDS width, a cutoff of >29mm was identified as optimal regarding outcome prediction in our cohort and termed "severe CDS." In multivariate Cox regression, the presence of severe CDS was associated with adverse outcome, independent of MR etiology or severity and other clinical and echocardiographic predictors of outcome, and provided incremental prognostic value on top of these parameters. In patients with MR, the presence of CDS is associated with more severe MR and worse outcomes. Severe CDS provides incremental prognostic value on top of traditional MR metrics and should alert the echocardiographer that MR severity may be underestimated.

New ESC/EACTS guideline recommendations for the treatment of secondary mitral regurgitation: reflections on the evidence

New <scp>ESC</scp>/<scp>EACTS</scp> guideline recommendations for the treatment of secondary mitral regurgitation: reflections on the evidence

Hemodynamic Modeling for Mitral Regurgitation

<h3>Purpose</h3> Mitral regurgitation (MR) is a serious valvular pathology that impacts over 2% of the total population. Despite evidence that MR poses potentially significant risks of RV dysfunction and failure, the risks of MR are mainly assessed based on left heart parameters, including the mitral regurgitant fraction (MRF) and effective regurgitant orifice area (EROA). To elucidate the links between MR and RV dysfunction, we propose a computational fluid dynamic (CFD) modeling pipeline aimed at providing a deeper understanding of the interplay between MR and RV function. <h3>Methods</h3> Dynamic CT data of a spatiotemporal motion of the patient's heart were segmented using a 3D U-Net based neural network. Meshed segmentations were propagated through time using IRTK non-rigid registration and volume preserving surface motion interpolation to recreate the motion of the patient's heart over the cardiac cycle. The 3D model was coupled to a closed loop 0D model that represents the remaining cardiovascular system and provides continuous feedback to the 3D model. This also allows the relationship between the complicated hemodynamics in the left heart and the state of the RV to be modeled. The functionality of the RV is prescribed by defining the stroke volume over the cardiac cycle. Mild, moderate, and severe MR was prescribed by defining the EROA's based on clinical parameters. <h3>Results</h3> We looked at how different MR jet areas (EROA) and RV functions pose risks to the cardiovascular system. Results from this study show that a high RV function reduces MRF at the expense of much higher right ventricle stroke work index (RVSWI) - which is strongly correlated with RV failure (Fig. 1). Variation in EROA has a lower impact on the RF and RVSWI than the RV functionality, but it does change the local hemodynamics (Fig. 2). <h3>Conclusion</h3> This process makes it possible to further understand the effect that MR has on right heart function. This is particularly important for patients who require a left ventricular assist device in which right heart failure, linked with MR, is a recognized complication.

Interobserver Variation in Echocardiographic Measurements and Grading of Tricuspid Regurgitation Based on a Novel Web-Based Assessment Environment

The primary aim of this study was to assess interobserver variability in grading tricuspid regurgitation (TR) severity. The authors' secondary goals were to delineate which transesophageal echocardiographic (TEE) parameters best correlate with severity and how consistent the participants were at grading severity. This was a prospective cohort study of how clinicians evaluated previously acquired TEE images and videos. The 19 TEE studies of patients with TR were recorded by 4 senior echocardiographers across 4 US academic institutions. The participants evaluated these cases on a novel, web-based, assessment environment designed specifically for this study. Twenty-nine fellowship-trained and board-certified cardiologists and cardiothoracic anesthesiologists volunteered to participate in the study as observers from 19 different institutions. No interventions were performed on the participants. For each case, participants measured the vena contracta (VC), proximal isovelocity surface area (PISA), and jet area before giving a final classification on the severity of TR. Variation was highest for effective regurgitant orifice area and lowest for VC and PISA. The coefficient of variation, defined as the standard deviation from the mean divided by the mean, for all cases of trace, mild, moderate and severe TR were as follows: Jet Area-111%, 46%, 48%, 76%; VC-67%, 44%, 43%, 36%; PISA-52%, 48%, 31%, 35%; and effective regurgitant orifice area-127%, 95%, 66%, 58%. The interobserver variation in quantifying TEE parameters for TR is high, suggesting these may be difficult to measure reliably in a busy perioperative setting. Of the parameters assessed, VC and PISA radius had the highest interobserver agreement and the highest correlation with severity.

Prognosis implications of quantified mitral regurgitation stratified by left atrial function in HFrEF population

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND The debate about the independent prognostic responsibility of functional mitral regurgitation (FMR) is still in turmoil. Growing findings about the predictive role of left atrial (LA) function are emerging in several scenarios. PURPOSE This study aims to define FMR linkage to cardiovascular (CV) outcomes and the interplay with LA function in a prospective cohort of consecutive heart failure patients with reduced ejection fraction (HFrEF). METHODS 286 consecutive outpatients with chronic HFrEF were enrolled. FMR was quantified by effective regurgitant orifice area (EROA). Global peak atrial longitudinal strain (PALS) was measured by speckle tracking echocardiography (STE). The primary endpoint was defined as a composite of congestive HF hospitalization and CV death. RESULTS The majority (81%) of patients were men (mean age: 67 ± 11 years, mean LVEF: 32 ± 6%). The median global PALS was 17.7% ranging from 2.7% to 49.2%. FMR was quantifiable in 240 (84%) patients. During a median follow-up period of 6.4 (IQR 3.9-7.7) years, the primary endpoint occurred in 88 (31%) patients (35 HF admissions, and 53 deaths). EROA showed independent prediction for the primary endpoint (HR 1.30 [1.05-1.57], P = 0.01). The spline modeling of the risk by EROA values showed an excess event risk starting at about the EROA value of 0.1 cm2 (Figure 1). There was a remarkable graded association between the EROA strata, even if tested per 0.1 cm2 increase, and the risk of congestive HF hospitalization and CV death (P = 0.0004). Any FMR grade presenting with reduced LA function (PALS &amp;lt; 14%) was associated with dismal outcome (event rate of 63 ± 10% for EROA exceeding 0.3 cm2 and 49 ± 6% for EROA ≥0.1 cm2 at 5 years). Conversely, the presence of EROA ≥0.1 in the context of preserved global PALS showed a better outcome (Figure 2). CONCLUSIONS Our results refine the independent association between FMR and CV outcome among HFrEF outpatients. The risk of CV events starts at a low EROA value, reaching a severe level above the threshold of 0.3 cm2. Within a moderate EROA range, the LA function mitigates the clinical consequences of the mitral regurgitation, providing measurable proof of the interplay between the regurgitation and the LA compliance. Abstract Figure 1 Abstract Figure 2

Impact of leaflet-tethering angle correction on the assessment of tricuspid regurgitation severity using the PISA method

Abstract Funding Acknowledgements Type of funding sources: None. Background Severe tricuspid regurgitation (TR) is associated with excess mortality and morbidity. Therefore, assessment of TR severity is pivotal. Calculation of the effective regurgitant orifice area (EROA) and the regurgitant volume (RVol) using flow convergence method (PISA) by echocardiography are still the recommended parameters to define TR severity. However, the distortion of the proximal convergence zone related to the extent of valve leaflet tethering may result in smaller PISA radius and in underestimation of TR severity. Correcting for the angle of the leaflet tethering could reduce errors due to geometric assumption of a flat valvular plane and improve the accuracy of the calculations. Purpose: The aims of our study were (1) to evaluate whether taking into account the extent of leaflet tethering by applying the angle correction (AC) in the PISA formula improves the accuracy of the quantitative assessment of TR severity; (2) to assess the potential clinical impact of AC. Methods Forty-one patients with functional TR (73.5 ± 11.8 years,51% men,36% sinus rhythm,17% severe), underwent 2D and 3D echocardiography. We compared the RVol obtained by volumetric method (as reference) with the RVol by PISA with and without AC. TR RVol by volumetric method was calculated as: total RV stroke volume (RVSV) – left ventricular forward SV (LVSV), where RVSV was obtained by subtracting the end-systolic from end-diastolic RV volume measured by 3D echocardiography and LV SV was calculated by multiplying LV outflow area by velocity time integral (VTI) (Fig. 1). TR RVol by PISA was calculated as EROA x VTITR. Uncorrected EROA was calculated using the formula: 6.28 r2 xVa/ PeakVTR (r - PISA radius, Va, aliasing velocity, PeakVTR – TR peak velocity). The corrected EROA accounting for the PISA geometric distortion by leaflet tethering angle (α) was calculated as: 6.28 r2 x Va (α/180)/ PeakV TR (PISAac), where α was measured using a protractor generated by dedicated software. Results Application of AC to PISA method resulted in larger EROA and RVol (0.34± 0.38 cm2 vs 0.24± 0.24cm2 and, 25.2± 19.3 mL vs 18.6 ± 13.1mL, respectively). The percentage change in EROAac was over 40%. When compared to the volumetric method, RVol by corrected PISA method was significantly closer and correlated (bias -3.95mL, LOA ± 6.41 mL, r= .987; p&amp;lt; .001) than the conventional PISA without AC (bias -10.5 mL, LOA ± 15 mL, r= .975). Angle correction resulted in a change of TR severity in 32% of cases (Fig. 2) and in a greater concordance of TR severity grade with the volumetric method (75%, 31/41 with AC vs 52%, 22/41 without AC). Conclusions Angle-corrected PISA method that accounts for the extent of the leaflet tethering in TR provided significantly larger TR RVol that were closely correlated with the volumetric RVol by 3D echocardiography. A simple geometric angle correction of the proximal flow with PISA method reclassified up to 1/3 of patients with functional TR. Abstract Figure. Representation of study method Abstract Figure. Reclassification of TR severity

Correlation between standard and adjusted echocardiographic quantitative methods for evaluating tricuspid regurgitation severity

Abstract Funding Acknowledgements Type of funding sources: None. Background Current guidelines advocate for a multi-parametric approach to echocardiographic quantitation of tricuspid regurgitation (TR). The primary quantitative measure of TR severity uses the proximal isovelocity surface area (PISA) method to calculate effective regurgitant orifice area (EROA) and regurgitant volume (RegVol). However, EROA-PISA may underestimate TR severity due to low flow and tethering of the tricuspid leaflets. Purpose The purpose of this study was to compare standard EROA-PISA quantitation of TR to alternative quantitative measures, including quantitative Doppler (EROA-Doppler), flow- and angle-corrected PISA method (EROA-Corrected), and three-dimensional vena contracta area (3D-VCA), in addition to the comparison of calculated RegVol-PISA, RegVol-Doppler, and RegVol-3DVCA. Methods Patients undergoing both transthoracic (TTE) and transesophageal (TEE) echocardiographic evaluation of TR severity for transcatheter treatment were included in this study. Patients were excluded if they had ≥ moderate aortic regurgitation. TTE measurements of EROA-PISA and RegVol-PISA were performed as per American Society of Echocardiography guidelines. EROA-Doppler was performed by quantifying RegVol-Doppler (diastolic stroke volume using biplane annular area, minus left ventricular outflow stroke volume) and deriving EROA. EROA-Corrected was calculated by adjusting for both aliasing velocity and leaflet angle as per published methods. 3D-VCA was measured on TEE performed within 14 days of TTE. Results Of 44 consecutive patients, the median age was 80 ± 9 years, 61% were female, and 89% had atrial fibrillation. Most patients (86%) had functional TR, 71% had a EROA-PISA ≥ 0.4 cm2. Table 1 shows the EROA and RegVol results for each method. EROA-PISA and RegVol-PISA were significantly lower than EROA-Doppler and RegVol-Doppler, as well as 3D-VCA and RegVol-3DVCA (all p &amp;lt; 0.0001). There was no significant difference between EROA-Doppler and 3D-VCA (p = 0.51), and RegVol-Doppler and RegVol-3DVCA (p = 0.66). EROA-Corrected reduced the absolute difference with EROA-Doppler (51% to 33%, p &amp;lt; 0.0001) and 3D-VCA (52% to 32%, p &amp;lt; 0.0001), but remained statistically lower than EROA-Doppler and 3D-VCA. Although EROA-PISA was strongly correlated to EROA-Doppler (r = 0.75, p &amp;lt; 0.0001) and 3D-VCA (r = 0.68, p &amp;lt; 0.0001), the correlation between EROA-Doppler and 3D-VCA was greatest (r = 0.77, p &amp;lt; 0.0001). Adjusting EROA-PISA for angle and flow demonstrated improved correlation to EROA-Doppler without affecting correlation to 3D-VCA (Figure 1). Conclusion Our study demonstrated that EROA-PISA significantly underestimates the severity of TR by EROA-Doppler and 3D-VCA. Although PISA correction methods reduced the underestimation, both EROA-Corrected and RegVol-Corrected remained significantly lower. EROA-Doppler and 3D-VCA and the calculated RegVol by each method, were closely correlated and not significantly different. Abstract Table 1 Abstract Figure 1

Right ventricular longitudinal strain remains unimpaired in severe primary mitral regurgitation and functional tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION The right ventricular global longitudinal strain (RV GLS) increasingly has been used for the prognosis of mortality in the heart failure patients. However, the relationship of RV strains to other RV functional parameters and its dependency of functional tricuspid regurgitation (TR) as a result of left heart valvular disease is not well studied. PURPOSE To investigate the relationship of RV geometry, functional and strain parameters to the predominant left heart aetiology in patients with functional TR as a result of left heart valvular disease. METHODS Prospective observational cohort study enrolled patients with functional TR caused by left heart valvular disease for whom surgical valvular repairment is scheduled. Patients with ischemic heart disease (assessed by coronary angiography) were excluded from the analysis. The current study included 52 patients with full sets of preoperative echocardiographic parameters. Echocardiographic quantification included the following parameters: the RV geometry (RV diameters, RV area), functional (velocity of the tricuspid annular systolic motion (S’) and RV fractional area change (FAC)) and strain parameters (RV GLS, longitudinal RV free wall strain (RVFWS) and longitudinal strains of each segment of RV free wall). The severity of TR was measured quantitively according the recent ESC guidelines. Patients were divided into groups according to the predominant left heart valvular disease causing moderate or severe functional TR: 1. TR caused by primary severe mitral regurgitation (MR) due to mitral valve (MV) prolapse and MV chordae rupture; 2. TR caused by other left heart valvular pathologies (severe aortic stenosis [16 pts.], severe rheumatic aortic and MV disease [11 pts], severe aortic regurgitation [3 pts]). The statistical analyses were performed using SPSS statistical software. RESULTS In 52 patients of current analysis 64% were female, mean age was 67 ± 9. The distribution of echocardiography parameters in study groups are shown in Table 1. The RV geometry parameters and parameter of TR severity (effective regurgitant orifice area (EROA) did not differ significantly between these two groups. The RV longitudinal function (S’) and RV strain parameters (RV GLS and longitudinal RVFWS) were better in severe MR group. CONCLUSIONS Although the right ventricular geometry and severity of functional tricuspid regurgitation does not depend on different predominant left heart valvular disease causing significant functional tricuspid regurgitation, the right ventricular longitudinal function and longitudinal right ventricular free wall strain are less affected and remains unimpaired in patients with functional tricuspid regurgitation caused by severe primary mitral regurgitation. Abstract Figure.

Right heart interplay with secondary tricuspid regurgitation. How can we predict clinical events?

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf TRAP Introduction. Secondary Tricuspid Regurgitation (TR) is a turning point in cardiac diseases. Symptoms occurred too late according to the right heart reverse remodelling capabilities. The ideal timing for proposing a valve repair remains a challenge. We sought to analyse characteristics of patients with significant secondary TR, seeking for changes in parameters over time that could be related to the risk of clinical event. Material and method. We designed a prospective observational French multicentre study of 160 patients with significant secondary TR (effective regurgitant orifice area &amp;gt; 30 mm²) and LVEF &amp;gt; 40%; we collected clinical, echocardiographic, and EKG data at baseline, 1- and 2-year follow-up. All echocardiographies were centrally analyzed. The primary outcome was death or hospitalization for heart failure Results. At 2-year 95 patients (59.3%) presented the primary outcome. They had significant morphological and functional alteration of the right heart parameters. Right Atrial Volume Index (RAVI) and right ventricular free wall Strain were respectively 73mL/m² and -19.8% versus 64.7mL/m² and 22.3% in the event-free group. None of them had significant group*time interaction. In the multivariable analysis, TAPSE/sPAP ratio &amp;gt; 0.4 (OR = 0.41 95%CL 0.2 to 0.82) associated to RAVI &amp;gt; 60mL/m² (OR = 2.13 95%CL 0.96 to 4.75) were the two independent parameters that enable the fairest and parsimonious evaluation. Conclusion. We demonstrated that short analysis using RAVI and TAPSE/sPAP almost reached us to an easier patient assessment by limiting the number of involved parameters. These parameters are now to be for defining the best timing and response to interventions. Abstract Figure. LAVI and TAPSE/sPAP according to events

Impact of endocardial leads on the effectiveness of interventional edge-to-edge repair of tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Background A considerable proportion of patients who are considered for percutaneous tricuspid valve edge-to-edge repair (pTVR) interventions have endocardial lead induced tricuspid regurgitation (TR). The aim of this study was to examine the impact of lead-leaflet interaction on the effectiveness of pTVR. Methods For each patient, the lead position within the tricuspid valve (central, commissural, or towards one of the three leaflets) and the type of lead-leaflet interaction (leaflet impingement or adhesion) were identified during thorough 2D/3D transthoracic and transesophageal echocardiography examinations. Before and after pTVR, echocardiographic data, including 3D full-volume datasets, were obtained and quantified. TR severity was graded from 1+ to 5+, based upon the effective regurgitant orifice area by the PISA method (EROAPISA) and the vena contracta area (VCA3D) as measured by multiplanar reconstruction from a 3D color Doppler loop. Maximal diastolic tricuspid annulus area from a 3D zoom image, tricuspid tenting area, and right atrial volume were quantified. Right ventricular assessments included ejection fraction (RVEF3D) and diastolic (RVVd3D) and systolic (RVVs3D) volumes. Results Out of 99 patients who underwent pTVR at our hospital, 38 patients had implanted cardiac devices of the following types: pacemakers (n = 25, 66%), cardiac defibrillators (n = 7, 18%), and biventricular pacemakers (n = 6, 16%). In 24 (63%) of these device patients, TR grade was ≤2+ after pTVR. In 14 of the device patients, TR grade remained severe after intervention (Grade 3+ in 15%, grade 4+ in 11%, and Grade 5+ in 11% of the device group). In comparison, in 78% of patients without endocardial leads, moderate TR was achieved after pTVR. Figure 1 shows the distribution of lead positions within the tricuspid valve. A relevant lead-leaflet interference (rLLI) for pTVR interventions was defined as impingement or adhesion in the target area of the coaptation device (anteroseptal or posteroseptal). Binary logistic regression analysis showed an increase risk (Odds ratio 11, R2 0.34, 95% CI 0.019-0.44, p = 0.003) for a suboptimal pTVR result (TR grade &amp;gt; 2+ after intervention) in patients with rLLI. Although patients with rLLI (n = 17) had significantly higher VCA3D values as compared to patients without rLLI (n = 21), it was not predictive for pTVR results. Echocardiographic parameters of right ventricular and tricuspid valve dimensions showed only a trend to higher values in the group with rLLI (Table 1). Conclusion Endocardial lead induced TR negatively impacts the effectiveness of pTVR irrespective of the initial degree of TR. Abstract Figure. Abstract Table 1 Echocardiographic parameters

Outcomes of patients with severe mitral regurgitation treated with transcatheter mitral valve implantation or medical therapy

Abstract Funding Acknowledgements Type of funding sources: None. Background Patients with severe mitral regurgitation (MR) unsuitable for standard therapy (i.e., open-heart surgery and transcatheter edge-to-edge repair [TEER]), often remain on medical therapy (MT) alone. Transcatheter mitral valve implantation (TMVI) may represent an alternative treatment option for these patients. Purpose We aimed to investigate differences in anatomical baseline characteristics and echocardiographic outcomes between MR patients unsuitable for standard therapy, that were either treated with TMVI or remained on MT. Methods Between 05/2016-02/2021, 121 high-risk patients with severe MR were evaluated for TMVI. Clinical, echocardiographic and functional outcomes between the subgroups of patients treated with TMVI and MT were compared. The primary combined endpoint was all-cause death or heart failure (HF) hospitalization at 1 year. Subgroup analyses were performed to define specific patient subsets favouring either TMVI or MT. Results At baseline, there were no differences between the TMVI group (n = 38) and the MT group (n = 44) regarding age (all TMVI vs. MT: 77.0 years [IQR 72.9, 80.1] vs. 79.0 [IQR 76.0, 81.7], p = 0.13), gender (42.1% female vs. 56.8% female, p = 0.27) and estimated surgical risk (EuroSCORE II 4.4% [IQR 2.8, 13.6] vs. 6.4 [IQR 3.4, 10.1], p = 0.72). Patients undergoing TMVI were more frequently treated for secondary MR (68.4%), while primary MR was the most prevalent MR etiology in patients remaining on medical therapy (50.0%). Left ventricular (LV) end-diastolic diameters (LVEDD) were larger and LV ejection fraction (LVEF) was lower in the TMVI group (LVEDD 58.0mm [IQR 51.4, 65.0], LVEF 37.0% [IQR 31.4, 51.2]) compared to the MT group (LVEDD 52.0mm [IQR 46.2, 58.8], LVEF 54.5% [IQR 40.8, 60.0]) (p = 0.02 for LVEDD, p &amp;lt; 0.001 for LVEF). MR was effectively reduced to ≤ mild MR in all patients undergoing TMVI. In the MT group, MR remained severe in 90% of patients after 1 year. The primary composite endpoint occurred numerically more often in the MT group (72.2%) compared to the TMVI group (51.6%, p = 0.061). Regarding the primary endpoint, the subgroups of patients with LVEF 30-49% (HR 0.28 [95%-CI 0.11-0.67], p = 0.004), effective regurgitant orifice area (EROA) &amp;lt;0.4 cm2 (HR 0.30 [95%-CI 0.13-0.71], p = 0.006), tricuspid annular plane systolic excursion (TAPSE) ≥17mm (HR 0.27 [95%-CI 0.11-0.67], p = 0.005) and New York Heart Association functional class III (HR 0.38 [95%-CI 0.18-0.81], p = 0.012) were more likely to benefit from TMVI compared to MT. Conclusions In patients with severe MR unsuitable for standard therapy, TMVI represents a reasonable therapeutic alternative yielding effective elimination of MR. While most patients eligible for TMVI suffer from secondary MR, the majority of patients remaining on MT has primary MR. The primary endpoint occurred numerically, yet not statistically, more often in patients on MT. Baseline echocardiography was able to identify subgroups of patients with beneficial outcome after TMVI.

Impact of proportionality of tricuspid regurgitation on outcome after tricuspid annuloplasty

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Sanming Project of Medicine in Shenzhen, China [No. SZSM201911020]; HKU-SZH Fund for Shenzhen Key Medical Discipline [No. SZXK2020081] Background Patients with secondary tricuspid regurgitation (TR) benefit differentially from tricuspid annuloplasty. We hypothesized that TR severity may be proportional or disproportional to right ventricular (RV) remodeling and investigated the prognostic implication of this novel framework. Methods The ratios of pre-procedural effective regurgitant orifice area (EROA) with right ventricular end-diastolic area (RVDA) and tricuspid annular plane systolic excursion (TAPSE) were retrospectively assessed in 307 patients undergoing tricuspid annuloplasty. Based on optimal thresholds derived from cubic splines and maximally selected rank statistics, patients were stratified into 3 groups: proportionate TR (Group 1: EROA/RVDA ≤1.70 and EROA/TAPSE ≤3.42), disproportionate TR to RV size (Group 2: EROA/RVDA &amp;gt;1.70 and EROA/TAPSE ≤3.42), and disproportionate TR to RV size and function (Group 3: EROA/RVDA &amp;gt;1.70 and EROA/TAPSE &amp;gt;3.42). Results Overall, 77 (25%), 126 (41%), and 104 (34%) patients were classified into Group 1, 2, and 3, respectively. Compared with those with proportionate TR (Group 1), patients with disproportionate TR (Group 2 and 3) had a higher prevalence of atrial fibrillation and smaller left ventricular end-diastolic and end-systolic volumes. During a median (interquartile range) follow-up of 4.1 (2.5-6.2) years, 81 adverse events (49 HF hospitalizations and 32 deaths) occurred. Patients with disproportionate TR (Group 2 and 3) had higher rates of adverse events than those with proportionate TR (22% and 44% versus 9%; P = 0.018 and P &amp;lt; 0.001, respectively) and were independently associated with poor outcomes on multivariate analysis. TR proportionality outperformed guideline-based prediction algorithm comprising EROA and RV assessment in outcome prediction (C-statistic 0.70 versus 0.62, p = 0.015; likelihood ratio test &amp;lt;0.001). Conclusion Disproportionate TR is independently associated with poor prognosis in patients undergoing tricuspid annuloplasty. Characterization of TR severity to RV size and function may aid patient selection and risk stratification for tricuspid annuloplasty. Abstract Figure.

Relationship between right ventricular geometry and function parameters and tricuspid annuloplasty efficacy

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION The prevalence of untreated moderate and severe functional tricuspid regurgitation (TR) eventually leads to heart failure and is associated with poor prognosis. Therefore, tricuspid annuloplasty (TA) is offered as a first-line treatment for significant functional TR. However, studies to investigate factors leading to recurrent TR after TA are still scarce. AIM The aim is to investigate the relationship between right ventricular (RV) geometry and function parameters and recurrent TR after TA. METHODS Prospective observational cohort study enrolled patients with moderate or severe functional TR caused by left heart valvular disease who underwent surgical tricuspid valve (TV) repair. The dominant pathology was severe mitral regurgitation. Patients with ischemic heart disease (assessed by coronary angiography) were excluded from the analysis. The current study included 60 patients with full sets of preoperative 2D and 3D echocardiographic parameters. Echocardiographic quantification included the following parameters: the RV and RA geometry, functional (velocity of the tricuspid annular systolic motion [S’] and RV fractional area change [FAC], tricuspid annular plane systolic excursion [TAPSE] and RV ejection fraction (EF)). The severity of TR was measured quantitatively according to the recent ESC guidelines. Patients were divided into two groups according to the outcomes of TA: effective (38 pts.) and ineffective (22 pts.) TV repair. Effective TA was considered if TR 1 year after surgery was mild, while ineffective – TR was moderate or severe (recurrent TR). The statistical analysis was performed using SPSS statistical software, univariate logistic regression was used. RESULTS In 60 patients of current analysis 67% were female, mean age was 67 ± 9 years. The odds ratio for risk of ineffective TA are shown in Table 1. Age, gender, body mass index, left ventricular (LV) functional, as well as left atrial parameters did not differ between effective and ineffective TA groups. When analysing echocardiographic parameters in univariate logistic regression, RV and RA geometry, TV annulus diameter had predictive value for ineffective TA. Preoperative effective regurgitant orifice area (EROA) did not differ significantly between two groups (ineffective TA vs. effective TA; 31 [60] mm2 vs. 24 [17] mm2, p = 0.308 respectively). Meanwhile, none of the RV functional parameters were significant. CONCLUSION Recurrent moderate or severe functional tricuspid regurgitation after tricuspid annuloplasty is associated with preoperative tricuspid annulus size, RA and RV geometry, but not with changes of RV function. Abstract Figure.

Prognostic implications of the proportionality of tricuspid regurgitation in tricuspid annuloplasty

Abstract Funding Acknowledgements Type of funding sources: None. Background Patients with secondary tricuspid regurgitation (TR) represent a heterogeneous group that benefits differentially from tricuspid annuloplasty. We hypothesized that TR severity may be proportional or disproportional to right ventricular (RV) remodeling and investigated the prognostic implications of this novel paradigm. Methods The ratios of pre-procedural effective regurgitant orifice area (EROA) with right ventricular end-diastolic area (RVDA) and tricuspid annular plane systolic excursion (TAPSE) were retrospectively assessed in 307 patients undergoing tricuspid annuloplasty. Based on optimal thresholds derived from cubic splines and maximally selected rank statistics, patients were stratified into 3 groups: proportionate TR (Group 1: EROA/RVDA ≤1.68 and EROA/TAPSE ≤3.42), disproportionate TR to RV size (Group 2: EROA/RVDA &amp;gt;1.68 and EROA/TAPSE ≤3.42), and disproportionate TR to RV size and function (Group 3: EROA/RVDA &amp;gt;1.68 and EROA/TAPSE &amp;gt;3.42). Results Overall, 72 (23%), 127 (41%), and 108 (35%) patients were classified into Group 1, 2, and 3, respectively. Compared with those with proportionate TR (Group 1), patients with disproportionate TR (Group 2 and 3) had a higher prevalence of atrial fibrillation, moderate to severe aortic stenosis, and smaller left ventricular end-diastolic and end-systolic volumes. During a median (interquartile range) follow-up of 4.3 (2.6-6.3) years, 74 adverse events (42 HF hospitalizations and 32 deaths) occurred. Patients with disproportionate TR (Group 2 and 3) had higher rates of adverse events than those with proportionate TR (21% and 38% versus 8%; P = 0.010 and P &amp;lt; 0.001, respectively; Figure) and were independently associated with poor outcomes on multivariate analysis. Importantly, this novel framework outperformed the TR grading system recommended by current guidelines, which was unable to effectively stratify prognosis in this population (Hazard Ratio for severe versus moderate TR 1.42; 95% CI 0.84-2.38; P = 0.194). Conclusion Disproportionate TR is independently associated with poor prognosis in patients undergoing tricuspid annuloplasty. Characterization of TR severity to RV size and function may aid patient selection and risk stratification for tricuspid annuloplasty. Abstract Figure.

Impact of regurgitant orifice ellipticity on quantitation of tricuspid regurgitation using the proximal isovelocity surface area method

Abstract Funding Acknowledgements Type of funding sources: None. Background The proximal isovelocity surface area (PISA) method to quantify tricuspid regurgitation (TR) severity relies on the geometric assumption of a circular, planar regurgitant orifice. However, the TR orifice is often non-circular resulting in underestimation of TR severity when calculating the effective regurgitant orifice area (EROA) and regurgitant volume (RegVol). Purpose To evaluate the effect of ellipticity of the tricuspid annulus on EROA-PISA correlation with quantitative Doppler (EROA-Dopp), and three-dimensional vena contracta area (VCA-3D). Methods Patients undergoing both transthoracic (TTE) and transesophageal (TEE) echo evaluation of TR severity were included in this study. Regurgitant orifice ellipticity was calculated as the ratio of the vena contracta maximum and minimum widths (VC-Ratio). Quantification of EROA and RegVol were performed on TTE for EROA-PISA and EROA-Dopp. Vena contract area was measured on TEE (VCA-3D). Results Of 44 total pts, the median age was 80 ± 9, 61% were female, 89% had atrial fibrillation, (86%) had functional TR, 32% were graded as severe, and 71% had a EROA-PISA ≥ 0.4 cm2. Median VC-Ratio was 1.3 (IQR 1.1-1.8) and was used to differentiate more circular orifices (VC-Ratio &amp;lt;1.3) from more elliptical orifices (VC-Ratio ≥1.3) (Table). EROA-PISA was significantly smaller compared to EROA-Dopp and VCA-3D in the whole group as well as elliptical subgroups (p &amp;lt; 0.0001 for all). There was no significant difference between EROA-Dopp and 3D-VCA for the whole group, or in circular or elliptical orifice subgroups (p &amp;gt; 0.5 for all). EROA-PISA correlated better with both EROA-Dopp and VCA-3D in circular compared to elliptical orifices (Table). EROA-Dopp and VCA-3D demonstrated high correlation for both circular and elliptical orifices (r = 0.76, p &amp;lt; 0.0001 and r = 0.77, p &amp;lt; 0.0001 respectively). Conclusion Our study demonstrated that there is a significant difference in quantitative measurements of tricuspid regurgitant orifice area, with EROA-PISA significantly underestimating both EROA-Dopp and VCA-3D. In more circular orifices, the EROA-PISA correlation was higher, however EROA-Dopp and VCA-3D were still significantly larger. Whether EROA-Dopp and VCA-3D are more predictive of outcomes requires further study. Abstract Table 1 Abstract Figure 1

Real-world outcomes for tricuspid edge-to-edge repair: initial echocardiographic results from the TriClip bRIGHT study

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Abbott Background Tricuspid regurgitation (TR) is a frequent disease with a graded increase in mortality as disease severity increases. The TriClip tricuspid valve repair system (TVRS) recently gained CE mark approval in March 2020 as a transcatheter treatment option for severe TR. The bRIGHT study was initiated to evaluate real-world safety and efficacy in patients treated with the TriClip TVRS and gather data to better understand these patients and this disease. Purpose To report real-world, core lab adjudicated changes in TR severity and echocardiographic parameters from baseline through 30-day follow-up in subjects treated with tricuspid transcatheter edge-to-edge repair (TEER). Methods bRIGHT is a prospective, multi-center, single arm post-market study evaluating the safety and effectiveness of the TriClip device in symptomatic patients with severe TR. Detailed echocardiographic assessment was performed on all available echo data for the first 175 enrolled subjects by an independent echo core lab. TR was categorized using a 5-grade scale, with the traditional "severe" grade further characterized as severe, massive and torrential. Results At baseline, TR was "severe" in 98% (143/146) of subjects, which further stratifies to severe in 9% (13/146), massive in 63% (92/146) and torrential in 26% (38/146) of subjects using the 5-grade scale. At 30 days, TR was reduced by ≥1 grade in 81% of subjects, with 70% of subjects at moderate or less residual TR compared to only 1% at baseline (p &amp;lt; 0.0001, Figure 1). Vena contracta width decreased from 0.79 ± 0.56 mm at baseline to 0.41 ± 0.37 mm at 30 days. Effective regurgitant orifice (EROA) area decreased from 0.87 ± 0.57 cm2 at baseline to 0.38 ± 0.25 cm2 at 30-days. Similarly, regurgitant volume, PISA radius and jet area showed significant reductions (Table 1). RV end diastolic dimension decreased from 4.70 ± 0.85 cm at baseline to 4.22 ± 0.83 cm at 30 days. No changes were observed in right atrial volume or right ventricular function. Subjects were treated with 1.9 ± 0.7 clips on average, with less than a 1 mmHg increase in mean tricuspid valve gradient; average gradient was 1.12 ± 0.65, 1.92 ± 1.15 and 1.97 ± 1.81mm Hg at baseline, discharge and 30 days respectively. Tricuspid annular diameter was significantly higher in subjects with torrential TR at baseline compared to subjects with severe or massive TR (p &amp;lt; 0.001). Conclusions Tricuspid TEER with the TriClip device showed significant reduction in TR severity in a real-world setting. Significant reduction were seen in vena contracta width, PISA radius, EROA, regurgitant volume and jet area among others. The majority of patients had massive TR at baseline. Future studies in larger cohorts are needed to investigate the relationship between the extent of TR reduction and clinical outcomes. Abstract Figure 1 Abstract Table 1

Prevalence and Prognostic Importance of Massive Tricuspid Regurgitation in Patients Undergoing Tricuspid Annuloplasty With Concomitant Left-Sided Valve Surgery: A Study on Rheumatic Valvular Heart Disease.

BackgroundThe presence of tricuspid regurgitation (TR) is very common in patients with concomitant left-sided valve disease. Recent studies have advocated an additional grading of massive TR that is beyond severe. The present study sought to characterize the spectrum of TR in patients undergoing tricuspid annuloplasty (TA) and to evaluate the prognostic value of TR severity for post-operative outcome following TA.MethodsA total of 176 patients who underwent TA with combined left-sided valve surgery, secondary to rheumatic valvular heart disease, were prospectively evaluated. The severity of TR was quantified by effective regurgitant orifice area (EROA) using the proximal isovelocity surface area method. Patients were categorized as having non-massive TR (EROA < 0.6 cm2) or massive TR (EROA ≥ 0.6 cm2). Adverse outcome was defined as all-cause mortality or heart failure requiring hospital admission following TA.ResultsA total of 55 (31%) patients were considered to have massive TR. Patients with massive TR had a greater right ventricular dimension but a smaller left ventricular dimension compared with those with non-massive TR. After a median follow-up of 39 months, 35 adverse events occurred. Cox-regression analysis showed that both continuous EROA and dichotomized EROA (massive vs. non-massive TR) were independently associated with adverse events even after multivariable adjustment. Further, Harrell C index demonstrated that the addition of massive TR provided better discrimination ability of a prediction model to known prognosticators following TA.ConclusionsMassive TR is common and up to 31% of study population had massive TR. Massive TR was associated with adverse outcome in patients undergoing TA. Classification of the severity of TR by quantitative measures and identification of massive TR in patients with concomitant left-sided valve disease are essential when considering the optimal timing of corrective surgery.

Quantified mitral regurgitation and left atrial function in heart failure with reduced ejection fraction: interplay and outcome implications.

The clinical and prognostic importance of functional mitral regurgitation (FMR) in heart failure patients with reduced ejection fraction (HFrEF) has been highly debated. This study aims to define FMR linkage to cardiovascular (CV) outcomes and the interplay with left atrial (LA) function in a prospective cohort of consecutive HFrEF outpatients. Overall, 286 consecutive outpatients with chronic HFrEF were prospectively enrolled. FMR was quantified by effective regurgitant orifice area (EROA). Global peak atrial longitudinal strain (PALS) was measured by speckle tracking echocardiography. The primary endpoint was a composite of congestive heart failure hospitalization or CV death. During a mean follow-up of 4.1 ± 1.5 years, the primary endpoint occurred in 99 patients (35%). The spline modelling of the risk by FMR severity showed an excess event risk starting at about the EROA value of 0.1 cm2 . There was a remarkable graded association between the EROA strata, even if tested per 0.1 cm2 increase, and the risk of CV events (hazard ratio [HR] EROA per 0.10 cm2 increase: 1.42, 95% confidence interval [CI] 1.19-1.68; p < 0.0001). EROA ≥0.30 cm2 was associated with CV events regardless of LA function (HR 2.34, 95% CI 1.29-4.19; p=0.005). Less severe FMR (EROA ≥0.10 cm2 ) was associated with a dismal outcome only in patients with reduced LA function (PALS <14%) (5-year CV event rate 51 ± 4%); conversely, the risk of events was relative reduced when preserved global PALS and FMR coexisted (5-year CV event rate 38 ± 6%). Our results refine the independent association between FMR and CV outcome among HFrEF outpatients. Within a moderate EROA range, LA function mitigates the clinical consequences of mitral regurgitation, providing measurable proof of the interplay between regurgitation and LA compliance.

Evolution of right ventricular dysfunction and tricuspid regurgitation after TAVI: A prospective study

BackgroundRight ventricular (RV) dysfunction and tricuspid regurgitation (TR) may impact prognosis of patients undergoing Transcatheter Aortic Valve Implantation (TAVI). We aimed to evaluate the evolution of previous RV dysfunction and/or significant TR after TAVI procedure. MethodsAll patients undergoing TAVI between January 2018 and January 2019 were enrolled in this prospective cohort. Patients with at least one right heart (RH) abnormality at baseline including RV dysfunction (TAPSE < 17 mm, S-wave < 9.5 cm/s, Fractional area change < 35%, Strain > −20%, Tei > 0.54) and/or significant TR (Effective Regurgitant Orifice Area ≥ 40 mm2 and/or Regurgitant Volume ≥ 45 mL) underwent transthoracic echocardiography at day 1 and 6-month after TAVI. The primary endpoint was the regression of pre-TAVI RV dysfunction and/or significant TR at 6-month follow-up. ResultsThe study enrolled 144 patients including 76 women (52.8%) with a mean age of 81.1 ± 6.8 yo, a mean EuroSCORE 2 of 5.2 ± 3.9%. At least one RH abnormality was observed in 53 patients (36.8%). At 6-month, at least one RV dysfunction parameter significantly improved in 26 patients (63.4%), TAPSE increasing from 13.0 ± 2.6 to 16.0 ± 9.8 mm, p < 0.0001 and S-wave from 7.7 ± 1.2 to 10.0 ± 2.6 cm/s, p = 0.004. Among 31 patients with baseline significant TR, TR decreased in 14 (45.2%); p = 0.003. Among patients with baseline RH abnormalities, 13 (24.5%) fully recovered. Baseline significant TR was predictive of 6-month clinical outcomes (OR = 3.1, 95%CI = [1.01–9.0], p = 0.03). ConclusionIn our recent intermediate surgical risk TAVI population, RV dysfunction and/or significant TR are frequent at baseline and fully or partially recover in most patients at 6-month follow-up.

Transesophageal echo-derived left ventricular ejection fraction versus myocardial performance index in predicting outcome following coronary artery bypass grafting surgery

BACKGROUND AND AIMS: Although left ventricular ejection fraction (LVEF) is the most commonly studied echocardiographic parameter for predicting postoperative outcome, its utility is limited by its preload dependency and ability to measure the only systolic function of the left ventricle. The myocardial performance index (MPI), a ratio obtained by summing up the time required for isovolumetric contraction and relaxation against the systolic ejection phase of the cardiac cycle, is the least studied parameter of left ventricular performance in perioperative settings. So, being a composite measure of systolic and diastolic function of the heart, we hypothesized that MPI can be a better predictor of postoperative outcome following coronary artery bypass grafting (CABG). The present study aimed at finding a correlation of LVEF and MPI with postoperative outcome indicators such as vasoactive inotropic score (VIS), the requirement of intra-aortic balloon pump (IABP) to maintain cardiac output, duration of mechanical ventilation, stay in the intensive care unit (ICU), postoperative morbidity and mortality.METHODS: A prospective, observational study was conducted on 110 subjects, scheduled for elective CABG. Transesophageal echocardiography (TEE) was performed after induction of anesthesia and before coronary grafting. Patients with no or grade I mitral regurgitation (vena contracta-VC <0.3 cm, effective regurgitant orifice area <0.2 cm2) and those in normal sinus rhythm were included. Patients with arrhythmia and MR of more than grade I (VC >0.3 cm, EROA >0.2 cm2) were excluded. Pre-CABG LVEF was measured using Simpson's biplane method. MPI was measured using Pulsed-wave Doppler across mitral inflow and left ventricular outflow tract. Subjects were labeled as “good” and “poor” outcomes based on standard criteria for defining the immediate postoperative outcome. Pre-CABG MPI and LVEF were correlated with these postoperative outcome variables following CABG.RESULTS: Of 110 subjects, 14 were excluded due to the presence of more than grade I MR (n = 8) and arrhythmias (n = 6) before CABG. Out of 96 subjects, 66% (n = 63) had “good” outcome and 34% (n = 33) had a “poor” outcome. Pre-CABG MPI and LVEF were (0.51 ± 0.12 and 47.2% ± 8.8%) in subjects with “good” compared to (0.57 ± 0.13 and 42.00% ± 8.70%) (P = 0.032 and 0.007 respectively) “poor” outcome following CABG. A higher pre-CABG MPI (0.57 ± 0.13) alone significantly correlated with increased VIS (r = 0.325, P = 0.001) in contrast to lower LVEF (42% ± 8.7%) (r = −0.181, P = 0.077). Both, lower precardiopulmonary bypass LVEF (40.46% ± 8.81%) and higher MPI (0.6 ± 0.11) were significantly correlated with increased ICU stay in days (r = −0.218 and r = 0.287, respectively). The mean MPI was 0.57 ± 0.08 and LVEF was 39.55% ± 4.05% in those subjects who succumbed in the postoperative period following CABG.CONCLUSION: MPI was a relatively better predictor of postoperative outcome following CABG. Increased Pre-CABG MPI was more consistent with the postoperative inotropic and vasopressor requirement. The requirement of an IABP to maintain cardiac output following CABG and mortality was correlated well with both low preoperative LVEF and higher MPI values.