Left Valvular Disease Research Articles

Management of tricuspid regurgitation, what is impacting mortality?

Tricuspid regurgitation (TR) is a common condition. It is often secondary to mitral or mitro aortic pathology. Its correction is complex and requires multi-parametric analysis of the associated disease with variable results. The aim of our study is to describe management of TR and analyze mortality factors. Our series is a descriptive and analytical retrospective study and has included 41 patients with tricuspid insufficiency associated to left valvular disease admitted in Cardiology Center, Mohammed V Military Hospital of Rabat, Morocco. All of them had concomitant corrective surgery of left valvular disease with tricuspid plasty. The mean age was 50.98 years. 92.7% of patients presented dyspnea (class III of NYHA). 73.2% had atrial fibrillation and 14.63% had a creatinine value of ≥ 15 mg/L. Tricuspid plasty has been performed on 40 patients. 97.6% of those patients benefited from prosthetic ring and 4.8% from De Vega technique. Mortality was 17.07% attributed to hemodynamic failure (5 cases), multiple ischemic stokes (1 case) and septic shock (1 case). Class ≥ IV of dyspnea, atrial fibrillation, renal failure and Left ventricle dysfunction were statistically associated with mortality in our series with a value of P ˂ 0.05, which is consistent with the literature's data. Management of tricuspid insufficiency certainly requires patients’ selection among candidates requiring left valvular surgery. It is to be performed concomitantly with correction of left heart valve diseases considering the high perioperative and at long term morbidity and mortality.

Severe tricuspid regurgitation as first manifestation of a primary ovarian carcinoid tumor

A 52-year-old woman presented with a 1 year-history of reduced exercise tolerance and fatigue. Physical examination revealed a grade II/VI systolic murmur at the left sternal border. Transthoracic echocardiography showed thickened tricuspid leaflets with retraction and restricted movement, resulting in a severe tricuspid regurgitation. The characteristic pattern aroused the suspicion of a systemic or hormonal etiology. 24-Hour urine analysis revealed an increased level of 5hydroxyindoleacetic acid and abdominal computed tomography (CT) showed a large tumor in the pelvis; however, without the presence of liver metastasis. During uncomplicated trans-abdominal surgery a large mass in the ovary was removed, and pathology showed a primary ovarian carcinoid tumor. One year after the diagnosis, patient remains clinically stable without signs of right heart failure and an excellent exercise tolerance. This case report shows that isolated tricuspid valve pathology in the absence of left valvular disease may raise the suspicion for an atypical cause of valvular dysfunction, in which carcinoid tumor is included.

An Uptated View on the Approach to Tricuspid Regurgitation

The incidence of tricuspid regurgitation (TR) associated with left valvular disease is significant ranging from 8% to 35% of cases. , This is most common in conjunction with mitral valve disease but association with aortic valve pathology is not uncommon and frequently related to rheumatic valve disease and much rarer in association with degenerative mitral valve disease. In most cases, the tricuspid regurgitation is so called “functional”, in other words, secondary to dilatation of the annulus as a consequence of [...]

Sex-Specific Differences in Etiology and Prognosis in Patients With Significant Tricuspid Regurgitation

The aim of this study was to assess differences in etiology, comorbidities, echocardiographic parameters, and prognosis between men and women with significant tricuspid regurgitation (TR). Clinical and echocardiographic characteristics of 1569 patients (age 71 [62 to 78] years) at first diagnosis of significant TR were compared between men and women. Patients with congenital heart disease or previous tricuspid valve surgery were excluded. TR etiologies were defined as primary, left valvular disease related, left ventricular (LV) dysfunction related, pulmonary hypertension related, or isolated. The primary endpoint was all-cause mortality. Sex-specific differences in outcomes were compared in the total population and after propensity score matching. There were 798 (51%) women and 771 (49%) men in the study population. Women were diagnosed with significant TR at an older age compared with men (72 [62 to 79] years vs. 70 [61 to 77] years; p = 0.003). The TR etiology in women was more often left valvular disease related and isolated whereas men more often had LV dysfunction related TR. In the total population women had better 10-year survival compared with men (49% vs. 39%; p=0.001). After propensity score matching, the influence of sex on survival was neutralized (p = 0.228) but the TR etiologies remained significantly associated with all-cause mortality. Patients with left valvular disease or LV dysfunction related TR had lower survival compared with patients with primary TR (p = 0.004 and p = 0.019, respectively). In conclusion, long-term survival of patients with significant TR was similar between men and women after propensity score matching, while the etiology of TR remained significantly associated with all-cause mortality.

Non-invasive Assessment of Pulmonary Hypertension Using a Small Portable Device Measuring Cardiac Intervals: Design for Telemonitoring

Background Pulmonary hypertension is a condition that pulmonary artery pressure iselevated. The diagnosis and monitoring of pulmonary artery pressure oftenrequiring invasive procedures. HEMOTAG, is a small portable device that usesmicro-sensors to capture cardiac vibrations and electrocardiogram, transducedvia thoracic electrodes. It is a viable option to measure cardiac timeintervals (CTIs), surrogate markers of intracardiac pressure. In this study,mitral valve closure (MVC) and isovolumetric contraction time (IVCT) wereassessed as valid markers for pulmonary artery pressure, compared againstintracardiac pressures measured simultaneously at the time of right heartcatheterization. Methods In 37 patients, mean pulmonary artery pressure (mPAP) was measured duringcardiac catheterization. Simultaneously, Hemotag analyzed CTIs: MVC and IVCT.The predictability value of non-invasively HEMOTAG-derived CTIs- MVC and IVCT -were assessed to determine elevated mPAP. Linear correlation analysisbetween CTIs and mPAP was performed. Sensitivity, specificity, positive, andnegative predictive values were calculated. Results Mean age was 65.40 ± 12.42years, mean ejection fraction was 54.61 ± 14.24%,48% were women, 55.2% had left valvular disease, 27.6% had systolicdysfunction, and mean mPAP was 16.10 ± 5.40 mmHg. With a paired dichotomous interpretation,sensitivity of 81% was noted for MVC and specificity of 100% was observed withIVCT. A receiver operator characteristic curve was employed to assessperformance with an AUC of 0.71 and 0.64 for MVC and IVCT, respectively. Therewere no strong correlations observed between mPAP and CTIs (Table 1). Conclusions HEMOTAG detected elevated mPAPwith good sensitivity and high specificity. This preliminary study hasdemonstrated the feasibility of estimating mPAP using a portable, non-invasivedevice that empowers patients to transmit such data from home instantaneouslyto providers. Further studies are required to validate HEMOTAG as apoint-of-care non-invasive assessment for pulmonary hypertension patients.

P4510Impact of secondary tricuspid regurgitation on survival in heart failure - insights from COMMIT-HF registry

Abstract Background Functional tricuspid regurgitation (fTR) is common in left sided heart disease, especially in patients with concomitant left-sided valvular diseases and can lead to functional impairment and reduced survival. However, the impact of fTR on survival in chronic heart failure with reduced left ventricular ejection fraction (HFrEF) without severe left valvular diseases (LVD) is not fully established. The aim of the present study was to observe if moderate to severe fTR may influence the survival in patients with HFrEF without severe LVD. Methods We have analyzed a large single-center registry (n=2731) of HFrEF patients treated in a large-volume cardiovascular center between 2009–2015. After exclusion of patients with severe aortic and mitral valve disease we have included 2435 patients with HFrEF (left ventricular ejection fraction (LVEF) ≤35%). Functional moderate to severe tricuspid regurgitation without severe left valvular diseases was present in 465 patients. Twelve -month vital status was available for the whole patient population. Univariate and multivariate Cox proportional hazard regression models were performed to evaluate the relationship between moderate to severe fTR and mortality in the study group. Results Comparison of clinical data of fTR and non-fTR in HFrEF patients revealed some significant differences (age 63.3±12.9 vs 61.3±12.4, p=0.002; female sex 25.8% vs 17,9%, p<0.001; chronic kidney disease stage III-V 45.3 vs 26.6%, p=0.001; atrial fibrillation 52.4% vs 28.5%, p<0.001). Twelve-month all-cause mortality was over 2-fold higher in the fTR group (21.2% vs 8.1%, p<0.001). There were no significant differences with regard to the medical treatment, implantable defibrillator or cardiac resynchronization therapy. The presence of fTR was identified as an independent echocardiographic factor impaired 12-month all-cause survival (HR 1.59, CI 1.2- 2.09, p<0.001, figure 1) Conclusion Apart from the LVEF, the presence of moderate to severe fTR may predict 12-month all-cause mortality in patients with HFrEF. Acknowledgement/Funding None

Tricuspid valve regurgitation: epidemiology and pathophysiology.

Compared with the vast literature concerning the prevalence, pathophysiology, and outcome of left valvular disease, the data concerning tricuspid regurgitation (TR) is very limited. In this review we summarized the present data concerning these important issues. We show that TR is as prevalent as aortic stenosis in the community, with increasing prevalence with age, and much more common in women. We review the present knowledge concerning the pathogenesis of TR, focusing on functional TR. We show that functional TR is multifactorial, resulting from both RV remodeling and pulmonary hypertension, and/or atrial fibrillation resulting in right atrial dilatation. We demonstrate that RV remodeling, mostly in the mid segment, will result in tethering. On the other side, right atrial remodeling will mostly result in pure annular dilatation and loss of valvular/annular coverage reserve. Finally, due to the heterogeneous nature of TR we review the outcome data for each presentation of TR and show that in most contexts TR is associated with very poor outcome, even when adjusted for left ventricular systolic, and diastolic function, pulmonary pressure, and RV dysfunction.

Secondary tricuspid valve regurgitation: a forgotten entity

### Learning objectives The tricuspid valve was virtually ignored for a long time in the past. However, the incidence of tricuspid insufficiency associated with left valvular disease is quite significant,...

Phenotypic patterns of right ventricular dysfunction: analysis by cardiac magnetic imaging

The aim of this study was to use magnetic resonance imaging (MRI) to classify the morphological changes and remodeling of the right ventricle (RV) that occur in different clinical situations and that have an impact on RV function. Most literature has traditionally focused on the left ventricle (LV) and as a result, few studies analyze RV behavior and remodeling. The study evaluated all cardiac MRI performed at our center from 2008 to 2010. We retrospectively identified 159 patients who had some sign of right ventricular dysfunction (RVD) based on MRI findings. We classified patients according to a combination of criteria for RVD and the presence of left ventricle dysfunction (LVD). We considered RVD as any of the following abnormalities: i) depressed RV function; ii) RV dilatation; iii) RV hypertrophy. LVD was considered when there was atrial dilatation, LV hypertrophy, LV dilatation and/or depressed LV function. We obtained 6 pathophysiological patterns: RV pressure overload (1.9%), RV volume overload (15.7%), RV volume overload + LVD (32.7%), depressed RV function + LVD (42.1%), mixed RV overload + LVD (6.9%) and other (0.6%). The most frequent etiology was congenital heart disease (33.3%), followed by idiopathic dilated cardiomyopathy (18.2%), left valvular disease (17.6%), ischemic heart disease (15%), pulmonary disease (9.8%), and other (6.1%). This study helps to classify the different patterns that RV can adopt in different clinical situations and can, therefore, help us to understand the RV pathophysiology.

Phenotypic Patterns of Right Ventricular Dysfunction. Analysis by Cardiac Magnetic Resonance Imaging

Objectives: To classify by magnetic resonance imaging (MRI) the morphological changes and remodeling of the right ventricle (RV) that occur in the different clinical scenarios that have impact on this ventricle. Background: Most of the scientific evidence in cardiology has traditionally focused on the left ventricle (LV). As a result, there are few studies focusing on the analysis of RV behavior and remodeling. Methods: This was a descriptive study evaluating all cardiac MRI exams performed at our center from 2008 to 2010. We retrospectively identified 159 patients who had some sign of right ventricular dysfunction (RVD) based on MRI findings. We classified patients based on a combination of criteria for RVD and the presence of left ventricle dysfunction (LVD). We considered RVD as any of the following abnormalities: 1) Depressed RV function; 2) RV dilatation; 3) RV hypertrophy. LVD was considered when there was atrial dilatation, LV hypertrophy, LV dilatation and/or depressed LV function. Results: We obtained 6 pathophysiologic patterns: RV pressure overload (1.9%), RV volume overload (15.7%), RV volume overload + LVD (32.7%), depressed RV function + LVD (42.1%), mixed RV overload + LVD (6.9%) and other (0.6%). By etiologies, the most frequent etiology was congenital heart disease (33.3%), followed by idiopathic dilated cardiomyopathy (18.2%), left valvular disease (17.6%), ischemic heart disease (15%), pulmonary disease (9.8%), and other (6.1%). Conclusions: This study helps to classify the different patterns that the RV can adopt in different clinical scenarios and thus help us to understand the pathophysiology of the RV

Bioprosthetic Pulmonary and Tricuspid Valve Replacement in Carcinoid Heart Disease From Ovarian Primary Cancer

Carcinoid tumors usually originate in the gastrointestinal tract, but in rare instances they may arise in other organs. A patient with severe tricuspid and pulmonary regurgitation because of carcinoid syndrome successfully underwent double valve replacement using bioprostheses. The patient was finally diagnosed with carcinoid heart disease from an isolated ovarian carcinoid cancer. The diagnosis of carcinoid syndrome should be recognized as an etiology in patients with organic tricuspid and pulmonary regurgitation without left valvular disease.