Persistent Tricuspid Regurgitation Research Articles

Abstract 4137396: Evolution of Tricuspid Regurgitation and Clinical Outcomes in Patients with Heart Failure with Preserved Ejection Fraction: Insights from the PURSUIT-HFpEF Registry

Background: Tricuspid regurgitation (TR) is prevalent in patients with heart failure with preserved ejection fraction (HFpEF). However, due to its high vulnerability to hemodynamic loads, the long-term observation may heighten its prognostic values. Purpose: To investigate the evolution of TR and its impact on clinical outcomes in patients with HFpEF. Methods: An analysis was performed from a prospective multicenter observational registry for HFpEF (PURSUIT-HFpEF Registry) conducted in the Osaka region of Japan. A total of 1238 patients hospitalized for acute heart failure (HF) (diagnosed by using Framingham criteria) met the inclusion criteria: an LVEF ≥50% and brain natriuretic peptide level ≥100 pg/ml. After excluding patients who died within 1 year, we included 761 patients (age 82 ± 9 years; men, 45%; atrial fibrillation, 37%) whose echocardiographic data at discharge and 1 year were available. Results: At discharge, 165 patients (21.7%) had moderate to severe TR, which increased to 185 patients (24.3%) at 1 year. Patients were categorized into 4 groups based on the TR evolution: no or mild TR that remained unchanged (n = 522 [69%]), no or mild TR that worsened to moderate to severe (n = 74 [9.7%]), moderate to severe TR that improved to no or mild (n = 54 [7.1%]), and moderate to severe TR that remained unchanged (n = 111 [15%]). During a subsequent follow-up of 33 months, patients with persistent moderate to severe TR had significantly higher mortality rates than the other groups (25.7% vs. 27.0% vs. 27.8% vs. 44.1%, log-rank p < 0.001). Even after adjusting for age, sex, body mass index, left atrial diameter, and left ventricular filling pressure, persistent moderate to severe TR was independently associated with subsequent mortality (hazard ratio, 2.06, 95% confidence interval 1.42-2.99, p < 0.001) Conclusions: During a one-year follow-up, changes in the TR severity were not rare in patients with HFpEF. Persistent moderate to severe TR alone was associated with subsequent mortality, highlighting the need to address persistent TR to improve the prognosis.

Insulin-like growth factor binding protein 2 predicts course of concomitant right-ventricular dilation and tricuspid regurgitation after transcatheter edge-to-edge mitral valve repair

Abstract Aims Right ventricular (RV) dilation and secondary tricuspid regurgitation (TR) are highly prevalent comorbidities in patients with mitral regurgitation and are associated with a worse prognosis. TR improvement after successful transcatheter edge-to-edge mitral valve repair (M-TEER) is reported regularly, however specific factors contributing to the recovery of RV function and TR after M-TEER are poorly understood. Particularly the role of serum biomarkers in this context is unclear. We aimed to identify specific biomarkers associated with the course of concomitant RV dilation and TR after M-TEER. Methods and Results We prospectively included 242 patients undergoing M-TEER at our center and obtained pre-procedural blood samples for biomarker analysis. A commercial multiplex protein assay (Cardiovascular III, Olink, Uppsala, Sweden) was used to quantify expression levels of 92 defined biomarkers. We then analyzed differences in biomarker expression between patients with and without right ventricular reverse remodeling (RVRR) as defined by improvement of concomitant TR by at least one grade and/or downsizing of the basal RV diameter of at least 10%. 242 patients were included in this analysis, 94 had no/mild concomitant TR at baseline, 148 had moderate/severe TR. RV diameters correlated with TR severity and were significantly larger in patients with moderate/severe TR. At baseline, expression of numerous cardiometabolic biomarkers was significantly higher in patients with moderate/severe TR. These included NT-proBNP (1.9-fold, p < 0.001), matrix metalloproteinase 2 (1.4-fold, p < 0.001) as well as insulin-like growth factor binding proteins 1 (1.7-fold, p < 0.001), -2 (1.3-fold, p = 0.001) and -7 (1.4-fold, p < 0.001). Follow-up analysis was performed in patients with initial moderate/severe TR. The course of TR and RV dimensions three months after M-TEER could be assessed in 99 patients (56 with moderate TR, 43 with severe TR). RVRR had occurred in 50 patients (50.5%). Patients without RVRR had a higher prevalence of chronic pulmonary disease (24.5 vs. 2.2%, p < 0.001). No further differences in clinical characteristics were found. Specifically, RV diameter, systolic pulmonary artery pressure (sPAP) and right-ventricular systolic function did not differ substantially between both groups. Strikingly however, the expression of insulin-like growth factor binding protein 2 (IGFBP-2) was significantly higher in patients, who did not develop RVRR (fold change 1.3 compared to patients with RVRR, p = 0.022). After adjustment for covariates IGFBP-2 was independently associated with absence of RVRR (Odds Ratio 2.078, 95% Confidence interval 1.108 – 3.897, p = 0.023). Conclusions In patients undergoing M-TEER with concomitant moderate or severe TR, numerous cardiometabolic biomarkers including IGFBP-2 are upregulated. Higher levels of IGFBP-2 at baseline are independently associated with persistent TR and/or RV dilation after M-TEER.

Dynamic evolution of tricuspid regurgitation during hospitalization in patients with acute decompensated heart failure.

Secondary tricuspid regurgitation (TR) is associated with poor prognosis in acute decompensated heart failure (ADHF). However, its dynamic evolution in response to volume status and treatment has never been previously investigated. In this study, we sought to explore the in-hospital evolution of TR in ADHF patients and to assess its prognostic implications. We retrospectively enrolled patients admitted for ADHF with ≥2 in-hospital echocardiographic evaluations of TR. Patients were categorized, according to TR evolution, into persistent moderate-severe TR, improved TR (from moderate-severe to trivial-mild) and persistent trivial-mild TR. The primary endpoint was a composite of 5-year all-cause mortality and heart failure hospitalization (HFH). A total of 1054 patients were included. Of 318 patients (30%) with moderate-severe TR at admission, 49% improved TR severity and showed better trends of decongestion, whereas those who maintained persistent moderate-severe TR had characteristics of more severe heart failure at admission and discharge. Atrial fibrillation, previous heart failure and higher dosage of loop diuretics before admission were associated with a lower probability of improved TR. After adjustment, improved TR was associated with lower risk of 5-year all-cause mortality/HFH compared with persistent moderate-severe TR (hazard ratio [HR] 0.524, p = 0.008) and no different from persistent trivial-mild TR (HR 0.878, p = 0.575). Results were consistent across all subgroups of in-hospital variation of mitral regurgitation. Among ADHF patients with moderate-severe TR at admission, 49% had an in-hospital improvement in TR severity, which was associated with a reduction in risk of 5-year all-cause mortality and morbidity outcomes.

Severity of tricuspid regurgitation predicts risk of atrial fibrillation recurrence after pulmonary vein isolation

Abstract Background Atrioventricular valve regurgitation (AVVR) results in atrial remodeling, thus promoting the formation of a substrate for atrial fibrillation (AF). On the other hand, AF may cause functional AVVR by annular dilatation of the atria. In this vicious circle, the identification of the leading pathomechanism and consequently the optimization of treatment can be challenging. Purpose Our aim was to investigate whether the presence of significant AVVR and especially of tricuspid regurgitation (TR) affects the efficacy of catheter-based pulmonary vein isolation (PVI) for AF. Furthermore, we evaluated whether rhythm control for AF through PVI could lead to an improvement of AVVR severity. Finally we examined the effect of concomitant right atrial flutter on the arrhythmic outcome in patients with significant TR . Methods We enrolled patients undergoing first-time PVI for symptomatic AF. We compared the severity of AVVR at the time of the procedure as well as after 6 months, using transthoracic echocardiography. Moderate to severe AVVR was defined as significant. Moreover, we evaluated whether the presence of significant AVVR, at baseline and 6 months after the procedure, could serve as an independent predictor for AF recurrence. Results Out of 320 consecutive patients (mean age 66.3 ± 10 years, 61.6% male, 60% paroxysmal AF) , significant TR at baseline was documented in 13.1%, while significant mitral regurgitation (MR) in 10.9%. Six months after PVI, the proportion of patients with moderate to severe TR (13.1% to 7.2%; p<0.001) and MR (10.9% to 6.6%; p<0.001) decreased significantly. Compared to patients with post-interventional improvement of significant TR, right atrial (RA) dilatation at baseline was more pronounced in patients with persistent significant TR (RA area 20.2 ± 4.4 vs. 26.6 ± 8.3 cm2; p=0.002). The presence of significant TR, particularly without improvement during the follow-up, independently increased the risk of atrial fibrillation recurrences. Even after propensity-score matching, TR at baseline remained an independent risk predictor regarding recurrent atrial fibrillation (HR 2.2 [95% CI, 1.1 - 4.9]; p=0.045). Among patients with significant TR, those with documented right atrial flutter were at high risk for recurrence of atrial arrhythmia (HR 2.69 [95% CI, 1.0 – 6.9]; p=0.039), despite the additional ablation of the cavo-tricuspid isthmus. Significant MR was not associated with increased risk of atrial arrhythmias. Conclusion In patients with symptomatic AF undergoing PVI, the presence of moderate to severe TR, particularly without improvement 6 months after the procedure, was associated with a worse arrhythmic outcome. Further investigations to enhance the understanding of the underlying electrophysiological substrate and the need for tailored ablation strategies are warranted.TR as predictor for AF(propensity score)AVVR improvement after PVI

Abstract 16252: A Survival Analysis in Patients With Tricuspid Regurgitation and Cardiac Resynchronization Therapy

Introduction: Cardiac resynchronization therapy (CRT) is a well established treatment in heart failure with reduced ejection fraction. It involves simultaneous pacing of the left and right ventricles to restore ventricular synchrony, leading to increased cardiac output and contractility. The impact of CRT on tricuspid regurgitation (TR) severity has not been evaluated. Studies have shown that up to 22% of CRT recipients have significant TR, and of these patients only 41% will improve to no or mild TR. For a majority of patients who have persistent significant TR despite CRT, long term outcomes are put into question. Hypothesis: Tricuspid regurgitation adversely affects the response and survival of CRT patients. Goals: To analyze the prevalence of TR in a cohort of patients admitted to The Christ Hospital who have undergone CRT. To assess the association between TR after CRT and long-term survivability. Methods: This is a retrospective cohort study conducted at The Christ Hospital in Cincinnati Ohio. 13292 patients diagnosed with tricuspid regurgitation (mild to severe) in total were included. 184 of these patients underwent CRT, and survival probability was measured against the no CRT group. Kaplan meier method was used for analysis. Results: Survival probabilities at 1 year, 2 years, and 3 years for patients with CRT = 0.769, 0.661, and 0.558 respectively. Patients without CRT = 0.911, 0.863, and 0.826 respectively. Hazard ratio = 2.84 (2.33, 3.47) compared to solely tricuspid regurgitation. Conclusions: Patients with TR without CRT had greater survival rates up to three years compared to TR with CRT. The risk of death in the TR with CRT was 2.84 times higher than the no CRT group. It can be further investigated why the no CRT group had a greater survival rate than CRT. Limitations include variable assessments of TR due to the subjective nature of grading TR. Future research could investigate the difference between primary (device-related) and secondary TR in this cohort.

Secondary tricuspid valve regurgitation after isolated aortic valve replacement: outcomes and predictors.

We sought to assess the evolution of secondary tricuspid regurgitation (TR) after isolated aortic valve replacement (AVR) and its impact on mortality and to identify possible clinical and echocardiographic predictors of persisting and new-onset TR (TR de novo) after isolated AVR. Clinical and echocardiographic data of 441 patients, consecutively operated for isolated AVR between January 2017 and January 2020, were retrospectively collected. Four time points were included: preoperative, discharge, 3-6 months and last available follow-up. We followed patients with at least moderate TR (TR ≥2) over time and monitored the impact on survival. Logistic regression analysis was performed to identify possible predictors of persistent TR and TR de novo. Median follow-up was 33 months. Incidence of TR ≥2 changed over the time points. Twenty-three percent of patients with preoperative TR ≥2 had persistent TR at 3-6 months follow-up, and this phenomenon was predicted by age at regression analysis. Preoperative TR ≥2 was associated with a 3-fold higher risk to die. At 3- to 6-month follow-up, 12% of patients developed TR de novo. At least moderate preoperative mitral regurgitation (≥2) was predictive of TR de novo. Patients with TR ≥2 undergoing isolated AVR had worse long-term survival, and this was particularly evident in the elderly. Older patients were also more prone to have persistent TR after AVR. Some patients developed TR de novo after isolated AVR, but this did not affect survival.

Multidetector CT-derived tricuspid annulus measurements predict tricuspid regurgitation reduction after transcatheter aortic valve replacement

To use multidetector row computed tomography (MDCT)-derived tricuspid annulus (TA) measurements to identify predictors for tricuspid regurgitation (TR) reduction after transcatheter aortic valve replacement (TAVR), and to investigate the impact of TR change on prognosis. A retrospective, single-centre study was conducted on consecutive patients who underwent TAVR with concomitant baseline mild or more severe TR from April 2012 to April 2022. TA parameters were measured using MDCT. The study comprised 266 patients (mean age 74.2±7.6 years, 147 men) and 45.1% had more than one grade of TR reduction at follow-up. Independent predictors of TR reduction at follow-up were distance between TA centroid and antero-septal commissure (odd ratio [OR] 0.776; 95% confidence interval [CI]: 0.672-0.896, p=0.001), baseline TR of moderate or worse (OR 4.599; 95% CI: 2.193-9.648, p<0.001), systolic pulmonary artery pressure (OR 1.018; 95% CI: 1.002-1.035, p=0.027), age (OR 0.955; 95% CI: 0.920-0.993, p=0.019), and pre-existing atrial fibrillation (OR 0.209; 95% CI: 0.101-0.433, p<0.001). Patients without TR reduction had higher rates of rehospitalisation (hazard ratio [HR] 0.642; 95% CI: 0.413-0.998, p=0.049). The MDCT-derived TA parameter was predictive of TR reduction after TAVR. Persistent TR after TAVR was associated with higher rates of rehospitalisation.

Outcome of moderate-severe tricuspid regurgitation after pulmonary endarterectomy or balloon pulmonary angioplasty

Introduction and objectivesThe management of persistent moderate-severe tricuspid regurgitation (TR) in patients with chronic thromboembolic pulmonary hypertension after treatment with pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) is not well defined. This study aimed to analyze the progression and predictors of significant persistent postintervention TR and its prognostic impact. MethodsThis single-center observational study included 72 patients undergoing PEA and 20 who completed a BPA program with a previous diagnosis of chronic thromboembolic pulmonary hypertension and moderate-to-severe TR. ResultsThe postintervention prevalence of moderate-to-severe TR was 29%, with no difference between the PEA- or BPA-treated groups (30.6% vs 25% P=.78). Compared with patients with absent-mild postprocedure TR, those with persistent TR had higher mean pulmonary arterial pressure (40.2±1.9 vs 28.5±1.3mmHg P <.001), pulmonary vascular resistance (472 [347-710] vs 282 [196-408] dyn.s/cm5; P <.001), and right atrial area (23.0 [21-31] vs 16.0 [14.0-20.0] P <.001). The variables independently associated with persistent TR were pulmonary vascular resistance> 400 dyn.s/cm5 and postprocedure right atrial area> 22cm2. No preintervention predictors were identified. The variables associated with increased 3-year mortality were residual TR and mean pulmonary arterial pressure> 30mmHg. ConclusionsResidual moderate-to-severe TR following PEA-PBA was associated with persistently high afterload and unfavorable postintervention right chamber remodeling. Moderate-to-severe TR and residual pulmonary hypertension were associated with a worse 3-year prognosis.

Evolución y pronóstico de la insuficiencia tricuspídea moderada-grave tras tromboendarterectomía pulmonar o angioplastia de arterias pulmonares

Introduction and objectivesThe management of persistent moderate-severe tricuspid regurgitation (TR) in patients with chronic thromboembolic pulmonary hypertension after treatment with pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) is not well defined. This study aimed to analyze the progression and predictors of significant persistent postintervention TR and its prognostic impact. MethodsThis single-center observational study included 72 patients undergoing PEA and 20 who completed a BPA program with a previous diagnosis of chronic thromboembolic pulmonary hypertension and moderate-to-severe TR. ResultsThe postintervention prevalence of moderate-to-severe TR was 29%, with no difference between the PEA- or BPA-treated groups (30.6% vs 25% P=.78). Compared with patients with absent-mild postprocedure TR, those with persistent TR had higher mean pulmonary arterial pressure (40.2±1.9 vs 28.5±1.3mmHg P <.001), pulmonary vascular resistance (472 [347-710] vs 282 [196-408] dyn.s/cm5; P <.001), and right atrial area (23.0 [21-31] vs 16.0 [14.0-20.0] P <.001). The variables independently associated with persistent TR were pulmonary vascular resistance> 400 dyn.s/cm5 and postprocedure right atrial area> 22cm2. No preintervention predictors were identified. The variables associated with increased 3-year mortality were residual TR and mean pulmonary arterial pressure> 30mmHg. ConclusionsResidual moderate-to-severe TR following PEA-PBA was associated with persistently high afterload and unfavorable postintervention right chamber remodeling. Moderate-to-severe TR and residual pulmonary hypertension were associated with a worse 3-year prognosis.

326 STAGED ENDOVASCULAR TREATMENT FOR MULTIVALVULAR HEART DISEASE: A CASE REPORT

Abstract Background: Multiple valvular heart disease is a very prevalent condition and represents a challenge in terms of diagnosis and treatment. In patients undergoing cardiac surgery, multiple valvular lesions are often treated during the same procedure. In older high-risk patients, the treatment of choice for VHD is usually percutaneous: transcatheter aortic valve replacement (TAVR) has been widely developed in the past years and percutaneous interventions on other valvular lesions are rapidly evolving. In patients undergoing TAVR, concomitant severe tricuspid regurgitation (TR) is frequent and it's a marker of advanced disease. After TAVR, secondary TR can regress to a lower grade; persistent TR is associated with higher incidence of heart failure and mortality, so an additional intervention for TR is reasonable. The aim of this case report is to highlight the role of staged percutaneous treatment of multiple VHD as a new paradigm, with reassessment of other valvular lesion severity after the first endovascular valvular treatment Case description: We describe a case of successful staged percutaneous treatment for severe low flow – low gradient aortic stenosis in a 71 years old patient, with previous mitral valve replacement with mechanical valve and tricuspid annuloplasty, atrial fibrillation and COPD (STS score 9.5%). Four years after cardiac surgery she experienced worsening dyspnea and two hospitalizations for pulmonary edema; the echocardiography showed significant biventricular dysfunction, severe aortic stenosis (low-flow low-gradient, with contractile reserve at dobutamine stress echocardiography) and normal function of mitral prosthesis. The case was evaluated by a multidisciplinary ‘’Heart Team’’ and a decision was made to undergo TAVR and then reassess TR severity and patient symptoms. She underwent TAVR (Evolut Pro 26 mm direct implantation) using a ‘’less-invasive totally-endovascular’’ technique, without complications. Two month later the echocardiogram showed a little improvement in left ventricular systolic function and persistent severe tricuspid regurgitations; the patient was still symptomatic for leg swelling and fatigue. After a second evaluation from the ‘’Heart Team’’, she underwent successful transcatheter tricuspid valve-in-ring implantation (Edwards Sapien3 29) via right transgiugular approach, with no complications. 19 months after she was alive, with no more hospitalization, NYHA class II, on heart failure therapy; at an echocardiogram tricuspid regurgitation was mild-to-moderate. Discussion: Multivalular heart disease patients more often have several comorbidities, greater cardiac damage, that leads to higher incidence of heart failure and death than single VHD. In particular right ventricular dysfunction and tricuspid regurgitation, mostly secondary to pressure overload, are associated with adverse outcomes in severe aortic stenosis, especially in the ‘’low flow- low gradient’’ group. After treatment of a severe valvular disease, hemodynamic changes in pression and volume loads may improve the function of other valves, so previous valvulopaties can regress to a lower stage of severity, with a better prognosis and the possibility to avoid a second valvular treatment and all the procedural risks. Conclusion There is lack of data in the literature concerning the management of multiple VDH, which does not allow for evidence-based recommendations in current guidelines. Transcatherer interventions offer the option of a staged approach and a tailored treatment, after accurate evaluation by the Heart Team.

Clinical significance of right ventricular-pulmonary arterial coupling in patients with tricuspid regurgitation before closure of atrial septal defect.

Functional tricuspid regurgitation (TR) usually decreases after atrial septal defect (ASD) closure; however, it may persist and cause heart failure that requires treatment. We aimed to investigate clinical and echocardiographic factors predicting persistent TR after ASD closure. Among 348 adults who underwent isolated ASD closure between January 2010 and September 2020, 91 (26.1%) patients with significant TR (at least moderate degree) before ASD closure were included. Persistent TR was defined as significant TR on echocardiography at 6 months to 1 year after ASD correction. We comprehensively analyzed the echocardiogram before ASD closure, including speckle-tracking imaging. Right ventricular (RV)-pulmonary arterial (PA) (RV-PA) coupling was assessed by the ratio of RV global longitudinal strain (RV GLS) and tricuspid annular S' velocity to PA systolic pressure (PASP). Persistent TR was observed in 22 (24.2%) patients. Patients with persistent TR were significantly older and had larger TR jet areas and lower RV-PA coupling parameters than those without persistent TR. On multivariable regression, persistent TR was independently associated with age [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.01-1.14, p = 0.030) and |RV GLS|/PASP (OR 0.001, 95% CI 0.00-0.017, p = 0.012). ROC curves analysis showed that |RV GLS|/PASP's best cut-off for persistent TR was 0.46 (cut-off 0.46, the area under the curve 0.789, p < 0.001). Persistent TR after ASD closure is not rare. Old age and RV-PA uncoupling could be associated with persistent TR after ASD closure. In older patients with abnormal RV-PA coupling, careful evaluation and concomitant or subsequent TR intervention may be considered.

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

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

Abstract 12165: The Ratio of Right Ventricular Global Longitudinal Strain and Pulmonary Artery Systolic Pressure Determines Persistent Tricuspid Regurgitation After Closure of Atrial Septal Defect

Introduction: Functional tricuspid regurgitation (TR) will decrease after atrial septal defect (ASD) closure, but it may persist and require additional tricuspid valve (TV) surgery or intervention. Hypothesis: We aimed to find echocardiographic predictors for persistent TR after successful ASD closure. Methods: Among 348 adults who underwent isolated ASD closure between January 2010 and September 2020, 91 (26.1%) patients with significant TR (at least moderate degree) before ASD closure were included. Persistent TR was defined as a significant TR even after ASD correction on echocardiogram after 6 months to 1 year. To find echocardiographic predictors for persistent TR, conventional and speckle tracking echocardiography performed before ASD closure were analyzed. The right ventricular (RV)-pulmonary arterial coupling was assessed by the ratio of RV global longitudinal strain (RV GLS) and pulmonary arterial systolic pressure (PASP) (RV GLS/PASP). Results: Persistent TR was observed in 22 (24.2%) patients. Patients with persistent TR were significantly older, with larger TR jet area and lower RV GLS/PASP (0.46 ± 0.14 vs. 0.37 ± 0.13, p = 0.013) than those without persistent TR. However, there were no significant differences in RV volumes, RV systolic function, and TV annular diameter between the two groups. On multivariable logistic regression, persistent TR was independently associated with age (HR:2.031, 95% CI, 1.113-2.046; p=0.003) and RV GLS/PASP (HR:0.009, 95% CI, 0.000-0.790; p=0.039). RV GLS/PASP showed a good predictive value for persistent TR after ASD closure (cut off 0.39, the area under the curve 0.702, p=0.003). Conclusions: Persistent TR after successful ASD closure is not uncommon in patients with ASD and significant TR. RV GLS/PASP can predict persistent TR after ASD closure. It can be suggested that concomitant or subsequent TR intervention should be considered in elderly patients and patients with abnormal RV-pulmonary arterial coupling.

Original Article--Predictors of Persistent Functional Tricuspid Regurgitation After Transcatheter Closure of Atrial Septal Defect and its Relationship to Tricuspid Valve Remodeling.

ObjectivesThe aim of this study is assessment of persistent functional tricuspid regurgitation in patients with atrial septal defect before and after successful device closure and its relationship to tricuspid valve remodeling.MethodsThe current study was conducted on 60 patients referred to Tanta University Hospital Cardiology Department with the provisional diagnosis of atrial septal defect secundum type for transcatheter closure from December 2017 to December 2019. All patients were subjected to history taking, clinical examination, 12 lead electrocardiography, plain chest X-ray, full two dimension transthoracic echocardiography (for assessment of tricuspid regurgitation severity) before and at 3, 6 months after transcatheter closure.ResultsTricuspid regurgitation was decreased significantly after atrial septal defect closure due to remodeling in the right side. Age, estimated systolic pulmonary artery pressure, right atrium end systolic area, right ventricular end diastolic area, tricuspid valve tenting area and height, tricuspid septal leaflet angle and tricuspid annular diameter were predictors of persistent tricuspid regurgitation after 3 and 6 months of closure. Only estimated systolic pulmonary artery pressure, tricuspid septal leaflet angle and tricuspid annular diameter were independent predictors of persistent tricuspid regurgitation after 3, and 6 months of closure.ConclusionTricuspid regurgitation significantly improved after transcatheter atrial septal defect closure despite its significance at baseline due to remodeling in right side and tricuspid valve.

Impact of additional annuloplasty on tricuspid valve and cardiac functions after atrial septal defect closure in adults.

Surgical indications for moderate to severe tricuspid regurgitation (TR) during atrial septal defect (ASD) closure are still unclear. Additional tricuspid valve annuloplasty (TVP) can be beneficial to avoid postoperative persistent TR. Therefore, we compared the results of surgical ASD closure with or without additional TVP in patients who presented with moderate-to-severe TR. Between November 2009 and June 2016, 103 patients with ASD and moderate-to-severe TR underwent surgical ASD closure without (n = 76, group 1) and with additional TVP (n = 27, group 2). Clinical outcomes and echocardiographic data were analyzed. There was no mortality. Postoperative outcomes were similar despite significantly longer aortic clamping time in group 2 (P = .003). Mean TR grade, right atrial diameter, right ventricular end-diastolic diameter, pulmonary artery pressure, and Qp/Qs ratio decreased significantly in both groups (P < .05). Mean follow-up time was 5.3 months (range: 1 month-6.2 years) in group 1 and 6.1 months (range: 1 month-4.1 years) in group 2 (P = .66). Echocardiography results showed significant decrease in TR grade in both groups (P = .93). The incidence of persistent moderate to severe TR was higher in isolated ASD closure group (14.4% vs 3.7%, P = .086). Additional TVP provided greater regression in TR grade (-1.49 ± 0.9 vs -1.89 ± 0.8, P = .041). Despite TVP being associated with longer ischemic time, postoperative outcomes were comparable to ASD closure alone. Both approach demonstrated an effective decrease in TR, but TVP provided greater regression and lower incidence of persistent TR. Therefore, additional TVP should be considered in patients undergoing ASD closure with moderate-to-severe TR.

Tricuspid regurgitation and in-hospital outcomes after transcatheter aortic valve replacement in high-risk patients.

BackgroundThe prognostic impact of tricuspid regurgitation (TR) following transcatheter aortic valve replacement (TAVR) is uncertain, and the management of patients with severe aortic stenosis and significant TR undergoing TAVR is unclear.MethodsRetrospective study investigating the role of TR severity on hospital outcomes in high risk patients with severe aortic stenosis undergoing TAVR.ResultsA total of 174 participants were included in the present study. The median age was 84 years and 48% were women. The median (IR) STS score was 7.3 (4.7–13.6). The pre-procedural mean (SD) aortic valve area (AVA) was 0.69 (0.2) cm2 and the average (SD) peak and mean gradients were 71 [23]/42 [15] mmHg. Pre TAVR, 28.7% of patients had significant (moderate or severe) TR. Significant TR pre-TAVR increased the risk of in-hospital cardiovascular (CV) and all-cause and mortality [adjusted relative risk (RR) (95% CI): 14.67 (1.35–159.51) and 5.09 (1.14–22.72), respectively], and those with severe TR post-TAVR had longer hospital stay [median (IR): 9.9 (2.9–17.0) days]. No improvement or worsened TR (greater than mild) post-TAVR was associated with higher CV and all-cause mortality [adjusted RR (95% CI): 21.5 (1.81–255.96) and 8.19 (1.67–40.29), respectively]. Right ventricular systolic pressure (RVSP) was independently associated with TR severity pre and post TAVR.ConclusionsSignificant TR was common among patients undergoing high risk TAVR, and is associated with increased in hospital mortality and longer hospital stay. Patients with elevated RVSP and persistent moderate or severe TR after TAVR are at higher risk of in hospital death.

TCT-37 Moderate to Severe Tricuspid Regurgitation in Adults Undergoing Transcatheter Atrial Septal Defect Closure

There remains a large proportion of patients who continue to have moderate to severe tricuspid regurgitation (TR) after transcatheter atrial septal defect (ASD) closure. The baseline predictors and long-term outcomes of persistent TR are not well defined. This study aims to determine the clinical

Predictors and Outcomes of Persistent Tricuspid Regurgitation After Transcatheter Aortic Valve Implantation

Persistent tricuspid regurgitation (TR) after transcatheter aortic valve implantation (TAVI) has been reported to increase mortality. The aim of this study was to investigate clinical and echocardiographic determinants and outcome of persistent TR after TAVI. We reviewed 1,085 patients who underwent TAVI. Among them, 100 patients who had ≥moderate TR without organic dysfunction of the tricuspid valve apparatus were studied. Preprocedural and follow-up transthoracic echocardiography after TAVI were analyzed. After TAVI, patients were divided into persistent TR group and improved TR group. Clinical event was defined as all-cause mortality and readmission for heart failure within 1,000 days. Fifty-three (53%) patients had persistent TR, whereas 47 (47%) patients had improved TR. Risk of clinical event was significantly higher in the persistent TR group compared with the improved TR group. Atrial fibrillation (AF) and tricuspid annular dimension (TAD; p <0.05 for all) were independent predictors of persistent TR. Receiver operating characteristic curve showed the optimal cut-off value of TAD for predicting persistent TR was 37 mm. The combination of AF and TAD ≥37 mm was associated with persistent TR (p <0.001). In conclusion, AF and dilated TAD before TAVI predicted persistent TR which was associated with higher all-cause mortality and readmission for heart failure.

Predictors of Persistent Tricuspid Regurgitation After Transcatheter Aortic Valve Replacement in Patients With Baseline Tricuspid Regurgitation.

This study sought to analyze outcomes in patients with moderate-severe tricuspid regurgitation (TR) undergoing transcatheter aortic valve replacement (TAVR). The consequences of uncorrected significant TR in patients undergoing TAVR remain undefined. Between 2009 and 2014, 369 patients underwent TAVR at our institution, and 58 of these had baseline moderate-severe TR. Preoperative, 30-day, and 1-year transthoracic echocardiograms were analyzed. Predictors of persistent TR at 30 days and survival were assessed. Fifty-eight patients with baseline moderate-severe TR underwent TAVR. Transcatheter aortic valve replacement resulted in significant reductions in pulmonary artery pressures and TR severity (100% vs 64%; P < 0.001) at 30 days. This was sustained at 1 year and was associated with significant improvements in stroke volume index and New York Heart Association functional class. No changes in right ventricular function or size were noted. The only independent predictor of persistent moderate-severe TR at 30 days was preoperative atrial fibrillation [AF; odds ratio (OR), 4.56; 95% confidence interval, 1.1-18.3; P = 0.033]. Independent predictors of overall long-term survival included AF (OR, 0.41; P = 0.001) and chronic lung disease (OR, 0.47; P = 0.011), but not baseline moderate-severe TR. In patients with baseline moderate-severe TR, persistent moderate-severe TR at 30 days was associated with worsened overall survival (log-rank P = 0.02). Baseline moderate-severe TR is not uncommon in patients undergoing TAVR, and frequently improves. However, the presence of AF suggests that that TR is likely to persist after TAVR and is also indicative of a poor long-term outcome. Whether redirecting such patients to surgery for concomitant tricuspid valve repair will further improve outcomes requires further study.

CHARACTERISTICS OF PERSISTENT TRICUSPID REGURGITATION AFTER TRANSCATHETER AORTIC VALVE REPLACEMENT

Tricuspid regurgitation (TR) concomitant with aortic stenosis persisting after surgical aortic valve replacement reportedly increases mortality. The aim of this study was to investigate the characteristics of persistent TR after transcatheter aortic valve replacement (TAVR). We reviewed 802