Postoperative Tricuspid Regurgitation Research Articles

Reverse RV remodeling after isolated tricuspid valve surgery

Abstract Background Impact of tricuspid regurgitation (TR) on right ventricular (RV) and atrial (RA) size and function is one of the main determinants of prognosis. However, there is scarce data about the recovery of right chambers after isolated tricuspid valve surgery (ITVS). Purpose Our aim is to evaluate postsurgical changes in right chamber morphofunctional parameters by echocardiography after ITVS. Methods We selected all the patients that underwent ITVS in our tertiary centre between 2009 and 2022 excluding those with congenital anomalies. Echocardiographic right ventricular classical parameters (RV diameters, RA area, TAPSE and fractional area change (CAF)) as well as myocardial deformation (free wall (FW)- and 4 chambers (4C)- global longitudinal strain (GLS)) were compared in baseline studies, early and late postsurgical periods. Results Among the 45 patients included (65 ± 2 years-old, 51% female, TRI-SCORE 2 [1-4]) surgical indication was functional TR in 51%, 29% underwent tricuspid valve repair and 71% replacement. The treatment was considered ineffective (postoperative TR ≥ moderate) in 9%. In the early postsurgical phase (1.9 [1.2 – 3] months) a significant reduction in basal (-17%, p<0.01), mid (-15%, p<0.01) and longitudinal (- 7%, p<0,01) RV diameters as well as RA area (-26%, p<0.01) was noted. These changes persist in the late postoperative period for basal (-16%, p<0.01) and mid (-20%, p<0.01) RV diameters and RA area (-19%, p=0.03). RV function parameters suffer significant reduction in the early phases: TAPSE (-39%, p<0.01), FAC (-24%, p<0.01), FW-GLS (-17.1%, p<0.01) and 4C-GLS (-16.3%, p<0.01). In later stages the major worsening in classical parameters persist: TAPSE (-28%, p=0.01) y FAC (-20%. P=0.01). However, strain variables recover to the baseline values. Postoperative RV reverse remodeling is reflected in Table and Figure. Conclusions Postoperative changes in echocardiographic right chambers features after ITVS suggest that myocardial deformation parameters should be the method of choice for follow-up of this surgical procedure. Table. Comparison of baseline and postsurgical echocardiographic parameters. Figure. Echocardiographic parameters evolution.TableFigure

Mid-term outcomes of tricuspid annuloplasty using the Tri-Ad Adams tricuspid annuloplasty ring.

The Tri-Ad Adams tricuspid annuloplasty ring is a recent innovative prosthesis characterized by a semi-rigid central component and fully flexible extremities. The goal of this study was to assess the short-term and mid-term results following implantation of the Tri-Ad Adams ring. A retrospective analysis was conducted on patients who underwent tricuspid annuloplasty using the Tri-Ad Adams ring between August 2016 and October 2021. Our study enrolled a total of 248 participants. The median age was 64.0 (interquartile range: 56.0-71.5) years. The median EuroSCORE II was 4.3% (2.7-7.5%), with 37 patients (14.9%) having a history of cardiac operations. Tricuspid regurgitation of grade 2-3 was observed in 63.7% of cases, and the median tricuspid annular diameter was 3.3 (2.8-3.6) cm. Concurrent procedures included mitral valve replacement (n = 160, 64.5%), mitral valve repair (n = 75, 30.2%), aortic valve replacement (n = 72, 29.0%) and the maze procedure (n = 170, 68.5%). Immediate postoperative tricuspid regurgitation≥moderate was present in 1 patient (0.4%). Early death occurred in 14 patients (5.6%). Major complications included low cardiac output syndrome (n = 18, 0.3%), acute kidney injury (n = 14, 5.6%) and permanent pacemaker placement (n = 15, 6.0%). According to the Kaplan-Meier analysis, the 4-year rates of freedom from overall mortality and moderate-to-severe tricuspid regurgitation were 96.9% and 91.6%, respectively. There were no incidents of tricuspid valve reoperations, ring detachment or significant tricuspid stenosis (trans-tricuspid valve gradient ≥ 5 mmHg). Tricuspid annuloplasty utilizing the Tri-Ad Adams ring demonstrated favourable outcomes in both the early and midterm periods. Further studies are warranted to confirm the long-term results.

Rigid ring vs. flexible band for tricuspid valve repair in patients with tricuspid valve regurgitation: A systematic review and meta-analysis

Background & objectivesRigid ring and Flexible band are techniques used to repair tricuspid valve regurgitation. The comparison between both techniques' effectiveness is controversial in the literature. We conducted this systematic review and meta-analysis to compare the safety and efficacy of rigid ring versus flexible band for tricuspid valve repair in patients with tricuspid valve regurgitation. MethodsWe conducted a PRISMA-compliant systematic review and meta-analysis. A systematic search was performed in major databases, including PubMed, Scopus, Web of Science, and Cochrane CENTRAL to identify relevant published studies. Data were extracted and analyzed using Stata (version 17 for Mac) and Revman (version 5.4 for Windows). ResultsTwelve studies were included in this meta-analysis. Total number of patients was 4259. The rigid ring wasn't superior to the flexible band in terms of postoperative tricuspid regurgitation RR 0.74, 95 % CI (0.43–1.27) (P = 0.29). However, the results were not homogeneous. After employing sensitivity analysis, the significance of the pooled effect estimate didn't change, showing no significant difference between the two annuloplasty RR 0.72, 95%CI (0.45–1.15). On the other hand, the rigid ring was associated with a higher bypass time than the flexible band (RR 4.85, P = 0.00). There were no differences between the two groups in terms of hospital stay, ICU stays, prolonged ventilation, mechanical ventilation time, annuloplasty size, stroke, concomitant mitral valve surgery, concomitant aortic valve surgery, atrial fibrillation, pacemaker implantation, low cardiac output, in-hospital death, or late death (all P > 0.05). ConclusionOur study findings suggested no difference between rigid ring compared to flexible band regarding the rates of postoperative tricuspid regurgitation; however, rigid ring may encompass a higher bypass time. Therefore, further research is required to ensure our findings.

Transcatheter tricuspid valve replacement for functional tricuspid regurgitation after left-sided valve surgery: A single-center experience.

Functional tricuspid regurgitation (FTR) following left-sided valve surgery (LSVS) is of clinical significance due to its high recurrence and mortality rates. Transcatheter therapy presents a potential solution to address this issue. The study aimed to assess the safety and efficacy of transcatheter tricuspid valve replacement using the Lux-Valve system in a single center for patients with FTR after LSVS. From June 2020 to April 2023, 20 patients with symptomatic severe FTR after LSVS were referred to our center. A multidisciplinary cardiac team evaluated these patients for suitability for transcatheter tricuspid valve replacement with Lux-Valve systems. Primary efficacy and safety endpoints were immediate postoperative tricuspid regurgitation severity ≤ moderate and major adverse events during follow-up. Twenty patients (average age 65.7 ± 7.4 years; 65.0% women) successfully underwent Lux-Valve system implantation after LSVS. All patients achieved ≤ moderate tricuspid regurgitation immediately after the procedure. Only one patient (5.0%) experienced a procedure-related major adverse event, leading to in-hospital mortality due to pulmonary infection. At the 6-month follow-up, 17 patients (89.5%) improved to New York Heart Association functional class I to II (p < 0.001). The overall Kansas City Cardiomyopathy Questionnaire score significantly improved (35.9 ± 6.7 points to 58.9 ± 5.8 points, p < 0.001). The Lux-Valve system was found to be safe and effective for treating FTR after LSVS. It resulted in positive early outcomes, including a significant reduction in FTR, improved functional status, and enhanced quality of life, especially in high-risk patients.

Preliminary Study of a Degenerated Tricuspid Bioprosthetic Valve Implanted via Transcatheter Valve-in-Valve Implantation Guided by 3-Dimensional Printing

BackgroundThe procedures of transcatheter tricuspid valve-in-valve (TTViV) replacement are challenging, and the clinical outcomes are still unclear. Our goal was to report the short- and mid-term clinical outcomes of patients who underwent a TTViV implantation guided by 3-dimensional (3D) printing. MethodsA retrospective analysis was performed on 6 patients who had TTViV implantation from May 2021 to March 2022. The median age was 51 years (range: 18-71 years), and 50.0% of the patients were male. Imaging assessments and 3D printing were performed on all 6 patients before the procedures. The perioperative data were evaluated, and the patients were followed up. ResultsAmong the 6 patients, the etiologies of conditions affecting the tricuspid valves at baseline varied widely, including 1 case of Ebstein anomaly, 2 cases of infective endocarditis, 1 case of ventricular septal defect, and 2 cases of rheumatic heart disease. TTViV implantation was successfully performed in all 6 patients via the femoral vein approach; postoperative tricuspid regurgitation disappeared immediately, and the hemodynamic results were satisfactory. During the follow-up, all patients had significant improvement in symptoms and functional status. ConclusionsTTViV implantation for the treatment of degenerated tricuspid bioprostheses should be considered safe and effective. Multimodal imaging and 3D printing may provide effective guidance for conducting the procedure. Clinical Trial RegistrationClinicalTrials.gov Protocol Registration System (NCT02917980).

Outcome of mitral repair combined with Cox-maze procedure for atrial functional mitral regurgitation with heart failure with recovered ejection fraction.

Atrial functional mitral regurgitation (AFMR) in patients with heart failure with recovered ejection fraction has received insufficient attention. This study analysed the prognosis and outcomes of mitral valve (MV) repair combined with the Cox-maze procedure. A prospective cohort study of patients with AFMR with left ventricular ejection fraction (LVEF) <40% was conducted. All patients received guideline-directed medical therapy. Those with recovered ejection fraction underwent MV repair combined with the Cox-maze procedure. Mortality, atrial fibrillation (AF) recurrence, mitral regurgitation (MR) and postoperative tricuspid regurgitation were assessed using the inverse probability weighting (IPW) method. In total, 312 patients were enrolled in this study between 2010 and 2019, 247 of whom underwent MV repair combined with the Cox-maze procedure [full recovery (LVEF > 50%): n = 132, partial recovery (LVEF of 40-50%): n = 115]. IPW-adjusted survival of patients with LVEF ≥50% and LVEF 40-50% showed no significant difference [hazard ratio (HR): 2.18, 95% confidence interval: 0.46-10.38, P = 0.33]. However, patients with LVEF ≥50% had better IPW-adjusted long-term freedom from recurrent MR [HR: 2.44 (1.28-4.63), P = 0.0065] and AF recurrence [HR: 1.85 (1.06-3.21), P = 0.030] than those with LVEF of 40-50%. MV repair combined with the Cox-maze procedure was effective and feasible in patients with severe AFMR with heart failure with recovered ejection fraction. Additionally, patients with LVEF ≥50% after guideline-directed medical therapy undergoing these combined procedures had better long-term freedom from recurrent AF and MR than those with LVEF of 40-50%.

Prognostic Predictors of Tricuspid Regurgitation Worsening after Mitral Regurgitation Surgery with Mild Tricuspid Regurgitation

We aimed to investigate the prevalence and predictors of postoperative tricuspid regurgitation (TR) worsening in patients with mitral regurgitation (MR) and concomitant ≤mild TR. A total of 620 patients underwent surgery for MR from 2013 to 2017. Of these, 260 had ≤mild preoperative TR and no concomitant tricuspid valve surgery and were enrolled in this single-center retrospective study. The primary endpoint was postoperative worsening of ≥moderate TR. The primary endpoint occurred in 28 of 260 patients (11%) during the follow-up period [median: 4.1 years (interquartile range: 2.9-6.1 years)]. In the multivariable analysis, age, female sex, and left atrial volume index (LAVI) were significant predictors of the primary outcome during intermediate-term follow-up (age: hazard ratio [HR] 1.05 per 1-year increment, 95% confidence interval [CI] 1.02-1.10, P = 0.003; female sex: HR 3.53, 95% CI 1.61-7.72, P = 0.002; LAVI: HR 1.17 per 10-mL/m2 increment, 95% CI 1.07-1.26, P < 0.001). The optimal LAVI cut-off value for predicting postoperative TR worsening was 79 mL/m2 (area under the curve: 0.69). A high LAVI (>79 mL/m²) was significantly associated with a low rate of freedom from postoperative TR worsening compared with a low LAVI (≤79 mL/m²) (82.6% vs 93.9% at 5 years, respectively; log-rank P = 0.008). In patients with ≤mild preoperative TR and no concomitant tricuspid surgery, the rate of postoperative TR worsening was 11% during intermediate-term follow-up. LA enlargement in patients with MR and ≤mild preoperative TR was significantly associated with postoperative TR worsening.

Prevalence and predictive factors for clinical outcomes of isolated functional tricuspid regurgitation

BackgroundA substantial number of patients have functional tricuspid regurgitation (TR).Isolated functional TR has been undertreated and may be a next target for transcatheter intervention. However, the prevalence, patient characteristics, and predictive factors for prognosis remain unclear. MethodsFrom patients in our echocardiographic database (N = 64,242), we extracted those with severe TR and examined prognosis according to etiologies of TR. Thereafter, we focused on two types of isolated functional TR; progressive TR after left-sided valve surgery (postoperative TR) and TR associated with annular dilatation (atrial TR). Composite adverse events were defined as all-cause death or hospitalization for heart failure (HF). ResultsOf 1001 patients with severe TR (median age, 77 years; female, 58 %), 71 (7 %) patients were classified as postoperative TR, and 149 (15 %) as atrial TR. During the follow-up period (median, 1.6 years), 30 composite adverse events were observed (postoperative TR, n = 14; atrial TR, n = 16). Composite adverse events were less frequent in these two types of functional TR than TR of other etiologies. Multivariate analysis adjusted for age and sex showed that a history of hospitalization for HF, history of cardiac surgery >2 times, loop diuretics, estimated glomerular filtration rate, blood urea nitrogen, hemoglobin, platelet level, left ventricular ejection fraction, and right ventricular dimension were associated with clinical adverse events (p < 0.05), while B-type natriuretic peptide level was not. ConclusionsA considerable number of patients had isolated functional TR. Extracardiac factors such as renal function, hemoglobin and platelet are important in determining clinical outcomes.

Distance between the lead-implanted site and tricuspid valve annulus in patients with left bundle branch pacing: Effects on postoperative tricuspid regurgitation deterioration

Left bundle branch pacing (LBBP) is an alternative strategy for His-bundle pacing (HBP); however, little is known about tricuspid regurgitation (TR) deterioration after LBBP implantation. The purpose of this study was to characterize the incidence of post-LBBP TR deterioration and identify predicting factors, especially lead position parameters. Patients who received LBBP were continuously enrolled from January 2018 to August 2020. The progression of TR and the anatomic position of LBBP were characterized by echocardiography. A total of 89 patients were enrolled and assigned to 2 subgroups based on the degree of TR before LBBP implantation: 58 (65.2%) with relatively normal tricuspid valve (TV) function (grade 0/1 subgroup: with none/trivial or mild TR) and 31 (34.8%) with more severe TR (grade 2/3 subgroup: with moderate or severe TR). At 19.0 ± 6.5 months of follow-up, 29 patients (32.6%) had TR deterioration, and 23 of them were in the grade 0/1 subgroup. In the grade 0/1 subgroup, patients with TR deterioration had a shorter distance between the lead-implanted site and TV (Lead-TA-dist) than those without TR (19.0 ± 7.6 vs 23.9 ± 5.4; P = .006). The receiver operating characteristic (ROC) curve (area under the curve 0.721; 95% confidence interval [CI] 0.575-0.867; P = .005) indicated the favorable efficacy of Lead-TA-dist for predicting TR deterioration after LBBP. Lead-TA-dist ≤16.1 mm was independently associated with TR deterioration after LBBP (hazard ratio 0.20; 95% CI 0.06-0.76; P = .017). TR was a common complication of LBBP implantation. In patients with none/trivial or mild TR, Lead-TA-dist ≤16.1 mm was an independent predictor of TR deterioration after LBBP implantation.

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

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

Transcatheter tricuspid valve-in-valve implantation with bioprosthetic balloon expandable valve.

This study was conducted to evaluate the outcome of the transcatheter valve-in-valve implantation for degenerated tricuspid bioprosthetic valves with transcatheter aortic valves. This retrospective study enrolled all consecutive patients who were considered high risk for reoperations by the heart team and who underwent transcatheter valve-in-valve implantation for degenerated tricuspid bioprosthetic valves in Tehran Heart Center, Tehran, Iran. All the procedures were performed via the transfemoral venous route under echocardiography and fluoroscopy guidance with Edwards SAPIEN transcatheter heart valves (Edwards Lifesciences, Irvine, CA). Ten patients underwent successful transcatheter valve-in-valve implantation in the tricuspid position without any major complications or need for emergency surgical interventions. The mean age was 54.1 ± 17.1years, and 8 patients were female. The median follow-up was 19.5months (16-32.25 mon). The mean period between the last tricuspid valve replacement and transcatheter valve-in-valve implantation was 4.9 ± 2.2years. The bioprosthetic valves were Hancock in three patients, Mosaic in the other three patients, and Biocor, Pericarbon, Perimount, and Epic in the other patients. After the procedure, the clinical and functional status improved significantly in all the patients. The mean transvalvular gradient decreased from 6.75 ± 2.66mm Hg to 2.85 ± 0.89 (P < 0.001), and the postoperative tricuspid regurgitation severity decreased significantly in almost all the patients. The hospitalization period after the procedure was 4.4 ± 1.7days. In high-risk patients, transcatheter valve-in-valve implantation seems to be a safe and minimally invasive alternative to reoperations for degenerated tricuspid bioprosthetic valves.

Early and Long-Term Outcomes of the Prophylactic Tricuspid Annuloplasty in Heart Transplantation

<h3>Purpose</h3> Significant tricuspid regurgitation (TR) is considered to adversely affect the clinical outcomes of heart transplantation. Incidence of significant TR has been reported from 20% to 40%. Prophylactic donor heart tricuspid valve annuloplasty (TVA) has been routinely performed during heart transplantation in our institution. The purpose of this study is to summarize and evaluate early and long-term outcomes of prophylactic TVA in heart transplantation. <h3>Methods</h3> Between August 2011 and August 2021, 350 patients underwent heart transplantation, and 349 patients who underwent concomitant prophylactic TVA were included in this study. TVA was performed using the De Vega annuloplasty technique. TR grade was evaluated with echocardiography, and significant TR was defined as moderate or greater TR in at least two consecutive echocardiographic asssesment. We retrospectively reviewed clinical outcomes including pacemaker implantation, the incidence of significant TR and survival. Long-term survival was assessed between the cohorts who did and did not develop significant TR using the Kaplan-Meier method. <h3>Results</h3> The mean age was 52.9 ± 13.3 years old and 266 patients (76.2%) were male. Four patients (1.1%) required pacemaker implantation within 1 month after the transplantation: 2 patients for sinus node dysfunction, 1 patient for atrio-ventricular block, and 1 patient for left bundle branch block. Mean follow-up period was 43.8 ± 32.9 months. Ten patients (2.9%, 10/349) developed significant TR during the follow up period. The rate of freedom from significant TR was 98.2% at 1 year, 96.6% at 3 years and 96.6% at 5years. There was no occurrence of tricuspid valve stenosis. The 5-year survival rate of patients who developed significant TR was lower than those who did not (61.7% vs 83.9%, log rank=0.29). <h3>Conclusion</h3> Prophylactic TVA is safe during the heart transplantation with no TV stenosis and a low rate of patients requiring pacemaker implantation. The incidence of significant TR was exceptionally low compared to published reports. Development of postoperative significant TR might negatively affect the long-term survival compared to those who did not develop significant TR.

The factors associated with progression of tricuspid regurgitation after left-sided double valve replacement in propensity score matched analysis.

Background This study aims to investigate the association of progression of tricuspid regurgitation following double-valve replacement by comparing the tricuspid valve repair and no repair groups, and to analyze outcomes of patients with non-repaired mild-to-moderate tricuspid regurgitation. Methods Between January 2014 and September 2017, a total of 157 patients (74 males, 83 females; mean age: 51.7±13.7 years; range, 18 to 78 years) who underwent aortic and mitral valve replacements with/without concomitant tricuspid valve repair were retrospectively analyzed. The patients were divided into two groups: no-repair (n=78) and repair groups (n=79). The primary outcome measure was development of more than moderate tricuspid regurgitation during follow-up. Results The data were evaluated according to propensity score matched analysis. The progression of tricuspid regurgitation was significantly increased in the no-repair group (p=0.006). Rheumatic etiology was independently associated with the presence of postoperative moderateto- severe tricuspid regurgitation (p=0.004, odds ratio: 3.40). There was no statistically significant difference between the groups in terms of the potential complications and mortality and survival rates. A multivariable subgroup analysis for the baseline mild-to-moderate tricuspid regurgitation without repair showed that rheumatic etiology was an independent factor for the progression of postoperative tricuspid regurgitation (p=0.01). Conclusion Our study results demonstrated that rheumatic etiology was an independent marker for increased tricuspid regurgitation and it was also independently associated with increased tricuspid regurgitation in patients with mild-to-moderate non-repaired patients. The degree of tricuspid regurgitation was improved in the repair group during follow-up.

Propensity Score-Matched Comparison of Right Ventricular Strain in Women and Men Before and After Left Ventricular Assist Device Implantation.

Objective: Adverse events following left ventricular assist device (LVAD) implantation are more common in women than in men, but the impact of gender differences on right ventricular (RV) failure is not well defined. Therefore, we calculated RV strain before and after LVAD implantation in matched groups of men and women to determine if gender differences in RV failure after LVAD might account for the gender differences in overall outcomes. Methods: RV free wall longitudinal strain (FWS) and fractional area change were calculated preoperatively and 3 months postoperatively using speckle-tracking echocardiography analysis. A total of 172 patients (86 women, 86 men) were then propensity score matched (1:1) for comparison. Results: Although women had higher preoperative CHA2DS2-VASc scores and more frequent moderate mitral regurgitation than men (P = 0.018), the preoperative hemodynamic parameters were similar. Preoperative RV-FWS was -6.7% in women and -6.0% in men (P = 0.65). Postoperatively, women had more progression to severe tricuspid regurgitation (TR) than men (15% vs 7%, P = 0.06). At 3 months the RV-FWS was -7.7% in women and -7.0% in men (P = 0.59). Postoperative TR was moderate-severe in 20% of women and in 9% of men (P = 0.001). Women had a higher incidence of venous thromboembolism, cardiac arrhythmias, and bleeding compared with men. Women also had higher mortality rates at discharge and 30 days after surgery, but the survival rates at 5 years were similar. Conclusions: RV strain measurements track standard hemodynamic and echocardiographic parameters and confirm that gender differences in outcomes following LVAD implantation are not related to gender differences in RV failure rates.

Predictors of functional tricuspid regurgitation after successful left-sided valve surgery

Tricuspid regurgitation (TR) is probably the most common and anticipated complication of left-sided heart valve pathology, especially MV disease. Whether preoperative functional TR will regress or progress after successful left-sided valve surgery is unknown. The aim of this study was to identify the predictors of significant TR after successful left-sided valve surgery. A retrospective analysis was performed on a total of 56 patients who underwent left-sided valve surgery (mitral or mitro-aortic valve surgery). We have excluded patients who had organic TR. All patients had complete clinical examination and echocardiographic studies preoperatively and clinical and echocardiographic follow-up postoperatively. Mean operative age of patients was 49,3 ± 13,7 years with a sex-ratio of 0,8. Tricuspid annuloplasty was associated to left-sided valve surgery in 18 (32%) patients. Postoperatively, significant TR was found in 13 patients (23%) with a mean follow-up of 20,5 ± 33 months. Patients with significant postoperative TR were more often female (83% vs. 48%, P = 0,03), had more often a previous mitral commissurotomy (58% vs. 23%, P = 0,02) and showed a higher prevalence of significant preoperative TR (69% vs. 42%, P = 0,04). Postoperatively, residual pulmonary hypertension ( P = 0,04), dilatation of left atrium ( P = 0,02) and dilatation of right cardiac cavities ( P = 0,01) were significant risk factors for development or progression of TR after surgery. Late onset or progression of functional TR after successful left-sided valve surgery is a significant clinical entity as it displays a great impact on patient prognosis. So, the identification of clinical and echocardiographic predictors of late TR allows an adequate screening of patients that will require tricuspid valve repair at the time of initial left-sided valve surgery.

Surgery for Functional Tricuspid Regurgitation in Adult Atrial Septal Defect - An Increasing Subject in a Decreasing Matter.

IntroductionFunctional tricuspid regurgitation (TR) is known to complicate adult atrial septal defect (ASD), but its management is still under debate. We reviewed our experience in ASD surgery, focusing on associated functional TR and its treatment.MethodsThis retrospective study (2005-2019) included 206 consecutive adult ASD surgical cases without associated valve pathology, except functional TR. Variables were statistically compared on TR classes and surgery-defined groups.ResultsMean age of the patients was 40.3±13 years; 19.9% had sinus venosus syndrome. TR severity was directly related to age, pulmonary systolic pressure, right ventricular and tricuspid annulus diameters, and heart failure class. TR ≥ 2 was found in 134 (65%) patients, while TR ≥ 3 in 56 (27.2%) patients. Tricuspid surgery was associated to shunt closure in 66 (32%) patients, almost all through valve repair; indication was directly related to age, right ventricular and tricuspid annulus diameters, and heart failure class ≥ 3. Tricuspid surgery was more efficient than isolated shunt closure in decreasing TR (79±23% vs. 36±26%; P=1.8 E-18). Device closure availability (last four years of the study) was associated with 1/3 reduction of surgical cases but increased the share of cases with TR>2 (> 51% vs. < 31%; P<0.05).ConclusionIn the era of device closure, surgery for adult ASD is less frequent, but the share of significant TR cases is in net increase. To avoid long-term postoperative TR, we plead for valve repair in all patients with severe TR and for considering repair in moderate TR at risk of persistence.

The role of left atrial strain in patients with functional tricuspid regurgitation before and after annuloplasty: a long-term follow-up study

BackgroundFunctional tricuspid regurgitation (TR) is common among patients with left heart disease and may recur during the follow-up period after selective tricuspid valve annuloplasty (TVA). This study aims to analyse the relationship between left atrial (LA) strain and the degree of preoperative functional TR and to explore the role of LA strain in predicting TR recurrence.MethodsThis study included 63 patients with rheumatic mitral stenosis who underwent mitral valve replacement and concomitant TVA. Additionally, 20 healthy controls were enrolled. Preoperative conventional LA echocardiographic parameters and LA strain were measured. The association between LA strain and preoperative functional TR severity was analysed by Pearson correlation. Predictors of recurrent TR were determined by multivariate logistic regression analyses.ResultsCompared with the control group, the mitral stenosis group developed a significant impairment in terms of LA strain. The degree of preoperative functional TR exhibited moderate correlations with LA reservoir strain (r = − 0.57) and LA conduit strain (r = 0.48). During a median follow-up period of 66.4 ± 36.4 months, TR recurred in 18 patients. Preoperative LA reservoir strain and the mean transmitral gradient were predictors of postoperative TR recurrence. When the two indexes were combined to establish a prediction, the sensitivity and specificity of prediction increased. The area under the receiver operating characteristic curve of the combined indicator was higher than those of the single indicators (0.90 vs. 0.70 and 0.72).ConclusionsLA strain correlates with preoperative functional TR severity in patients with rheumatic mitral stenosis. The LA reservoir strain and preoperative mean transmitral gradient are independent predictive factors for recurrent TR after TVA.

Outcome of consistent guideline-based tricuspid management in patients undergoing degenerative mitral regurgitation correction

ObjectivesDespite coherent guidelines, management of functional tricuspid regurgitation (FTR) consequences on outcome in the context of degenerative mitral regurgitation (DMR) remains controversial due to lacking series of large magnitude with rigorous application of tricuspid guidelines and strict long-term echocardiographic follow-up. Thus, we aimed at gathering such a cohort to examine outcomes of patients undergoing DMR surgery following tricuspid surgery guidelines. MethodsAll consecutive patients with isolated DMR 2005-2015 operated on with baseline FTR assessment and tricuspid annulus diameter measurement were identified. Operative complications, postoperative tricuspid regurgitation incidence, and survival were assessed overall and stratified by guideline-based tricuspid annuloplasty (TA) indication (severe FTR or tricuspid annulus diameter ≥40 mm). ResultsAmong 441 patients with DMR undergoing mitral repair (66 ± 13 years, 30% female, ejection fraction 66 ± 10%, systolic pulmonary artery pressures 39 ± 12 mm Hg) followed 6 [3-9] years, patients with TA (n = 234, 53%) had generally similar presentation versus without TA (n = 207, 47%; all P ≥ .2) except for more atrial fibrillation and larger left ventricle (both P ≥ .0003). Patients with TA showed longer bypass time, more maze procedures (all P ≤ .001), but hospital stay, renal-failure, pacemaker implantation, and operative mortality (overall 0.9%) were comparable (all P ≥ .2). Postoperative incidence of moderate/severe FTR (0% at 1 year) became over time greater among patients without TA (5-year 8% [4%-13%] vs 3% [1%-11%] and 10-year 10% [6%-16%] vs 4% [1%-16%], P = .01). Survival (95% confidence interval) throughout follow-up was 85% (77%-89%) at 10 years, with hazard ratio 0.57 (0.29-1.10), P = .09. for patients with TA versus without. ConclusionsIn this large surgical DMR cohort, guideline-based FTR management was safe and effective. While long-term mortality did not reach significance, postoperative incidence of moderate/severe FTR, overall low, was nevertheless greater in patients who did not appear to require TA at surgery and linked to tricuspid annular dimension. Thus, future multicenter prospective cohorts with long-term follow-up are warranted to re-examine thresholds for TA performance and impact on survival.

Tricuspid regurgitation associated with implantable electrical device insertion: A systematic review and meta-analysis.

Implantable cardioverter defibrillator (ICD) and permanent pacemaker (PPM) lead placement may worsen or result in tricuspid regurgitation (TR). While the association between lead placement and the incidence of TR has been established, current understanding of this problem remains incomplete. This systematic review and meta-analysis sought to pool the existing evidence to better understand the occurrence and severity of TR associated with cardiac implantable electrical device (CIED) insertion. An electronic search was performed to identify all relevant studies published from 2000 to 2018. Overall, 15 studies were selected for the analysis comprising 4019 patients with data reported on TR development following ICD or PPM lead placement. Demographic information, perioperative clinical variables, and clinical outcome measures, including pre and postoperative echocardiographic TR grade changes, were extracted and pooled for systematic review. Mean patient age was 69 years [95% CI: 64.62-73.59], and 63% [95% CI: 57-68] were male. Devices implanted included ICD in 57% [95%CI: 43-70] and PPM in 41% [95%CI: 31-52]. The most common indications for pacemaker implantation were sick sinus syndrome in 22% [95% CI: 22-37] and AV block in 21% [95%CI:12-34. The commonest indications for ICD implantation were primary and secondary prevention of sudden cardiac death. Atrial fibrillation was present in 37% [95%CI: 28-46] and congestive heart failure in 15% [95%CI: 2-57]. Baseline distribution of TR grades were as follows: grade 0/1 TR in 89% [95%CI: 82-93], grade 2 TR in 8% [95%CI: 5-13], grade 3 TR in 2% [95%CI: 0-7] and grade 4 TR in 2% [95%CI: 1-4]. Post-procedure, grade 0/ 1 TR decreased to 68% [95% CI: 51-81] (p<0.01), grade 2 TR increased to 21% [15-28] (p<0.01), grade 3 TR increased to 13% [95%CI: 5-32] (p=0.02), and grade 4 TR increased to 7% [95%CI: 5-9] (p<0.01). ICD and PPM lead placement is associated with increased TR post-procedure. Further studies are warranted to evaluate changes in TR grade in the long term.

Impact of tricuspid regurgitation on late right ventricular failure in left ventricular assist device patients ~can prophylactic tricuspid annuloplasty prevent late right ventricular failure? ~

BackgroundIn this study, we evaluated the prevalence of tricuspid regurgitation (TR) worsening in patients with left ventricular assist devices (LVADs) and its impact on late right ventricular (RV) failure.MethodsWe enrolled 147 patients of the 184 patients who underwent continuous-flow LVAD implantations from 2005 to March 2018. The prevalence of postoperative TR worsening and late RV failure were retrospectively evaluated.ResultsConcomitant tricuspid annuloplasty (TAP) was performed in 28 of 41 patients (68%) with preoperative TR greater than or equal to moderate (TR group) and in 23 of 106 patients (22%) with preoperative TR less than or equal to mild (non-TR group). Regarding the TR-free rates, despite receiving or not receiving concomitant TAP, there was no significant difference between the 2 groups (TR group: p = 0.37; non-TR group: p = 0.42). Of the 9 patients with postoperative TR greater than or equal to moderate, late RV failure developed in 3 patients, with TR worsening after RV failure in each case. During follow-up, 16 patients (11%) had late RV failure. As for the late RV failure-free rates, despite receiving or not receiving concomitant TAP, there was no significant difference between the 2 groups (TR group: p = 0.37; non-TR group: p = 0.96).ConclusionsTR prognosis was preferable regardless of a patient receiving concomitant TAP; however, the presence of postoperative TR seemed to unrelated to late RV failure. Prophylactic TAP might not be necessary to prevent late RV failure.