Prevalence Of Severe Tricuspid Regurgitation Research Articles

Long-Term Mortality after Transcatheter Edge-to-Edge Mitral Valve Repair Significantly Decreased over the Last Decade: Comparison between Initial and Current Experience from the MiTra Ulm Registry.

(1) Objective: We aimed to assess whether the candidate profile, the long-term outcomes and the predictors for long-term mortality after transcatheter edge-to-edge mitral valve repair (M-TEER) have changed over the last decade; (2) Methods: Long-term follow-up data (median time of 1202 days) including mortality, MACCE and functional status were available for 677 consecutive patients enrolled in the prospective MiTra Ulm registry from January 2010 to April 2019. The initial 340 patients treated in our institution before January 2016 were compared with the following 337 patients; (3) Results: Patients treated after 2016 showed significantly less ventricular dilatation (left ventricular end-systolic diameter of 43 ± 13 mm vs. 49 ± 16 mm, p < 0.007), lower systolic pulmonary pressures (50 ± 15 mmHg vs. 57 ± 21 mmHg, p = 0.01) and a lower prevalence of severe tricuspid regurgitation (27.2% vs. 47.3%, p < 0.001) at baseline than patients treated before 2016. Compared to the cohort treated before 2016, patients treated afterwards showed a significantly lower all-cause 3-year mortality (29.4% vs. 43.8%, p < 0.001) and lower MACCE (38.6% vs. 54.1%, p < 0.001), without differences for MR etiology. While severe tricuspid regurgitation and NYHA class IV remained independently associated with an increased long-term mortality over the last decade, severe left ventricular dilatation (hazard ratio, HR 2.12, p = 0.047) and severe pulmonary hypertension (HR 2.18, p = 0.047) were predictors of long-term mortality only in patients treated before 2016. (4) Conclusions: The M-TEER candidates are currently treated earlier in the course of disease and benefit significantly in terms of a better long-term survival than patients treated at the beginning of the M-TEER era.

Right Heart Adaptation to Exercise in Pulmonary Hypertension: An Invasive Hemodynamic Study

BackgroundRight heart failure (RHF) is associated with a dismal prognosis in patients with pulmonary hypertension (PH). Exercise right heart catheterization may unmask right heart maladaptation as a sign of RHF. We sought to (1) define the normal limits of right atrial pressure (RAP) increase during exercise; (2) describe the right heart adaptation to exercise in PH owing to heart failure with preserved ejection fraction (PH-HFpEF) and in pulmonary arterial hypertension (PAH); and (3) identify the factors associated with right heart maladaptation during exercise. Methods and ResultsWe analyzed rest and exercise right heart catheterization from patients with PH-HFpEF and PAH. Right heart adaptation was described by absolute or cardiac output (CO)-normalized changes of RAP during exercise. Individuals with noncardiac dyspnea (NCD) served to define abnormal RAP responses (>97.5th percentile). Thirty patients with PH-HFpEF, 30 patients with PAH, and 21 patients with NCD were included. PH-HFpEF were older than PAH, with more cardiovascular comorbidities, and a higher prevalence of severe tricuspid regurgitation (P < .05). The upper limit of normal for peak RAP and RAP/CO slope in NCD were >12 mm Hg and ≥1.30 mm Hg/L/min, respectively. PH-HFpEF had higher peak RAP and RAP/CO slope than PAH (20 mm Hg [16–24 mm Hg] vs 12 mm Hg [9–19 mm Hg] and 3.47 mm Hg/L/min [2.02–6.19 mm Hg/L/min] vs 1.90 mm Hg/L/min [1.01–4.29 mm Hg/L/min], P < .05). A higher proportion of PH-HFpEF had RAP/CO slope and peak RAP above normal (P < .001). Estimated stressed blood volume at peak exercise was higher in PH-HFpEF than PAH (P < .05). In the whole PH cohort, the RAP/CO slope was associated with age, the rate of increase in estimated stressed blood volume during exercise, severe tricuspid regurgitation, and right atrial dilation. ConclusionsPatients with PH-HFpEF display a steeper increase of RAP during exercise than those with PAH. Preload-mediated mechanisms may play a role in the development of exercise-induced RHF.

Sub-phenotyping of patients with severe aortic stenosis undergoing transcatheter aortic valve replacement by unsupervised agglomerative clustering of echocardiographic and hemodynamic data

Abstract Background Severe aortic stenosis (AS) can trigger a deleterious cascade of impairments including left heart dysfunction, pulmonary hypertension (PH), and eventually right heart failure. Clinical phenotypes therefore appear heterogeneous, depending on disease progression and comorbidities. Purpose This retrospective analysis aims to categorize patients with severe AS according to clinical presentation by applying unsupervised machine learning in combination with an artificial neural network (ANN). Methods Unsupervised agglomerative clustering was applied to pre-procedural data from echocardiography and right heart catheterization from 366 consecutively enrolled patients undergoing transcatheter aortic valve replacement (TAVR) for severe AS at two tertiary centers in Germany between 2014 and 2020. Association between cluster and 2-year all-cause mortality after TAVR was assessed, and an ANN was trained to open the avenue to prospectively predict cluster assignment in future patients. Results Cluster analysis revealed four distinct phenotypes, reflecting various extents of disease severity, and hence differing in mortality. Patients from cluster 1, constituting the majority of cases and hereinafter referred to as reference, presented with regular cardiac function and without PH. Accordingly, estimated 2-year survival was 90.6% (95% CI: 85.8–95.6%). Contrarily, patients from smallest cluster 3 displayed most extensive disease characteristics, i.e. left and right heart dysfunction together with combined pre- and postcapillary PH, and their 2-year mortality was increased (2-year survival: 77.3% (95% CI: 65.2–91.6%), HR for 2-year mortality: 2.6 (95% CI: 1.1–6.2); p-value: 0.025). Clusters 2 and 4 comprised patients suffering from postcapillary PH. Whilst patients from cluster 2 showed similar survival as cluster 1 (2-year survival: 85.8% (95% CI: 76.9–95.6%)), patients from cluster 4 with right atrial enlargement and high prevalence of severe tricuspid regurgitation (TR) deceased more often (2-year survival: 74.9% (95% CI: 65.9–85.2%), HR for 2-year mortality: 2.8 (95% CI: 1.4–5.5); p-value: 0.004). After randomly dividing the study population into derivation and validation cohorts, an ANN could precisely predict cluster assignment (accuracy: 83.5%), significantly outperforming the no information rate (46.8%; p-value: 2.26e-15). Importantly, patients from high-risk clusters 3 and 4 were detected with high sensitivity (100.0% and 85.2%, respectively) and specificity (95.9% and 95.1%, respectively). Conclusion Expanding the analytical armamentarium by machine learning technology aids in capturing complex clinical presentations as observed in patients with severe AS. Assigning patients to clusters can thus facilitate a more sophisticated risk stratification in future clinical practice. Addressing irreversibility of PH and persistence of severe TR after TAVR should obtain paramount priority in order to improve long-term survival. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Mark Lachmann receives funding from Technical University of Munich (Clinician Scientist Grant).

Clinical significance of spleen stiffness in patients with acute decompensated heart failure.

AimsCongestive splenomegaly is a classic sign of organ congestion in acute decompensated heart failure (ADHF). Shear wave elastography (SWE) allows the measurement of spleen stiffness (SS). We hypothesized that SS could quantify the severity of splenic congestion and predict adverse events in ADHF.Methods and ResultsThis study included two cohorts: a haemodynamic cohort (62 HF patients) and an outcome cohort (115 ADHF patients). SS was measured by two‐dimensional SWE on the same day of right heart catheterization in the haemodynamic cohort. Right atrial pressure (RAP) independently correlated with SS (β = 0.32, P = 0.002). SS was measured in the outcome cohort before discharge. The 115 patients were divided into three groups on the basis of the tertile value of SS. The third tertile SS group had a higher prevalence of severe tricuspid regurgitation, higher N‐terminal B‐type natriuretic peptide (NT pro‐BNP), and larger right ventricular diastolic diameter, than had the first tertile group and the second tertile group. During a median follow‐up period of 105 (77–135) days, adverse events occurred in 25 patients (one death and 24 rehospitalizations for HF). The third tertile SS group had a significantly higher rate of adverse events (P < 0.001). A higher SS was independently associated with adverse events after adjusting for conventional validated risk score, liver function test, liver stiffness, and estimated RAP.ConclusionsThe degree of SS at discharge can be used as a marker of residual splenic congestion, which is predictive of adverse events in patients with ADHF.

Right-to-Left Shunt Through Iatrogenic Atrial Septal Defect After MitraClip Procedure

ObjectivesThe aim of this study was to investigate the incidence, characteristics, hemodynamic conditions, and clinical significance of right-to-left (R-L) shunt through an iatrogenic atrial septal defect (iASD) after the MitraClip procedure. BackgroundR-L shunt through an iASD after the MitraClip procedure has not been well investigated. MethodsFrom 2014 to 2017, 385 consecutive patients with mitral regurgitation underwent the MitraClip procedure. iASD was assessed using intraprocedural transesophageal echocardiography. Right and left heart catheterization was used to assess the hemodynamic status of patients. All patients provided written informed consent for the procedure. All data for this study were collected from an established interventional cardiology laboratory database approved by the Cedars-Sinai Medical Center Institutional Review Board. ResultsR-L shunt was observed in 20 patients (5%). In 7 of these patients (35%), R-L shunt was accompanied by acute deoxygenation. Prevalence of severe tricuspid regurgitation (55% vs. 20%; p = 0.001), serum B-type natriuretic peptide (664 pg/ml [434 to 1,169 pg/ml] vs. 400 pg/ml [195 to 699 pg/ml]; p = 0.006), mean pulmonary artery pressure (38 mm Hg [34 to 45 mm Hg] vs. 29 mm Hg [22 to 37 mm Hg]; p < 0.001), and right atrial pressure (19 mm Hg [13 to 20 mm Hg] vs. 10 mm Hg [7 to 14 mm Hg]; p < 0.001) were significantly higher in patients with R-L shunt than in those with left-to-right shunt. Patients with R-L shunt also showed a more prominent reduction in the left atrial V-wave and mean pressure from baseline to post-procedure compared with those with left-to-right shunt (−22.8 ± 2.6 mm Hg vs. −11.8 ± 0.9 mm Hg [p = 0.002] and −7.9 ± 0.8 mm Hg vs. −4.0 ± 0.4 mm Hg [p = 0.003], respectively). ConclusionsR-L shunt through an iASD was observed in 5% of patients who underwent the MitraClip procedure and in one-third of patients with R-L shunt presented acute deoxygenation. Elevated right atrial pressure concomitant with pulmonary hypertension and significant reduction in left atrial pressure after MitraClip deployment were associated with R-L shunt.

Should Moderate or Less Functional Tricuspid Regurgitation be Repaired During Surgery for Degenerative Mitral Valve Disease?

ABSTRACTBackground: It is unclear whether moderate or less functional tricuspid regurgitation (TR) should be repaired during surgery for degenerative mitral valve (MV) disease. We studied the natural course of unaddressed moderate or less TR and identified risk factors for TR progression after surgery for degenerative MV disease.Methods: From 2001 to 2011, 2,982 patients with isolated degenerative MV disease and no evidence of coronary artery disease underwent MV surgery. To generate an enriched sample of patients with TR, by random selection 200 patients without TR, 197 with mild TR, and 177 with moderate TR were studied. A total of 1,150 echocardiograms were available for longitudinal analysis of TR progression after surgery in 550 of these 574 patients.Results: Overall prevalence of severe TR was 1.1%, 2.2%, 3.6%, and 4.4% by 1, 3, 5, and 7 years, respectively. Patients with moderate preoperative TR were more likely to progress to severe TR by 7 years (8.6%) than those with mild TR (3.2%) or no TR (1.3%) preoperatively (p < 0.001). Other risk factors for progression to severe TR included larger diastolic tricuspid valve diameter (p = 0.03), shorter right ventricular base-to-apex length (p = 0.0004), smaller tethering area (p = 0.01), older age, and preoperative heart failure. During follow-up, no patient underwent TV intervention.Conclusion: Routine repair of moderate or less functional TR during surgery for degenerative MV disease does not appear to be warranted, because progression to severe TR is uncommon. Instead, we suggest a tailored approach, reserving TR repair during surgery for degenerative MV disease for patients with known risk factors.