Primary Tricuspid Regurgitation Research Articles

Clinical aspects and treatment of tricuspid valve regurgitation

Tricuspid regurgitation (TR) leading to right heart failure is prevalent and associated with increased mortality. The significant under-recognition of the disease resulted from insufficient medical therapies and the high associated risk of surgical therapy. Over the last decade there has been a rapid development of interventional treatment options so that the disease has increasingly become the focus of attention of specialists in internal medicine and interventional cardiologists. The etiology of TR is differentiated into primary TR, secondary atrial TR, secondary ventricular TR and TR associated with cardiac implantable electronic devices (CIED). The TR was identified as an independent predictor of mortality, independent of associated diseases such as atrial fibrillation, left-sided heart failure or pulmonary hypertension. Even patients with low to moderate TR have asignificantly increased risk of mortality. Early diagnostics and estimation of the severity by echocardiography as well as timely referral to atertiary heart valve center are decisive in order to evaluate possible treatment options before irreversible right ventricular damage and secondary organ dysfunction occur. For transcatheter edge-to-edge repair and transcatheter tricuspid valve replacement there is now first evidence from randomized controlled studies. While the understanding of TR is continuously improving, new tricuspid valve repair and replacement systems are in a state of steady progress. Whether the treatment has an effect on reduction of the mortality and stabilization of right ventricular failure with a reduction in hospitalization, will first be shown in future studies.

Right Ventricular Dysfunction in Patients With Concomitant Tricuspid Regurgitation Undergoing Transcatheter Aortic Valve Implantation.

This study investigated the impact and predictive factors of concomitant significant tricuspid regurgitation (TR) and evaluated the roles of right ventricle (RV) function and the etiology of TR in the clinical outcomes of patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI).Methods and Results: We assessed grading of TR severity, TR etiology, and RV function in pre- and post-TAVI transthoracic echocardiograms for 678 patients at Keio University School of Medicine. TR etiology was divided into 3 groups: primary TR, ventricular functional TR (FTR), and atrial FTR. The primary outcomes were all-cause and cardiovascular death. At baseline, moderate or greater TR was found in 55 (8%) patients and, after adjustment for comorbidities, was associated with increased all-cause death (hazard ratio [HR] 2.11; 95% confidence interval [CI] 1.19-3.77; P=0.011) and cardiovascular death (HR 2.29; 95% CI 1.06-4.99; P=0.036). RV dysfunction (RVD) also remained an independent predictor of cardiovascular death (HR 2.06; 95% CI 1.03-4.14; P=0.042). Among the TR etiology groups, patients with ventricular FTR had the lowest survival rate (P<0.001). Patients with persistent RVD after TAVI had a higher risk of cardiovascular death than those with a normal or recovered RV function (P<0.001). The etiology of TR and RV function play an important role in predicting outcomes in concomitant TR patients undergoing TAVI.

Outcomes of Concomitant Maze Procedure in Tricuspid Repair for Severe Tricuspid Regurgitation.

We aimed to analyze the impact of concomitant Maze procedure on the clinical and rhythm outcomes, and echocardiographic parameters in tricuspid repair for patients with severe tricuspid regurgitation (TR) and persistent atrial fibrillation (AF). Patients who had severe TR and persistent AF and underwent tricuspid valve (TV) repair were included in the study. Both primary TR and secondary TR were included in the current study. The study population was stratified according to Maze procedure. The primary outcome was major adverse cardiovascular and cerebrovascular event (MACCE) at 15 years post-surgery. Propensity-score matching analyses was performed to adjust baseline differences. Three hundred seventy-one patients who underwent tricuspid repair for severe TR and persistent AF from 1994 to 2021 were included, and 198 patients (53.4%) underwent concomitant Maze procedure. The maze group showed 10-year sinus rhythm (SR) restoration rate of 55%. In the matched cohort, the maze group showed a lower cumulative incidence of cardiac death (4.6% vs. 14.4%, P = 0.131), readmission for heart failure (8.1% vs. 22.2%, P = 0.073), and MACCE (21.1% vs. 42.1%, P = 0.029) at 15 years compared to the non-maze group. Left atrial (LA) diameter significantly decreased in the maze group at 5 years (53.3 vs. 59.6 mm, P < 0.001) after surgery compared to preoperative level, and there was a significant difference in the change of LA diameter over time between the two groups (P = 0.013). The Maze procedure during TV repair in patients with severe TR and persistent AF showed acceptable SR rates and lower MACCE rates compared to those without the procedure, while also promoting LA reverse remodeling.

Atrial functional tricuspid regurgitation in patients undergoing transcatheter aortic valve replacement

Abstract Introduction Recently, a novel entity of tricuspid regurgitation (TR) – atrial functional TR, which is caused by enlargement of the right atrium – has gained in awareness. In comparison, ventricular functional TR occurs in the setting of left heart disease with pulmonary hypertension and subsequent enlargement of the right ventricle. While it could be demonstrated that in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR), an improvement of moderate or severe tricuspid regurgitation (TR) can be observed in many patients, knowledge about the association between entity and improvement of TR is scarce. Purpose The aim of this study was to analyse if atrial functional TR, defined by the enlargement of the right atrium is associated with the persistence of TR after TAVR in patients with severe AS and at least moderate concomitant TR at baseline. Moreover, 3-year all-cause mortality in patients with atrial and ventricular TR was assessed. Methods We retrospectively examined 363 patients with at least moderate tricuspid regurgitation undergoing TAVR from January 2013 to December 2020 due to severe AS. Patients with primary TR, a history of tricuspid valve surgery or with TAVR due to severe aortic regurgitation were excluded. Endsystolic area of the right atrium (RA) and enddiastolic area of the right ventricle (RV) were assessed in transthoracic echocardiography and atrial TR was defined as RA/RV area ratio above the median value of 1.125. Results TR improvement of at least one grade after transcatheter aortic valve replacement was significantly less frequent in patients with atrial compared to patients with ventricular TR (29.2% vs. 60.3%, p &amp;lt; 0.001, Figure 1). Multivariate logistic regression analysis with adjustment for left ventricular ejection fraction, Vena contracta and CT-determined tricuspid annulus diameter confirmed that atrial functional TR was an independent predictor for absence of TR improvement after TAVR (adjusted odds ratio: 3.03, 95% CI 1.65-5.64; p&amp;lt;0.001). Moreover, improvement of TR was associated with a significantly lower 3-year all-cause mortality compared to patients with persistence of TR (log rank test p&amp;lt;0.001, Figure 2A). However, no difference could be observed regarding 3-year all-cause mortality between patients with atrial and ventricular TR (log-rank test p=0.500, Figure 2B). Conclusion In patients undergoing TAVR for severe AS and at least moderate concomitant TR, atrial functional TR is an independent predictor for TR persistence. In addition, TR persistence is associated with increased 3-year all-cause mortality.Figure 1:Development of TR after TAVRFigure 2:3-year all-cause mortality

Characteristics and outcomes of patients with atrial versus ventricular secondary tricuspid regurgitation undergoing tricuspid transcatheter edge-to-edge repair-Results from the TriValve registry.

Functional or secondary tricuspid regurgitation (STR) is the most common phenotype of tricuspid regurgitation (TR) with atrial STR (ASTR) and ventricular STR (VSTR) being recently identified as two distinct entities. Data on tricuspid transcatheter edge-to-edge repair (T-TEER) in patients with STR according to phenotype (i.e. ASTR vs. VSTR) are lacking. The aim of this study was to assess characteristics and outcomes of patients with ASTR versus VSTR undergoing T-TEER. Patients with STR undergoing T-TEER were selected from the Transcatheter Tricuspid Valve Therapies (TriValve) registry. ASTR was defined by (i) left ventricular ejection fraction ≥50%, (ii) atrial fibrillation, and (iii) systolic pulmonary artery pressure <50 mmHg. Patients not matching these criteria were classified as VSTR. Patients with primary TR and cardiac implantable electronic device were excluded. Key endpoints included procedural success and survival at follow-up. A total of 298 patients were enrolled in the study: 65 (22%) with ASTR and 233 (78%) with VSTR. Procedural success was similar in the two groups (80% vs. 83% for ASTR vs. VSTR, p = 0.56) and TEER was effective in reducing TR in both groups (from 97% of patients with baseline TR ≥3+ to 23% in ASTR and to 15% in VSTR, all p = 0.001). At 12-month follow-up, survival was significantly higher in the ASTR versus VSTR cohort (91% vs. 72%, log-rank p = 0.02), with VSTR being an independent predictor of mortality at multivariable analysis (hazard ratio 4.75). In a real-world, multicentre registry, T-TEER was effective in reducing TR grade in both ASTR and VSTR. At 12-month follow-up, ASTR showed better survival than VSTR.

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.

Management of severe tricuspid valve regurgitation due to ruptured papillary muscle in a patient with mediastinitis early after heart transplant.

Even though severe tricuspid regurgitation is not uncommon after cardiac transplantation, primary severe tricuspid regurgitation is rare. We present such a case with additional complexities. The patient was 44-year-old man with a HeartWare durable left ventricular assist device (Heartware Inc) who received a temporary right ventricular assist device (RVAD) with a ProtekDuo cannula (LivaNova Inc USA) for refractory ventricular fibrillation and underwent a heart transplant as United Network for Organ Sharing Status 1, in the presence of partially compensated cardiogenic shock, renal failure. Given complex re-operative surgery in a volume-overloaded patient with unknown pulmonary vascular resistance, an RVAD cannula was preserved and re- inserted during cardiac transplant. Postoperatively he required hemodialysis, had severe primary tricuspid regurgitation discovered after RVAD removal and developed Enterobacter mediastinitis. He underwent complex tricuspid valve repair for flail tricuspid leaflet due to ruptured papillary muscle likely due to RVAD cannula injury, after multiple mediastinal washouts and was followed by delayed chest reconstruction. The patient is doing well, 6 months after discharge to home, asymptomatic, without re-admissions, on renal recovery path, with no tricuspid regurgitation and good biventricular function. Replacing the tricuspid valve in presence of hemodialysis catheter, immunosuppression and mediastinitis could be high risk for endocarditis. Even though we have short-term follow-up, tricuspid valve repair can be an effective way of managing primary severe regurgitation especially when there is a desire or need to avoid valve replacement.

Is it real that no idiopathic tricuspid regurgitation anymore after atrial tricuspid regurgitation regarded as a distinct entity?

Abstract Funding Acknowledgements Type of funding sources: None. Background We have recently found that idiopathic tricuspid regurgitation (TR) had unique characteristics after a systemic approach to strictly define it. Atrial TR has been proposed that TR caused by right atrial dilatation related to the atrial fibrillation and without other causes of TR. Some researchers suggested idiopathic TR was no longer existed. Methods We retrospectively recruit 978 subjects with significant (moderate and severe) TR during a period of 9 months. We carefully evaluated their echocardiography images and divided these subjects into different type of TR according to a step-by-step systemic approach which we have developed. The characteristics of these TR were compared. Results After a step-by-step diagnostic approach, we found that there were 105 subjects with primary TR (10.7%), 76 (7.8%) pacemaker or other intracardiac instrumentation related, 388 (39.7%) left heart disease related, 32 (3.3%) congenital heart disease related, 160 (16.3%) pulmonary hypertension related, 7 (0.7%) right ventricular myopathy, and 210 (21.5%) idiopathic TR. Among idiopathic TR, 81 (38.6%) men, mean age 74.4 ± 14.0 years, 35 (16.7%) severe TR, and 82 (39%) atrial fibrillation. Compared to the idiopathic TR in sinus rhythm, subjects with atrial fibrillation had older age (78.1 ± 10.4 vs. 72.0 ± 13.9 years, p = 0.001), more severe TR (32 vs. 7 %, p &amp;lt;0.001), higher pulmonary artery pressure (43.5 ± 9.8 vs. 38.9 ± 7.9 mmHg, p = 0.001), less fractional area fraction of right ventricle (44.9 ± 13.3 vs. 51.1 ± 10.8 %, p = 0.001), larger tricuspid annulus (3.4 ± 0.7 vs. 2.8 ± 0.6 cm, p &amp;lt;0.001), and large right atrial area (23.2 ± 7.6 vs. 13.6 ± 4.5 cm2, p &amp;lt;0.001). Conclusion There were only 39% atrial TR among idiopathic TR in our study. Many significant TR subjects without other causes were still in sinus rhythm with smaller annulus and right atrial size. Even atrial TR do a distinct entity, there are still have TR subjects without any obvious causes (idiopathic TR).

Mild Tricuspid Regurgitation: A Marker of Disease Burden Independently Associated with Increased Mortality

Introduction: Tricuspid regurgitation (TR) is a common finding which appears to be associated with a worse prognosis. There are conflicting data regarding the prognostic impact of mild TR. We examined the clinical characteristics and echocardiographic properties of subjects with TR and its impact on clinical outcome with particular emphasis on subjects with mild TR. Methods: Consecutive echocardiography examinations during 5 years were evaluated for TR severity and outcome including mortality and cardiovascular hospitalizations. Results: The study included 21,429 subjects; 45% of the subjects had mild TR, 15% had moderate TR, and 6.5% had severe TR. Primary organic TR was evident in 7% of the subjects, a percentage that increased with increasing TR severity. TR severity was incrementally associated with older subjects with an increasing number of comorbidities and echocardiographic abnormalities. 29% of the subjects died at a median follow-up duration of 8.7 years. Increasing severity of TR was independently and incrementally associated with mortality. Subjects with mild TR had a 25% increased mortality rate compared to subjects with minimal TR (HR 1.25, 95% CI: 1.12–1.39, p < 0.001) after adjustment for significant clinical parameters. TR severity was also an independent incrementally graded predictor of cardiovascular hospitalization and mortality (mild TR: HR 1.23, 95% CI: 1.12–1.34, p < 0.001). Conclusions: TR is associated with older and sicker patients with numerous comorbidities. TR severity is a predictor of a worse clinical outcome. Mild TR was independently associated with decreased survival. TR should be considered a marker of a disease burden with a poor prognosis.

Isolated tricuspid regurgitation: a new entity to face. Prevalence, prognosis and treatment of isolated tricuspid regurgitation.

In recent years the tricuspid is no longer considered the "forgotten valve," but nowadays, specialists focused the treatment of tricuspid regurgitation (TR) especially at the time of left heart valve (LHV) surgery, overlooking the emerging entity of isolated TR. Its incidence appears to be rising along with the higher prevalence of atrial fibrillation (AF), intracardiac devices and intravenous drug users. Hence, the aim of the present review is to summarize the available evidences in terms of natural history, clinical presentation and treatment of isolated TR. Tricuspid regurgitation is commonly classified into primary and secondary etiology. Primary or organic TR is relatively uncommon (10%) and may be due to either acquired or congenital diseases. Conversely, secondary or functional TR, caused by dilatation and flattening of the tricuspid annulus along with increase of leaflet tethering due to the remodeling of the right ventricle (RV) has become in last decade an emerging entity. Secondary TR may be due grade progression after left heart valve surgery, to previous TV surgery failure, RV remodeling or permanent AF. Primary TR causes pure volume overload on initially normal right-sided cardiac chambers. Conversely, RV enlargement is the major finding of secondary TR; RV systolic area, RV spherical index and right atrial area were identified as independent factors correlated with TV tethering height. The RV has less muscle mass than the left ventricle, and RV systolic function is therefore more load sensitive. Thus, pulmonary hypertension results in an early fall in RV ejection fraction and associated RV enlargement. An interesting entity is isolated TR related to AF, whose prevalence is estimated to be 14% in recent studies. It is known to cause dilation of the mitral and tricuspid annulus, together with changes in the dynamic mechanisms that govern the variation in area size during the cardiac cycle; as a matter of fact the relative change in TA area was significantly lower in AF (13.5%) than in sinus rhythm (SR) (33.1%). In isolated TR, medical therapy (MT) is indicated only in patients with secondary TR having also severe RV/LV dysfunction or severe pulmonary hypertension. Diuretics are the main MT in case of isolated TR in the presence of right HF in carefully selected candidates, surgery can be performed safely with good long-term survival and it should be considered early at first stages. In the treatment of isolated TR we had two diametrically opposed approaches so far, such as medical therapy, based almost exclusively on diuretics, and surgical therapy. In this scenario, trans-catheter approach is gaining momentum, including repair or replacement treatment. The former sees the use of devices for direct or indirect annuloplasty, or leaflet approximation. The second consists of orthotopic or heterotopic replacement devices (transcatheter tricuspid valve replacement devices). Evidences from randomized studies and longer follow-up will help clarify the best patient selection and treatment strategies.

Evaluation of systemic impact of tricuspid regurgitation: an appleal for the notion of tricuspid regurgitation.

Evaluation of systemic impact of tricuspid regurgitation: an appleal for the notion of tricuspid regurgitation.

Long-term prognosis of severe tricuspide regurgitation induced by hypothroidism

Hypothyroidism is associated with multiple heart diseases such as tricuspid regurgitation (TR). We aimed to investigate in the prognosis of TR induced by hypothyroidism. We conducted a cohort study included all patients with severe primary TR. Long-term prognosis of TR induced by hypothyroidism was compared to the prognosis of other severe primary TR causes. Among 43 patients with severe primary TR, 19 patients presented hypothroism considered as the only cause of severe TR. Thirteen females patients had hypothyroidism. Hypothyroidism was associated with significantly higher renal failure with no difference in hypertension, diabetes and atrial fibrillation or flutter. At two-years evaluation, there were a significantly higher prevalence rehospitalization and mortality in patients with hypothyroidisme despite the treatment of hypothroidism (Table 1). Despite adequate hypothroidism treatment, severe TR induced by hypothyroidism had a long-term poor prognosis.

303 IMPACT OF LEAD POSITION IN THE TRICUSPID ANULUS ON THE DEVELOPMENT OF CARDIAC IMPLANTABLE ELECTRONIC DEVICES RELATED TRICUSPID REGURGITATION

Abstract Introduction Originally considered as the “forgotten valve disease”, tricuspid regurgitation (TR) has recently been shown to correlate with consistent morbidity and mortality, suggesting the need for a deeper understanding of its natural course. Direct injury from Cardiac Implantable Electrical Device (CIED) leads is one of the most common causes of primary TR, with a prevalence up to 40%. The aim of the present proof-of-concept study was to evaluate the effect of CIED right ventricular (RV) lead position within the tricuspid anulus on TR development. Methods Consecutive patients undergoing CIED implantation at our institution (Humanitas Research Horpital IRCCS, Milan, Italy) were included, as long as they had been performed pre- and post- transthoracic echocardiogram (TTE) and a chest CT scan after the implantation. TTE and CT images were retrospectively reviewed. TR severity was graded using a pre-specified 4-class grading scheme: mild, moderate, severe and massive. CIED RV lead position was defined as postero-septal, antero-septal or antero-posterior, based on the commissure in which the lead was observed on a cross-sectional view of the tricuspid anulus at CT scan. Results 64 patients undergoing CIED implantation from January 2015 to December 2021 were included. All CT scans were non-ECG gated. TR was detected in 42 patients (65.62%) at pre-implantation TTE. The RV lead was implanted across the postero-septal, antero-posterior and antero-septal commissures in 35 (54.7%), 16 (25%) and 13 (20.3%) patients respectively. After the implantation, 12 individuals (18.75%) had new-onset or worsening TR, with CIED lead contributing to TR in 46.88% of cases (30/64), and 26 (40.63%) had worse RV function. At logistic regression analysis, the absence of atrial fibrillation was the only independent predictor of new-onset or worsening TR (OR: 0.17, 95% CI: 0.03-0.86, p=0.032), while CIED RV lead in the postero-septal commissure was associated with a numerically lower risk as compared to other sites (OR: 0.34, 95% CI: 0.09-1.27, p=0.108). Consistently, the degree of increase in TR severity was numerically lower in patients with a lead in the postero-septal commissure (Δ = 0.38±0.10 vs. 0.63±0.13, p=0.07). Conclusions CIED implantation is associated with increasing TR severity and worsening RV function. Positioning a lead across the postero-septal commissure of the tricuspid anulus might have a lower impact on TR development and worsening, thus representing a feasible option to prevent CIED-related TR.

Prognostic value of functional tricuspid regurgitation quantified by cardiac magnetic resonance in heart failure.

Quantitative assessment of tricuspid regurgitation (TR) is challenging, and the prognostic implications of cardiac magnetic resonance (CMR)-quantified measures of TR remain unclear in patients with heart failure with reduced ejection fraction (HFrEF). This study investigated the prognostic value of functional TR quantified by CMR in patients with HFrEF. A total of 262 patients with HFrEF who underwent CMR were analysed. Patients who had primary TR, who had acute HF, or for whom cardiac surgery was planned were excluded. TR volume and fraction were indirectly calculated via subtracting methods. The primary outcome was defined as a composite of all-cause death and hospitalization for HF. Renal outcome was defined as a composite of a decrease in estimated glomerular filtration rate ≥50% or progression to end-stage renal disease. During the follow-up period (median 921 days), 62 primary outcomes and 48 renal outcomes occurred. When divided into two or three groups based on TR fraction in Kaplan-Meier analysis, patients with higher TR fractions showed worse primary outcomes and renal outcomes than those with lower TR fractions. In Cox regression analysis, a 10% increase in TR fraction was significantly associated with primary outcome [hazard ratio (HR) 1.49, 95% confidence interval (CI) 1.29-1.73, P < 0.001] and renal outcome (HR 1.31, 95% CI 1.12-1.55, P = 0.001). TR fraction exhibited a strong positive linear relationship with primary outcomes and renal outcomes in restricted cubic spline curves. CMR-quantified measures of TR were independently associated with adverse clinical outcomes in patients with HFrEF.

Phẫu thuật nội soi điều trị bệnh lý van ba lá tại Trung tâm Tim mạch, Bệnh viện E

Background. Tricuspid regurgitation is one of the most common heart valve diseases, affecting 65-85% of the population. Primary tricuspid regurgitation has causes in the tricuspid valve including rheumatic, degenerative, congenital, infectious, etc. Secondary tricuspid regurgitation is more common, associated with right ventricular dysfunction, dilated annulus. valves, often secondary to left-sided valve disease (especially mitral valve disease), atrial fibrillation, and pulmonary hypertension. Traditional sternal open surgery has the advantage of being spacious and convenient for technical manipulations, but the method still has many traumas and risks of sternum inflammation. Endoscopic surgery avoids opening the sternum with the advantages of minimizing trauma, eliminating sternitis, being more aesthetic is becoming a trend and is increasingly applied in cardiovascular surgery.&#x0D; Aims: Evaluation of early and medium-term results of endoscopic surgery for tricuspid valve disease at cardiovascular center, E Hospital&#x0D; Method. Cross-sectional descriptive study, data were collected retrospectively and prospectively&#x0D; Result. From January 2020 to December 2021, we studied 42 patients undergoing endoscopic surgery for tricuspid valve disease, including 13 men (31%), 29 women (69%). Average age is 53.98±12.51 years. The number of patients with tricuspid valve repair and mitral valve replacement surgery was 34 patients, the number of patients with tricuspid valve repair after mitral valve replacement surgery was 4 patients, there were 2 patients with severe tricuspid regurgitation due to infective endocarditis . There was 1 patient with tricuspid valve repair combined with atrial septal defect patching. Immediately after surgery, the proportion of patients with no regurgitation or mild regurgitation of the tricuspid valve was 35 patients (83.3%), moderate regurgitation had 6 patients (14.3%), severe regurgitation had 1 patient (2.4%) ), 41 patients (97.6%) were discharged from hospital, 1 patient (2.4%) died early after surgery. The longest follow-up time was 17 months, the shortest was 6 months, the results were no longer tricuspid regurgitation or mild regurgitation in 37 patients (90.2%), moderate regurgitation in 4 patients (9.8%), there aren’t patients with severe regurgitation of the tricuspid valve or late death.&#x0D; Conclusion. Endoscopic surgery for the treatment of tricuspid valve disease has good results, aesthetics, few complications.

Significance of strictly defined idiopathic tricuspid regurgitation.

Moderate to severe tricuspid regurgitation (TR) is known to cause right ventricular (RV) failure and death. Although TR is traditionally classified as primary or secondary, recently, a new class of TR called idiopathic TR has been proposed, with varying definitions among different studies. The data were retrospectively collected for the period of January to June 2018 for 8711 patients from the patient cohort of the National Cheng Kung University Hospital echocardiography laboratory. A total of 670 patients (7.7%) with moderate-to-severe TR were included. Idiopathic TR was diagnosed strictly using a new systematic approach. The distribution of significant TR included 74 (11.0%) primary TR cases, 48 (7.2%) with pacemaker-related TR, 267 (39.9%) with left heart disease, 24 (3.6%) with congenital heart disease, 6 (0.9%) with RV myopathy, 105 (15.7%) with pulmonary hypertension, and 146 (21.8%) with idiopathic TR. The mean age in primary and idiopathic TR groups was older ( p = 0.004), with lower estimated pulmonary pressure ( p < 0.001), higher RV fraction area change (FAC, p < 0.001), and tricuspid annulus systolic velocity (S', p = 0.004) compared with functional TR group. Multivariate analysis showed that idiopathic TR ( p = 0.002) and primary TR ( p = 0.008) had better RV FAC than functional TR. Idiopathic TR was associated with better RV function than the other secondary TRs. Thus, idiopathic TR should be strictly defined and regarded as a distinct type of TR.

Transcatheter interventions for severe tricuspid regurgitation: a literature review.

The prevalence of tricuspid regurgitation (TR) increases with age, affecting 65%-85% of adults. Primary TR is caused by a congenital or acquired abnormality of the tricuspid valve apparatus (leaflets, chordae, papillary muscles, or annulus). Secondary TR is due to insufficient coaptation from dilation of tricuspid valve annulus due to the right ventricle (RV) or right atrium (RA) remodeling and increased RV pressures. Isolated TR is without increased RV pressures and is associated with atrial fibrillation. Mild TR is a benign disease. Moderate to severe tricuspid regurgitation has independently been associated with increased mortality. Most of these patients are treated medically due to poor outcomes with surgical repair of isolated TR. The in-hospital mortality rate is 8.8%, and the median length of stay in hospital is 11 days resulting in higher healthcare costs. Even if the patients undergo surgical repair or replacement, available data do not show improvement in survival. With a more detailed understanding of the complex anatomy and physiology of the tricuspid valve and significant complications from untreated tricuspid valve disease, the approach to the management of TR has shifted from a conservative approach to a process of prevention and intervention. In the past decade, transcatheter tricuspid valve interventions and tricuspid annuloplasty rings have been developed, contributing to decreased mortality from surgical repair. Transcatheter tricuspid valve intervention techniques have improved survival, quality of life, and reduced heart failure rehospitalization. This review summarizes normal anatomy, types of TR, etiology and different mechanisms of TR, echocardiographic assessment of the severe TR, and highlights various percutaneous transcatheter techniques for tricuspid valve repair.

Surgical management of transvenous lead-induced tricuspid regurgitation in adult and pediatric patients with congenital heart disease.

The objective of this study was to evaluate outcomes of surgical management of lead-induced tricuspid regurgitation (TR) in patients with congenital heart disease. We analyzed data of 54 consecutive patients who underwent tricuspid valve (TV) surgery from 1998 to 2015 for lead-induced TR. Primary end points, including mortality, TV reinterventions, and longitudinal TR measurements, were analyzed with the Kaplan-Meier method or with repeated measures proportional odds modeling. The median age of patients was 48.2years (interquartile range, 37.3-59.0years); 31 (57.4%) were female; 2 (3.7%) were children. Thirty patients (55.6%) underwent TV repair and 24 (44.4%) had replacement, and 52 underwent concomitant cardiac procedures. Thirty-day mortality was 1.9% (repair: 3.3%, replacement: 0.0%). Five-year survival was 80.4% overall and 79.7% and 81.4% for the repair and replacement groups, respectively. In response to surgery, TR improved in both groups (each P<.001) but more with replacement than repair (P<.001); longitudinal analysis showed that TR trends observed early on favoring replacement were sustained across follow-up (P<.001). The model-estimated risk of moderate or severe TR at 5-year follow-up, conditional on having severe preoperative TR, was 74.4% for the repair and 10.7% for the replacement group. Five-year cumulative risk of TV reintervention was comparable for valve repair and replacement. Despite the need for concomitant cardiac procedures in most of the patients, early mortality was low after TV surgery. Survival and rate of TV reintervention were comparable for the repair and replacement groups. However, TV repair was associated with progressive TR during intermediate follow-up, especially in patients with severe preoperative TR.

Prognostic value of tricuspid regurgitation.

Tricuspid regurgitation (TR) has a considerable prevalence in the overall population, that further increases in selected categories of patients. Three morphologic types of TR prevail, namely primary, secondary and atrial TR, mostly, but not always, occurring in different subsets of patients. Recent evidences demonstrate a negative impact of TR on outcomes, irrespective of etiology and even when less than severe in grading. Unfortunately, current surgical standards are void of strong prospective evidence of positive impact on clinical outcomes. While on one hand recent advances in diagnosis and risk stratification of patients with TR are shedding light onto the population that may benefit from intervention and its appropriate timing, on the other hand the arrival on stage of percutaneous treatment options is widening even more the therapeutic options for such population. In this review we will address and discuss the available evidence on the prognostic impact of TR in different clinical contexts encountered in practice.

Assessing the position of pacemaker leads via transthoracic echocardiography: a prospective study

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND/ INTRODUCTION Lead-induced tricuspid regurgitation (TR) in patients with cardiac implantable electronic devices (CIED) is associated with increased morbidity and mortality. Mechanisms proposed to explain CIED-induced TR can be classified as primary (implantation-related, lead-related) and secondary (pacing related). Primary CIED-induced TR results from the direct interaction of the lead with the tricuspid valve (TV). Determination of exact lead position via echocardiography is crucial however often difficult via standard views. Previous research has shown the value of an atypical subcostal 2D en-face view to describe the exact anatomy of the TV (Figure 1) (1-3). PURPOSE In this prospective observational investigation, we aimed to demonstrate the feasibility of the subcostal 2D en-face view of the TV to determine RV lead position at the level of TV passage and thereby to unmask potentially unfavorable lead-positions and interactions with the TV, which might otherwise remain unnoted. METHODS Consecutive patients who underwent implantation of CIED with at least one RV lead were prospectively included. Comprehensive transthoracic echocardiography (TTE) was performed before and after the procedure. An en-face view of the TV by an approximately 90° counter-clockwise rotation of the transducer from a standard subcostal 4-chamber view was attempted in all patients. Exact lead-position (e.g. postero-septal commissural, central, etc., see Figure 1) was described whenever possible. RESULTS A total of 35 patients were included in the final analysis, median age was 62 years, 27/35 (77%) were male. Thirteen patients (37%) already had an RV lead prior to the recent procedure and therefore showed 2 or more leads passing the TV in post-procedural controls. Implanted devices included cardiac contractility modulation (CCM) (7/35 patients, 20%), implantable cardioverter-defibrillator (ICD) (11/35 patients, 31%), cardiac resynchronization therapy (CRT) (7/35 patients 20%) and pacemaker (PM) (7/35 patients, 20%). Three patients (9%) received an additional RV lead due to RV lead dysfunction. The exact position of the RV lead could be determined applying the en-face view in 27/35 patients (77%). In the majority of cases (20/35 patients, 57%), the RV lead passed through the tricuspid plane in a postero-septal commissural position. Central trajectory was observed in 5/35 patients (14%). Anteroseptal and anteroposterior passage were each found in one patient. In the remaining 8/35 patients (23%), lead position could not be determined due to inferior image quality from the subcostal view. CONCLUSIONS RV lead position can be determined from a subcostal en-face view of the TV in a majority of patients after CIED implantation. Hereby, 2D-TTE can add significant value to the management, follow-up, and monitoring and should therefore be included in the standard TTE protocol of every patient with CIED. Abstract Figure 1