Regurgitant Orifice Research Articles

1038 RIGHT VENTRICULAR-PULMONARY ARTERIAL (UN)COUPLING ESTIMATION IN PATIENTS WITH TRICUSPID REGURGITATION

Abstract Background right-ventricular (RV)-pulmonary arterial (PA) uncoupling expressed by Tricuspid Annular Plane Systolic Excursion (TAPSE)/Pulmonary Artery Systolic Pressure (PAPs) ratio is associated with poor outcomes in patients with heart failure (HF). TAPSE/PAPs ratio has been poorly investigated in patients with tricuspid regurgitation (TR) with related volume overload and progressive right chambers remodeling. Purpose to assess the effectiveness of other estimation methods of RV-PA coupling in different TR severity groups compared to the classic TAPSE/PAPs ratio. Material and Methods 116 stable patients with TR were enrolled at the time of echocardiography (43 men, 37%; mean age 74±13 years). TR severity was quantified by means of proximal isovelocity surface area (PISA) derived effective regurgitant orifice area (EROA) and regurgitant volume (RVol). RV function was assessed by RV Free Wall Longitudinal Strain (FWLS). PAPs was obtained using the following formula: 4*(peak tricuspid regurgitation velocity)2 + right atrial pressure (RAP); meanPAP was estimated using TR continuous wave signal mean gradient (PAPmIT) and pulmonary artery regurgitation peak gradient (PAPmIP), adding RAP for both. RV-PA coupling was evaluated by TAPSE/PAPs ratio, TAPSE/PAPmIT and TAPSE/PAPmIP ratios. Result TR was quantified mild in 23 patients, moderate in 49, severe and torrential in 29 and 15 patients respectively. Mean RV-FWLS was -26.4±6.9% in mild, -21.8±7.4% in moderate, -18±7% and -18.3±4.2% in severe and torrential TR respectively (p<0.0001). Mean TAPSE/PAPs ratio was 0.6±0.23 mm/mmHg, 0.44±0.19, 0.38±0.19 and 0.37±0.12 mm/mmHg in mild, moderate, severe and torrential TR respectively, with a statistically significant difference between the 4 groups (p<0.0001). Mean TAPSE/PAPmIP ratio was 1.08±0.5 mm/mmHg in mild TR, 0.68±0.34 in moderate, 0.67±0.5 in severe TR and 0.47±0.13 mm/mmHg in torrential TR with a statistically significant difference between distinct TR grades (p=0.004). Mean TAPSE/PAPmIT in mild TR was 0.92±0.5 mm/mmHg, 0.63±0.29 in moderate, 0.53±0.29 and 0.51±0.16 mm/mmHg in severe and torrential TR respectively with a statistically significant difference between the groups (p<0.0001). Finally, an analysis of covariance with RV-FWLS as potential confounder was performed: only the adjusted means of TAPSE/PAPmIP and TAPSE/PAPmIT ratios preserved a statistically significant difference between distinct TR groups (p=0.01 and p=0.019 respectively). Conclusion TAPSE/PAPmIP and TAPSE/PAPmIT ratios seem to preserve a stronger relation with increasing TR grade and worsening of RV disfunction, suggesting it as a more powerful index in this subset of patients. The progression of TR grade leading to a right chamber remodeling could influence the reliability of RV-PA uncoupling expressed by standard TAPSE/PAPs ratio.

Pulmonary Hypertension in Mitral Valve Disease-Rheumatic Mitral Stenosis versus Organic Mitral Regurgitation: The Doppler-Echocardiographic Study Revisited

Background: Pulmonary hypertension (PH) is common in patients with mitral valve disease. Objective: To determine the factors associated with PH among patients with mitral valve disease, and the similarities and differences in the subgroups of mitral stenosis (MS) and mitral regurgitation (MR). Materials and Methods: Patients with isolated moderate to severe organic mitral valve disease were prospectively enrolled. PH was defined echocardiographically as pulmonary artery systolic pressure of more than 50 mmHg. Patients with MS who had mitral valve area of more than 1.5 cm² and patients with MR who had effective regurgitant orifice area of less than 20 mm² were excluded. Results: Three hundred eighteen patients with a mean age of 54.3±15.5 years including 57.6% female and 66.7% MR were included in this study. PH was present in 119 patients (37.4%), including 48.1% in MS and 31.8% in MR. Severe mitral valve disease was reported in 245 patients (77.0%). Left atrial (LA) diameter and pulmonary artery pressure were significantly higher in patients with MS. Dyspnea, LA volume index, significant tricuspid and pulmonary regurgitation, severe mitral valve disease, and the presence of MS were independently associated with PH. Among patients with MS, LA volume index and severe disease were independently associated with PH. Significant tricuspid and pulmonary regurgitation, LA volume index and severe disease were independently associated with PH in patients with MR. Conclusion: PH is common in patients with mitral valve disease. LA volume index and severe disease were, in common, independently associated with PH in patients with mitral valve disease and in the subgroups of MS and MR. Keywords: Mitral regurgitation; Mitral stenosis; Pulmonary hypertension; Rheumatic heart disease

1000 THE EFFECT OF RIGHT VENTRICULAR SIZE AND FUNCTION ON TRICUSPID REGURGITATION SEVERITY

Abstract Background Tricuspid regurgitation (TR) is a relatively common echocardiographic finding and its proportional influence on prognosis and quality of life has been well described. A bidirectional relationship connects TR severity and its volume overload with right ventricular (RV) dilation and dysfunction. Purpose to assess the impact of RV size and function on TR severity. Material and Methods 116 stable patients with TR were enrolled at the time of echocardiography (43 men, 37%; mean age 74±13 years). TR severity was quantified by means of proximal isovelocity surface area (PISA) derived effective regurgitant orifice area (EROA) and regurgitant volume (RVol). RV size was assessed by RV End Diastolic Area (EDA) and RV function by RV Free Wall Longitudinal Strain (FWLS). Results TR was quantified mild in 23 patients, moderate in 53 and severe in 40 patients, with higher predominance of functional rather than organic etiology (101 vs 15 patients); median EROA was 31 mm2 and median RVol was 30 mL. Mean RV-FWLS was -25.9±7%, -21.4±7.4% and -18.4±6.4% respectively in mild, moderate and severe TR with a statistically significant difference between the groups (p=0.001). Mean RV-EDA was 19±7.7 cm2 in mild TR, 21.7±8.5 cm2 and 26.2±7 cm2 in moderate and severe TR respectively (p=0.002). In univariate analysis both RV-FWLS and RV-EDA were predictor of TR grade estimated by TR-EROA (p=0.012 and p<0.0001 respectively). In linear multivariable analysis only RV-EDA was an independent predictor of TR-EROA (p=0.001). A ROC curve analysis confirmed the better ability of RV-EDA to identify severe TR (sTR) compared to RV-FWLS (AUC=0.738 vs AUC=0.669). Conclusions RV remodeling in terms of chamber dilation seems to better predict a higher TR severity compared to RV dysfunction.

959 AN UNEXPECTED DIAGNOSIS BY ECHOCARDIOGRAPHY: APPLICATION IN CLINICAL PRACTICE

Abstract A carcinoid tumore is a rare neuroendocrinologic malignancy that commonly origins from enterochromaffin or Kulchitsky cells in the gastrointestinal tract and secretes bioactive molecules in blood. Up to 60% of patients with carcinoid tumors have cardiac involvement, often on the right-sided heart valves (typically the tricuspid valve and the pulmonic valve). A 66 year old woman was admitted to hospital with congestive heart failure, chronic diarrhea and weight loss. A contrast-enhanced computed tomography scan of the liver showed multiple masses (the largest 70 mm×45mm) compatible with metastases. A transthoracic echocardiogram showed dilatation of right sections of the heart with severe tricuspid regurgitation (RV 64 ml/beat, ERO 1 cmq) and mild pulmonary valve stenosis (Peak gradient 13 mmHg). Patient's aortic and mitral valves were normal in structure and function. The EKG revealed low-voltage QRS complexes of all leads, unspecific ST segment changes and sinusal rhythm. The blood tests showed a significant increase in chromogranin A (17670 ng/ml) and enolase; a 24-hour urine collection showed a total output of 5-hydroxyindoleacetic acid eleveted. A biopsy of the liver with immunostaining for chromogranin and synaptophysin were strongly positive and confirmed the diagnosis of metastatic carcinoid syndrome (grade 1, cells CDX2 positive). The echocardiographic findings of carcinoid heart disease is drumstick-like, rigid, and shortened leaflets with a visible regurgitant orifice, causing torrential tricuspid regurgitation. The pulmonic valve presents more frequently valvular stenosis. A combination of biomarkers and cardiac imaging is useful in screening and diagnosis of carcinoid heart involvement in patients with carcinoid syndrome. The management of carcinoid heart disease is hardful and requires a multidisciplinary approach, medical and surgical treatment, for optimized care.

Echocardiography in the Assessment of Valve Regurgitation- Incremental Role of Three Dimensional Echocardiography.

Echocardiography (Echo) has a primary role in the evaluation of cardiac valve regurgitation. Echo valve regurgitation assessment includes multiple qualitative and quantitative methods which require adequate image quality, comprehensive echocardiographic images and precise measurements to obtain accurate assessment. For patient management, it is also important to investigate the mechanism of valve regurgitation. Severity and mechanism of valve regurgitation determine whether continued medical follow up is optimal or surgical or percutaneous valve repair, or replacement option should be necessary. Transthoracic Echo (TTE) is the gold standard most commonly used for the assessment of valve leaflet anatomy, valve motion and regurgitation severity to determine primary versus secondary causes of valve regurgitation, however transesophageal echo (TEE) provides high resolution imaging of valve leaflets and supporting apparatus and oftentimes determines mechanism of valve regurgitation particularly for mitral and tricuspid valves when TTE is unable to determine the mechanism. By providing surgical type views in a moving heart under normal hemodynamic conditions, 3D TEE has greatly improved assessment of mechanism and etiology of valve regurgitation. Besides, TEE also allows quantitation of valve regurgitation severity by Doppler methods as well as direct 3D planimetry of valve area and regurgitant orifice area. Doppler methods are pre and afterload dependent whereas direct 3D planimetry allows assessment of location and severity of valve regurgitation irrespective of ventricular loading conditions. Pre or intraoperative 3D TEE assessment can provide valuable information for surgical planning of valve repair or replacement. This review discusses various valvular pathologies causing regurgitation and the role of TTE and TEE in improving this assessment as shown by several case examples.

NT-proBNP increase during stress echocardiography predicts significant changes in ischemic mitral regurgitation severity in patients qualified for surgical revascularization.

In many patients, significant changes in ischemic mitral regurgitation (IMR) severity during exercise can be observed independent of the degree of IMR at rest. This study aimed to investigate the correlations between N-terminal fragment B-type natriuretic peptide (NT-proBNP) and echocardiography measurements at rest and at peak exercise in patients with moderate IMR who qualified for surgical revascularization. A total of 100 patients eligible for coronary artery bypass grafting, were included in this prospective study. All patients underwent exercise echocardiography. Additionally, the levels of NT-proBNP were measured at rest and after peak exercise. A positive correlation of absolute NT-proBNP levels with effective regurgitant orifice area (EROA) were observed and with tricuspid regurgitant peak gradient (TRPG) at peak exercise. Absolute ΔNT-proBNP during exercise and the tenting area at rest were independent predictors of severe IMR at peak exercise. The level of absolute ΔNT-proBNP during exercise and coaptation height at rest were the most important predictors of significant increases in TRPG. The best cutoff value for ΔNT-proBNP as a predictor for increases in EROA at peak exercise was 68.9 pg/mL and to predict an increase in TRPG ≥ 50 mmHg at peak exercise was 68 pg/mL. The level of ΔNT-proBNP during exercise was the most important parameter in predicting significant changes in IMR severity and pulmonary pressure. Based on the present data, it can be speculated that integration of the assessment of NT-proBNP at rest and at exercise might improve patient selection for valve surgery.

Quantifying Valve Regurgitation Using 3-D Doppler Ultrasound Images and Deep Learning.

Accurate quantification of cardiac valve regurgitation jets is fundamental for guiding treatment. Cardiac ultrasound is the preferred diagnostic tool, but current methods for measuring the regurgitant volume (RVol) are limited by low accuracy and high interobserver variability. Following recent research, quantitative estimators of orifice size and RVol based on high frame rate 3-D ultrasound have been proposed, but measurement accuracy is limited by the wide point spread function (PSF) relative to the orifice size. The aim of this article was to investigate the use of deep learning to estimate both the orifice size and the RVol. A simulation model was developed to simulate the power-Doppler images of blood flow through orifices with different geometries. A convolutional neural network (CNN) was trained on 30 000 image pairs. The network was used to reconstruct orifices from power-Doppler data, which facilitated estimators for regurgitant orifice areas and flow volumes. We demonstrate that the network improves orifice shape reconstruction, as well as the accuracy of orifice area and flow volume estimation, compared with a previous approach based on thresholding of the power-Doppler signal (THD), and compared with spatially invariant deconvolution (DC). Our approach reduces the area estimation error on simulations: (THD: 13.2 ± 9.9 mm2, DC: 12.8 ± 15.8 mm2, and ours: 3.5 ± 3.2 mm2). In a phantom experiment, our approach reduces both area estimation error (THD: 10.4 ± 8.4 mm2, DC: 10.98 ± 8.17, and ours: 9.9 ± 6.0 mm2) and flow rate estimation error (THD: 20.3 ± 9.9 ml/s, DC: 18.14 ± 13.01 ml/s, and ours: 7.1 ± 10.6 ml/s). We also demonstrate in vivo feasibility for six patients with aortic insufficiency, compared with standard echocardiography and magnetic resonance references.

Abstract 10890: A Simplified Method for Correction of Effective Regurgitant Orifice and Flow Underestimation by Pisa in Non-Circular Orifices: An in vitro Study

Introduction: The proximal isovelocity surface area (PISA) method has been validated for quantifying severity of mitral regurgitation (MR) in orifices with circular geometry. However, functional MR often has an elliptical orifice, which alters the proximal isovelocity contour from a hemisphere to a hemi-ellipsoid. Studies have previously shown that PISA underestimates regurgitant flow (RF) and effective regurgitant orifice (ERO) in functional MR. Hypothesis: The application of a simplified hemi-ellipsoid formula based on biplane color Doppler improves accuracy in calculating RF and ERO across elliptical orifices. Methods: An in vitro model for flow quantification was used for all experiments. Multiple size orifices with minor to major ratios ranging from 1:1 to 1:9 were constructed by 3D printing. Flow was adjusted at multiple intervals to generate peak flow velocities ranging from 4.1 to 5.5 m/s and aliasing velocities from 12 to 18 cm/s. Isovelocity contours were evaluated by biplane color Doppler (Figure 1A). RF and ERO were estimated using the traditional hemispheric PISA (HS-PISA) formula and a simplified hemiellipsoid formula (HE-PISA) based on two orthogonal diameter measurements (Figure 1A and 1B). The estimated RF and ERO values were compared and validated against those derived from a magnetic flowmeter (FM). Results: Isovelocity contours changed from hemisphere to hemi-ellipsoid orifices with increasing ellipticity ratios. HS-PISA significantly underestimated RF (116 ± 27 vs FM 155 ± 20 ml/s) and ERO (26 ± 4 vs FM 34 ± 1 mm 2 ). Underestimation was significantly reduced by HE-PISA (135 ± 17 ml/s and 30 ± 2.5 mm 2 , both p<0.001). Conclusions: A simplified hemi-ellipsoid PISA method provides more accurate assessment of RF and ERO in regurgitant orifices with non-circular geometries.

Abstract 10766: Analysis of Cardiac Ct Anatomy in Patients With Severe Tricuspid Regurgitation Considered for Transcatheter Intervention

Introduction: Severe tricuspid regurgitation (TR) is associated with considerable morbidity/mortality in an elderly population with multiple comorbidities. There is interest in transcatheter interventions to manage severe TR in this population. Understanding right heart (RH) anatomy has implications for patient/device selection for transcatheter intervention. Hypothesis: We analyzed RH anatomy by CT of patients referred for TR therapy to determine transcatheter tricuspid intervention device sizing needs. Methods: Retrospective Mayo Clinic study of 29 patients considered for intervention of severe TR from 3/1/2016-12/15/2020; echocardiogram and CT angiogram obtained in all patients. Results: Mean age was 83±8 (83% female), 100% had atrial fibrillation, and 62% had chronic kidney disease ≥3a. 97% were symptomatic, 93% were prescribed loop diuretics, and 24% had device leads. Mean tricuspid annular plane systolic excursion 16.8±4.5 mm, effective regurgitant orifice area (EROA) 81±33 mm 2 , and cardiac index 2.6±0.6 L/min/m 2 . 41% had at least moderate right ventricular (RV) dysfunction with a mean RV systolic pressure of 46±16 mmHg. Patients receiving intervention had significantly larger EROA (101±33 v. 63±22 mm 2 , P=0.033), shorter tricuspid leaflet tenting length (6.5±3.0 v. 8.9±2.7 mm, P=0.042), and smaller annuloplasty diagnostic perimeter during diastole (120.1±16.6 v. 131.1±7.4 mm, P=0.041). Intervention patients tended to have better right ventricular function, smaller RV and IVC size, and more severe symptoms. Max tricuspid annulus diameter in systole and diastole was 51±5 and 53±7 mm, respectively. Conclusions: Severe TR patients referred for transcatheter intervention present with severe RH enlargement with a large proportion having tricuspid annulus dimensions outside the range for current devices available in clinical trials. These data have implications for device development/selection and procedural feasibility.

Impact of assuming a circular orifice on flow error through elliptical regurgitant orifices: computational fluid dynamics and in vitro analysis of proximal flow convergence.

Grounded in hydrodynamic theory, proximal isovelocity surface area (PISA) is a simplistic and practical technique widely used to quantify valvular regurgitation flow. PISA provides a relatively reasonable, though slightly underestimated flow rate for circular orifices. However, for elliptical orifices frequently seen in functional mitral regurgitation, PISA underestimates the flow rate. Based on data obtained with computational fluid dynamics (CFD) and in vitro experiments using systematically varied orifice parameters, we hypothesized that flow rate underestimation for elliptical orifices by PISA is predictable and within a clinically acceptable range. We performed 45 CFD simulations with varying orifice areas 0.1, 0.3 and 0.5 cm2, orifice aspect ratios 1:1, 2:1, 3:1, 5:1, and 10:1, and peak velocities (Vmax) 400, 500 and 600cm/s. The ratio of computed effective regurgitant orifice area to true effective area (EROAC/EROA) against the ratio of aliasing velocity to peak velocity (VA/Vmax) was analyzed for orifice shape impact. Validation was conducted with in vitro imaging in round and 3:1 elliptical orifices. Plotting EROAC/EROA against VA/Vmax revealed marginal flow underestimation with 2:1 and 3:1 elliptical axis ratios against a circular orifice (< 10% for 8% VA/Vmax), rising to ≤ 35% for 10:1 ratio. In vitro modeling confirmed CFD findings; there was a 8.3% elliptical EROA underestimation compared to the circular orifice estimate. PISA quantification for regurgitant flow through elliptical orifices produces predictable, but generally small, underestimation deemed clinically acceptable for most regurgitant orifices.

Analysis of Cardiac Computed Tomography Anatomy in Patients With Severe Tricuspid Regurgitation Considered for Transcatheter Intervention

BackgroundSevere tricuspid regurgitation (TR) is associated with considerable morbidity/mortality in an elderly population with multiple comorbidities. There is interest in transcatheter interventions to manage severe TR. Understanding complex right heart (RH) geometry and tricuspid valve shape and size has implications for patient/device selection for transcatheter intervention. We characterized RH anatomy by computed tomography in patients with symptomatic severe TR considered for intervention. MethodsThe retrospective Mayo Clinic study included 29 patients with an echocardiogram and cardiac computed tomography angiogram considered for intervention of severe TR from March 01, 2016 to December 15, 2020. Patients were divided into 2 groups: intervention (surgical or transcatheter; n = 17) and medical management alone (n = 12). ResultsMean age was 83 ± 8 (83% female), 100% had atrial fibrillation, and 62% had chronic kidney disease ≥3a. Ninety-seven percent were symptomatic, 93% had been prescribed loop diuretics, and 24% had device leads. Mean tricuspid annular plane systolic excursion was 16.8 ± 4.5 mm, effective regurgitant orifice area was 81 ± 33 mm2, and cardiac index was 2.6 ± 0.6 L/min/m2. Forty-one percent had at least moderate right ventricular (RV) dysfunction with a mean RV systolic pressure of 46 ± 16 mmHg. Patients receiving intervention had significantly larger effective regurgitant orifice area (101 ± 33 vs. 63 ± 22 mm2, p = 0.033), shorter tricuspid leaflet tenting length (6.5 ± 3.0 vs. 8.9 ± 2.7 mm, p = 0.042), and smaller annuloplasty diagnostic perimeter during diastole (120.1 ± 16.6 vs. 131.1 ± 7.4 mm, p = 0.041). Intervention patients tended to have better right ventricular function, smaller RV and inferior vena cava size, and more severe symptoms. The maximal tricuspid annulus diameter in systole and diastole was 51 ± 5 and 53 ± 7 mm, respectively. ConclusionsSevere TR patients referred for transcatheter intervention present with severe RH enlargement with a large proportion having tricuspid annulus dimensions outside the range for current devices available in clinical trials. The presented data have implications for device development/selection and procedural feasibility.

Evaluation of Mitral-Aortic Flow Velocity Integral Ratio as a Tool to Differentiate Between Severe and Nonsevere Mitral Regurgitation

To evaluate mitral-aortic flow velocity integral ratio (MAVIR) as an echocardiographic tool to differentiate between severe and nonsevere mitral regurgitation (MR), compared with regurgitant volume (RVol) and effective regurgitant orifice area (EROA), with subgroup analysis in patients with calcific mitral valve, both by transthoracic (TTE) and transesophageal (TEE) echocardiography. Also, whether MAVIR can be used as a screening tool for severe MR. Prospective, cross-sectional, observational. Cardiac operating room of a tertiary-care hospital. One hundred adult patients with chronic mitral regurgitation with at least mild MR by two-dimensional Doppler and with absence of mitral stenosis, aortic valve disease, and rhythm other than sinus scheduled for cardiac surgery. The subgroup (n=24) consisted specifically of patients with a calcific mitral valve. Preinduction TTE and postinduction TEE in the operating room. MAVIR, RVol, and EROA were measured in all patients both by TTE and TEE. Cohen's kappa statistics was employed to quantify concordance among RVol, EROA, and MAVIR. Diagnostic indices of MAVIR toward diagnosis of severe MR also were quantified. The results showed a strong agreement, in differentiating severe from nonsevere MR, between MAVIR and both RVol and EROA in the whole cohort (n=100) and the subgroup (n=24), both by TTE and TEE. Diagnostic indices were high for MAVIR compared with RVol and EROA in detecting severe MR, both by TTE and TEE. MAVIR may be used as an echocardiographic tool to differentiate between severe and nonsevere MR, even in patients with calcific valves. It also can be used to screen patients for severe MR.

Edge-to-edge repair for tricuspid valve regurgitation. Preliminary echo-data from the Tricuspid Regurgitation IMAging (TRIMA) study

Abstract Background The natural history of tricuspid valve regurgitation (TR) is characterized by dismal prognosis and high in-hospital mortality when treated with isolated surgery. We report preliminary procedural and echocardiographic results of our experience with the TriClip System in a cohort of “real-life” patients with functional tricuspid regurgitation. Methods From June 2020 to March 2022, 27 consecutive patients with &amp;gt; moderate TR have been screened, 12 underwent transcatheter TriClip repair. The anatomical feasibility was established through a complete transthoracic (TTE) and transesophageal echocardiogram (TEE), and a dedicated CT scan for the right cardiac chambers. The procedure was conducted under general anesthesia, guided by TEE and fluoroscopy. Results A total of 12 subjects (83% female) with significant comorbidities and at high surgical risk were included. The mean age was 82±4 years with an average EuroSCORE II of 8.5±4%. TR included functional (75%) and (25%) mixed etiology (lead-induced and functional) and all patients were classified as at least NYHA functional class III. Nine patients (75%) had severe, two patients (17%) massive and one patient (8%) torrential TR. The implant and procedural success were achieved in all cases, implanting one device in 8 patients (67%) and two in 4 patients (33%). The device was positioned antero-septal in 83% (10of12) and postero-septal in 50% (6of12) of cases. A TR reduction of≥1 grade after procedure was achieved in all patients; 5 (42%) subjects had moderate, 6 (50%) mild, and one patient (8%) with previous torrential TR treated with two clips had severe post-procedural TR because of partial leaflet detachment 48-hours post-procedure. On TTE, significant reductions in effective regurgitant orifice area (0.61±0.28 to 0.31±0.22 cm2; p&amp;lt;0.001) and regurgitant volume (56.3±16.7 to 27.5±16.6ml; p&amp;lt;0.001) occurred between baseline and before hospital discharge. We also observed a significant reduction of tricuspid annulus diameter (43.8±5.6 to 39.8±4.2 mm; p&amp;lt;0.001), right ventricular basal diameter (47.2±6.8 to 42.9±4.5 mm; p=0.001), right atrial area (28.8±8.8 to 26.7±9.4 cm2; p=0.033). While 3 patients demonstrated a reduced TAPSE/PASP ratio (&amp;lt;0.31 mmHg) before the intervention, the overall ratio significantly improved after device placement (0.37±0.1 to 0.46±0.1 mmHg; p=0.011). At 30-days-follow-up, there was significant and sustained improvement in NYHA class with all patients reaching class II or less without additional reported hospitalizations. Conclusion In this single center experience, we have shown that treatment with the edge-to-edge TriClip device is safe and effective and is associated with marked clinical benefits and reduced rates of hospitalizations. The resulting echocardiographic improvements indicate leaflet grasping does not just significantly reduce the grade of TR, but also affects adjacent structures and improves right ventricular afterload adaptation. Funding Acknowledgement Type of funding sources: None.

Echocardiography and computed tomography predictors of successful transcatheter direct annuloplasty for mitral regurgitation

Abstract Background Secondary mitral regurgitation (SMR) is associated with adverse outcomes and the optimal treatment modality remains challenging due to extensive variety in the pathology of SMR. Percutaneous direct annuloplasty using the Cardioband system emerged as a promising treatment in selected patients. However, success predictors of this intervention and their association with prognosis remain unclear. Purpose To investigate the role of echocardiographic and computed tomography (CT) data in patients with SMR undergoing percutaneous direct annuloplasty. Methods We retrospectively analyzed patients who underwent catheter-based direct annuloplasty with the Cardioband system for SMR at five tertiary centres in Germany and Switzerland between 2013 and 2020. Patients with procedural success (defined as postprocedural MR grade ≤2+) were compared to those with MR &amp;gt;2+ with respect to baseline echocardiographic data and outcome. Results We included 130 patients (median age 75.5 [71–79], 37% female). Most patients were severely symptomatic (NYHA class III/IV 86.9%), had a median EF of 39 (29–52) with an ischaemic etiology in 39%. Procedural success was achieved in 68%. Procedural time was 178.5 (147.5–214.5) minutes. Patients with and without procedural success differed significantly in measures of MR severity (defined as postprocedural SMR severity (grade, vena contracta (VC), effective regurgitation orifice area and regurgitation volume), annular dilatation (leaflet length, LA sphericity index at end-systole and CT-derived intercommissural distance) and leaflet tethering (tenting area, regurgitation jet direction). In multivariable analysis of echocardiographic parameters including significant measures of annular dilatation and leaflet tethering, predictors of procedural treatment success were tenting area (OR 0.54; 95% CI 0.33–0.98 per mm2, p=0.016) and central regurgitation jet direction (OR 2.96; 95% CI 1.06–8.25, p=0.038). After adding CT data in the multivariable model, intercommissural distance proved to be the most significant predictor (OR 0.96; 0.92–0.99, p=0.009), whereas VC was the only echo predictor (OR 0.84; 0.73–0.98, p=0.03). NYHA class III/IV at last follow up was significantly different between groups, with 34.1% vs. 55.2% of patients with vs. without procedural success, respectively (p=0.04). The combined endpoint of mortality or reintervention at 1 year was significantly lower in patients with procedural success (27% vs. 63%, p=0.002), whereas the association of procedural success with 1-year mortality was of borderline significance (13% vs. 32%, p=0.05). Conclusion Two thirds of patients undergoing transcatheter direct annuloplasty for SMR had procedural success. Careful patient selection by assessment of mitral valve anatomy is helpful to predict procedural success, which translates into less symptom burden and better clinical outcome. Funding Acknowledgement Type of funding sources: None.

Many hands make light work. Echocardiography and computed tomography results from the Tricuspid Regurgitation IMAging (TRIMA) study

Abstract Background Anatomic knowledge of the tricuspid valve (TV) is the first step in the diagnostic algorithm of patients with tricuspid regurgitation (TR), who are candidates for transcatheter tricuspid valve intervention (TTVI). Currently, echocardiography and computed tomography (CT) are available instruments to study the TV anatomy, guide the decision-making process and support the development of novel transcatheter therapies. Purpose The Tricuspid Regurgitation IMAging (TRIMA) study aimed to correlate CT parameters to commonly used echocardiographic variables. Methods This prospective, single-center study enrolled 22 consecutive patients with TR equal to or greater than severe (≥3+). All patients underwent transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE) and cardiac CT study, in order to obtain anatomical dimensions of the tricuspid annulus and quantification of right-chambers remodeling and function. Novel CT scan measurements were analyzed. Correlation between measurements on echocardiography and CT imaging was assessed. Results Severe TR (3+) was present in 27.4% patients, massive (4+) in 4.8% and torrential (5+) in 3.2%. The mean right ventricle (RV) length, RV mid diameter, and right atrium area were 60.81±9.11 mm, 41.27±7.67 mm and 31.72±9.66 cm2, respectively. Tricuspid annular plane excursion, fractional area change, longitudinal myocardial velocity (S') were 16.09±3.25 mm, 33.36±9.47% and 9.18±1.94 cm/sec, respectively. The annular dimensions obtained by CT scan were generally observed to reduce from diastole to systole, except for eccentricity, angles and distance between the postero-septal and antero-posterior commissure and distance between centroid and antero-posterior commissure. A Kruskal-Wallis test showed a stepwise increase in the tricuspid anatomical regurgitant orifice area (AROA) values by CT across the expanded TR grades by TEE, χ2(2)=6,466, p=0.039. Using the Pearson correlation coefficient, we found a relationship between the AROA and TR grade (r=0.593; p&amp;lt;0.004), as well as ARO-perimeter and TR grade (r=0.470; p&amp;lt;0.027). Additionally, a significant correlation was found between septal lateral annulus diameter obtained by TEE and CT (r=0.637; p=0.001). Anyway, no correlations were found between novel CT variables and TR grade or RV function assessed by echocardiogram, as well as between CT systo-diastolic annulus variability and RV function. Conclusions Standard echocardiographic study provide invaluable information about the anatomy and function of the right-chambers, as well as an accurate grade of TR. Conventional and novel variables derived by CT scan may step up the anatomical assessment of the complex morphology of the TV apparatus, thanks to the high spatial resolution of the technique. Therefore, an integrated multimodality assessment is the key point of the screening process of TR candidates for TTVI. Funding Acknowledgement Type of funding sources: None.

Tricuspid annulus deformation indices predicting severe functional tricuspid regurgitation: 3D echocardiographic study

Abstract Introduction In these past few years tricuspid valve (TV) got its appreciation due to the latest focus of complications driven by tricuspid regurgitation (TR). Even though severe TR may require surgical repair, precise analyses performed by 3D echocardiographic tools to determine severe functional TR (FTR) are scarce. Aim To determine the accuracy of 3D echo-derived TV parameters in predicting severe FTR. Methods Prospective observational cohort study enrolled 90 patients (pts) with functional moderate (70%) or severe (30%) TR. Pts with FTR of various aetiologies (due to left-sided valvular heart disease, pulmonary arterial hypertension [invasively measured pulmonary capillary wedge pressure &amp;lt;15 mmHg]) were included in this study. Pts with ischemic heart disease (assessed by coronary angiography) were excluded from the analysis. TR severity was measured quantitatively: severe FTR was defined by 2 parameters: vena contracta ≥7 mm and TR effective regurgitant orifice area ≥40 mm2. The transthoracic echocardiography was performed and included the following 2D and 3D-derived TV parameters: the systolic and diastolic 4-chambers (septal – lateral), 2-chambers (anterior-posterior), major and minor axis TA diameters, TA area, perimeter, leaflet tenting height and volume. The 3D TV analysis was made using the 4D Auto TVQ quantification software package. Receiver Operating Characteristic (ROC) curves, area under the curve (AUC), specificity and sensitivity were analysed. Results Study cohort included 66% females; mean age was 65±11 years. The results of the ROC analysis are shown in Table 1. Of all TA 3D parameters, septal-lateral systolic (AUC 0.859) and diastolic (AUC 0.840) diameter, major axis systolic (AUC 0.816) and diastolic (AUC 0.810) diameter, as well as leaflet tenting volume (AUC 0.769) have the highest predictive value for severe FTR. 3D TA analysis provides 75–88% sensitivity for defying pts with severe FTR. Meanwhile, septal-lateral diameter, major axis diameter and annulus perimeter are the most specific to determine severe FTR. 2D echo-derived TA 4-chamber diastolic diameter index has a lower predictive value with worse sensitivity and specificity, compared to 3D parameters. Conclusions Analysis of three-dimensional echocardiographic parameters is an accurate method, suggesting that dilation of tricuspid annulus is a precise measure for identifying patients with severe FTR. Funding Acknowledgement Type of funding sources: None.

Man-machine interaction-based phenotyping identifies pathophysiologically and prognostically informative clusters among patients with mitral regurgitation undergoing transcatheter edge-to-edge repair

Abstract Background Depending on etiology, extent of disease progression, and comorbidities, patients with severe mitral regurgitation (MR) typically present with considerable heterogeneity. Purpose This study therefore sought to improve diagnostic and prognostic resolution in patients undergoing mitral valve transcatheter edge-to-edge repair (MV TEER) for severe MR by developing a man-machine interaction-based phenotyping approach. Methods All 609 patients from this single-center registry underwent MV TEER for severe MR between 2009 and 2020. Unsupervised agglomerative clustering was applied to preprocedural echocardiography data, and an artificial neural network (ANN) was subsequently trained for future patient-to-cluster assignment. Primary outcome measure was postprocedural 5-year survival Results Cluster analysis revealed four pathophysiologically and prognostically informative phenotypes: Cluster 1 was constituted by patients (n=188) presenting with preserved left ventricular ejection fraction (LVEF; 56.5±7.79%) and regular left ventricular end-systolic diameter (LVESD; 35.2±7.52 mm). 5-year survival in patients from cluster 1, hereinafter serving as a reference, was 60.9% (95% CI: 53.3–69.7%). Patients from cluster 2 (n=102) also presented with preserved LVEF (55.7±7.82%) and regular LVESD (34.9±7.68 mm), but showed the largest mitral valve effective regurgitant orifice area (0.623±0.360 cm2) and highest systolic pulmonary artery pressures (68.4±16.2 mmHg). Consequently, their 5-year survival ranged at 43.7% (95% CI: 33.2–57.6%; p-value: 0.032). Patients from cluster 3 (n=270) were predominantly characterized by impaired left ventricular systolic function (LVEF: 31.0±10.4%) and dilated left ventricular diameters (LVESD: 53.2±10.9 mm), and their 5-year survival was reduced to 38.3% (95% CI: 31.9–46.1%; p-value: &amp;lt;0.001). Poorest 5-year survival (23.8% [95% CI: 12.8–44.3%]; p-value: &amp;lt;0.001) was observed in patients from cluster 4 (n=49) with biatrial dilatation (left atrial volume: 312±113 mL; right atrial area: 46.0±8.83 cm2) although LVEF was only slightly reduced (51.5±11.0%). All patients from cluster 4 were diagnosed with atrial fibrillation. An ANN could precisely predict cluster assignment (accuracy: 85.2%), detecting patients from high-risk clusters 3 and 4 with excellent specificity (95.0% and 99.4%, respectively). Conclusion Assigning patients to clusters using a multiparametric phenotypic approach can facilitate risk stratification in future clinical practice. Our unsupervised machine learning-based classification system differs from previous approaches for risk stratification, because we do neither hypothesize a linear sequence of accumulated pathologies caused by severe MR (potentially ignoring the aggravating impact of comorbidities), nor do we stratify patients into low- and high-risk cohorts in accordance with a single variable's dichotomy (prone to oversimplification). Funding Acknowledgement Type of funding sources: None.

Tricuspid regurgitation severity and transcatheter tricuspid annuloplasty

Abstract Introduction Transcatheter tricuspid annuloplasty is a promising therapeutic alternative for the treatment of tricuspid regurgitation (TR) in patients with a high surgical risk. To date, the published experience with percutaneous tricuspid devices is quite limited. The objective of this study is to present the impact of the transcatheter tricuspid annuloplasty with band implantation on the degree of TR and on several echocardiographic parameters in a series of 27 patients. Methods A single-center cohort of 27 patients was followed up prospectively after the transcatheter tricuspid annuloplasty with band implantation (mean follow-up: 10,39 months) (Figure 1). The degree of tricuspid regurgitation (mild, moderate, severe, massive, torrential) was measured before and after the procedure, as well as at 6 months and one year of follow-up. Other parameters have also been considered, such as the septal-lateral end-diastolic diameter of the tricuspid annulus, the vena contracta (VC), regurgitant orifice area (ROA) 2D, tricuspid annular plane systolic excursion (TAPSE), right ventricular ejection fraction (RVEF) and fractional area change (FAC). Results Initially, there were 22.3% of patients with torrential TR, 29.6% massive and 48% severe. After the procedure, these percentages were reduced to 3.8%, 7.7% and 23.1% respectively, leading to an amount of 65% of patients with mild or moderate TR. With respect to the the diameter of the lateral septum ring, the mean was initially 44.74 mm. After the procedure, it decreased to 34.5 mm (22% of reduction) and, as can be seen during follow-up, it remains stable over time. The ROA and VC were also significantly reduced while TAPSE, CAF and RVEF do not show significant changes (Figure 2). Percutaneous tricuspid annuloplasty demonstrated a notable impact on the degree of tricuspid regurgitation reduction in the patients in our study. The differences are already noticeable from the moment of the procedure and are maintained throughout the follow-up, where the stability of the diameter of the septolateral ring, the ERO and the vena contracta is observed. Funding Acknowledgement Type of funding sources: None.

Impact of proportionate versus disproportionate mitral regurgitation on acute procedural changes and clinical outcomes following transcatheter mitral valve repair

Abstract Background Transcatheter mitral edge-to-edge repair (TEER) with MitraClip offers a less invasive alternative for patients with severe, symptomatic mitral regurgitation (MR) who are considered high risk for surgery. However, patient selection for TEER remains challenging given the variability in underlying MR pathology and current discordance among studies regarding predictors of procedural efficacy and clinical outcomes. Purpose This study aimed to assess acute procedural changes and long-term outcomes in patients who underwent TEER according to the proportionality of MR, defined as the ratio of the effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV). Methods We analyzed patients who underwent TEER at our institution between 2014 and 2020 with available biplane left ventricular volume measurement. Relevant clinical comorbidities, demographics, and anthropometrics, along with pertinent pre- and post-procedural echocardiogram measurements, were obtained by review of the electronic medical record. The EROA to LVEDV index was calculated for all patients who were then stratified by quartiles. Patients with an EROA/LVEDV index in the lowest quartile were defined as having the most proportionate MR and those with an index in the highest quartile were defined as the most disproportionate MR. Baseline and post-TEER parameters were used to assess acute procedural and longitudinal outcomes. Results Baseline clinical and echocardiographic parameters of the 230 subjects according to quartile are shown in the table. Following TEER, there was a larger reduction in the left ventricular end-diastolic diameter and increased MR reduction with increasingly disproportionate MR (p=0.03 and p=0.05, respectively). The change in ejection fraction pre- versus post-TEER did not significantly differ across groups (p=0.64). Median follow up time was 1.7 (0.7–3.5) years; mortality occurred in 77 patients (33.5%) and heart failure hospitalizations occurred in 20 patients (8.7%) during follow up. No significant difference in all-cause mortality or post-procedural heart failure hospitalizations was identified across groups. Conclusions In our series, patients with proportionate MR were similarly symptomatic to those with disproportionate MR but had less severe MR with increased comorbidities. Post-TEER MR grade was similar between groups. Longer-term follow up in larger groups of patients is needed to determine the clinical implications. Funding Acknowledgement Type of funding sources: None.

Acute and chronic changes in LV performance in patients with primary severe mitral regurgitation undergoing percutaneous mitral valve repair

Abstract Background The non-invasive assessment of myocardial work allows to evaluate LV performance by taking into account the effect of LV load. Aim of this study was to evaluate the acute and chronic impact of percutaneous mitral valve repair (PMVR) on LV performance, in patients with severe primary mitral regurgitation (PMR). Methods 71 patients (age: 77±9 years, females: 44%) with severe PMR (effective regurgitant orifice: 0.57±0.31 cm2, regurgitant volume: 80±34 ml) and preserved LV ejection fraction (LVEF: 60±10%) underwent PMVR according to current recommendations. Myocardial work indices were evaluated before the procedure, 2 days after the procedure and at 1-year follow-up. Results PMVR was associated with an acute reduction in LVEF, global longitudinal strain (GLS), myocardial work index (MWI), and work efficiency (MWE), and a significant increase in myocardial wasted work (MWW) and mechanical dispersion (MD). 1-year after the procedure, LV size significantly decreased, GLS, MWI, MWE and MD improved, whereas GWW remained significantly reduced. LVEF improved but remained significantly altered compared with baseline values (Table 1). Conclusions In patients severe PMR undergoing PMVR, the acute reduction in LV preload causes a significant impairment of all parameters of LV performance. After 1-year, progressive LV remodeling is associated a significant improvement in MCW, counterbalanced by a persistently high MWW, which can explain the partial recovery of LVEF. Funding Acknowledgement Type of funding sources: None.