Severe Tricuspid Regurgitation Research Articles

Cardiac magnetic resonance correlates of staging algorithm in patients with asymptomatic severe aortic stenosis

Abstract Background The staging algorithm recently proposed to risk stratify patients with severe aortic stenosis (AS) has not been largely applied to patients who are asymptomatic. While the presence of severe tricuspid regurgitation, pulmonary hypertension and right ventricular dysfunction (stages 3-4) is expected to be low, the prevalence of left ventricular damage (LV), mitral regurgitation, left atrial (LA) dilation and atrial fibrillation (stages 1-2) can be higher in patients with asymptomatic severe AS. The cardiac magnetic resonance (CMR) correlates of the staging algorithm have not been described. Purpose To investigate the distribution of patients with asymptomatic severe AS in the staging algorithm and its differences with CMR findings. In addition, differences in CMR data between patients presenting with AS-related adverse events at 1-year follow-up and patients free of events were compared. Methods Patients with asymptomatic severe AS (aortic valve area, AVA<1.0 cm2) and preserved LV ejection fraction (EF) (>50%) that were referred to CMR were included. Biomarkers, echocardiographic and CMR data were assessed retrospectively. CMR-derived parameters included LV and right ventricular (RV) volumes and systolic function, LA volumes and tissue characterization were reported at baseline and compared with AS-related events (a composite of all-cause mortality, symptoms onset, or need for aortic valve replacement) during 1-year follow-up. Results Of 97 patients included (73±9 years old; 36% males), 3 (%) patients were classified in Stage 0, 34 (35%) in Stage 1, 59 (61%) in Stage 2, and 1 (1%) in Stage 3 or 4. Compared to stage 1, patients in stage 2 were older (P=0.006) and had a higher prevalence of overweight (P=0.037), hypertension (P=0.018), NT-proBNP (P=0.030) and hsTnT (p=0.011) levels. On CMR, they showed higher LV volumes and mass index, larger LA volumes and reduced LA ejection fraction, but no differences on myocardial tissue characteristics (Table 1). Regarding prognosis, 45 (46.5%) patients presented AS-related events at 1-year follow-up. Those with events were mainly in stage 2 (36%) and presented higher NT-proBNP levels despite showing no differences in AVA. On CMR, those with events had lower LVEF, greater LV to RV end-diastolic volume ratio, greater left atrio-ventricular coupling index, reduced LA function and a higher extension of late gadolinium enhancement (Table 2). Conclusions In our cohort, most patients with severe asymptomatic AS were in stage 2. Stage 2 patients presented a higher degree of left-chambers remodelling on CMR compared to patients in stage 1. Patients in stage 2 or with lower LVEF, LV remodelling or reduced LAEF on CMR were those with an increased risk for events at follow-up.

Predictive value of right ventricular geometry and function evaluated in AI-computed tomography in patients undergoing transcatheter tricuspid valve repair

Abstract Background The role of cardiac geometry and function for outcome after transcatheter tricuspid valve repair is poorly understood. This study sought to investigate whether right ventricular geometry and function are predictors for clinical outcome in patients undergoing transcatheter tricuspid valve repair (TTVR). Methods and results 60 Patients (mean age 79 ± 6 years, 53% female) suffering from severe tricuspid regurgitation underwent full cardiac cycle computed tomography (CT) for TTVR procedure planning. In comparison to conventional CT-measuring of left and right ventricle, AI-based data showed excellent correlation of cardiac volumes in diastole and systole (R-value for Pearson´s correlation ranging from 0.926 – 0.991; each P-value for correlation < 0.001). We tested whether patients with reduced right ventricle function are associated with worse outcome regarding mortality and re-hospitalization after one year. The mean follow-up was 198 ± 143 days. After 1 year the combined endpoint of death and re-hospitalization occurred in significantly fewer patients with >50% RV-EF (12.1% vs. 37%; X²=5.2; P=0.023). Furthermore, enlarged right ventricle with ≥220 ml end diastolic volume (RVEDV) was associated with poor outcome (0% vs. 33.4%; X²=6.842; P=0.009). The right ventricle was classified as "dysfunctional" with RVEDV ≥200 ml and RV-EF <55% or "functional" with RVEDV < 200 ml or RV-EF > 55%. Patients with "dysfunctional" right ventricle showed poorer outcome in comparison to patients with "functional" right ventricle. (11.1% vs. 32.3%; X²=4.916; P=0.027). Conclusions AI-based 3D-reconstruction of right ventricular geometry in full cycle cardiac CT shows excellent correlation with conventional cardiac CT-reconstruction. Patients with enlarged ventricle > 220 ml RVEDV or RV-EF ≤ 50 % and patients who have ≥ 200 ml RVEDV and ≤ 55 % were associated with poor outcome after TTVR.Outcome based on RVEDV after TTVROutcome based on RV-EF after TTVR

Role of right ventricular remodeling in functional status and prognosis after transcatheter tricuspid valve repair

Abstract Background Severe tricuspid regurgitation (TR) is associated with chronic volume overload and right ventricular remodeling (RVR). Transcatheter tricuspid valve repair (TTVr) reduces TR and can improve quality of life (QoL), but the role of preprocedural RVR on functional and clinical outcomes after TTVr remains unclear. Purpose Aim of this study was to investigate the role of RVR on functional and clinical outcomes after TTVr for severe TR. Methods RVR was defined as dilation of right ventricular mid-level diameter (>35 mm) according to current guidelines. In 226 patients undergoing TTVr (edge-to-edge repair or annuloplasty) for severe TR with heart failure (HF), outcomes were compared between 139 patients with RVR and 87 patients without RVR. Functionality and QoL were evaluated using NYHA class, Minnesota Living With Heart Failure Questionnaire (MLHFQ), 36-Item Short-Form Health Survey (SF-36), and 6-Minute-Walking-Distance (6MWD) 30 days after TTVr. Clinical outcome was assessed through one-year and long-term mortality, HF rehospitalization and need for repeat TV intervention. Results Symptomatic improvement of at least one NYHA class was achieved regardless of RVR (58% vs. 66% of patients with vs. without RVR). Functionality and QoL improved without statistical difference in both groups, with clinically relevant 6MWD improvement of ≥50m in 34% vs. 36% of patients with vs. without RVR; clinically relevant MLHFQ improvement of ≥5 points was present in 70% vs. 81% of patients with vs. without RVR; and clinically relevant SF-36 improvement of ≥2.5 points in 65% vs. 69% with vs. without RVR. One-year mortality after TTVr was 24% vs. 8% in patients with RVR vs. without RVR (p=0.02). One-year HF rehospitalization after TTVr was 30% vs. 13% in patients with vs. without RVR (p=0.04), whereas need for repeat TTVr was not associated with RVR. Long-term follow-up was available after 457±403 days. In multivariable analysis, RVR remained an independent predictor of long-term mortality (HR 2.3, 95%CI [1.03-5.1], p=0.04) and of the combined endpoint of long-term mortality or HF rehospitalization (HR 2.4, 95%CI [1.06-5.5], p=0.04). Conclusion TTVr resulted in clinically relevant improvement of functionality and QoL in patients with HF already after one month, irrespective of RVR. Patients with preprocedural RVR had higher rates of one-year mortality and HF hospitalization. However, preprocedural RVR should not be considered as marker of TTVr futility.

Right ventricular-arterial coupling and exercise-induced tricuspid regurgitation

Abstract Background Right Ventricular-pulmonary Artery (RV-PA) coupling is prognostic in a variety of cardiovascular disorders, including heart failure with preserved ejection fraction, pulmonary hypertension and severe aortic stenosis. The functional aspects of RV-PA coupling are less investigated than rest ones especially in what is their interaction with tricuspid regurgitation (TR). Purpose We sought to understand the association of RV-PA coupling with extent of exercise induced TR by combining gas exchange abnormalities through cardiopulmonary exercise test (CPET) imaging. Methods We prospectively studied patients with indication to perform a CPET imaging test due to dyspnoea and underlying heart disease of any left ventricular ejection fraction. Demographics, baseline characteristics, echo and CPET parameters [(e.g. VE/VCO2 slope and peak oxygen consumption (pVO2)] were evaluated across 3 sub-cohorts phenotyped according to TR severity pattern at rest and at peak exercise . Mitral and tricuspid regurgitation degree were adjudicated accordingly to ESC guidelines. RV-PA coupling function was assessed through the ratio between tricuspid annular plane systolic excursion (TAPSE), and non-invasive pulmonary artery systolic pressure (PASP) with echocardiography. Dynamic TR was defined as detection of at least moderate TR grade from rest to stress. Results A total of 73 patients (age 67±13 years, 52% men), with a mean LVEF of 50±14% were studied. Overall 50 (69%) patients had less than moderate TR which did not increase during stress (Controls), 11 (15%) patients exhibited a dynamic TR pattern (Group 1), and 12 (16%) already had significant TR at rest (Group 2). TAPSE/PASP at rest and peak exercise were significantly lower in Group 1 and 2 compared to Controls (Figure), while the mean PAP/cardiac output (CO) ratio at rest and at peak exercise were significantly higher (Table). As to gas exchange data, Group 1 and 2 exhibited a lower median peak VO2, while Group 2 patients had also a higher median VE/VCO2 slope compared to Controls (Table). 10 (14%) patients showed at least moderate mitral regurgitation (significant MR) at rest and the prevalence of significant MR at peak was higher in group 1 and 2 compared to Controls (Table). A weak negative correlation was found between TAPSE/PASP slope and E/e’ ratio at peak exercise (r =-0.435, p<0.01). Conclusion In presence of exercise dyspnoea, patients with dynamic TR during maximal exercise exhibit a worse degree of RV-PA coupling and gas exchange profile compared to the group without significant exercise-induced TR. Moreover, the exercise-induced TR profile behaves similarly to the one of those presenting with moderate to severe TR already detectable at rest. Phenotyping dynamic TR and RV-PA warrants further evidence on therapies and outcomes prediction in exertional dyspnoea patients.FigureTable

Functional volume distribution in tricuspid regurgitation associated right heart failure

Abstract Background Tricuspid regurgitation (TR) associated right heart failure is a significant challenge, and while tricuspid edge-to-edge repair (TEER) has been suggested to improve outcomes, patients remain at substantial residual risk. Thus, adjunctive therapies to treat associated right heart failure are warranted. Sympathetically mediated venoconstriction with subsequent changes in functional volume distribution with increases in stressed blood volume (SBV) ( the volume compartment which generates intravascular pressure) has been shown to importantly mediate hemodynamic derangements in heart failure and might pose an attractive adjunctive treatment target (e.g. by means of splanchnic denervation). Objectives This study aimed to elucidate the determinants of unfavorable functional volume distribution in patients with TR-associated right heart failure and investigate the prognostic role of SBV after TEER. Methods and Results A total of 279 patients underwent right heart catheterization (RHC) prior to TEER. SBV was estimated (eSBV) from hemodynamic variables fit to an extensively validated and comprehensive cardiovascular model. eSBV was associated with obesity, renal and hepatic dysfunction, and cardiac remodeling (p < 0.05 for all). Hemodynamically, eSBV correlated with pulmonary artery (PA) and cardiac filling pressures, as well as right ventricular-PA coupling (p < 0.05 for all). After TEER, patients with eSBV above the median demonstrated less reduction in right atrial pressures, peripheral edema, and ascites compared to lower eSBV patients (p < 0.05 for all). Higher eSBV was a powerful predictor of the occurrence of death and heart failure hospitalization during a median follow-up of 618 days (p < 0.05 for all) independent of all clinical, imaging, and invasive hemodynamic parameters. Conclusion In severe TR, eSBV is associated with obesity, renal and liver dysfunction, more severe heart failure, attenuated reduction of venous congestion after TEER, as well as adverse clinical outcomes. Estimation of SBV should be incorporated in future trials in the field to identify patients in need of adjunctive therapies and test its role as a potential treatment target.

Abstract 12453: Racial Disparities in Long-Term Survival Among Patients With Moderate and More Severe Tricuspid Regurgitation

Introduction: Tricuspid regurgitation is a common echocardiographic finding leading to excess morbidity and mortality in adult population. Hypothesis: Racial and ethnic disparities have been observed in various cardiovascular disorders’ prevalence and natural course, including valvular lesions. However, little is known about the epidemiology and clinical correlations of TR among non-Hispanic Black adults. Methods: To examine risk factors and clinical outcomes in non-Hispanic Black adults with moderate or more severe TR, 685 patients (7%) self-identified as non-Hispanic Black and 9127 (93%) self-identified as non-Hispanic White with a first echocardiographic report of moderate or more severe TR between 2005-2016 were studied. Results: Non-Hispanic Black patients had more severe TR when compared to white patients (25% vs. 20%, p<0.001). After adjusting for age and sex, non-Hispanic Black patients had significantly higher 10-year all-cause mortality (HR=1.34 (1.18, 1.52), p<0.001). Black race remained a risk factor for all-cause mortality even after adjustment for comorbidities like CHF, COPD, DM, CKD, hypertension, and ischemic heart disease (HR=1.23 (1.08, 1.40), p=0.002). Conclusions: Significant racial disparities exist in demographic, clinical and echocardiographic characteristics between non-Hispanic Black and White patients with moderate or more severe TR. Black race is a potential disease modifier leading to excess mortality.

Abstract 18422: Long-Term Changes in Tricuspid Regurgitation and Right Ventricular Function in Patients Undergoing Lung Transplantation: A 5-Year Study

Introduction: The presence and severity of tricuspid regurgitation (TR) has been associated with cardiovascular morbidity and mortality in a number of disease states. The impact of TR on future outcomes in patients selected for lung transplantation has not been adequately evaluated. Methods: We retrospectively evaluated patients who underwent lung transplant at Cleveland Clinic between 2000 and 2022. Patients undergoing multi-organ transplant, CABG, surgery or valve repair were excluded. The presence of baseline TR and its severity was assessed on the closest echo antecedent to transplantation utilizing an IRB approved Echocardiography registry. We used survival analyses to assess our primary outcome of all-cause mortality. We also assessed distribution of TR severity over short and long-term follow up. Results: We evaluated pre-transplant echocardiograms in 1490 individuals who had a mean age of 55 years; 60% being female. The proportion of 0, 1+, 2+, 3+ and 4+ TR was 56%, 25%,12%, 4% and 3% respectively. During a 5-year post-transplant follow-up period, the presence of severe TR pre-operatively was associated with an increased risk for all-cause mortality [aHR 2.1, 95% CI (1.09, 5.1); p = 0.029]. The distribution of TR severity did not appear to be significantly modified by the procedure at 6, 12, 24, 36, 48 and greater than 48-month follow up [OR 1.32, 95% CI (1.76), p = 0.062). Conclusions: Pre-operative TR severity as measured by echocardiography was associated with an increase in all-cause mortality in patients undergoing lung transplant, but the distribution of TR severity did not significantly differ on long-term post-transplant follow up.

Abstract 11763: A Unique Presentation of Heart Failure With Severe Pulmonary Hypertension and Pericardial Effusion in a Young Patient With a Ruptured Sinus of Valsalva Aneurysm

Case: 26 y/o female immigrant from a developing nation presented with shortness of breath at rest. On physical exam, she desaturated to 75% with minimal movement, had an audible pansystolic murmur, and 2+ pitting edema. Initial presentation was indicative of decompensated Heart Failure (HF). 2D Echocardiogram (Echo) showed a right sinus of Valsalva aneurysm (SOV) with a left to right shunt to the pulmonary artery, as well as, severe pulmonary hypertension (PHTN) and moderate pericardial effusion. CT Scan of the chest showed a right Ruptured SOV (RSOV) with a dissection flap extending into the aorta. Transesophageal Echocardiogram confirmed the diagnosis; noted a right RSOV extending into the pulmonary artery causing severe pulmonary HTN leading to HF and pericardial effusion. The patient underwent surgical correction with full recovery and resolution of symptoms. Conclusions: SOV is a rare cardiac complication with variable etiology. Congenital causes are often found early in age and resolved surgically. Cases regarding the management of adults, especially in the critical care setting, are not well described. Here we report a 26-year-old female who rapidly developed HF with PHTN and pericardial effusion secondary to an RSOV. This case shows the importance of Echo in managing HF and determining its etiology. Using Echo we saw a dilated Inferior Vena Cava of 2.7 cm characteristic of HF. Next, we were able to visualize a dilated RSOV with a shunt to the right, subsequent turbulent flow through the Aortic valve, and severe tricuspid regurgitation. Lastly, we were able to see elevated pulmonary artery systolic pressure secondary to the shunt, and subsequent pericardial effusion (fig 1). The patient's symptoms were initially managed with IV diuretics and resolved with surgery. This is a rare case of right-sided RSOV extending into the pulmonary artery, its successful treatment, and the important role of Echo in treating HF and PHTN.

Abstract 15372: The Lewis Lead

The Lewis lead is a modified ECG configuration that can enhance the amplitude of the atrial electrical activity and is useful when the atrial activity cannot be discerned in the standard ECG. The configuration involves applying the right arm electrode on the manubrium, left arm electrode to the 5th intercostal space on the right sternal border, left leg electrode over the right lower costal margin and right leg electrode in the standard position. The ECG is then interpreted in lead I and II. Herein we present a case where the Lewis lead aided in the diagnosis of complete heart block with underlying atrial fibrillation. Case Presentation: A 75 year old female with severe tricuspid regurgitation was admitted for tricuspid valve replacement. She had previous paroxysmal atrial fibrillation status post pulmonary vein isolation. The preoperative ECG revealed normal sinus rhythm. Postoperatively, ECG demonstrated a narrow complex ventricular rhythm at 70 beats per minute. No atrial activity could be clearly discerned (Image 1). The epicardial atrial wire placed intraoperatively was not functioning, therefore atrial electrogram could not be obtained. It was unclear from repeat ECGs if there was sinus arrest or atrial fibrillation in the atria. The Lewis lead was then utilized and revealed underlying atrial fibrillation (Image 1); together, this was consistent with atrial fibrillation and complete heart block with a junctional escape rhythm. The rhythm did not recover and there was progressive conduction system disease with widening of the QRS and episodes of severe bradycardia. She underwent pacemaker implantation. Discussion: By utilizing the Lewis lead we were able to establish the atrial rhythm and differentiate between atrial fibrillation and sinus arrest. The Lewis lead can also help narrow the differential for wide complex tachycardia by magnifying the p wave, thus making it easier to detect ventriculoatrial dissociation, a hallmark feature of ventricular tachycardia.

Abstract 17742: Anterior Papillary Muscle Rupture After a Motor Vehicle Collision: A Rare Case of Torrential Tricuspid Regurgitation After Blunt Cardiac Injury

Introduction: Blunt cardiac injury is difficult to diagnose in the setting of polytrauma. Here we present a rare case of a torrential tricuspid regurgitation from a ruptured anterior papillary muscle after a motor vehicle collision (MVC). Case: A 55-year-old male presented to the ED after an MVC. He was hemodynamically unstable and hypoxic en route complaining of severe chest and left leg pain. Imaging demonstrated multiple rib fractures, a left acetabular fracture, and left open distal femur fracture. EKG identified atrial fibrillation with RVR and nonspecific ST changes. Labs were significant for leukocytosis and a troponin elevation to 11.98 concerning for blunt cardiac injury. A TTE demonstrated a mobile density in the RA and RV consistent with papillary muscle rupture and severe tricuspid regurgitation. An underfilled left ventricle compressed by the right heart and dilated RV were noted with septal flattening consistent with RV pressure and volume overload. Cardiothoracic surgery was consulted and recommended delayed tricuspid valve repair after other acute injuries were addressed considering the need for full anticoagulation. While in the ICU, his orthopedic injuries were addressed though his hemodynamics were complicated by frequent orthopedic interventions requiring blood transfusions. He later underwent TV replacement and it was found that the anterior papillary muscle was ruptured at its base without leaflet perforation. One week post-operatively the patient suffered a hypoxic PEA arrest. The shock team was consulted and he underwent bedside ECMO cannulation with impella placement for LV failure. After ten days on ECMO he was decannulated. Ultimately, the patient recovered well and was discharged to acute rehab. Discussion: MVCs are a leading cause of traumatic tricuspid insufficiency. However, this life-threatening condition may go undetected due polytrauma and the presence of coexisting distracting injuries. Guidelines are needed for the specific management of traumatic tricuspid regurgitation and associated right heart dysfunction. Additionally, the need for multiple surgical interventions can preclude anticoagulation which is a unique barrier to urgent valve replacement in these patients.

Abstract 17552: Pre-Existing Right Ventricular Lead Performance After Transcatheter Tricuspid Valve Replacements (TTVR)?

Introduction: Transcatheter tricuspid regurgitation (TTVR) is an investigational method for nonsurgical candidates with severe tricuspid regurgitation (TV). Many of these patients possess transvenous right ventricular (RV) leads, which can be a cause for TTVR. Outcomes regarding RV lead viability and functionality after TTVR have varied widely. We sought to describe the outcomes and management of RV leads after TTVR at our institution. Hypothesis: We expect transcatheter tricuspid valve replacement to negatively impact the performance of pre-existing right ventricular leads. Methods: This was a retrospective observational analysis of patients who received TTVR at our center independent of other clinical trials. Statistical analysis was performed using SPSS BMI Software. Results: A total of 30 patients underwent TTVR between 2021 and 2023. Nine patients had CIEDs, including one with SICD and one with transcatheter pacemaker. This resulted in 7 (23%) with an RV lead crossing the TV at the time of TTVR (3 Evoque valves, 5 S3 valves). The RV leads were connected to a pacemaker (PM) in five (71%) patients, an implantable cardiac defibrillator (ICD) in one and a CRT-D in another. On average, the patients underwent TTVR 5 years after cardiac implantable electronic device (CIED) implantation. All patients received RV lead testing at least once after TTVR and they were followed up for a median of 7 months after TTVR. 3 patients underwent pre-emptive lead extraction, which let to four (57%) patients with “jailed” RV leads. 3 of the four patients with jailed leads had lead dysfunction requiring system revision or reprogramming - including elevated lead threshold, clinical evidence of transient loss of capture, and non-jailed atrial lead undersensing post TTVR. Conclusions: We report a high incidence of lead malfunction due to RV jailing with TTVR and good outcomes of those undergoing preemptive extraction strategies. Approaches such as leadless systems and coronary sinus systems may be useful in this patient population.

Abstract 14216: Acute Heart Failure and Mitral Stenosis in a Patient With Spindle Cell Sarcoma of the Mitral Valve

A 27-year-old male with no past medical history presented with a productive cough, intermittent hemoptysis, dyspnea, orthopnea, and lower extremity edema. He underwent an echocardiogram that was significant for a large 6.2 cm x 3.5 cm left atrial mass moving into the left ventricle across the mitral valve concerning for a myxoma. Other pertinent findings were an ejection fraction of 50-55%, severe mitral stenosis with a mean mitral valve gradient of 23, severely reduced right heart function, and severe tricuspid regurgitation. Cardiovascular surgery was consulted for evaluation of atrial mass. He underwent left atrial mass resection. The left atrial mass was attached to the mitral valve, so the mitral valve was repaired with Onyx mechanical valve. After the surgery, there was a significant improvement in right heart function, mitral valve gradient, and velocities were within the expected range. Pathology from atrial mass back with high-grade spindle cell sarcoma so Oncology was consulted. Further studies were negative for metastatic spread. He was started on adjuvant chemotherapy and currently, he is undergoing his fourth cycle. Follow-up TEE six months later noted a left atrial mass located in or where the left atrial appendage should be approximately that was 2.5cm x 1.5cm concerning for recurrence of his sarcoma. This case demonstrates a rare primary cardiac tumor, spindle cell sarcoma, which is generally aggressive and therefore has a poor prognosis. The clinical symptoms are more related to the location of the sarcoma than the histopathology. Depending on location, cardiac sarcomas generally present with heart failure as in this patient. About 25% of cardiac tumors are malignant with the majority of those being sarcomas. Initial evaluation of primary cardiac sarcomas should include echocardiography. The primary treatment is surgical resection of the mass with adjuvant chemotherapy, however, there is a high rate of recurrence and metastatic spread.

Abstract 13665: Clinical Outcomes and Predictors of Residual Pulmonary Hypertension in Patients Undergoing Transcatheter Aortic Valve Replacement

Background: Although transcatheter aortic valve replacement (TAVR) improves pulmonary hypertension (PH) secondary to aortic stenosis (AS), PH can remain after TAVR. We sought to investigate the outcomes and predictors of residual PH after TAVR. Methods: A total of 491 consecutive patients underwent TAVR between 2014 and 2023 at our institution. After excluding patients without baseline or postoperative transthoracic echocardiography, we stratified 483 patients according to baseline and postprocedural PH estimated by systolic pulmonary artery pressure >36 mmHg as follows: no PH group (n=285), improved PH group (n=87), residual PH group (n=111). Outcome measures were the composite of cardiac death and heart failure (HF) hospitalization. Logistic regression analysis was used to identify the predictors of residual PH. Variables included in the model were age, atrial fibrillation (AF), left ventricular ejection fraction, left atrial dilatation, moderate/severe mitral regurgitation, moderate/severe tricuspid regurgitation (TR). Results: The mean age was 83.6±5.4 years, and 314 (65%) were female. Patients in residual PH group were more likely to have AF, higher left atrial volume index, moderate/severe MR, and moderate/severe TR, compared with patients in no PH group. Compared with no PH group, the cumulative incidence of the composite of cardiac death and HF hospitalization were comparable in improved PH group (6.1% vs. 10.5 at 2 years, P=0.3), but significantly higher in residual PH group (6.1% vs. 20.6% at 2 years, P=0.002) (Figure). Multivariable logistic regression analysis showed that AF (Odds ratio [OR] 1.91, 95% confidence interval [CI] 1.09-3.32), moderate/severe TR (OR 4.09, 95% CI 2.30-7.28) were independently associated with residual PH. Conclusions: Among patients undergoing TAVR, residual PH were associated with increased risk of adverse cardiac events. AF, moderate or severe TR were independent predictors of residual PH after TAVR.

Abstract 13181: Tricuspid Regurgitation Impact on Outcomes (TRIO) Score in Patients With Tricuspid Regurgitation and Severe Pulmonary Hypertension

Background: Clinically significant tricuspid regurgitation (TR) is an important contributor to morbidity and mortality. The Tricuspid Regurgitation Impact on Outcomes (TRIO) score based on 8 parameters (age, gender, chronic heart failure, chronic lung disease, heart rate, creatinine, aspartate transaminase level, and TR severity) is used for risk stratification. The performance of the TRIO score in patients with TR secondary to severe pulmonary hypertension (PH) is unknown. Research Questions: To evaluate whether the TRIO score can be applied in patients with TR and pulmonary hypertension (PH), and to identify other predictors of mortality. Methods: Retrospective study including patients with TR ≥ moderate. Severe PH was defined as right ventricular systolic pressure (RVSP) ≥50 mmHg. The impact of clinical, echocardiographic and laboratory variables on mortality was evaluated with the Cox proportional hazard method. Results: A total of 13,482 patients from the TRIO population were included; severe PH was present in 6,530 (48.4%); mean age 73.4 + 13.3, 55.7% females. TRIO score performance was modest (AUC 0.62) in risk stratification (Figure A). PH patients had significantly higher mortality than those without PH at all levels of TRIO score (Figure B); differences were progressively lower with increasing TRIO scores. At multivariate analysis, only TRIO score [HR = 1.54 (1.35-1.77) per unit change], presence of an elevated NT-proBNP [HR = 1.02 (1.02-1.03) per 1000 pg/ml change], RVSP (HR = 1.08 (1.02-1.16) per 10 mmHg change], presence of RV dysfunction [HR = 1.15, (1.05-1.26)] and pulmonary artery pulsatility index (PAPi) ≤ 4 [HR = 1.34 (1.07-1.67)] were significant predictors of mortality (model AUC 0.65). Conclusions: TRIO score allows risk stratification in PH patients, but performance is modest; incorporating additional factors marginally increased model performance. PH patients have higher mortality at all levels of TRIO score, more so at low scores.

Abstract 18651: Case Report: Transcatheter Edge-to-Edge Repair in a 59-Year-Old Patient With Mitral Regurgitation and Challenging Anatomy

Re-intervention for patients with mitral valve disease is a growing challenge. We present a 59-year-old male with a history of a congenitally bicuspid aortic valve. He had valve and root replacement for aortic regurgitation in his 30s and two subsequent sternotomies for prosthesis failure and endocarditis. After admission with acute pulmonary edema, there was persistent NYHA class II-III dyspnea. Echo showed severe (grade IV) mitral regurgitation due to the dehiscence of a 32mm mitral annuloplasty ring. The coaptation point of the leaflets was posterior to the posterior aspect of the ring. No regurgitation was observed through the ring’s central orifice, but the tissue was seen on its posterior aspect, suggesting torn posterior leaflet or healed vegetation. The left ventricle was mildly dilated, and the LVEF was 53%. The right ventricle was moderately dilated with severe functional tricuspid regurgitation with a normally functioning aortic valve prosthesis. After extensive discussion, due to his multiple previous surgeries and challenging anatomy, the patient was deemed unsuitable for surgical treatment. There is some limited registry data to support TEER as a safe and feasible alternative to surgery in this cohort. He underwent successful implantation of two clip devices in the A2/P2 and A2/P2b positions via a trans-septal approach under a general anesthetic. Femoral venous access was used. Some useful learning points relate to the challenges posed by the unusual anatomy in terms of imaging and trajectory. No MVARC complications. Postoperatively the LVEF was 55% with a mean transvalvular gradient of 5mmHg and only mild (grade I) transvalvular MR. At three months the patient reported an improvement of overall functional status. This successful case of “clip-in-ring” TEER illustrates one of the expanding indications for existing trans-catheter valvular therapies as well as the potential for creative application of TEER in helping patients with high surgical risk.

Abstract 15376: Candidacy and Fate of Right Heart Failure Patients Undergoing Tricuspid Valve Surgery

Objective: There are no current guidelines for risks and benefits of cardiac surgery for patients with right heart failure (RHF). In this study, we analyzed pre-operative RHF variables aiming to assess candidacy for surgery and impact of tricuspid intervention. Methods: We retrospectively identified 522 patients with severe (+3 or more) tricuspid regurgitation (TR) who underwent cardiac surgery between 01/2007 and 01/2014 . The mean follow up was 4.7 years (± 4.3 years). Cluster analysis was performed using preoperative RHF clinical and hemodynamics variables, and outcomes after surgery were assessed. Results: Cluster analysis divided the cohort into three distinct clusters representing different phenotypes of patients with RHF-associated TR (cluster 1: 220 patient, cluster 2: 224 patients, cluster 3: 78 patients). Cluster I had highest concomitant left-sided valve procedure (72% mitral valve surgery, p<.0001) with best RV function (fractional area change % 35 ± 13, p=.0002). Cluster II had highest MELD score (14 ± 4, p<.0001), creatinine (1.4 ± 0.6, p<.0001), and worst RV function (fractional area change % 30 ± 12, p=.0002). Cluster III had the most dilated right heart with right atrial area of 42 ± 14 mm, p<.0001 and RV area in diastole 42 ± 10 mm, p<.0001. Survival was best in Cluster I followed by Cluster III while worst in Cluster II (70%, 59%, and 29% at 8-years, respectively), Figure 1. Recurrent TR was highest in Cluster III, followed by Cluster II while least in Cluster I at 10-years (9%, 8%, and 5%, respectively). Conclusions: Cluster analysis of RHF identified three distinct groups of patients presenting for cardiac surgery. Pre-operative RV dysfunction was associated with worse clinical outcomes and need careful assessment before surgery. Pre-operative right heart dilation was associated with recurrent TR for which more aggressive tricuspid repair or even replacement might be considered.

Abstract 13061: Association of Right Ventricular - Pulmonary Arterial Coupling and Progression of Tricuspid Regurgitation in Patients With Non-Valvular Atrial Fibrillation

Introduction: Tricuspid regurgitation (TR) severity in patients with atrial fibrillation (AF) is associated with poor prognosis. Recently, right ventricular-pulmonary arterial (RV-PA) coupling has been shown to be related to clinical outcomes in TR patients. However, data on the relationship of RV-PA coupling to the progression of significant TR is limited. Hypothesis: This study aimed to investigate whether RV-PA coupling affects the progression of significant TR in patients with non-valvular AF. Methods: A total of 300 consecutive AF patients with insignificant TR were included among 371 patients with AF who underwent follow-up echocardiography. Insignificant TR was defined as TR less than a mild degree. We excluded other significant valvular diseases, regional wall motion abnormality, LVEF <50%, the cardiac implantable electronic device, cardiac surgery, and poor echo image for RV analysis. RV-PA coupling was assessed by the ratio of RV global longitudinal strain (GLS) using speckle tracking echocardiography to pulmonary artery systolic pressure (PASP). Results: During a mean 4.7±2.5 years of follow-up, 31 (10.3%) patients (mean age 67.5±11.7 years, 37.0% female) have progressed to significant TR as more than moderate degree. The patients who progressed to significant TR were older, more likely to be female, and had a higher prevalence of ischemic stroke, higher PASP, larger RV size, lower right atrial (RA) strain, lower RVGLS, and lower RVGLS/PASP than patients without TR progression. RV-PA coupling reflected by RVGLS/PASP was independently related to the progression of TR after adjusting for age, gender, and history of stroke (p<0.001). It remained significant for predicting TR progression even after further adjustment for PASP, RA strain, or RV strain (Figure). Conclusions: RV-PA coupling was associated with the progression of TR in patients with non-valvular AF, which might suggest that it can be a helpful parameter in monitoring this population.

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.

Abstract 18974: Transcatheter Tricuspid Valve Replacement in a Symptomatic Bioprosthetic Tricuspid Stenosis Patient With Carcinoid Heart Disease: A Case Report

Background: Patients with carcinoid heart disease are prone to the development of mild to severe tricuspid regurgitation with or without accompanying tricuspid stenosis. We present an interesting case of a patient with bioprosthetic tricuspid valve stenosis secondary to carcinoid heart disease undergoing transcatheter tricuspid valve replacement (TTVR). Case history: The patient is a 64-year-old female with metastatic carcinoid syndrome and subsequent tricuspid valve replacement with 25 mm Magna ease bovine pericardial valve. The surgery was complicated by carcinoid crisis, pneumothorax, and complete heart block. She presented with worsening shortness of breath with exertion. Echocardiography revealed severe tricuspid stenosis associated with a severely dilated right atrium, moderate pulmonary stenosis. Transesophageal echocardiography confirmed carcinoid degeneration of the bioprosthetic tricuspid valve. CT chest and abdomen with contrast showed consistent findings of severe tricuspid stenosis, metastatic carcinoid tumor with new foci in liver, lungs. Ischemic evaluation with angiography revealed normal coronaries. Decision making: The patient was evaluated by the heart team and was considered to be a prohibitive risk patient for redo surgery. We then evaluated her suitability for transcatheter valve replacement, and the patient was felt suitable for undergoing valve-in-valve transcatheter tricuspid valve replacement via the right internal jugular vein approach because of the coaxial alignment of the valve through this route. The patient successfully underwent this procedure with a 26 mm balloon-expandable valve without any complications and is currently in NYHA class I functional status. Conclusion: Carcinoid syndrome can affect bioprosthetic tricuspid valves and transcatheter valve replacement may be advantageous in replacing the affected bioprosthetic valves by reducing morbidity and mortality.

Abstract 14350: Prognostic Impact of Right Ventricular Free Wall Longitudinal Strain in Tricuspid Regurgitation: A Systematic Review and Meta-Analysis

Introduction: Traditional echocardiography is limited in the early assessment of right ventricular (RV) dysfunction, especially in cases of tricuspid regurgitation (TR). In this context, right ventricular free wall longitudinal strain (RVFWLS) has emerged as a promising tool to enhance this evaluation. Hypothesis: We aimed to conduct a systematic review and meta-analysis to investigate whether impaired RVFWLS in patients with moderate to severe TR is associated with an increased risk of all-cause mortality and heart failure (HF) hospitalization. Methods: We searched Pubmed, Embase and Cochrane for studies that examined our clinical question. Two reviewers performed study selection, data extraction and assessment of bias. RVFWLS was evaluated as a binary variable: normal/near-normal vs. impaired. The latter was defined as a RVFWLS > -17%. Statistical analysis was performed using Review Manager 5.4.1. We calculated pooled hazard ratios (HR) with 95% confidence intervals (CI) under a random effects model. We also performed a subgroup analysis of multivariable analyses to minimize the effect of confounding variables. Results: We included 1,523 patients from 5 cohort studies. The mean follow-up ranged from 2.2 to 3.9 years. Mean age ranged to 62 to 84 years and 1,462 (96%) had functional TR. All-cause mortality (HR 1.06; 95% CI 1.02-1.10; p=0.002) and the composite of all-cause mortality or HF hospitalizations (HR 1.10; 95% CI 1.03-1.18; p=0.006) were significantly higher in patients with impaired RVFWLS compared with normal or near-normal RVFWLS. When considering only the multivariable analyses, patients with reduced RVFWLS also had a higher adjusted risk of all-cause mortality (HR 1.05; 95% CI 1.02-1.08; p=0.003). Conclusions: Our findings indicate that RVFWLS is an independent prognostic factor for all-cause mortality among patients with moderate to severe TR. The use of RVFWLS to guide management of this population warrants further investigation.