Severe Tricuspid Regurgitation Research Articles

Study of right atrial and right ventricular function in dual chamber pacemaker patients

Abstract Background Unlike left ventricular function, right ventricular (RV) function in pacemaker patients is less well studied with less studies comparing septal versus apical pacing effects on the RV function and almost none on the right atrial (RA) function. Purpose To assess the effect of RV pacing on the echocardiographic and clinical parameters of the RV and RA function and their correlation with the site of right ventricular lead implantation. Methods The study assessed 59 patients in need of permanent dual chamber pacemaker implantation using clinical and echocardiographic data of the RV and RA size and function using tricuspid annular plane systolic excursion (TAPSE), S wave velocity of the tricuspid annulus and fractional area change (FAC), free wall strain (FWSL), global longitudinal strain (GLS) of the RV, RA strain including reservoir, conduit and contraction phases and 3D ejection fraction of the RV using Epiq 7 Ultrasound machine (Philips Healthcare) by the same echocardiographer before implantation and 6 months after. All programming parameters were recorded postoperative and 6 months later. Results 31 patients had the RV lead in the RV apex whereas 28 had it in the septum and all patients had their RA lead in the right atrial appendage, with no significant difference between both groups regarding baseline demographic, clinical nor echocardiographic data. At 6 months, there was a significant decline of the 3D RVEF from a mean of (58.57% ± 6.35%) to (56.41% ± 6.17%), TAPSE from (2.61 cm ± 0.51) to (2.35 cm ± 0.52) and S wave from (13.73 cm/sec ± 2.84) to (12.64 cm/sec ± 2.61) but none showed a significant difference between septal and apical pacing, on the other hand, the RV strain showed a significant decline 6 months after implantation in both the FWSL from (-31.75% ± 5.39) to (-27.82% ± 5.73) and the GLS from (-25.89% ± 5.17) to (-21.65% ± 4.51) with more decline in the septal group compared to the apical (-20.33% ± 4.70 versus -22.84% ± 4.04 regarding the GLS and -26.11% ± 6.41 versus -29.37% ± 4.62 in the FWSL, respectively). There was no difference in the FAC, tricuspid regurgitation severity, gradient nor the estimated pulmonary artery pressure at 6 months. The RA size showed a significant decline at 6 months but no difference in any of the strain parameters. No clinical RV failure symptoms nor signs were observed. Programming revealed a mean percentage of ventricular pacing of (97.92% ± 2.67%) with a minimum of 91% and atrial pacing of (10.41% ± 12.52%), and the thresholds, impedance and atrial high-rate episodes were comparable postoperatively and 6 months after, with no difference between the septal and apical groups. Conclusion At 6 months follow-up after pacemaker implantation, right ventricular function starts to show decline in both the septal and apical groups with only the right ventricular strain more affected in the septal group compared to the apical.3D right ventricular ejection fraction3D right ventricular strain

Prognostic value of the right coronary venous anatomy in patients undergoing cardiac resynchronization therapy

Abstract Background The size and distribution of the coronary veins (CV) reflect both intracavitary pressure and myocardial blood flow, and therefore, in patients with cardiomyopathy, CV anatomy could potentially become a biomarker of disease severity. While the left coronary veins have been well described, there are few descriptions of the right CV system. Purpose Given these considerations, the aim of the study was to evaluate the anatomy of the right CV system and its potential prognostic significance in patients with advanced cardiomyopathy. Methods We analyzed CV angiograms from 121 patients (age 67±14 years) undergoing cardiac resynchronization therapy (CRT). The right ventricular (RV) veins were seen to fill during the injection of contrast through multiple connections with the left sided venous system. Patients were followed for a median of 43 [IQR 3-73] months, during which 12 patients expired. Results Anterior cardiac veins (ACV), which overlay the RV wall were observed in 85 (70%) patients and had a maximum ostial diameter of 2.04±0.8 mm. Multiple ACVs were seen in 62 patients. These veins were observed to empty directly into the venous sinus of right atrium (VSRA), into the RV, the right atrium (RA), or into the small cardiac vein (SCV) in 68, 9, 5, and 3 patients respectively. The right marginal vein (RMV) was visualized in 21 (17%) patients, had a diameter of 2.3±1.2 mm, and ran a course along the right border of the RV, emptying directly into RV, RA or into VSRA in 9, 4 and 8 patients respectively. The VSRA present in 91 (75%) patients, coursed parallel to the right coronary sulcus, collecting blood from the ACV’s and RMV’s and drained into the RA (Figure A); in 7 patients, 2 VSRA ostia were noted. VSRA lengths and diameters varied (11-119 mm, mean 41±25 mm) and (1.2-6.9mm, mean 2.7±1.2mm) respectively. The VSRA lengths correlated significantly with RV fractional area change, RV systolic pressure, tricuspid regurgitation severity evaluated by echocardiography, and P wave amplitude in ECG lead II (r=-0.65; p=0.041, r=0.88; p=0.019, r=0.52; p=0.030, and r=0.79; p=0.031 respectively). The VSRA diameters, which were significantly larger in patients with obstructive sleep apnea (3.6±1.5 vs. 2.3±1.2mm; p=0.021) correlated significantly with RV systolic pressure, and tricuspid regurgitation severity by echocardiography (r=0.77; p=0.009, and r=0.63; p=0.006 respectively). Patients who expired during follow-up had a significantly longer VSRA than patients who remained alive (Figure B). The VSRA length, RV fractional area change, and baseline QRS duration independently predicted survival in a Cox multivariate model that also included age and left ventricular ejection fraction. Conclusions RV venous system demonstrates a highly variable anatomy that has not been previously well described. The size of the VSRA correlated with parameters of RV function and predicted survival in patients undergoing CRT.Figure

Left atrial strain is associated with cardiovascular outcomes in children with congenitally corrected transposition of the great arteries

Abstract Background The assessment of the systemic right ventricular (sRV) function in congenitally corrected transposition of the great arteries (ccTGA) by echocardiography is restricted by its complex geometry. Purpose To determine the utility of left atrial strain (LAS) and sRV longitudinal strain (sRV-LS) in the prediction of outcomes in children with ccTGA. Methods This nested case-control study included all patients <21 years old with unrepaired ccTGA at our tertiary pediatric institution who had an echocardiogram prior to cardiovascular outcomes (milrinone-dependent heart failure, ventricular assistant device, heart transplant or death). LAS (both R wave and P wave references) and sRV-LS were measured using TomTec AutoStrain. To account for potential confounders, cases and controls were matched (1 cases vs 3 controls) by age ± 1 year and tricuspid regurgitation (TR) severity (none/mild vs. moderate/severe). Univariable conditional logistic regression was employed to assess the association between LAS and sRV-LS with outcomes among matched patients. Results Of 101 patients (64% male) with echocardiogram performed at 1.78 years old (IQR 0.02, 9.80), 14 (14%) developed an outcome. Baseline characteristics, LAS, and sRV-LS are depicted in Table 1. LAS and sRV-LS were not discriminative between age-matched cases and controls. In the matched cases and controls for TR severity, each unit-increase in LAS conduit phase (LAScd R and LAScd P) was associated with 18% and 22% higher odds of outcomes respectively, although these did not achieve statistical significance (LAScd R OR 1.2, 95% CI 1.0-1.4, p=0.09; LAScd P OR 1.2, 95% CI 1.0-1.5, p=0.08, Table 2). Conclusions After controlling for TR severity as a potential confounding factor, the conduit phase of LAS by both R wave and P wave references may have clinical implications as predictors of cardiovascular outcomes in patients with ccTGA. Larger and more well-powered studies are needed to further evaluate this association and studying longitudinal changes in LAS may provide insight in the development of outcomes in this population.

Predictive factors for recurrent tricuspid regurgitation after tricuspid annuloplasty: 3D echocardiography study

Abstract Introduction There is growing concern about the recurrence of tricuspid regurgitation (TR) after tricuspid annuloplasty (TA) in individuals with functional tricuspid regurgitation (FTR). While TA is effective in treating FTR, a comprehensive understanding of the echocardiographic factors influencing TR recurrence is crucial. Aim This study aims to employ multivariate regression analysis to investigate the prognostic significance of tricuspid valve (TV) geometry and echocardiographic parameters associated with both RV geometry and function. The focus is on comprehending these relationships in the context of recurrent TR subsequent to TA. Methods This prospective observational cohort study aimed to explore factors contributing to recurrent tricuspid regurgitation (TR) after tricuspid annuloplasty (TA). The focus was on patients with moderate or severe functional TR due to left heart valvular disease, particularly severe mitral regurgitation, excluding those with ischemic heart disease. The cohort included 66 individuals undergoing preoperative assessments with 2D and 3D echocardiography, quantifying RV and right atrial (RA) geometry, functional, and tricuspid valve (TV) parameters. TR severity followed ESC guidelines. Patients were categorized into effective TA (50 patients) and recurrent TR (16 patients) groups, defined by mild-moderate TR and significant moderate-severe TR one year post-surgery, respectively. SPSS software facilitated statistical analysis, with adjusted logistic regression considering parameters such as age and gender. Results Among the patients (54% male, mean age 68±9 years), no significant differences were found in gender, left ventricular and atrial parameters, or preoperative TV orifice area between groups (recurrent TR vs. effective TA: 38 [33] mm2 vs. 29 [15] mm2, p=0.117). Univariate logistic regression analysis identified Septal-Lateral Systolic TA Diameter (OR 1.62), Septal-Lateral Diastolic TA Diameter (OR 1.99), and Major Axis Diastolic TA Diameter (OR 1.59) as key predictors. For diagnostic efficacy, ROC analysis revealed Major Axis Diastolic TA Diameter (AUC 0.848; cut-off 52.5 mm), TV Leaflet Tenting Volume (AUC 0.778; cut-off 5.1 ml), and RV Basal Diameter (AUC 0.763; cut-off 47.5 mm) as the most predictive parameters. The combined use of predefined RV basal diameter and Major Axis Diastolic TA Diameter showed the highest odds ratio for recurrent TR. Conclusion Key predictors, including Septal-Lateral Systolic and Diastolic TA Diameters, and Major Axis Diastolic TA Diameter, were identified, emphasizing their significance in understanding TR recurrence after tricuspid annuloplasty. The combination of predefined RV basal diameter and Major Axis Diastolic TA Diameter showed the highest odds ratio for recurrent TR, offering valuable insights for clinical assessment and preventive strategies.

Prognostic preoperative factors for recurrence of tricuspid regurgitation following annuloplasty: examining the influence of 3d echocardiography

Abstract Introduction The increasing worry revolves around the reappearance of tricuspid regurgitation (TR) following tricuspid annuloplasty (TA) among individuals dealing with functional tricuspid regurgitation (FTR). Despite TA's efficacy as a treatment, a complete understanding of the echocardiographic elements influencing the recurrence of TR is pivotal. This knowledge holds the potential to guide the development of more robust preventive strategies, aiming to ease the incidence of recurrent TR after TA. Aim The aim of this study was to examine the prognostic value of tricuspid valve (TV) and echocardiographic parameters related to both right ventricular (RV) geometry and function. Specifically, our focus is on understanding these relationships in the context of recurrent TR following TA. Methods This prospective observational cohort study aimed to investigate determinants of recurrent TR post-surgical TV repair. The focus was on patients with moderate or severe functional TR related to left heart valvular disease, primarily severe mitral regurgitation, excluding those with ischemic heart disease. The study involved 66 participants, assessed preoperatively with 2D and 3D echocardiography, examining RV and right atrial (RA) geometry, functional, and TV parameters. TR severity followed ESC guidelines. Two groups were formed: effective TA group (50 patients) and recurrent TR group (16 patients), defined by mild to moderate TR and significant moderate-severe TR one year post-surgery, respectively. Statistical analysis employed SPSS software, with adjusted univariate logistic regression considering age and gender. Results Of the patients, 54% were male, with a mean age of 68±9 years. Echocardiography parameters in Table 1 showed no significant differences in gender, left ventricular, atrial geometrical, functional parameters, or preoperative effective regurgitant TV orifice area between groups (recurrent TR vs. effective TA: 38 [33] mm2 vs. 29 [15] mm2, p=0.117). Univariate logistic regression analysis highlighted RV and RA geometry, along with TV diameter, as predictors for recurrent TR. Notably, 3D TV geometrical parameters had prognostic significance, as confirmed by univariate adjusted logistic regression analysis. Functional RV parameters did not exhibit statistical significance in this analysis. Conclusion In conclusion, the recurrence of moderate-severe functional tricuspid regurgitation following tricuspid annuloplasty is linked to the tricuspid annulus size, as well as the geometry of the right atrium and right ventricle before surgery. Notably, no correlation was identified between the recurrence of TR and alterations in RV function.

Association between left atrial dysfunction and adverse outcomes after tricuspid valve surgery for atrial functional tricuspid regurgitation

Abstract Objectives To identify factors associated with clinical outcomes in patients undergoing tricuspid valve (TV) surgery for atrial functional tricuspid regurgitation (AF- TR). Methods Among 1,670 patients who underwent TV surgery between January 2000 and December 2020, we included 83 AF-TR patients (69.1±9.2 years, 50 women) who had severe TR without any cause other than atrial fibrillation. A comprehensive analysis of right ventricular (RV) and left atrial (LA) function on preoperative and postoperative echocardiography was performed. LA function was evaluated by LA emptying fraction (LAEF), LA reservoir strain, and LA stiffness index. The primary outcome was a composite of all-cause death and heart failure hospitalization during follow up after surgery. Results For a median of 39.9 (interquartile range 19.9 to 55.8) months, the primary outcome occurred in 20 (24.1%) patients. Patients with a primary outcome showed significantly lower LAEF (9.7±7.3 vs. 21.8±6.7 %, p<0.001) and LA reservoir strain, and higher LA stiffness index than those without. However, there was no difference in RV chamber size and functional parameters according to the occurrence of a primary outcome. The restricted cubic spline plot exhibited a significant relationship between LAEF and primary outcome. The low baseline LAEF (<17%) group showed a poorer outcome than the high LAEF group (log rank p<0.001). In the Cox regression analysis, the low LAEF (<17%) was independent predictor for primary outcome (adjusted hazard ratio 13.5, 95% confidence interval 3.1–58.6). Conclusion In patients undergoing TV surgery with AF-TR, preoperative LA dysfunction was independently associated with adverse outcomes.Figure1

Predicting the severity of valvular heart diseases using ai integrated with ECG and anthropometric data

Abstract Background AI has been used in studies to predict the severity of aortic stenosis (AS) from electrocardiography (ECG), but the application of AI to predict the severity of aortic regurgitation (AR), mitral regurgitation (MR) and tricuspid regurgitation (TR) has not been widely explored. This study aimed to determine whether deep learning can predict the severity of valvular heart disease (AS, AR, MR and TR) assessed by echocardiography using ECG data. Methods and Results We analyzed data from 31,787 adult patients who underwent ECG and echocardiography within three days of each other between 2014 and 2019 at two hospitals. Valvular heart diseases, including AS, AR, MR, and TR, were classified into categories; normal, mild, moderate, and severe; according to guidelines. ECGs, along with patient age, gender, height, and weight, were inputs to a LightGBM machine learning model. The model was trained on 80.6% of the data, with the remaining 19.4% used for validation. The sensitivity for predicting moderate or severe valvular heart disease was 85% for AS, 88% for AR, 85% for MR, and 85% for TR. The negative predictive values for AS, AR, MR, and TR were all 100%. Prediction accuracies for the severity of each disease were AS at 0.857, AR at 0.871, MR at 0.855, and TR at 0.890. Predictions based on AS diagnostic parameters; mean pressure gradient, valve area, and maximum blood flow velocity also showed favorable accuracies at 0.891, 0.821, and 0.877, respectively. Conclusion Integrating AI with standard clinical parameters, including ECG data, height, and weight, showed potential in accurately predicting the severity of various valvular heart diseases. Further researches across diverse populations and settings are necessary to validate the approach's effectiveness and explore its impact on patient care.

Sinus rhythm maintenance and the changes of echocardiographic parameters in patients with late persistent atrial fibrillation at 6 months after direct current cardioversion

Abstract Background Late persistent non-valvular atrial fibrillation (AF), with a duration of its episode ≥90 days and up to 12 months, is considered a distinct persistent AF entity, which might possess substantial differences as compared to its early persistent pattern (up to 3 months) in terms of myocardial remodeling and its reversibility after cardioversion. Purpose To study the changes of echocardiographic parameters in patients with non-valvular late persistent AF with respect to sinus rhythm (SR) maintenance at 6 months after successful direct current cardioversion (DCCV). Methods The cohort single-center study enrolled 59 late persistent AF patients, who underwent a successful elective DCCV. At 6-months follow-up, patients were subdivided into the groups regarding SR maintenance: 32 (54 %%) patients with a maintained SR (G1), and 27 (46 %) patients with a failure to maintain SR (G2). The parameters of myocardial remodeling and function were evaluated by transthoracic (TTE) and transesophageal echocardiography (TEE) baseline (by TTE and TEE) and at 6-months follow-up (by TTE). Results TTE data from G1 patients, in contrast to G2, suggested better baseline status of left heart chambers, particularly the lower diameter of left atrium (LA), left ventricular (LV) end-diastolic and end-systolic volumes and higher LV systolic function (by LV ejection fraction [EF]). According to the TEE data, G2 (vs. G1) was characterized by more prevalent cases of LA spontaneous (echo) contrast (41 % vs. 15 %, respectively; p=0,042) and LA appendage flow velocity ≤40 cm/s (82 % vs. 53 %, respectively; p=0,022). At 6-months follow-up TTE, G1 patients, as opposed to G2, demonstrated a better profile of echocardiographic parameters, namely a lower LA diameter, LA and right atrium (RA) volumes, along with less advanced LV remodeling and higher LV EF. TTE data from G1 at 6-months follow-up after DCCV suggested the reverse remodeling of both atria, namely the decrease of LA diameter, LA volume and its index (Fig. 1), as well as RA volume and its index. Moreover, G2 demonstrated a decline in LV systolic function, in particular the rise of LV end-systolic volume and decrease of LV EF (Fig. 2), as compared to G1. Furthermore, at 6-months follow-up, G2 patients presented with more advanced severity of PH and tricuspid regurgitation, in comparison with G1. Conclusions Late persistent AF patients with a SR maintenance at 6-months follow-up after successful DCCV presented a better baseline profile of myocardial remodeling and systolic function. The SR maintenance at 6-months follow-up after DCCV was associated with the reverse remodeling of left heart chambers (LA and LV) and RA. On the contrary, a failure to maintain SR in late persistent AF patients was associated with a deterioration in LV systolic function, and more advanced PH and tricuspid regurgitation.

Tricuspid regurgitation in rheumatic heart valve disease. New insights from 3D transthoracic echocardiography

Abstract Background The assessment of tricuspid valve (TV) and functional tricuspid regurgitation (FTR) in left side valvular disease is crucial in assessing the need for surgical intervention. Despite the declining incidence of rheumatic disease, it remains a a common cause of valvulopathy. According to current guidelines, TV surgery is recommended in presence of severe TR or non-severe with annulus dilatation assessed by two-dimensional echo (2DE). Objectives To assess tricuspid annulus (TA) 3D dimensions in relation to the severity of tricuspid regurgitation (TR) and to identify new parameters associated with the presence of severe TR in this scenario. Methods Fifty patients (Age: 69±9, 82% women) with rheumatic heart disease without previous valve replacement and functional tricuspid regurgitation (FTR) were prospectively included. Two-dimensional echocardiography (2DE) and three-dimensional transthoracic full-volume datasets of the tricuspid valve (TV) were acquired. Two orthogonal planes corresponding to the anatomical antero-posterior (APD), septum-lateral (SLD), long intercommisural (LID), and area (A3D) of the TA were analyzed by 3D transesophageal echocardiography (3DTE) (Figure 1), in addition to 2D diameter. TR was graded into two groups: severe (n=14) or non-severe (n=26). The area under the curve (AUC), sensitivity (Se), and specificity (Sp) to identify the presence of severe FTR were calculated. Results All parameters differed significantly (p<0.05) between the two groups (2D: 18.6±1.9 vs. 23.3±2.0 mm/m2; APD 17.0±3.3 vs. 21.5±3.0 mm/m2; SLD: 18.9±2.0 vs. 22.5±2.0 mm/m2; LID: 20.9±2.6 vs. 26.1±3.5 mm/m2; A: 5.6±1.3 vs. 7.6±1.4 cm2/m2). 2D diameter (Cut-off point: 20.6 mm/m2, AUC: 0.850, Se: 86%, Sp: 72%), A3D (Cut-off point: 6.5 cm2/m2, AUC: 0.835, Se: 86%, Sp: 78%), and LID (Cut-off point: 23.3 mm/m2, AUC: 0.833, Se: 78.6%, Sp: 77.8%) were the parameters with the best performance for severe FTR detection. Conclusions New 3D-derived parameters provide relevant information in the assessment of TA and offer good diagnostic performance for identifying severe FTR in this subgroup of patients.2D/3D Echo TA measurements

The impact of tricuspid regurgitation on the timing of pulmonary valve replacement in adult patients after Tetralogy of Fallot repair

Abstract Background Tricuspid regurgitation (TR) in patients with repaired tetralogy of Fallot (rTOF) is an important finding with a wide spectrum of etiologies. TR represents an important risk factor in adult patients with rTOF, influencing clinical outcomes and the requirement for additional surgical interventions. In this study, we reviewed the long-term outcomes of TR in ACHD patients with rTOF as well as its impact on the timing of surgical pulmonary valve replacement (PVR). Methods This was a retrospective analysis of a single institutional cohort which included 149 ACHD patients with a history of rTOF (transannular patch only) with CMR data, complete follow-up, and a recent (< 1 year) outpatient clinic visit. Results Overall follow-up time was 25.5 years (95% CI 24.5,26.4). Between 2002 and 2021, 93 patients required isolated PVR at a mean time from TOF repair of 16.6 years (95% CI 15.5,17.7) and at a mean age of 17.9 years (95% CI 16.8,19.0). In the whole cohort, significant TR was associated with a two-fold increase in the likelihood of requiring PVR (log-rank p = 0-.0023, HR 2.02; 1.09-4-47). Moderate to severe TR was more frequent in those who underwent VSD closure through a right atriotomy (17 versus 0, p = .0002) and affected time to PVR (13.9 versus 16.3 years, p = .0071), with equal preoperative RVEDVi at CMR. After PVR, RVEDVi normalized in all patients, regardless of the preoperative amount of TR (median 115.3 ml/m2 versus 112.3 ml/m2, p = .7). At a median time of 6.5 years from PVR, 13 patients (13/93, 14%) underwent redo PVR. Conclusions The preoperative severity of tricuspid regurgitation (TR) may have a substantial role on the likelihood of patients needing PVR at a younger age. This, in turn, could result in a reduced duration of freedom from valve failure. Replacing the pulmonary valve too early can effectively increase the lifetime number of procedures, preserving the function of the tricuspid valve at the time of TOF repair is of paramount importance.

Echocardiographic predictors of cardiovascular outcome in heart failure with preserved ejection fraction

Abstract Background The optimal echocardiographic predictors of cardiovascular outcome in heart failure with presereved ejection fraction (HFpEF) are unknown. Purpose We aimed to identify independent echocardiographic predictors of cardiovascular outcome in patients with HFpEF. Methods Systematic literature search of three electronic databases was conducted from date of inception until November 2022. Hazard ratios (HRs) and their 95% confidence intervals (CIs) for echocardiographic variables from multivariate prediction models for the composite primary endpoint of cardiovascular death and heart failure (HF) hospitalization were pooled using a random effects meta-analysis. Specific subgroup analyses were conducted for studies that enrolled patients with acute versus chronic HF, and for those studies that included E/e’, pulmonary artery systolic pressure (PASP), renal function, natriuretic peptides and diuretic use in multivariate models. Results Forty-six studies totalling 20,056 patients with HFpEF were included. Three echocardiographic parameters emerged as independent predictors in all subgroup analyses: Decreased left ventricular (LV) global longitudinal strain (HR 1.24, 95% CI 1.10-1.39 per 5% decrease), decreased left atrial (LA) reservoir strain (HR 1.30, 95% CI 1.13-1.1.50 per 5% decrease) and lower tricuspid annular plane systolic excursion (TAPSE) to PASP ratio (HR 1.17, 95% CI 1.07-1.25) per 0.1 unit decrease). Other independent echocardiographic predictors of the primary endpoint were a higher E/e’, moderate to severe tricuspid regurgitation, LV mass index and LA ejection fraction, although these variables were less robust. Conclusion Impaired LV global longitudinal strain, lower LA reservoir strain and lower TAPSE/PASP ratio predict cardiovascular death and HF hospitalization in HFpEF and are independent of filling pressures, clinical characteristics and natriuretic peptides. These echocardiographic parameters reflect key functional changes in HFpEF, and should be incorporated in future prospective risk prediction models.

Mortality rates by therapeutic approaches for isolated severe tricuspid regurgitation: a systematic review

Abstract Background Managing isolated severe tricuspid regurgitation (TR) poses significant challenges, with questions recently arising about the efficacy of surgical and percutaneous therapies compared to conservative approaches in improving survival. Purpose This systematic review aims to evaluate the mortality associated with various treatment modalities for isolated severe TR. Methods A comprehensive search of medical databases was conducted. Studies reporting mortality of isolated TR at 1-year follow-up, with TR severity classified as moderate-to-severe or worse, were included. Exclusion criteria were TR associated with left-heart disease and combined procedures (treating other valves). The primary endpoint was all-cause mortality at 1-year, with secondary outcomes including in-hospital, 2 and 5 years mortality. Patients with isolated severe TR were categorized by management type: medical, percutaneous, or surgical. Percutaneous treatment included all types of transcatheter therapy (repair or replacement), and surgical interventions encompassed both repair and replacement procedures. Results Twenty-nine studies met the inclusion criteria. Mean age was 72 years among the 5970 patients managed medically, 77 years among the 1205 patients treated percutaneously, and 60 years among the 1754 patients managed surgically. In medically managed patients, 1-year, 2-year, and 5-year mortality rates were 23.6%, 32.5%, and 45.9% respectively. Among percutaneously managed patients, there was an in-hospital mortality of 2.5% and a 1-year mortality rate of 16.9%, which increased to 27.9% at 2 years. Surgically managed patients experienced an in-hospital mortality of 8.6% (p<0.001 compared to percutaneous treatment), with 1-year, 2-year, and 5-year mortality rates of 19.8%, 21.7% and 33.5%, respectively. Compared to medical management, both transcatheter therapy and surgical management demonstrated significantly lower mortality rates at 1 year (p<0.001 vs. percutaneous treatment; p=0.02 vs. surgery), with no significant differences between surgical and percutaneous treatment (p=0.16). At 2-year follow-up, patients undergoing surgical management exhibited significantly lower mortality compared to the other groups (p<0.001 vs. medical treatment; p=0.02 vs. percutaneous treatment), while mortality rates between medical and percutaneous treatment was not different (p=0.11). Conclusion The findings underscore the significant long-term mortality associated with isolated severe TR. While selection bias should be considered, invasive management, through either percutaneous or surgical interventions, demonstrates superior 1-year survival rates compared to medical management. Surgical therapy appears to offer the lowest long-term mortality in selected, operable patients, potentially due to their younger age. Further research is warranted to refine patient selection criteria and optimize therapeutic strategies to improve outcomes in the management of isolated TR.

CMR predictors of acute right heart failure after LVAD implantation

Abstract Background Acute right heart failure (RHF) is one of the most dangerous complications after placement of left ventricular assisted device (LVAD), having a significant impact on prognosis, and is estimated to be around 3 to 35%. Even though right ventricular evaluation with hemodynamical and echocardiographic measurements is a key aspect prior to LVAD implantation, prediction of RHF remains a challenge in daily clinical practice. Purpose To identify cardiac magnetic resonance (CMR) predictors of RHF after LVAD placement. Methods We retrospectively enrolled patients referred to our centre for implantation who also underwent CMR scan prior to LVAD implantation. Acute RHF was defined according to Mechanical Circulatory Support Academy Research Consortium (MRC ARC) criteria. Baseline characteristics, preoperative laboratory, echocardiographic, right heart catheterization (RHC) and CMR parameters were obtained. Patients were divided into two groups based on the development of acute RHF. The variables showing significant differences between the two groups were analysed with the receiver operating characteristic (ROC) curves to find the best cut-offs and then combined into a risk score. Results We enrolled 54 patients who underwent continuous-centrifugal flow LVAD implantation from 2013 to 2021 in whom a CMR within median time of 30 days pre-implantation was available. Four patients were excluded due to low quality images. Among the final cohort of 50 patients, 15 (28%) developed acute RHF. Patients who developed RHF showed worse INTERMACS class, worse renal and liver function, higher central venous pressure at RHC, worse TAPSE at echocardiography and overall smaller left ventricles at the CMR analysis when compared to those who had not acute RHF. No CMR derived right ventricle parameters nor moderate to severe tricuspid regurgitation at echocardiography were different among the two groups. We found that CMR-derived LV mass indexed < 65 g/m2, left ventricular end diastolic diameter (LVEDD) < 70 mm, and LV eccentricity index >1,12 were independent predictors of acute RHF. A CMR-derived score with these three parameters was built (1 point for each). This CMR score has shown to be an independent predictor of acute RHF at multivariate analysis with an odds ratio of 7,084 (CI 95%1.614-37.734) when corrected for other clinical and instrumental predictors of acute RHF. Conclusions Our study proposes a simple scoring system based on three CMR- derived parameters (LVEDD, LV mass indexed and LV eccentricity index) to screen for acute RHF prior LVAD implantation. This score shows promise to be an independent predictor of acute RHF, even when adjusted for clinical, echocardiographic, and haemodynamic parameters. Our model is built on CMR measurement of the LV, showing how patients with smaller ventricles and a left displacement of the interventricular septum (expressed with a higher LV eccentricity index) are at higher risk of developing acute RHF.ROC curves

Clinical outcomes according to clinical and surgical risk scores for tricuspid regurgitation

Abstract Background TRIO score, the clinical risk score in significant tricuspid regurgitation (TR), and TRI-SCORE, the surgical mortality risk for tricuspid valve (TV) surgery, have been proposed. We aimed to investigate the correlation and distribution of two risk scores, and to define the clinical benefit of TV surgery in patients with low or intermediate TRIO score and TRI-SCORE. Methods In a total of 10,054 patients diagnosed with moderate to severe TR between January 2008 to December 2020, TRIO score and TRI-SCORE were stratified into low, intermediate, and high-risk groups. Patients of all etiologies of TR were included and patients who underwent prior tricuspid valve surgery were excluded. The clinical outcome was all-cause death. Results TRI-SCORE and TRIO scores were moderately correlated (r =0.39, p<0.001). 9,104 (90.6%) patients (age 67 ± 14 years, 42% male) had low or intermediate TRI and TRIO score. During 12.6 ± 10.1 years, 885 (9.7%) underwent TV surgery and 1,268 (13.9%) experienced clinical outcomes. Kaplan-Meier analysis revealed significant differences in clinical outcomes according to TV surgery in both low and intermediate TRIO score patients (log-rank, p<0.001) and sub-analyzed them according to the TRI-SCORE group (Figure). In multivariable Cox regression analysis, TV surgery (HR 0.37, 95% CI 0.28-0.49, p<0.001) were significantly associated with clinical outcomes after adjusting confounding factors. Conclusions TV surgery is clinically beneficial in moderate to severe TR patients with a low or intermediate TRIO score and TRI-SCORE.

Residual tricuspid regurgitation after transcatheter tricuspid valve edge-to-edge repair: the EuroTR Registry

Abstract Background Data on the prognostic impact of residual tricuspid regurgitation (TR) after transcatheter tricuspid valve edge-to-edge repair (T-TEER) are scarce. Purpose The aim of this analysis was to evaluate two-year survival and symptomatic outcomes of patients in relation to residual TR after T-TEER. Methods Using the large European Registry of Transcatheter Repair for Tricuspid Regurgitation (EuroTR Registry) we investigated the impact of residual TR on two-year all-cause mortality and New York Heart Association (NYHA) functional class at follow-up. The study further identified predictors for residual TR ≥3+ using a logistic regression model. Results The study included a total of 1286 T-TEER patients (53.6% females, mean age 78.0 ± 8.9 years). TR was successfully reduced to ≤1+ in 42.4%, 2+ in 40.0% and 3+ in 14.9% of patients at discharge, while 2.8% remained with TR ≥4+ after the procedure. Residual TR ≥3+ was an independent multivariable predictor of two-year all-cause mortality (hazard ratio 2.06, confidence interval 1.30-3.26, p=0.002, Figure 1). The prevalence of residual TR ≥3+ was 4-times higher in patients with higher baseline TR (vena contracta > 11.1 mm) and more severe TV tenting (tenting area >1.92 cm2) (Figure 2). Of note, no survival difference was observed in patients with residual TR ≤1+ vs. 2+ (76.2% vs. 73.1%, p=0.461). The rate of NYHA functional class ≥ III at follow-up was significantly higher in patients with residual TR ≥3+ (52.4% vs. 40.5%, p<0.001). Of note, the degree of TR reduction significantly correlated with the extend of symptomatic improvement (p=0.012). Conclusions T-TEER effectively reduced TR severity in the majority of patients. While residual TR ≥3+ was associated with worse outcomes, no differences were observed for residual TR 1+ vs. 2+. Symptomatic improvement correlated with the degree of TR reduction.Figure 1- Residual TR after T-TEERFigure 2 - Predicting residual TR

Mortality based right ventricle functional echocardiographic cutoffs in patients with compared to without tricuspid regurgitation

Abstract Introduction Tricuspid-annular-plane-systolic-excursion (TAPSE) and peak-lateral-tricuspid-annular-systolic-velocity (S’) are frequently used echocardiographic indices of right-ventricle (RV) function. Tricuspid regurgitation (TR) is present in 70-90% of the general population, and while trivial or mild TR may not have prognostic implications, several studies have demonstrated that ≥moderate TR is an independent predictor of adverse outcomes, and that increasing TR severity incurs an increased risk of mortality. The abnormality thresholds for TAPSE and S' are based on published mean and standard deviation data obtained from healthy adults, but not on outcome data. The effect of significant TR on the abnormality threshold of TAPSE and S’ prime is currently unknown. Purpose We aimed to re-examine the abnormality thresholds for TAPSE and S' based on their association with mortality in consecutive patients, stratified to with, or without, significant tricuspid regurgitation (TR). Methods We performed a retrospective analysis of consecutive patients undergoing echocardiography between 2011-2021 in a large tertiary center. TR was assessed using a semi-quantitative method. Cut-off values associated with excess mortality were assessed using spline curves in univariate, and multivariate Cox logistic regression analyses. Results A total of 24717 subjects were included in the current analysis with a median (interquartile range) follow up of 1321 (581-1902) days. 1143 (4.6%) subjects had clinically significant (≥moderate) TR. In the entire cohort, TAPSE<20.9 mm and S’ <10.9 cm/s were associated with excess mortality. In sub-group analysis, among subjects with significant TR, TAPSE<18.0 mm and S'<10.0 cm/s was the cutoff associated with excess mortality, while subjects without TR had a higher cutoff of TAPSE<21.5 mm and S'<10.9 cm/s. In a multivariate model adjusted for the presence of TR and baseline characteristics, TAPSE<20.9 mm (HR 1.20, 95% CI 1.14-1.27; p<0.001) and S’<10.9 cm/s (HR 1.07, 95% CI 1.01-1.13; p=0.015) were independent predictors for mortality. A sensitivity analysis, which included 14,664 patients with additional echocardiographic indices, demonstrated that low TAPSE remained an independent predictor of mortality (aOR=1.15; 95% CI: 1.07-1.24; p<0.001) Conclusion TAPSE and S’ thresholds associated with excess mortality are higher than those previously reported in healthy adults. The TAPSE and S' cutoffs associated with excess mortality were lower in patients with significant TR compared to patients without, suggesting that a personalized approach for their interpretation is needed.Central illustration

Predictors of progression to significant atrial functional tricuspid regurgitation in patients with paroxysmal or persistent atrial fibrillation

Abstract Background Atrial functional tricuspid regurgitation (atrial TR) has received growing recognition as a TR entity with a distinct cause owing to its independence from valvular tethering as the predominant mechanism underlying TR. Atrial fibrillation (AF) is highly prevalent in patients with AFTR and is considered a major contributor to its development. However, evidence on predictors of progression to significant atrial function TR in patients with diagnosed AF is lacking. Methods At a single tertiary university hospital, we studied 11445 patients who underwent echocardiograms at least 1 year apart between 2010 and 2023. Patients with moderate or greater TR at the initial examination (n=432) were excluded to ensure that only subjects with confirmed progression to atrial functional TR were included. Only those with EF > 50%, no other moderate or severe valve stenosis or regurgitation, no valve surgery, and RVSP < 40mmHg were subsequently identified (n= 8159). Patients diagnosed with AF 3 months before or after the echocardiogram were included. The final analysis included 629 patients, 44 progressed to moderate or worse TR during follow-up. Results The mean age of the patients was 68 (62-74) years and 57% were male. The mean time to progression to severe TR was 5.7 years. There was no difference in left ventricle size, ejection fraction of LV, right atrium, and right ventricle size on the initial echocardiogram between the group that progressed to significant TR (group 1) and the group that did not progress (group 2). LA diameter (LAAP), LAV(LA volume), and LAVi were significantly larger in group 1. In particular, the Kaplan-Meier graph of TR progression divided into two groups based on LAV 75ml and LAVi 45ml/m2 showed a significant difference, and in particular, LAVi was a significant predictor compared to other factors. Conclusion In patients with AF, the most common cause of atrial functional TR, an initial LAVi >45ml/m2 was shown to be a predictor of progression to significant TR.cumulative survival rate

3D transesophageal echocardiographic assessment of acute reverse remodeling of the tricuspid annulus after transcatheter edge-to-edge repair.

Our study aims to evaluate the acute remodeling of the tricuspid valve annulus immediately after the T-TEER by using intraprocedural transesophageal three-dimensional (3D) echocardiography. We prospectively enrolled 62 consecutive symptomatic patients with at least severe TR, who underwent T-TEER with the TriClip System between March 2021 and June 2024. The following parameters were assessed using a multiplanar reconstruction analysis performed off-line using a 3D dataset: septal-lateral (SL) and antero-posterior (AP) annulus diameters; annulus area; annulus perimeter and eccentricity index.The acute procedural success was achieved in 85,5%. We observed an acute reduction in SL (from a median of 43 to 38 mm, p<0,0001), AP (from a median of 46 to 45 mm, p<0,0001), area (from a median of 17,9 to 15,95 cm2, p<0,0001), perimeter (from a median of 145,5 to 137 mm, p<0,0001) and eccentricity index (from 0,92 to 0,87, p<0,0001). The TV annulus was progressively larger in patients with higher residual TR. Analysis of the subgroups according to procedural success showed an acute inverse remodeling of the TV annulus independent of the acute procedural success. The TV geometry necessitates the use of 3D echocardiography for accurate assessment of annular remodeling post T-TEER. The reduction in TR grade and TV annulus dimensions begins immediately after TriClip implantation. Concurrently, the baseline TV geometry influences the procedural results.

Efficacy and Safety of Cardioband in Patients with Tricuspid Regurgitation: Systematic Review and Meta-Analysis of Single-Arm Trials and Observational Studies.

Background/Objectives: The incidence and prevalence of tricuspid regurgitation (TR) are increasing worldwide. "Traditional" drug therapy with diuretics is often ineffective and the identification of new strategies, including non-pharmacological ones, is an urgent need. The aim of this study was to summarize the results on the efficacy and safety of Cardioband, one of the few approved transcatheter tricuspid valve repair systems, in patients with TR. Methods: Three databases (Medline, Scopus, and CENTRAL) were searched to identify clinical trials and observational studies on the efficacy (primary outcome) and safety (secondary outcome) of Cardioband. A random-effects meta-analysis was performed with R software (version 4.3.3). Survival and freedom from heart failure (HF) hospitalization were estimated with the method of reconstructing individual patient data from Kaplan-Meier curves (IPDfromKM). Results: Eleven studies were included in this systematic review and meta-analysis. Cardioband significantly reduced annulus diameter (-9.31 mm [95% Confidence Interval, CI: -11.47; -7.15]), vena contracta (-6.41 mm [95% CI: -8.34; -4.49]), and effective regurgitant orifice area (EROA) (-0.50 cm2 [95% CI: -0.72; -0.28]) in patients with TR. Cardioband reduced the severity of TR and the extent of heart failure in 91% [95% CI: 85; 97] and 63% [95% CI: 52-75] of patients, respectively. Finally, Cardioband implantation was associated with prolonged survival and freedom from HF hospitalization (80.1% and 57.8% at 24 months, respectively). Conclusions: This study demonstrates that Cardioband implantation leads to cardiac remodeling and mechanical improvements, reduces the severity of TR, and improves quality of life. Therefore, Cardioband is an effective option for the non-pharmacological treatment of TR.

Transcatheter Valve Repair for TricuspidRegurgitation: 1-Year Results from a Large European Real-World Registry.

Tricuspid valve transcatheter edge-to-edge repair has emerged as a valuable treatment option for patients with severe tricuspid regurgitation (TR). This study aims to investigate the safety and effectiveness of the PASCAL transcatheter valve repair system in treating severe TR in a real-world patient population. The PASTE (PASCAL for Tricuspid Regurgitation-a European registry) study is an investigator-initiated, multicenter, retrospective, and prospective observational cohort analysis conducted across 16 European heart valve centers including consecutive patients treated with the PASCAL transcatheter valve repair system from February 2019 to November 2023. Echocardiographic assessments were performed at baseline, discharge, and follow-up, and were subjected to centralized analysis. The study included 1,059 high-risk patients (mean age 79 ± 9 years; 53% female; TRI-SCORE risk 23% ± 18%; 87% NYHA functional class III/IV) with multiple comorbidities. Severe or higher graded TR was observed in 96% of patients. Intraprocedural success according to Tricuspid Valve Academic Research Consortium criteria was achieved in 85%, and TR reduced to ≤moderate in 87%. Independent predictors for a postprocedure residual TR of >moderate were coaptation gaps≥8mm (OR: 1.67; 95%CI: 1.03-2.72; P=0.038), tenting height≥10mm (OR: 2.18; CI: 1.30-3.65; P=0.003), the presence of a transvalvular lead (OR: 1.91; 95% CI: 1.19-3.05; P=0.007), right ventricular dilatation >42mm (OR: 3.35; 95% CI: 1.37-9.1; P=0.009) and massive/torrential TR at baseline (OR: 4.59; 95% CI:2.35-8.96; P< 0.001). At 1 year, 83% of patients showed ≤moderate TR. Significant clinical improvements included enhanced NYHA functional class (66% class I/II vs 17% at baseline; P< 0.001). Patients treated with the first-generation PASCAL system (n = 570) and with the new PASCAL Precision system (n = 489) had similar clinical profiles and TR severity at baseline. However, the Precision cohort showed greater TR reduction to trace/mild (63% vs 49%; P< 0.001), shorter procedure times (median 93minutes [Q1-Q3: 69-130 minutes] vs 120minutes [Q1-Q3: 82-165 minutes]; P< 0.001), and higher clinical success rates according to the Tricuspid Valve Academic Research Consortium at 30days and 1 year (87% vs 81% [P=0.021] and 56% vs 50% [P=0.044], respectively). Higher center experience (≥21 patients/year) resulted in higher intraprocedural and clinical success. The PASCAL system effectively treats severe TR in high-risk patients, offering sustained TR reduction and significant clinical improvements at 1-year follow-up. (PASCAL for Tricuspid Regurgitation-a European registry [PASTE]; NCT05328284).