Severe Tricuspid Regurgitation Research Articles

Improvement in atrial functional and ventricular functional tricuspid regurgitation following catheter ablation or cardioversion of atrial fibrillation

Abstract Background The majority of cases of significant tricuspid regurgitation (TR) are secondary to tricuspid annular dilation and leaflet tethering in the context of RV remodeling due to pressure or volume overload, as seen in patients with pulmonary hypertension (primary or secondary to left-sided heart disease) or dilated cardiomyopathies. Secondary TR induced by tricuspid valve annular dilatation secondary to right atrial dilatation is referred to as atrial functional TR, while secondary TR caused by RV remodeling is referred to as ventricular functional TR. In current guidelines, GDMT (Guideline-Directed Medical Therapy) is effective for secondary TR attributable to HF with reduced LVEF. Normal sinus rhythm should be restored for secondary TR caused by AF-related annular dilatation. In patients with ventricular functional TR, however, AF may also accompany the clinical condition. It is unknown whether restoring sinus rhythm will reduce tricuspid regurgitation in these patients. Purpose The objective of this study was to investigate the degree of tricuspid regurgitation change in patients with atrial and ventricular functional tricuspid regurgitation after sinus rhythm restoration. Methods A retrospective cohort study of patients undergoing AF ablation and cardioversion at a single center between 2019 and 2023 was performed. Patients with at least grade 1 TR on echocardiography and a baseline echocardiogram and a follow-up echocardiogram after ablation were included. A-FTR and V-FTR were defined according to the latest ACC/AHA guidelines. According to the latest guidelines, patients with mild to severe FTR were classified as A-FTR if they had atrial fibrillation, left ventricular ejection fraction >60%, pulmonary artery systolic pressure (PASP) <50 mm Hg, no left-sided valve disease, and normal-appearing tricuspid leaflets. FTR patients who did not meet at least one of these three criteria were defined as ventricular FTR (V-FTR). Results A total of 88 patients were enrolled. The prevalence of A-FTR in our cohort was 62% (53 patients), and 38% of the patients were in the V-FTR group. There was no significant difference between the A-FTR and V-FTR groups regarding age, gender, and NYHA class. 21 of the patients underwent DCCV, and 67 underwent catheter ablation. The prevalence of severe FTR was similar (%17 in A-FTR vs. %8,6 in V-FTR, p= 0.205). There was no difference in preintervention TR grade between the two groups. TR severity improved significantly from baseline to follow-up in both V-FTR and A-FTR patients. These outcomes were observed in patients who underwent both DCCV and catheter ablation. Conclusion The degree of tricuspid regurgitation is reduced with sinus rhythm restoration in patients with both ventricular functional and atrial functional TR.Changes in TR severity with interventionGraph of changes in severity of TR

Atrial fibrillation after transcatheter tricuspid valve repair: rhythm control strategies and outcomes

Abstract Background Transcatheter tricuspid valve (TV) repair emerged as a viable treatment option in patients with severe tricuspid regurgitation and high operative risk. Although atrial fibrillation (AF) is common in these patients, the prognostic value of maintenance of sinus rhythm (SR) after transcatheter TV repair is unknown. Purpose We sought to assess the prevalence and efficacy of rhythm control strategies and impacts of maintenance of sinus rhythm on outcomes after transcatheter TV repair. Methods All patients undergoing transcatheter TV repair in our center between April 2017 and December 2022 were included in this single-center retrospective analysis. Patients who maintained SR throughout the follow-up (FU) were compared to patients who did not. The composite study endpoint included death from any cause, heart failure (HF) hospitalization and repeat TV repair. Furthermore, prevalence and efficacy of rhythm control strategies were evaluated. Results A total of 203 patients (mean age 78 ± 7 years, 145 (68 %) female) after transcatheter TV repair was analyzed. After a median follow-up of 12 months (IQR 4-20), 21 patients (10 %) did maintain SR. AF was present in 183 patients (90 %), of whom 134 had permanent AF. In the AF group, direct-current cardioversion (DCCV) was performed in 6 patients (3 %). Following DCCV, SR was restored in 4 patients (75 %), of whom 3 patients (75 %) presented in SR 30 days after DCCV. 2 patients (1 %) underwent AF ablation. After a case-control matching including 38 patients (SR vs. AF), during a median follow-up of 8 months (IQR 1-20) the study endpoint occurred in 7 of 19 patients (37 %) in the SR group and 12 of 19 patients (63 %) in the AF group (HR 0.70, p = 0.43). Conclusions The incidence of AF among patients undergoing transcatheter TV repair is high. In the present patient cohort, there was a trend towards a higher likelihood of death from any cause, HF hospitalization and repeat transcatheter TV repair in patients with AF. Further randomized studies are needed to evaluate the impact of rhythm control in patient undergoing TV repair.

Unsupervised machine learning defines subgroups in ischemic heart disease patients presenting with ventricular tachycardia

Abstract Background Ventricular tachycardia (VT) in ischemic heart disease (IHD) is the leading cause of sudden cardiac death (SCD). Despite the well-defined recommendations, tailoring therapies individually is often a challenge owing to the great heterogeneity in this population. We hypothesized that unsupervised machine learning can uncover hidden patterns to identify patient subgroups with similar characteristics. Aims To use unsupervised machine learning methods on a database of patients with ischemic VT, to discover subgroups with similar characteristics and compare the survival of the identified groups. Methods We collected the data of 566 patients with IHD hospitalized for sustained monomorphic VT, excluding those with acute coronary syndrome. The 17 recorded features included medical history and echocardiography. All-cause mortality was registered with one-year follow-up. We performed dimension reduction using T-distributed Stochastic Neighbor Embedding (TSNE) to produce 3 dimensions of the data. Then, we applied spectral clustering to create three groups within the population. Each group was compared to the rest of the population for each variable. Finally, we compared the survival across the three groups using Kaplan-Meyer analysis, univariate Cox-regression, and Log-rank test. Results We identified three groups with distinct characteristics. Group 1 represented the healthiest population; patients had no previous VT hospitalizations, and none of HD instability, LBBB, SCD, diabetes, VT storm or ICD shocks; additionally, they always had a single VT episode at presentation. They showed better left ventricular ejection fraction (LVEF) (38% vs. 33%, p<0.001) and TAPSE (20 mm vs. 18 mm, p=0.01), less severe mitral and tricuspid regurgitation (MR, TR), smaller left ventricular end-systolic diameter, and longer DT. Conversely, patients in Group 2 (n=349) had more previous VT hospitalizations (30% vs. 18%, p=0,003), more often had diabetes (46% vs. 18%, p<0.001), left bundle branch block (23% vs. 13%, p=0.006), and more often presented with HD instability (47% vs. 28%, p<0.001). Group 3 contained all seriously ill patients with VT storm or incessant VT, more commonly presenting with ICD shocks (34% vs. 21%, p=0.004), SCD (24% vs. 15%, p=0.004), hemodynamic instability (50% vs. 37%, p=0.01). This group had the poorest LVEF (30% vs. 35%, <0.001) and TAPSE (17 mm vs. 19 mm p=0.001), more severe MR and TR, and the shortest DT (140 ms vs. 173 ms p<0.001). Finally, we compared survival across the three groups. Significantly better survival was found in Group 1 (HR: 0.52 CI [0.28 - 0.98]) and Group 2 (HR: 0.61 CI [0.42 - 0.88]), while Group 3 had higher mortality (HR: 2.7 CI [1.83 - 3.97]). Conclusions Using spectral clustering we identified three groups in our cohort of ischemic VT patients. This method delineates the group of ischemic VT patients with the highest risk of mortality who might need more aggressive treatment and closer follow-up.

Severe lead induced tricuspid regurgitation - clinical impact of repair or replacement of tricuspid valve

Abstract The prevalence of lead-induced tricuspid regurgitation (LITR) ranges between 7 to 45%. The most frequent mechanism of LITR is the impingement of the leaflets, but right ventricle remodelling, pacing-induced cardiomyopathy and tricuspid annular dilatation also can contribute to the severity of tricuspid regurgitation (TR). Different studies concluded that LITR was associated with an increased risk of all-cause mortality and heart failure hospitalizations. Beyond diuretics, patients (P) may be candidates for interventional treatment, including lead extraction, surgery, or percutaneous tricuspid trans-catheter ‘edge-to-edge’ repair (TEER) and heterotopic bicaval devices (HBD). Despite its importance, there is a scarcity of data concerning the management and clinical impact of severe LITR. The purpose of the current analysis is to improve the knowledge regarding the impact of interventional treatment on the outcomes in this population. Methods A retrospective, single-centre analysis was made including P with severe LITR referred to evaluation regarding eligibility for tricuspid percutaneous intervention in a tertiary hospital. All P were evaluated using both transthoracic echocardiography (TTE) and transoesophageal echocardiography (TEE). Data were collected regarding clinical characterization, management, intervention and follow-up. Results From January 2020 to September 2023, of the 97 P referred for tricuspid intervention eligibility, 36 (37%) had LITR, with 14 cases (39%) presenting lead impingement as the TR mechanism. The majority of P were female (58%), with a median age of 78 [IQR 72-83] years. Median Euroscore II was 6 % [IQR 3-9]), with 51% of the P having a previous heart surgery, and 97% presenting atrial fibrillation. Prior to cardiac electronic device (CIED) implantation, 14% already presented TR. When analysing post-CIED TR, 30% increased 1 grade of TR at 1-year follow-up, and 68% increased 2 grades of TR at 5 years. According to TTE, ventricular desynchrony was present in 30% of the P. After evaluation of TR, 30% underwent intervention (22% percutaneous - TEER or HBD - and 8% surgical). All P remained with the previous electrodes. Mortality was 21.1% in the intervention population and 78.9% on the remaining pts (p=0.027). The type of intervention had no statistically significant differences in outcome. Conclusions In our study, more than 1/3 of the cases referred due to severe TR presented lead impingement as the mechanism underlying TR. As previously reported, the intervened population had better outcomes than the remaining pts.

Severity of tricuspid regurgitation predicts risk of atrial fibrillation recurrence after pulmonary vein isolation

Abstract Background Atrioventricular valve regurgitation (AVVR) results in atrial remodeling, thus promoting the formation of a substrate for atrial fibrillation (AF). On the other hand, AF may cause functional AVVR by annular dilatation of the atria. In this vicious circle, the identification of the leading pathomechanism and consequently the optimization of treatment can be challenging. Purpose Our aim was to investigate whether the presence of significant AVVR and especially of tricuspid regurgitation (TR) affects the efficacy of catheter-based pulmonary vein isolation (PVI) for AF. Furthermore, we evaluated whether rhythm control for AF through PVI could lead to an improvement of AVVR severity. Finally we examined the effect of concomitant right atrial flutter on the arrhythmic outcome in patients with significant TR . Methods We enrolled patients undergoing first-time PVI for symptomatic AF. We compared the severity of AVVR at the time of the procedure as well as after 6 months, using transthoracic echocardiography. Moderate to severe AVVR was defined as significant. Moreover, we evaluated whether the presence of significant AVVR, at baseline and 6 months after the procedure, could serve as an independent predictor for AF recurrence. Results Out of 320 consecutive patients (mean age 66.3 ± 10 years, 61.6% male, 60% paroxysmal AF) , significant TR at baseline was documented in 13.1%, while significant mitral regurgitation (MR) in 10.9%. Six months after PVI, the proportion of patients with moderate to severe TR (13.1% to 7.2%; p<0.001) and MR (10.9% to 6.6%; p<0.001) decreased significantly. Compared to patients with post-interventional improvement of significant TR, right atrial (RA) dilatation at baseline was more pronounced in patients with persistent significant TR (RA area 20.2 ± 4.4 vs. 26.6 ± 8.3 cm2; p=0.002). The presence of significant TR, particularly without improvement during the follow-up, independently increased the risk of atrial fibrillation recurrences. Even after propensity-score matching, TR at baseline remained an independent risk predictor regarding recurrent atrial fibrillation (HR 2.2 [95% CI, 1.1 - 4.9]; p=0.045). Among patients with significant TR, those with documented right atrial flutter were at high risk for recurrence of atrial arrhythmia (HR 2.69 [95% CI, 1.0 – 6.9]; p=0.039), despite the additional ablation of the cavo-tricuspid isthmus. Significant MR was not associated with increased risk of atrial arrhythmias. Conclusion In patients with symptomatic AF undergoing PVI, the presence of moderate to severe TR, particularly without improvement 6 months after the procedure, was associated with a worse arrhythmic outcome. Further investigations to enhance the understanding of the underlying electrophysiological substrate and the need for tailored ablation strategies are warranted.TR as predictor for AF(propensity score)AVVR improvement after PVI

Clinical and electrophysiological characteristics and long term outcomes of catheter ablation for right and left atrial tachycardias

Abstract Background Atrial tachycardias (AT) are complex supraventricular tachycardias which are refractory to antiarrhythmic drugs that require catheter ablation. Purpose In this trial, we aimed to evaulate the outcomes of catheter ablation in patients with symptomatic atrial tachycardia, define the acute procedural success and the recurrence rates in long-term follow-up and determine the clinical and electrophysiological features that affect these outcomes. Methods A total of 666 [mean age: 55 ±16, gender: 344 (51.7%) female] symptomatic patients with AT were enrolled. Prior catheter or surgical ablation history for ATa was present in 199 (29.9%) and 18 (2.7%) of these patients, respectively. Activation mapping was performed during tachycardia in all patients as well as entrainment mapping when needed. Voltage mapping were performed in sinus rhythm in both atriums, late potential mapping was also performed in some patients. Low voltage areas and signals with continuous-fragmented morphology were tagged. Results Macroreentry was the primary mechanism in right and left atrium (70.2% and 52.8%, respectively). Cavotricuspid isthmus (CTI) dependent macroreentry was the most frequent mechanism in right ATs and perimitral reentry and roof-dependent macroreentry were the most common mechanisms in left ATs. A total of 59 (7.5%) complications were observed in 780 procedures.(2.1% major and 5.5% minor) Acute procedural success was 95.9%. Freedom from ATa was 72.8 % during a mean follow-up of 39±23 months. Freedom from ATa after index procedure was 82.3% at 12 months and 75.9 % at 24 months. After multiple procedures, freedom from ATa was 90% at 12 months and 86% at 24 months during the follow-up. In multivariate Cox regression analysis, atrial fibrillation (AF) [(HR) 2.43, 95% c(CI) 1.78-3.30; p<0.001] , history of cardiac surgery [(HR) 1.68, 95% c(CI) 1.22-2.30; p=0.001] and moderate to severe tricuspid regurgitation [(HR) 1.47, 95% c(CI) 1.08-2.01; p=0.014] were significant predictors of ATa recurrence. Conclusion Our findings demonstrated that tailored catheter ablation of ATs especially guided by high density mapping has a high acute success rate and favourable long-term outcomes in patients with symptomatic AT episodes.

The Connection Between Anatomical Substrate and Clinical Severity in Fetal Ebstein Anomaly.

Ebstein anomaly (EA) is a rare congenital heart defect characterized by abnormal development of the tricuspid valve (TV) and right ventricular myocardium. This study documents 2 dramatic cases of fetal EA characterized by hydrops and cardiomegaly, leading to intrauterine or early neonatal death. These clinical outcomes were associated with morphological abnormalities including severe tricuspid regurgitation, unguarded TV orifice, pulmonary atresia, and flattened right ventricular myocardium. This study highlights that these adverse anatomical features may result in unfavorable clinical outcomes in fetal EA. While timely identification of such features by prenatal ultrasound is crucial for providing accurate prognostic stratification and guiding treatment decisions, fetopsy may be necessary to discern EA among the spectrum of right-heart anomalies.

AUTOIMMUNE MYOCARDITIS IN MELANOMA IMMUNOTHERAPY–COMPLEX CLINICA PRESENTATION AND ADVERSE THERAPEUTIC RESPONSE

Abstract A 68–year–old Caucasian female presented to the ED with cardiac chest pain and dyspnea. The patient had a history of arterial hypertension and was equipped with a biventricular pacemaker due to atrial fibrillation with low ventricular response. She had recently been diagnosed with metastatic melanoma and initiated treatment with nivolumab and ipilimumab two weeks prior. Troponin levels were elevated (700 ng/ml), and no ST–segment elevation was observed on the electrocardiogram (ECG). In suspicion of NSTEMI–ACS, coronary angiography was performed, revealing an intact epicardial coronary circulation without stenotic lesions. The echocardiogram showed borderline left ventricular systolic function (EF 50%), and the right ventricle exhibited initial signs of reduced systolic function (TAPSE, 15 mm; S RV, 9.5 m/s). The following day, there was a deterioration in hemodynamics and respiratory exchange, with evidence of apical and mid–distal interventricular septum hypokinesia of the left ventricle (EF 40%) and dilated right ventricle (BD 4.8 cm; MD 4 cm) with severely reduced systolic function (TAPSE 10 mm, S RV 7 m/s, FAC, 20%), and severe tricuspid regurgitation. Urgent computed tomography pulmonary angiography (CTPA) excluded pulmonary embolism. Additionally, there was a new troponin increase (5000 ng/ml) and elevated hepatic biomarkers. The clinical picture raised suspicion of myocarditis related to immune checkpoint inhibitor therapy. Corticosteroid therapy was initiated with a daily administration of methylprednisolone 1000 mg. Diagnostic confirmation was sought through autoimmune panel and viral marker assessments, which yielded negative results. Endomyocardial biopsy (EMB) revealed CD4 and CD8–positive lymphocytic infiltration and myocardial necrosis. Despite initial clinical improvement, an arrhythmic storm developed. Despite treatment with a defibrillator, intravenous antiarrhythmic therapy (beta–blocker, amiodarone, and lidocaine), and sedation, the patient unfortunately succumbed. Immune checkpoint inhibitors (ICIs) have been revolutionary in the treatment of many solid tumors. However, the dysregulation of immune mechanisms can rarely (2%) lead to autoimmune events involving multiple organs. Myocarditis, despite optimal treatment, is characterized by a mortality rate exceeding 50%, representing a significant challenge in the Intensive Care Unit.

SEVERE MITRAL REGURGITATION TREATED WITH TRANSCATHETER AORTIC VALVE IMPLANTATION IN MITRAL RING (TMVIR): A CASE REPORT

Abstract Introduction The increasing prevalence of mitral regurgitation (MR), combined with a growing population of elderly patients at risk of being unsuitable for surgical options, has led to a greater interest in the use of less invasive treatments such as transcatheter heart valve (THV) implantation. This case involves the use of transcatheter aortic valve implantation in a patient with a previous mitral annuloplasty (TMViR). Case Presentation A 77–year–old woman had previously undergone mitral annuloplasty (Physio Ring II 32 mm, Medtronic), Neocord implantation and closure of the posterior commissure for severe MR due to anterior leaflet prolapse. She presented to our attention with worsening dyspnea (NYHA Class III) and a sudden weight gain. Transesophageal echocardiogram (TEE) revealed findings indicative of a previous mitral annuloplasty failure, with residual severe MR along with severe tricuspid regurgitation (TR). The case was discussed in the Heart Team and given the elevated surgical risk and the patient‘s anatomical unsuitability for edge–to–edge therapy, it was decided to perform a TMViR implantation. Under echocardiographic guidance and general anesthesia, right common right femoral vein access was obtained. After transseptal puncture, predilation of the interatrial septum was performed with balloon (Evercross 12 mm, Medtronic). Subsequent access to the left ventricle was achieved with a 6F PigTail catheter, and a stiff exchange guide (Safari S, Boston Scientific) was used to advance the 16Fr Delivery system. With the assistance of TEE, aortic valve implantation on the mitral ring was performed (Sapien 29 mm, Edwards Lifesciences) with rapid pacing via transvenous temporary PM placed in right ventricle (Spikeflow, Fiab). At the end of the procedure, two closure systems (Proglide, Abbott) were used for right femoral vein access. Post–implantation TEE showed a trivial paravalvular leak external to the annulus and a mean transvalvular gradient of 5 mmHg. The postoperative course proceeded without complications, facilitating the patient‘s discharge on the third postoperative day. Currently no further hospitalization in the last 6 months. Conclusion Despite surgical intervention remaining the gold standard in treating severe MR in patients who have undergone a previous annuloplasty, in patients at high surgical risk for a re–operation, who are not eligible for other percutaneous options, TMViR could be a safe and effective option for treatment.

MISDIAGNOSED PARTIAL ANOMALOUS PULMONARY VENOUS RETURN AS A CAUSE OF RIGHT VENTRICULAR DILATION IN TRICUSPID VALVE DYSPLASIA

Abstract A 38–year–old woman comes to our attention for regular follow–up of a known tricuspid valve dysplasia, diagnosed since she was 19 years old. The patient has been persistently asymptomatic and hemodynamically compensated. In previous cardiac assessments, there was moderate and stable tricuspid regurgitation (TR) that never reached the diagnostic criteria for Ebstein‘s anomaly (7 mm). The right atrium was dilated, and the right ventricle was at the upper limits of normal dimensions. However, our evaluation revealed a worsening of TR to a severe degree, associated with valvular annulus dilation and severe dilation of the right ventricle, which remained normokinetic, and evident diastolic overload of the interventricular septum. Therefore, a cardiac surgery intervention was indicated to correct the valvulopathy. During hospitalization, a transthoracic echocardiogram was repeated to investigate a possible cause of right ventricular overload, not fully explained by the relatively short duration of severe TR. During the exam, suspecting Partial Anomalous Pulmonary Venous Return (PAPVR) as one of the possible determinants, a vessel compatible with left superior pulmonary venous return was visualized, which converged into the anonymous vein and then into the right superior vena cava. Further diagnostic investigation with magnetic resonance angiography and computed tomography angiography confirmed the severe dilation of the right cardiac chambers and the presence of left upper pulmonary venous return and part of the left lower lobe into the left anonymous vein, with a Qp/Qs of 1.7 in relation to the pre–tricuspidal shunt. Therefore, a cardiac surgery intervention was indicated for PAPVR correction. However, previously unnoticed thrombocytosis was revealed in the hematological exams, leading to the initiation of a pertinent hematological workup and the cardiac surgery intervention was postponed to reduce the risk of perioperative complications. In conclusion, PAPVR is a rare congenital condition that can remain asymptomatic until adulthood due to a chronic adaptation of the right heart to volume overload and should, therefore, be considered in the differential diagnosis of right cardiac chambers dilation, especially when other causes do not justify its pathophysiology.

Clinical and echocardiographic characterization of patients hospitalized for severe tricuspid valve regurgitation: a single tertiary-care center experience with two-year follow-up.

Tricuspid regurgitation (TR) is a common acquired valvular heart disease. Recently new transcatheter treatment options for severe TR have emerged that could change the management of this condition, which warrants better characterization of this specific patient group. The aim of the study was to describe the clinical and echocardiographic characteristics of patients with severe TR and to evaluate their short- and mid-term prognosis. This retrospective, observational single-center study enrolled consecutive patients with severe TR hospitalized between January 2016 and September 2021 in the 1st Chair and Department of Cardiology, Medical University of Warsaw, Poland. The severity of heart failure (HF) was evaluated using New York Heart Association (NYHA) classification. Echocardiographic assessment was performed by experienced sonographer. EuroSCORE II and TRI-SCORE were computed for each patient. 12- and 24-month clinical outcomes were reported. There were 172 patients [93 female (54.1%)] included. The mean age was 76.4 (± 10.5) years. The most common comorbidities included: atrial fibrillation (84.9%), hypertension (68.0%), chronic kidney disease (54.1%), coronary artery disease (45.3%), diabetes mellitus (30.9%). The median EuroSCORE II and TRI-SCORE values were 4.68% and 14.0%, respectively. The median follow-up was 24 months. The overall mortality was 29.7% at 1 year and 47.3% at 2 years. TR grade, TAPSE <17 mm, TAPSE/SPAP <0.26 and right atrial area were significant factors associated with mortality. Patients presenting with severe TR are characterized by a large comorbidity burden and poor prognosis, despite intensive heart failure management.

Severe postransplant tricuspid regurgitation: treatment with the PASCAL system

Severe postransplant tricuspid regurgitation: treatment with the PASCAL system

Portal Vein Doppler tracks volume status in patients with severe tricuspid regurgitation: A Proof-of-Concept Study.

Renal and liver congestion are associated with adverse outcomes in patients with tricuspid regurgitation (TR). Currently, there are no valid sonographic indicators of fluid status in this population. Intra-renal venous Doppler (IRVD) is a novel method for quantifying renal congestion but its interpretation can be challenging in severe TR due to altered hemodynamics. This study explores the potential of portal vein Doppler (PVD) as an alternative marker for decongestion during volume removal in patients with severe TR. 42 patients with severe TR undergoing decongestive therapy were prospectively enrolled. Inferior vena cava diameter (IVCd), PVD and IRVD were sequentially assessed during volume removal. Improvement criteria were Portal Vein Pulsatility Fraction (PVPF) < 70% and Renal Venous Stasis Index (RVSI) < 0.5 for partial improvement, and PVPF <30% and RVSI <0.2 for complete improvement. After volume removal, PVPF significantly improved from 130 ± 39% to 47 ± 44% (p < 0.001), while IRVD improved from 0.72 ± 0.08 to 0.54 ± 0.22 (p < 0.001). A higher proportion of patients displayed improvement in PVD compared to IRVD (partial: 38% vs. 29%, complete: 41% vs. 7%) (p < 0.001). IRVD only improved in patients with concomitant improvement in severe TR. PVD was the only predictor of achieving ≥5 litres of negative fluid balance (AUC 0.83 p = 0.001). This proof-of-concept study suggests that PVD is the only sonographic marker that can track volume removal in severe TR, offering a potential indicator for decongestion in this population. Further intervention trials are warranted to determine if PVD-guided decongestion improves patient outcomes in severe TR.

Personalized Guidance of Edge-to-Edge Transcatheter Tricuspid Valve Repair by Multimodality Imaging.

Background: Transcatheter edge-to-edge tricuspid valve repair (T-TEER) for tricuspid regurgitation (TR) is always guided by transesophageal echocardiography (TEE). As each patient has unique anatomy and acoustic window, adding transthoracic echocardiography (TTE) and cardiac CT could improve procedural planning and guidance. Objectives: We aimed to assess T-TEER success and outcomes of a personalized guidance approach, based on multimodality imaging (MMI) of patient-tailored four right-sided chamber views (four-right-ch), as depicted by CT, TTE, TEE and fluoroscopy. Methods: Patients were assigned to MMI or classical TEE guidance, depending on TTE acoustic window. In MMI patients, planning included cardiac CT, which determined the fluoroscopic angulations of the specific four-right-ch, while guidance relied heavily on TTE, with minimal intermittent TEE for leaflet grasping and result confirmation. Both TTE and TEE were matched to respective CT and fluoroscopy four-right-ch. TR severity and quality of life (QoL) parameters were assessed from baseline to 12 months. Results: A total of 40 T-TEER patients were included, with 17 procedures guided by MMI and 23 solely by TEE. Baseline characteristics were similar between groups, e.g., age (83.1 ± 4.1 vs. 81 ± 5.3, p = 0.182) or STS-Score (11.1 ± 7.4% vs. 10.6 ± 5.9%, p = 0.813). The primary efficacy endpoint of ≥one-grade TR reduction at 30 days was 94% (16/17) in MMI vs. 91% (21/23) in TEE patients, with two or more TR grade reduction in 65% vs. 52% (p = 0.793). Device success was overall 100%, with no device-related complications, but three TEE-associated cases of gastrointestinal bleeding in the TEE-only group. By 12 months, all 15 MMI and 19 TEE survivors improved NYHA functional class and QoL, e.g., Kansas City Cardiomyopathy Questionnaire Score Δ29.6 ± 6.7 vs. 21.9 ± 5.8 (p = 0.441) pts., 6-min walk distance Δ101.5 ± 36.4 vs. 85.7 ± 32.1 (p = 0.541) meters. Conclusions: In a subset of patients with good TTE acoustic window, MMI guidance of T-TEER is effective and seems to avoid gastroesophageal injuries caused by TEE probe manipulation. TR reduction, irrespective of guidance method, impacts long-term QoL.

Influence of tricuspid regurgitation on the prognosis of patients with cardiogenic shock

Objective Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations. However, data regarding the prognostic impact in patients with cardiogenic shock (CS) is limited. The study investigates the prognostic impact of pre-existing TR in patients with CS. Methods Consecutive patients with CS from 2019 to 2021 were included in a monocentric registry. Every patient's medical history, including echocardiographic data, was recorded. The influence of pre-existing TR on prognosis was investigated. Furthermore, Kaplan-Meier analyses based on TR severity were conducted. Statistical analyses comprised univariable t-test, Spearman´s correlation, Kaplan-Meier analyses, as well as multivariable Cox proportional regression models. Analyses were stratified by the underlying cause of CS such as acute myocardial infarction (AMI), or the need for mechanical ventilation. Results 105 patients with CS and pre-existing TR were included. In Kaplan Meier analyses, it could be demonstrated that patients with severe TR (TR III°) had the highest 30-day all-cause mortality compared to mild (TR I°) and moderate TR (TR II°) (44% vs. 52% vs. 77%; log rank p = 0.054). In the subgroup analyses of CS-patients without AMI, TR II°/TR III° showed a higher all-cause mortality after 30 days compared to TR I° (39% vs. 64%; log rank p = 0.027). In multivariable Cox regression TR II°/TR III° was associated with 30-day all-cause mortality in CS-patients without AMI (HR = 2.193; 95% CI 1.007–4.774; p = 0.048). No significant difference could be found in the AMI group. Furthermore, TR II°/III° was linked to an increased 30-day all-cause mortality in non-ventilated CS-patients (6% vs. 50%, log rank p = 0.005), which, however, could not be confirmed in multivariable Cox regression. Conclusion The occurrence of pre-existing TR II°/III° was independently related with 30-day all-cause mortality in CS-patients without AMI. However, no prognostic influence was observed in CS-patients with AMI.

Prognostic Implications of Residual Tricuspid Regurgitation Grading After Transcatheter Tricuspid Valve Repair.

The safety profile of transcatheter tricuspid valve (TTV) repair techniques is well established, but residual tricuspid regurgitation (TR) remains a concern. The authors sought to assess the impact of residual TR severity post-TTV repair on survival. We evaluated the survival rate at 2 years of 613 patients with severe isolated functional TR who underwent TTV repair in TRIGISTRY according to the severity of residual TR at discharge using a 3-grade (mild, moderate, and severe) or 4-grade scheme (mild, mild to moderate, moderate to severe, and severe). Residual TR was none/mild in 33%, moderate in 52%, and severe in 15%. The 2-year adjusted survival rates significantly differed between the 3 groups (85%, 70%, and 44%, respectively; restricted mean survival time [RMST]: P= 0.0001). When the 319 patients with moderate residual TR were subdivided into mild to moderate (n=201, 33%) and moderate to severe (n=118, 19%), the adjusted survival rate was also significantly different between groups (85%, 80%, 55%, and 44%, respectively; RMST: P = 0.001). Survival was significantly lower in patients with moderate to severe residual TR compared to patients with mild to moderate residual TR (P = 0.006). No difference in survival rates was observed between patients with no/mild and mild to moderate residual TR (P = 0.67) or between patients with moderate to severe and severe residual TR (P = 0.96). The moderate residual TR group was heterogeneous and encompassed patients with markedly different clinical outcomes. Refining TR grade classification with a more granular 4-grade scheme improved outcome prediction. Our results highlight the importance of achieving a mild to moderate or lower residual TR grade during TTV repair, which could define a successful intervention.

Isolated rheumatic tricuspid valve regurgitation: it is only rare not just a myth: rare case report

BackgroundIsolated rheumatic tricuspid regurgitation (IRTR) is a rare condition that can manifest as right heart failure (RHF) and pulmonary hypertension (PH) symptoms. Diagnosing and treating IRTR in cases of latent RHD can be a challenge and crucial for future research to establish new guidelines for echocardiography in RHD that focus not only on the mitral and aorta but also the tricuspid valve.Case presentationA young female patient with clinical symptoms of RHF suspected IRTR due to latent RHD from echocardiography. Echocardiography revealed significant thickening and calcification of all tricuspid valve (TV) leaflets, with partial prolapse posterior leaflet and severe tricuspid regurgitation (TR) with a high probability of PH, no significant anatomical and functional abnormality pulmonary valve (PV), mitral valve (MV), and aortic valve (AV). She was administered daily doses of Ramipril, bisoprolol, spironolactone, and furosemide. Although she received therapy, she persisted in suffering dyspnea when doing mild physical activity (NYHA functional class III). She was admitted to the surgical conference, due to our center’s limitation of percutaneous intervention for valve replacement, and she was approved to undergo tricuspid valve replacement (TVR) surgery.ConclusionsEchocardiography plays a crucial role in identifying latent RHD. Isolated rheumatic TR shows echocardiographic results similar to rheumatic mitral regurgitation, except for the presence of a high-velocity jet. Diuretics temporarily slow symptoms, but disease progression remains uncertain. TV surgery is effective for severe symptoms, but isolated TVR is rare and has a poor prognosis.

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

The optimal echocardiographic predictors of cardiovascular outcome in heart failure (HF) with preserved ejection fraction (HFpEF) are unknown. We aimed to identify independent echocardiographic predictors of cardiovascular outcome in patients with HFpEF. 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 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. 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. 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.

Isolated Tricuspid Valve Surgery for Functional Tricuspid Regurgitation.

Severe tricuspid regurgitation (TR) adversely affects long-term survival; however, isolated tricuspid valve (TV) surgery has been rarely performed due to high operative mortality. In addition, the previous literature included heterogeneous TR etiologies. Therefore, we aimed to elucidate early and long-term outcomes of isolated TV surgery for functional TR. An electronic search was performed to identify all relevant studies. Baseline characteristics, perioperative variables, and clinical outcomes were extracted and pooled for meta-analysis. This meta-analysis included seven studies. Pooled analyses showed that 68% (35, 89) of patients had preoperative atrial fibrillation or flutter, and 58% (11, 94) had a history of left-sided valve surgery. Seventy-three percent (65, 80) of patients had at least one physical exam finding of right-sided heart failure, and 57% (44, 69) were in New York Heart Association class III or IV. TV replacement was more common than repair. In TV replacement, bioprosthetic valve (39%, 13, 74) was more common than mechanical prosthesis (22%, 18, 26). The early mortality rate was 7%. Twenty percent of patients required a permanent pacemaker postoperatively. The overall 1- and 5-year survival rates were 84.5 and 69.1%, respectively. More than half of the patients who underwent isolated TV surgery for functional TR had undergone left-sided valve surgery and had significant heart failure symptoms at the time of surgery. Further studies on the surgical indication for concomitant TV surgery at the time of left-sided valve surgery and the appropriate timing of surgery for isolated functional TR are needed to improve survival.

Multiorgan congestion assessment by venous excess ultrasound score in acute heart failure

This study sought to explore the prevalence and clinical utility of different patterns of multi-organ venous congestion as assessed by the Venous Excess Ultrasound (VExUS) score in hospitalized patients with acute heart failure (HF). Consecutive patients admitted for acute HF were prospectively enrolled. Inferior vena cava (IVC) diameter, hepatic vein, portal vein and renal vein Doppler waveforms were assessed at admission and patients were stratified based on VExUS score from 0 to 3, with higher values indicating worse congestion. The clinical score Get With The Guidelines (GWTG)-HF for predicting in-hospital mortality in HF was evaluated. In-hospital mortality was recorded. Two-hundred-ninety patients admitted with acute HF were included and 114 (39%) of them were classified as VExUS score 3 which was the most prevalent group. Patients with VExUS score 3 suffered more frequently from chronic atrial fibrillation, chronic kidney disease and anemia. Parameters independently associated with VExUS score 3 were higher mean E/e' ratio, larger right ventricular size, severe tricuspid regurgitation and impaired right atrial function. VExUS score 3 was associated with in-hospital mortality [OR 8.03, 95% CI (2.25-28.61), p=0.001]. The addition of VExUS score on top of the GWTG-HF score improved the predictability of the model (Δx2=+8.44, p=0.03) for in-hospital mortality, whereas other indices of venous congestion (right atrial function, IVC size) did not. Patients admitted with acute HF commonly had severe venous congestion based on VExUS score. VExUS score improved the prediction of in-hospital mortality as compared to other indices of venous congestion.