Torrential Tricuspid Regurgitation Research Articles

Delayed Diagnosis of Right Heart Failure Due to Sinus Venosus Atrial Septal Defect, Persistent Left Superior Vena Cava and Partial Anomalous Pulmonary Venous Return

Sinus venosus atrial septal defects (SVASD) are uncommon and often underdiagnosed as they are visualised poorly on transthoracic echocardiography (TTE). A 59-year-old man was referred following worsening dyspnoea. A TTE demonstrated dilated right chambers, with torrential tricuspid regurgitation and a dilated coronary sinus. Agitated saline test raised the suspicion of both persistent left superior vena cava (PLSVC) and an intracardiac shunt, despite interrogation of the interatrial septum not demonstrating any defects. CT imaging of the thorax was performed revealing a superior SVASD alongside a PLSVC, and partial anomalous pulmonary venous return. SVASD are considerably uncommon, compared to other types of atrial septal defects (ASD). TTE has poor sensitivity in diagnosing SVASD, highlighting the importance of multimodality imaging in such cases. The purpose of this case report is to highlight unique features demonstrated on TTE, especially during the agitated saline study, which showcased the presence of a PLSVC alongside an intracardiac shunt that was undetected through conventional TTE alone.

Novel percutaneous technique for creation of porcine model of tricuspid regurgitation via two routes.

To develop an experimental porcine model of tricuspid regurgitation using two induction routes: the inferior vena cava and superior vena cava. Tricuspid regurgitation was generated using the loop wire cutting method. The tricuspid regurgitation jet direction was controlled by accessing the valve through the inferior (n = 7) or superior (n = 6) vena cava. The occurrence, direction, and progression of tricuspid regurgitation were assessed postoperatively, and echocardiography was performed at 4 to 6 weeks. Right heart dilatation was assessed using computed tomography after 6 weeks. Moderate to severe or torrential tricuspid regurgitation occurred immediately after the procedure in 12 of 13 animals. The jet was directed toward the septum in five of seven animals in the inferior vena cava group and toward the posterolateral side in four of six animals in the superior vena cava group. The dimensions of the right heart (right atrium, ventricle, and tricuspid valve annulus) were significantly enlarged at the 4- to 6-week follow-up echocardiographic examination and confirmed to be enlarged by computed tomography, independent of the route used. The loop wire cutting method successfully induced a disease model of tricuspid regurgitation while controlling the regurgitation jet direction via two procedural routes.

Refining accuracy of RV–PA coupling in patients undergoing transcatheter tricuspid valve treatment

BackgroundAssessing right ventricular (RV) function is paramount for risk stratification, which remains challenging in patients with tricuspid regurgitation (TR). We assessed RV–pulmonary artery (PA) coupling and its predictability of outcomes after transcatheter tricuspid valve repair (TTVR).MethodsStudy participants comprised patients undergoing transcatheter tricuspid valve repair to treat symptomatic TR from June 2015 to July 2021. We calculated an RV–PA coupling ratio using a formula, which is dividing tricuspid annular plane systolic excursion (TAPSE) by echocardiographically estimated (ePASP) or invasively measured PASP (iPASP) at baseline. The primary outcome was all-cause mortality or heart failure rehospitalization within one year.ResultsThe study participants (n = 206) were at high surgical risk (EuroSCORE II: 7.4 ± 4.8%). The primary outcome occurred in 57 patients within one year. The c-statistics for the outcome were 0.565 (95% CI 0.488–0.643) for TAPSE/ePASP and 0.695 (95% CI 0.631–0.759) for TAPSE/iPASP. The correlation between the ePASP and iPASP was attenuated in patients with massive/torrential TR compared to those with severe TR (interaction p = 0.01). In the multivariable Cox proportional model, TAPSE/iPASP was inversely associated with the risk of the primary outcome (per 0.1-point increase: adjusted-HR 0.67, 95% CI 0.56–0.82, p < 0.001), independent of baseline demographics. According to the TAPSE/iPASP quartiles (i.e., ≤ 0.316; 0.317–0.407; 0.408–0.526; ≥ 0.527), the event-free survival was 43.4%, 48.3%, 77.9%, and 85.4% at one year after TTVR.ConclusionRV–PA coupling predicts one-year mortality and heart failure rehospitalization after TTVR in patients with TR. The predictability is improved if invasively-measured PA pressure is included.Graphical abstractAssessing right ventricular (RV) function is paramount for risk stratification. The present analysis confirms that RV–PA coupling, measured as TAPSE/PASP, predicts one-year mortality and heart failure rehospitalization in patients undergoing TTVR. There is a significant interaction between TR severity and the correlation of ePASP with iPASP, and therefore the correlation is attenuated in patients with massive to torrential TR. The predictability of RV–PA coupling is improved if PA pressure is measured invasively and included in the formula.

Relative size of the effective regurgitant orifice to right ventricular cavity contributes significantly to the underestimation of 2D PISA method in tricuspid regurgitation quantitation

Abstract Background 2D proximal isovelocity surface area (PISA) method underestimates tricuspid regurgitation (TR) severity largely due to the distortion of proximal flow geometry under low jet velocity. Previous studies demonstrated that the confining wall geometry also strained the streamline distribution in the proximal flow field. This could add to the variability when applying 2D PISA in TR as TR presents with wider range of effective regurgitant orifice area (EROA). Purpose We aim to examine (1) the impact of ventricular wall constraint to proximal flow region on TR quantitation and (2) its relative contribution to the underestimation of 2D PISA compared with the distortion of proximal flow field under low jet velocity. Methods 150 pts with more than mild TR underwent comprehensive echocardiographic session. The standard 2D PISA EROA (EROASD)was derived as per guideline with angle correction applied for tethering leaflets. The underetimation caused by low jet velocity was corrected by multiplying the standard EROA (EROASD) with VOrifice/(VOrifice-VNyquist), where the VOrifice stands for the peak regurgitant velocity and the VNyquist represents the color Doppler aliasing velocity (EROAVo-VN). The volumetric EROA and vena contracta area serves as two independent reference methods. The ventricular wall constraint was quantified as the ratio of reference EROA to right ventricular end-diastolic volume (RVEDV). Results A consistent significant underestimation by standard 2D PISA methods, either corrected for low jet velocity or not, was observed as a function of the EROA (Figure 1). In Bland-Altman analysis, correction for low jet velocity lessened the systematic underestimation but still leaves minor while could-be-important error (VCA, bias = 19.6 and 15.1 mm2; volumetric EROA, bias = 10.1 and 5.6 mm2 for EROASD and EROAVo-VN respectively). The accuracy of both methods to differentiate severe TR was similar but the cut-off values were lower compared with guideline recommendation (AUC = 0.905 and 0.903, cut-off = 0.26 and 0.29 cm2 for EROASD and EROAVo-VN respectively). In multi-linear regression model (Table 1), the difference between standard 2D PISA EROA and reference EROA (mean of volumetric EROA and vena contracta area) was significantly related to etiology, the jet velocity-related correction coefficient, and the reference EROA/RVEDV ratio. The ventricular wall constraint contributes to the underestimation of 2D PISA to a greater extent than the low jet velocity (beta = -0.269 and 0.592 for VOrifice/(VOrifice-VNyquist) and reference EROA/RVEDV respectively). Conclusion Correction for low jet velocity lessens the extent of underestimation of TR severity by 2D PISA method but still leaves important measurement error. The confining wall geometry to proximal flow region contributes significantly to the understimation but is not accounted for in current recommendation. This could be especially important in massive and torrential TR.

Right heart function in isolated severe tricuspid regurgitation. a new stratification approach by Speckle tracking echocardiography

Abstract Background Optimal management of severe tricuspid regurgitation (TR) remains controversial. While right ventricular (RV) systolic function is an established prognostic marker of outcomes, the potential role of right atrial (RA) function is unknown. Purpose to evaluate the clinical utility of combining RV and RA strain by Speckle-tracking echocardiography to assess RV and RA function for prediction of cardiovascular outcomes. Methods Consecutive patients with at least severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic were prospectively included following a comprehensive clinical protocol. Consecutive control subjects and patients with permanent atrial fibrillation were included for comparison. An independent cohort of patients was included for external validation. RA and RV mechanics analysis was performed using a novel, automated 2D strain analytical software. A combined endpoint of hospital admission due to heart failure (HF) or all-cause mortality was defined. Results 176 patients with at least severe TR, 20 AF patients and 20 control subjects were included in this study. Patients with TR showed lower RA reservoir strain (RASr) and RV-free wall longitudinal strain (RV-FWLS) compared to controls and to AF patients (p&amp;lt;0,001). After a median follow-up of 2,2 years (IQR: 12-41 months), 38% reached the combined endpoint. Reservoir RA strain (RASr) and RV-FWLS were predictors of outcomes independently of TR severity and RV dimensions in a multivariate Cox analysis (table, model 1). RA strain showed incremental value to RV strain. Conventional parameters of RV function were not predictive of events. RV-FWLS&amp;gt;-20% and RASr &amp;lt;10% identified patients with a higher event rate (p&amp;lt;0,001). The combination of abnormal values of RA and RV strain (STREI stratification) stratified 4 different groups of risk independently of TR severity, RV dimensions and clinical status (adj HR per stratum 1,89 (1,4-2,34), p&amp;lt;0,001) (table-model 2 and figure). Pre-defined cut-off values achieved similar prognostic performance in the validation cohort (n=50). Conclusion Clinical outcomes demonstrate that strain parameters are superior to conventional indices of RV function in patients with at least severe TR. The combination of RA and RV strain stratify better patients’ risk, reflecting a broader effect of TR on right heart chambers.STREI STRATIFICATION.Cox regression analysis

Clinical utility and prognostic value of right atrial function in severe tricuspid regurgitation. One more piece of the puzzle

Abstract Background Optimal management of severe tricuspid regurgitation (TR) remains controversial. While right ventricular systolic function is an established prognostic marker of outcomes, the potential role of right atrial (RA) function is unknown. Purpose This study aimed to describe RA function by 2D speckle tracking echocardiography (STE) in at least severe TR and to evaluate its potential association with cardiovascular outcomes. Methods Consecutive patients with at least (≥) severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic following a comprehensive clinical protocol were included. Consecutive control subjects and patients with permanent isolated AF were included for comparison (control and AF group respectively). RA function was measured with 2D-STE and RA reservoir strain (RASr) was calculated in all subjects (figure 1, AutoStrain, Philips Medical Systems the EPIQ system). The interobserver variability of RA strain was assessed in 30 randomly selected subjects (20 TR+5 AF+5 controls). A combined endpoint of hospital admission due to heart failure (HF) or all cause mortality was defined. Results A total of 227 patients with severe TR, 20 AF patients and 20 controls subjects were included in this study. Patients with at least severe TR showed lower RASr compared to controls and to AF patients (p&amp;lt;0,05). After a median follow-up of 26 months (IQR: 15-48 months), n=83 patients with severe TR (37%) reached the combined endpoint. Patients with events showed lower values of RASr (p&amp;lt;0,01 for both). RASr was an independent predictor of heart failure and all cause mortality adjusted by additional imaging prognostic parameters in a multivariable analysis (biplane vena contracta, RV end-diastolic area, and RV- free wall longitudinal strain [LR Chi2 : 49,7, p&amp;lt;0,001]). RA area or volume was not associated with outcomes. A cut-off value of RASr of &amp;lt;10% held the best accuracy to predict outcomes (adjusted HR 3,8 (2,4-6,1), p&amp;lt;0,001, figure 2). Inter-observer agreements for RA strain values across the whole cohort were high (intraclass correlation coefficient for RASr, RAScd and RASct, r= 0,95, r=0,86, r=0,92 respectively). Conclusions Evaluation of RA function by 2D-STE is feasible, reproducible and is an independent predictor of heart failure and all-cause mortality in patients with at least severe TR.LA STRAINKaplan Meier Curves

Abstract 12851: Severe Right and Left-Sided Multi-Valvular Carcinoid Heart Disease Associated With Ovarian Carcinoid Tumor

Carcinoid tumors are neuroendocrine neoplasms that secrete vasoactive substances, primarily serotonin, and have an incidence of approximately 2 in 100,000 people. Up to 60% of carcinoid tumors result in carcinoid heart disease (CHD), and unlike other carcinoid tumors, ovarian carcinoid tumors can involve the heart without liver metastasis. By bypassing the liver, ovarian carcinoid tumors can result in CHD in the absence of liver metastasis. We present a rare case of a 40-year-old female who presented in cardiogenic shock requiring inotropic support with echocardiographic evidence of preserved left ventricular systolic function (LVEF 50-55%) and multiple retracted leaflets that exhibited poor coaptation resulting in severe mitral regurgitation, torrential tricuspid regurgitation, and moderate-to-severe aortic regurgitation. Her left heart catheterization revealed non-obstructive coronary artery disease. A non-contrast CT torso revealed an isolated large septated left ovarian cystic mass (7.1x5.2 x7.1cm) without any other mass or lesion. In the setting of an elevated CA-125 (536units/mL, normal 0-35units/mL) and 24-hour urinary 5-HIAA (12.1mg, normal 2-9mg) with a normal CEA, CHD was suspected as the most likely diagnosis given the isolated ovarian mass and severe valvular disease. She underwent triple valve surgery in which valvular pathology revealed myxoid degeneration. Her post-operative course was complicated by multi-organ failure requiring multiple inotropes and V-A ECMO shortly thereafter, but the patient unfortunately passed away. While there are a few documented cases of CHD from ovarian carcinoid (less than 0.5% of cases) and left-sided CHD (less than 10% of cases), this is the first documented case, to our knowledge, describing severe right and left-sided CHD associated with a suspected ovarian carcinoid tumor.

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.

First-in-Human Treatment of Severe Tricuspid Regurgitation Using a Novel Cross-Caval Heterotopic Device

A 79-year-old woman, previously surgically treated for mitral and aortic valve replacement, experienced recurrent torrential tricuspid regurgitation after 2 transcatheter edge-to-edge repair procedures. Heart team assessment deemed the patient high risk for redo surgery and excluded transcatheter edge-to-edge repair and orthotopic replacement. The patient was then scheduled for a novel cross-caval device implantation.

Right ventricular remodeling and clinical outcomes following transcatheter tricuspid valve intervention.

Characterize the impact of residual tricuspid regurgitation (TR) on right ventricle (RV) remodeling and clinical outcomes after transcatheter tricuspid valve intervention. We performed a single-center retrospective analysis of transcatheter tricuspid valve repair (TTVr) or replacement (TTVR) patients. The primary outcomes were longitudinal tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), pulmonary artery systolic pressure (PASP), and RV dimensions (RVd). We used multivariable linear mixed models to evaluate association with replacement versus repair and degree of TR reduction with changes in these echo measures over time. Multivariable Cox regression was used to identify associations between changes in these echo measures and a composite clinical outcome of death, heart failure hospitalization, or re-do tricuspid valve intervention. We included a total of 61 patients; mean age was 77.5 ± 11.7 and 62% were female. TTVR was performed in 25 (41%) and TTVr in 36 (59%). Initially, 72% (n = 44) had ≤ severe TR and 28% (n = 17) had massive or torrential TR. The median number of follow up echos was 2: time to 1st follow-up was 50 days (interquartile range [IQR]: 20, 91) and last follow-up was 147 (IQR: 90, 327). Median TR reduction was 1 (IQR: 0, 2) versus 4 (IQR: 3, 6) grades in TTVr versus TTVR (p < 0.0001). In linear mixed modeling, TTVR was associated with decline in TAPSE and PASP, and TR reduction was associated with decreased RVd. In multivariable Cox regression, greater RVd was associated with the clinical outcome (hazard ratio: 9.27, 95% confidence interval: 1.23-69.88, p = 0.03). Greater TR reduction is achieved by TTVR versus TTVr, which is in turn associated with RV reverse remodeling. RV dimension in follow-up is associated with increased risk of a composite outcome of death, heart failure hospitalization, or re-do tricuspid valve intervention.

Buying time! VA-ECMO as a bridge to successful reoperative cardiac surgery in a case of traumatic tricuspid valve injury

Abstract Cardiac surgery performed on patients in cardiogenic shock is associated with a high mortality and morbidity. Preoperative Extra Corporeal Membrane Oxygenation (ECMO) in cardiogenic shock gives critically-ill patients a chance for surgical intervention and is associated with better surgical outcomes. We present a 29-year-old male who had a ventricular septal defect closure as a child and presented with multi-organ injuries following polytrauma. He was in cardiogenic shock despite maximal inotropic support. Transesophageal echocardiography demonstrated torrential tricuspid regurgitation (TR) from a flail tricuspid valve (TV) leaflet as the cause of cardiogenic shock. He was stabilized on Veno-Arterial ECMO and underwent reoperative cardiac surgery. Intra-operatively, the anterior leaflet of his TV and its papillary muscle was detached from the right ventricle. He had a successful tissue TV replacement. Early surgery was indicated to treat right ventricular failure due to torrential TR, but due to his restricting non-cardiac injuries, ECMO was successfully used as a short-term support strategy and as a bridge to definitive surgery.

A rare case of extensive biventricular cardiac sarcoidosis with reversible torrential tricuspid regurgitation

Reversal of torrential tricuspid regurgitation is rarely seen. We describe a case in which effective immunosuppression alongside conventional heart failure therapies lead to reversibility of torrential tricuspid regurgitation in a patient with cardiac sarcoidosis. We also discuss the diagnostic challenge in distinguishing cardiac sarcoidosis from other myocardial diseases in a patient presenting with biventricular failure.

Comparison of procedural characteristics of percutaneous annuloplasty and edge-to-edge repair for the treatment of severe tricuspid regurgitation.

In recent years, new interventional therapies for tricuspid regurgitation (TR) demonstrated their effectiveness in reducing TR severity and improving symptoms. Currently, tricuspid transcatheter edge-to-edge repair (T-TEER) and percutaneous annuloplasty are the most widely used techniques in Europe. In this retrospective study, we compared procedural characteristics and learning curves of both TR devices in a real-world cohort. Eligible patients with severe to torrential TR underwent either percutaneous annuloplasty or T-TEER as recommended by the local heart team. Patients with combined mitral and tricuspid interventions were excluded from the analysis. The study focused on procedural characteristics, TR reduction and learning curves. A total of 122 patients underwent either percutaneous annuloplasty (n = 64) or T-TEER (n = 58) with a technical and device success rate of 98% and 97%, respectively. Reasons for technical failure included right coronary artery (RCA) dissection prior to percutaneous annuloplasty, and two single leaflet device attachments (SLDA) during T-TEER implantation. The mean improvement of TR severity was 2.4 ± 0.8 degrees after T-TEER and 2.5 ± 0.8 after percutaneous annuloplasty. T-TEER procedures were shorter in terms of both procedure time and radiation exposure, while percutaneous annuloplasty, although taking longer, showed a significant reduction in procedure time over the course of the analysed period. In summary, both interventional therapies reduce TR severity by approximately two degrees when used in the appropriate anatomy. The learning curve for annuloplasty group showed a significant decrease of procedure times.

Impact of the new classification of tricuspid regurgitation on the baseline characteristics and prognosis of a wide series of "real life" patients

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Andalusian Society of Cardiology Introduction A new classification of severe tricuspid regurgitation (TR) has recently been described that distinguishes three subgroups: severe, massive and torrential. Our objective was to analyse the prevalence of the new categories, describe their baseline characteristics according to severity group and assess their impact on the prognosis in a large series of patients with severe TR of a tertiary care hospital in our area. Methods All consecutive patients ≥18 years with severe TR studied with echocardiography in a tertiary care hospital in our area from 01.01.2008 to 12.31.2017 were retrospectively included. Images were analysed off-line to measure the maximum vena contracta (VC) in any echocardiographic plane and severe TR was classified into three groups: severe (VC≥7mm), massive (VC 14–20mm) and torrential (VC≥21mm). Baseline characteristics were analysed in the different subgroups and follow-up events by univariate and multivariate techniques. The combined event of death and heart failure (HF) admission on follow-up was investigated. Results A total of 661 patients (69±13 years, 72% women) with severe TR were included. 81.5% (539) presented severe TR, 15.6% (103) massive TR and 2.9% (19) torrential TR. The baseline characteristics were different according to the different subgroups of severity (Table). The 5-year HF-free survival was 42%, 44% and 11% (p&amp;lt;0.0005), for the different subgroups, respectively (Figure). After adjusting for baseline characteristics, the severity of TR assessed by VC was independent predictor of HF-free survival, HR 0.89 [95%CI 0.70–1.15] p = 0.39, for massive TR; and HR 2.48 [95% CI 1.52–4.05] p&amp;lt;0.0005, for torrential TR considering severe TR as reference. Conclusions In this large monocentric study, severe TR measured by VC was the most frequent subgroup, followed by massive and torrential. The prognosis was significantly worse in patients with torrential TR.

Short-Term Outcomes of Tricuspid Edge-to-Edge Repair in Clinical Practice

BackgroundSevere tricuspid regurgitation (TR) is known to be associated with substantial morbidity and mortality. ObjectivesThe authors sought to study the acute outcomes of subjects treated by tricuspid transcatheter edge-to-edge repair with the TriClip system (Abbott) in a contemporary, real-world setting. MethodsThe bRIGHT (An Observational Real-World Study Evaluating Severe Tricuspid Regurgitation Patients Treated With the Abbott TriClip™ Device) postapproval study is a prospective, single-arm, open-label, multicenter, postmarket registry conducted at 26 sites in Europe. Echocardiographic assessment was performed at a core laboratory. ResultsEnrolled subjects were elderly (79 ± 7 years of age) with significant comorbidities. Eighty-eight percent had baseline massive or torrential TR, and 80% of subjects were in NYHA functional class III or IV. Successful device implantation occurred in 99% of subjects, and TR was reduced to ≤moderate at 30 days in 77%. Associated significant improvements in NYHA functional class (I/II, 20% to 79%; P < 0.0001) and Kansas City Cardiomyopathy Questionnaire score (19 ± 23 points improvement; P < 0.0001) were observed at 30 days. With baseline TR grade removed as a variable, smaller right atrial volume and smaller tethering distance at baseline were independent predictors of TR reduction to ≤moderate at discharge (OR: 0.679; 95% CI: 0.537-0.858; P = 0.0012; OR: 0.722; 95% CI: 0.564-0.924; P = 0.0097). Fourteen subjects (2.5%) experienced a major adverse event at 30 days. ConclusionsTranscatheter tricuspid valve repair was found to be safe and effective in treating significant TR in a diverse, real-world population. (An Observational Real-World Study Evaluating Severe Tricuspid Regurgitation Patients Treated With the Abbott TriClip™ Device [bRIGHT]; NCT04483089)

Venae Cavae Anatomic Characteristics in Severe Tricuspid Regurgitation: Implications for Transcatheter Interventions

Transcatheter tricuspid valve interventions (TTVIs) are rapidly expanding with new technologies being developed and investigated to address the unmet clinical need of severe tricuspid regurgitation (TR), a condition with significant morbidity and mortality, and relatively high associated surgical risk.1Wang N. Fulcher J. Abeysuriya N. et al.Tricuspid regurgitation is associated with increased mortality independent of pulmonary pressures and right heart failure: a systematic review and meta-analysis.Eur Heart J. 2019; 40: 476-484https://doi.org/10.1093/eurheartj/ehy641Crossref PubMed Scopus (139) Google Scholar These technologies either target the valve (repair, replacement, annular remodeling) to address the TR or the venae cavae (VC) to prevent the downstream complications of the reflux. For valve therapies, VC are the main access route to deliver the equipment, ideally in a coaxial fashion, to the tricuspid valve (TV). This may be challenging and depends on the angulation, distance, and offset between the VC axes (access) and the TV axis (target). For heterotopic valve therapies, caval valve implantation (CAVI) is used in patients with right heart failure and unsuitable anatomy for orthotopic TV replacement or transcatheter edge-to-edge repair, who are at high or prohibitive surgical risk for TV surgery. However, little is known about the normal VC dimensions and how they change in patients with severe TR, important data for device sizing and anchoring. We included 71 patients with isolated severe TR and none to mild mitral regurgitation (MR), referred to the Cleveland Clinic between 2017 and 2022 who had undergone multiphase cardiac computed tomography (CT) with right-sided contrast. Comparator groups included patients with isolated severe MR and none to mild TR, matched by age and gender (caliper 0.1) and patients without any valvular dysfunction (normal coronary CT), matched by gender (caliper 0.1). We evaluated VC diameter and area at the junction with the right atrium (RA), junction with supra-hepatic veins for inferior VC (IVC) and at the level of the pulmonary artery (PA) for superior VC (SVC). These measurements were done at systole and diastole and were stratified based on TR severity. We measured the angle between VC and the TV annulus, the height between these structures and the offset to the TV as previously described by Harb et al.2Harb S.C. Krishnaswamy A. Kapadia S.R. Miyasaka R.L. The inferior vena cava-tricuspid valve anatomic relationship: an underrecognized cornerstone for transcatheter tricuspid valve interventions.JACC Cardiovasc Imaging. 2023; 16: 118-127https://doi.org/10.1016/j.jcmg.2022.07.023Crossref Scopus (0) Google Scholar All measurements were indexed to body surface area. Variables are presented as mean ± standard deviation. We used analysis of variance (ANOVA) test for comparison between groups. This study was approved by the Institutional Review Board of the Cleveland Clinic. Of 206 included patients, mean age was 77 years for the TR and MR groups and 38 years for the control group with 58%, 64%, and 56% females, respectively. Mean TV effective regurgitant orifice area was 0.66 ± 0.32 cm2 in the TR group, with 30% having torrential TR, and mitral valve effective regurgitant orifice area being 0.42 ± 0.23 cm2 in the MR group. VC dimensions were significantly larger in the severe TR cohort (Table 1), although no significant differences in systole versus diastole were observed (area of IVC at supra-hepatic veins junction mean 3.91 vs 3.87 cm2/m2; p = 0.53, and area of SVC at level of PA mean 2.67 vs 2.43 cm2/m2; p = 0.161). The IVC offset was increased in patients with severe TR compared to the MR and control group (mean 9.79, 7.08, and 5.87 mm/m2, respectively; p < 0.001). On the contrary, while the SVC to TV angle was smaller in patients with severe TR compared to the other groups, the IVC angle was larger.Table 1Cardiac CT angiography VC dimensions between groupsIndexed variables≥ Severe TR (n = 71)Stratified TR severitySevere MR (n = 64)Controls (n = 71)p val†p value for ANOVA test comparing ≥ severe TR vs severe MR vs controls.Severe TRMassive TRTorrential TRp val∗p value for ANOVA test comparing severe vs massive vs torrential TR.Indexed IVC dimensions, mean/BSA (SD) RA junction area at systole, cm2/m24.89 (1.9)4.94 (1.99)4.74 (1.74)5.22 (1.35)0.7033.56 (1.3)2.92 (0.9)< 0.001 RA junction area at diastole, cm2/m24.72 (1.7)4.80 (2.03)4.54 (1.52)5.13 (1.34)0.5213.33 (1.0)2.92 (0.9)< 0.001 RA junction diameter at systole, mm/m215.61 (3.2)18.25 (4.08)17.59 (3.27)19.44 (2.61)0.24715.61 (3.2)13.71 (2.9)< 0.001 RA junction diameter at diastole, mm/m217.82 (3.2)18.16 (3.87)17.27 (3.09)19.09 (2.46)0.20115.06 (2.5)13.77 (2.7)< 0.001 SHV junction area at systole, cm2/m23.91 (1.2)3.97 (1.14)3.53 (1.13)4.74 (1.10)0.0153.03 (0.9)2.81 (0.9)< 0.001 SHV junction area at diastole, cm2/m23.87 (1.2)3.84 (1.30)3.64 (1.18)4.62 (1.09)0.073.05 (0.9)2.91 (0.9)< 0.001 SHV junction diameter at systole, mm/m216.34 (2.8)16.59 (2.47)15.29 (2.84)18.53 (2.46)0.00615.17 (3.6)13.47 (2.9)< 0.001 SHV junction diameter at diastole, mm/m216.24 (2.6)16.47 (2.48)15.51 (2.92)18.05 (2.29)0.03414.55 (2.4)13.7 (2.9)< 0.001 Length from RA junction to SHV junction at systole, mm/m29.44 (6.4)9.19 (9.83)10.04 (6.19)8.35 (6.16)0.7839.06 (3.7)9.12 (4.8)0.934 Length from RA junction to SHV junction at diastole, mm/m29.8 (6.7)10.60 (10.20)10.47 (6.22)6.93 (4.54)0.299.17 (3.5)9.5 (5.0)0.839 Offset, mm/m29.79 (5.6)10.83 (4.59)10.03 (5.99)7.98 (4.67)0.3677.08 (4.4)5.87 (2.9)< 0.001 Angle to TVA, degrees/m251.36 (9.9)6.34 (4.71)4.83 (4.48)8.36 (4.70)0.0748.45 (11.3)46.8 (10.7)0.038 Height to TVA, mm/m227.98 (8.7)53.61 (8.72)50.52 (9.88)51.32 (9.24)0.68321.69 (8.1)16.84 (5.5)<0.001Indexed SVC dimensions, mean/BSA (SD) Level of PA area at systole, cm2/m22.67 (0.9)2.84 (0.98)2.41 (0.80)3.31 (0.90)0.0121.71 (0.7)1.26 (0.5)< 0.001 Level of PA area at diastole, cm2/m22.43 (0.9)2.51 (1.01)2.26 (0.65)2.83 (0.82)0.0851.97 (1.5)1.22 (0.5)< 0.001 Level of PA diameter at systole, mm/m213.46 (2.7)13.94 (2.65)12.63 (2.48)15.41 (2.26)0.00610.58 (2.8)9.03 (2.3)< 0.001 Level of PA diameter at systole, mm/m212.89 (2.7)13.14 (2.64)12.23 (2.14)14.31 (3.09)0.04910.89 (2.5)8.89 (2.0)< 0.001 RA junction area at systole, cm2/m23.72 (1.6)4.16 (1.63)3.36 (1.42)4.48 (1.56)0.0761.66 (0.7)1.23 (0.5)< 0.001 RA junction area at diastole, cm2/m23.34 (1.4)3.75 (1.78)3.13 (1.21)3.62 (1.53)0.3941.85 (1.4)1.11 (0.4)< 0.001 RA junction diameter at systole, mm/m215.84 (3.7)16.84 (3.50)14.79 (3.83)17.88 (3.27)0.03810.68 (2.7)8.92 (2.3)< 0.001 RA junction diameter at diastole, mm/m214.97 (3.5)15.94 (3.98)14.38 (3.48)15.81 (3.61)0.35110.72 (2.6)8.5 (1.9)< 0.001 Length from RA junction to PA level at systole, mm/m214.3 (4.9)13.29 (5.05)15.12 (5.41)12.93 (5.18)0.40714.27 (4.9)13.7 (5.6)0.817 Length from RA junction to PA level at diastole, mm/m214.8 (5.3)14.73 (6.50)15.44 (5.55)12.62 (5.00)0.30313.98 (4.5)13.5 (5.2)0.312 Offset, mm/m25.84 (4.8)6.34 (4.71)4.83 (4.48)8.36 (4.70)0.076.13 (4.8)3.43 (2.6)< 0.001 Angle to TVA, degrees/m258.34 (12.0)53.61 (8.72)50.52 (9.88)51.32 (9.24)0.68363.83 (10.4)59.11 (11.9)0.017 Height to TVA, mm/m228.02 (7.4)59.79 (9.68)55.80 (12.4)60.72 (10.02)0.35520.89 (6.2)15.58 (4.4)< 0.001Bold values indicate p < 0.05.BSA, body surface area; CT, computed tomography; IVC, inferior vena cava; MR, mitral regurgitation; PA, pulmonary artery; RA, right atrium; SD, standard deviation; SHV, supra-hepatic veins; SVC, superior vena cava; TR, tricuspid regurgitation; TVA, tricuspid valve annulus.∗ p value for ANOVA test comparing severe vs massive vs torrential TR.† p value for ANOVA test comparing ≥ severe TR vs severe MR vs controls. Open table in a new tab Bold values indicate p < 0.05. BSA, body surface area; CT, computed tomography; IVC, inferior vena cava; MR, mitral regurgitation; PA, pulmonary artery; RA, right atrium; SD, standard deviation; SHV, supra-hepatic veins; SVC, superior vena cava; TR, tricuspid regurgitation; TVA, tricuspid valve annulus. Understanding the VC anatomy, their dimensions (at various levels), and spatial relationship (angle, offset, distance) to the TV are crucial for TTVI procedural success, although these considerations remain not well studied, underappreciated, and often overlooked. To our knowledge, this is the first detailed report assessing the VC anatomic characteristics as they pertain to TTVI on cardiac CT, which is typically used for procedural planning.3Layoun H. Schoenhagen P. Wang T.K.M. et al.Roles of cardiac computed tomography in guiding transcatheter tricuspid valve interventions.Curr Cardiol Rep. 2021; 23: 114https://doi.org/10.1007/s11886-021-01547-7Crossref Scopus (2) Google Scholar Procedural evaluation for CAVI also requires the presence of significant caval reflux for proper valve function after implantation. Earlier heterotopic therapies mainly involved the IVC with complications including residual leaks, improper sizing, and device embolization and thrombosis.4Abdul-Jawad Altisent O. Benetis R. Rumbinaite E. et al.Caval valve implantation (CAVI): an emerging therapy for treating severe tricuspid regurgitation.J Clin Med. 2021; 10: 4601https://doi.org/10.3390/jcm10194601Crossref Scopus (8) Google Scholar Currently, TricValve (Products + Features) is the only dedicated CAVI system. The early experience of TricValve in 35 patients has demonstrated the procedure’s feasibility (94% procedural success) and safety (no procedural deaths or conversions to surgery) as well as functional status and patient-reported quality of life (NYHA functional class and Kansas City Cardiomyopathy Questionnaire) benefits.5Estévez-Loureiro R. Sánchez-Recalde A. Amat-Santos I.J. et al.6-Month outcomes of the TricValve system in patients with tricuspid regurgitation: the TRICUS EURO study.JACC Cardiovasc Interv. 2022; 15: 1366-1377https://doi.org/10.1016/j.jcin.2022.05.022Crossref PubMed Scopus (17) Google Scholar However, these findings are largely limited by the small sample size. With the increasing use of CAVI therapies, knowing how substantially larger the VC dimensions are in the severe TR group has important implications, particularly in terms of device sizing and catheter approach in advanced disease. First, we present the VC dimensions at multiple levels for patients with severe TR and how they compare to normal younger patients (normal coronary CT) and age-matched and gender-matched patients with nonsevere TR (MR group). Second, since these dimensions were not significantly different across the cardiac cycle, a single-phase CT rather than a multiphasic acquisition may be used, significantly limiting the amount of radiation exposure associated with such scans. Finally, the angulation, distance, and offset required to reach the TV in a coaxial fashion from both the SVC and IVC are outlined, which have important implications in terms of designing TTVI delivery guides’ physical properties and capabilities in terms of maneuverability. Careful understanding of the VC anatomic characteristics is key for TTVI procedural success, as they are either the access routes or the targets for these rapidly evolving therapies. This study was approved by the Institutional Review Board of the Cleveland Clinic, and written informed consent was waived.

1-Year Outcomes of Transcatheter Tricuspid Valve Repair

BackgroundSurgical management of isolated tricuspid regurgitation (TR) is associated with high morbidity and mortality, thereby creating a significant need for a lower-risk transcatheter solution. ObjectivesThe single-arm, multicenter, prospective CLASP TR (Edwards PASCAL TrAnScatheter Valve RePair System in Tricuspid Regurgitation [CLASP TR] Early Feasibility Study) evaluated 1-year outcomes of the PASCAL transcatheter valve repair system (Edwards Lifesciences) to treat TR. MethodsStudy inclusion required a previous diagnosis of severe or greater TR and persistent symptoms despite medical treatment. An independent core laboratory evaluated echocardiographic results, and a clinical events committee adjudicated major adverse events. The study evaluated primary safety and performance outcomes, with echocardiographic, clinical, and functional endpoints. Study investigators report 1-year all-cause mortality and heart failure hospitalization rates. ResultsSixty-five patients were enrolled: mean age of 77.4 years; 55.4% female; and 97.0% with severe to torrential TR. At 30 days, cardiovascular mortality was 3.1%, the stroke rate was 1.5%, and no device-related reinterventions were reported. Between 30 days and 1 year, there were an additional 3 cardiovascular deaths (4.8%), 2 strokes (3.2%), and 1 unplanned or emergency reintervention (1.6%). One-year postprocedure, TR severity significantly reduced (P < 0.001), with 31 of 36 (86.0%) patients achieving moderate or less TR; 100% had at least 1 TR grade reduction. Freedom from all-cause mortality and heart failure hospitalization by Kaplan-Meier analyses were 87.9% and 78.5%, respectively. Their New York Heart Association functional class significantly improved (P < 0.001) with 92% in class I or II, 6-minute walk distance increased by 94 m (P = 0.014), and overall Kansas City Cardiomyopathy Questionnaire scores improved by 18 points (P < 0.001). ConclusionsThe PASCAL system demonstrated low complication and high survival rates, with significant and sustained improvements in TR, functional status, and quality of life at 1 year. (Edwards PASCAL TrAnScatheter Valve RePair System in Tricuspid Regurgitation [CLASP TR] Early Feasibility Study [CLASP TR EFS]; NCT03745313)

Hyepereosiniphilic syndrome and COVID-19: 2 case reports

BackgroundNearly half of the patients with hypereosinophilic syndrome (HES) have cardiovascular involvement, a major cause of mortality. COVID-19 infection can lead to cardiac involvement, negatively impacting the clinical course and prognosis. We reported two patients with HES complicated by COVID-19, with cardiac involvement and valve replacement.Case presentationOur first patient was a 27-year-old woman admitted due to dyspnea and signs of heart failure. She had severe mitral stenosis and mitral regurgitation on the echocardiogram. Corticosteroid therapy improved her symptoms initially, but she deteriorated following a positive COVID-19 test. A repeated echocardiogram showed right ventricular failure, severe mitral regurgitation, and torrential tricuspid regurgitation and, she underwent mitral and tricuspid valve replacement. Our second patient was a 43-year-old man with HES resulted in severe tricuspid stenosis, which was improved with corticosteroid treatment. He underwent tricuspid valve replacement due to severe valvular regurgitation. He was admitted again following tricuspid prosthetic mechanical valve thrombosis. Initial workups revealed lung involvement in favor of COVID-19 infection, and his PCR test was positive.ConclusionCOVID-19 infection can change the clinical course of HES. It may result in a heart failure exacerbation due to myocardial injury and an increased risk of thrombosis in prosthetic valves or native vessels due to hypercoagulability.

Clinical utility and prognostic value of right atrial function in severe tricuspid regurgitation: one more piece of the puzzle.

The optimal management of severe tricuspid regurgitation (TR) remains controversial. While right ventricular systolic function is an established prognostic marker of outcomes, the potential role of right atrial (RA) function is unknown. This study aimed to describe RA function by 2D speckle-tracking echocardiography (STE) in at least severe TR and to evaluate its potential association with cardiovascular outcomes. Consecutive patients with at least (≥) severe TR (severe, massive, or torrential TR) evaluated in the Heart Valve Clinic following a comprehensive clinical protocol were included. Consecutive control subjects and patients with permanent isolated atrial fibrillation (AF) were included for comparison (control and AF group, respectively). RA function was measured with 2D-STE and two components of RA function were calculated: reservoir (RASr) and contractile (RASct) strain (AutoStrain, Philips Medical Systems the EPIQ system). A combined endpoint of hospital admission due to heart failure (HF) or all-cause mortality was defined. Patients with ≥ severe TR (n = 140) showed lower RASr compared with controls (n = 20) and with the AF group (n = 20) (P < 0.001). Atrial TR showed lower RASr compared with other aetiologies of TR (P < 0.001). After a median follow-up of 2.2 years (IQR: 12-41 months), RASr remained an independent predictor of mortality and HF. A cut-off value of RASr of <9.4% held the best accuracy to predict outcomes. RA function by 2D-STE independently predicts mortality and HF hospitalizations in patients with ≥ severe TR.

Baseline Characteristics and Clinical Outcomes of a Tricuspid Regurgitation Referral Population

Adverse outcomes in tricuspid regurgitation (TR) have been associated with advanced regurgitation severity and right-sided cardiac remodeling, and late referrals for tricuspid valve surgery in TR have been associated with increase in postoperative mortality. The purpose of this study was to evaluate baseline characteristics, clinical outcomes, and procedural utilization of a TR referral population. We analyzed patients with a diagnosis of TR referred to a large TR referral center between 2016 and 2020. We evaluated baseline characteristics stratified by TR severity and analyzed time-to-event outcomes for a composite of overall mortality or heart-failure hospitalization. In total, 408 patients were referred with a diagnosis of TR: the median age of the cohort was 79 years (interquartile range 70 to 84), and 56% were female. In patients evaluated on a 5-grade scale, 10.2% had ≤moderate TR; 30.7% had severe TR; 11.4% had massive TR, and 47.7% had torrential TR. Increasing TR severity was associated with right-sided cardiac remodeling and altered right ventricular hemodynamics. In multivariable Cox regression analysis, New York Heart Association class symptoms, history of heart failure hospitalization, and right atrial pressure were associated with the composite outcome. One-third of patients referred underwent transcatheter tricuspid valve intervention (19%) or surgery (14%); patients who underwent transcatheter tricuspid valve intervention had greater preoperative risk than that of patients who underwent surgery. In conclusion, in patients referred for evaluation of TR, there were high rates of massive and torrential regurgitation and advanced right ventricle remodeling. Symptoms and right atrial pressure are associated with clinical outcomes in follow-up. There were significant differences in baseline procedural risk and eventual therapeutic modality.