TR Severity Research Articles

The prognostic impact of tricuspid regurgitation improvement after left-sided valvular interventions

Abstract Background Tricuspid regurgitation is a common bystander in patients with left-sided valvular heart disease such as mitral regurgitation (MR) or aortic stenosis (AS). Data on the prognostic impact of potential TR improvement after interventions for left sided valvar disease is scarce. Objectives This study aimed to assess incidence and prognostic value of TR improvement after left-sided valvular interventions (M-TEER and TAVI) using merged data from two prospective single-center registries. Methods The merged database included all consecutive patients with symptomatic left-sided valvular heart disease (MR or AS) undergoing either M-TEER or TAVI from 2008 until 2023. The prognostic impact of baseline TR severity and TR improvement was assessed using Kaplan-Meier estimates and stepwise Cox regression. TR improvement was defined as a reduction in TR severity at discharge by at least one grade compared to baseline in patients with ≥moderate TR at baseline. Results A total of 4,461 patients undergoing left-sided valvular interventions (M-TEER: N=663; TAVI: N=3,798) were eligible for study inclusion (age 81.0 years [IQR 76.2-84.7], 52.7% male). TR severity at baseline was none or mild in 70.9% (N=3,161), moderate in 19.4% (N=864), and severe in 9.8% (N=436). Patients with ≥moderate TR at baseline showed significantly higher rates of all-cause mortality (p<0.001) and of the combined endpoint after 3 years (p<0.001), compared to patients with none or mild TR. This finding was consistent for the M-TEER and TAVI subgroups. Among patients with ≥moderate TR at baseline (N=1,300), 499 patients (38.4%) showed TR improvement by at least one grade following left-sided valvular intervention, while TR did not improve in 801 patients (61.6%). In the overall study population, patients with TR improvement showed lower rates of all-cause mortality (p<0.001) and the combined endpoint after 3 years (p=0.006) (Figure 1A, 1B). This finding was consistent only in the subgroup of patients undergoing M-TEER (p=0.013 and p=0.003), but not for patients undergoing TAVI (p=0.12 and 0.62) (Figure 2A, 2B). Following stepwise Cox regression (incl. adjustment for treatment), TR ≥moderate at baseline was independently associated with death (p=0.0019) and combined death or HF rehospitalization (p=0.0068) 3 years after intervention (Figure 3A,3B). TR improvement was independently associated with survival (p=0.015) and combined survival or absent HF rehospitalization (p=0.032) 3 years after intervention (Figure 4A, 4B). Conclusions Patients with TR improvement after left sided valvular interventions showed significantly better clinical outcomes compared to those without. These results reinforce the need for assessment for TR assessment before and after left-sided valvular interventions and may identify patients that qualify for subsequent TR intervention.

Morphologic differences in atrial and ventricular secondary tricuspid regurgitation by computed tomography

Abstract Background Differences in the mechanism behind atrial (ASTR) and ventricular (VSTR) secondary tricuspid regurgitation cause distinct remodeling in the tricuspid valve annulus (TA), right atrium (RA) and right ventricle (RV). Although these morphological changes have been described by echocardiography, computed tomography (CT) can provide better spatial resolution and detailed anatomical information particularly when planning valvular interventions. Purpose To compare the morphologic characteristics of the TA, RA and RV between ASTR and VSTR as measured by CT. Methods Patients with at least moderate secondary TR and who underwent CT were selected as follows: for the ASTR group (n=32), patients referred for atrial fibrillation (AF) ablation; for the VSTR group, patients referred for transcatheter aortic valve implantation, and which were further subdivided according to the presence of AF (with AF [n=51] and without AF [n=68]). Multiparametric echocardiographic approach was used to define TR severity. CT dataset were analyzed in diastole using a dedicated software for the following parameters: TA area, perimeter, antero-posterior (AP) and septal-lateral (SL) diameters, eccentricity index, annulus depth (to assess TA saddle shape), and RA and RV dimensions and volumes (Fig. 1). Results TR was more severe in VSTR, as 55% and 43% of patients had severe to massive TR in the VSTR group with and without AF, respectively, as compared to 12% in the ASTR group (p<0.001). The TA area was significantly larger in the ASTR and VSTR with AF patients (Fig.2), with a trend towards a more circular annulus by eccentricity index. Annulus depth was lower (flatter) in ASTR compared to both VSTR groups. For the RA, annulus to roof distance was larger in VSTR patients with AF, but the diameter width was wider for both ASTR and VSTR with AF. Indexed RA volume was larger in the VSTR with AF compared to both ASTR and VFTR without AF. The RV, on the other hand, showed a wide base and narrow mid in the ASTR group, both a wide base and mid in the VSTR group with AF, and slightly narrower base and wider mid in the VSTR without AF. RV base-to-mid ratio was lower for both VSTR groups compared to ASTR, but volumes did not significantly differ. RA-to-RV-volume ratio, however, was higher for the ASTR and VSTR with AF. Conclusion Remodeling of the TA and right chambers differ significantly between TR etiologies. ASTR is characterized by a larger and flatter TA, a widened RA and RV base, narrow RV mid, and almost proportional RA-to-RV volumes. VSTR remodeling differs with the presence of AF, as those without AF have a smaller and deep TA, smaller RA, a proportional dilatation of RV diameters, and a larger RV compared to RA. Differentiating these patterns may be useful to guide future interventions.

Late Follow-up for a Randomized Trial of Surgical Treatment of Tricuspid Valve Regurgitation in Patients Undergoing Left Ventricular Assist Device Implantation

ObjectivesWe previously reported that concurrent tricuspid valve surgery (TVS) was not associated with a lower incidence of early RHF among patients undergoing durable LVAD implantation. This is a follow-up analysis to further define the clinical impact of concurrent TVS within 12-months of follow-up. MethodsPatients with moderate or severe TR on pre-operative echocardiography (n=71) were randomized to either LVAD implantation alone (No TVS, n=34) or with concurrent TVS (TVS, n=37). Randomization was stratified by pre-operative right ventricular dysfunction. Patients were followed for at least 12-months after surgery. The incidence of RHF was determined using INTERMACS criteria by an adjudication committee. Functional studies and repeat echocardiography were performed at 12-months. ResultsDemographics were similar between the two arms. At 12-months, the rate of moderate or severe RHF was 50.0% (No TVS) versus 51.4% (TVS). No patients developed RHF between 6- and 12-months following the procedure. Death from RHF was 5.4% (TVS) versus 8.8% (No TVS). At 12-months, there was no significant difference in TR severity between the two arms due to improvement in TR severity in the No TVS arm. On cardiopulmonary exercise testing at 12+ months, there was no significant difference in peak oxygen consumption. ConclusionsIn patients with significant pre-implant TR, the severity of TR improved over time in the LVAD implantation alone arm. By 12-months, there is no significant difference in TR severity between the two arms. This may account for the lack of difference in late clinical or functional parameters.

Prevalence and Prognostic Implications of Changes in Tricuspid Regurgitation Severity in Acute Heart Failure

BackgroundTricuspid regurgitation (TR), prevalent in acute heart failure (AHF), has a poor prognosis; however, the dynamics of TR severity during hospitalization and its prognostic implications remain unclear. We investigated TR dynamism during hospitalization and its prognostic impact in AHF. Methods and ResultsThis is a post hoc analysis of a prospective multicenter study of patients with AHF who underwent echocardiographic TR severity evaluation at admission and before discharge. The primary end point was a combined of 1-year all-cause mortality and HF rehospitalization after discharge. Among 1079 participants, TR severity changed dynamically, with 60.3% of those with moderate TR and 29.6% of those with severe TR at admission being diagnosed as no or mild TR at discharge. In 3 groups stratified by changes in TR severity, the persistent TR groups had a higher incidence of the primary end point than the resolution and absence groups. In adjusted analyses, the persistent group (hazard ratio, 1.37; 95% confidence interval, 1.04–1.80), but not the resolution group (hazard ratio, 1.07; 95% confidence interval, 0.79–1.44), had a higher primary end point incidence than the absence group. ConclusionsTR severity at admission in patients with AHF can change dynamically and is associated with subsequent prognosis. Significant TR that remains even after decongestive therapy might be a target for further treatment in hospitalized patients with AHF.

Sinus rhythm restoration reverses tricuspid regurgitation in patients with atrial fibrillation: a systematic review and meta-analysis

BackgroundTricuspid regurgitation (TR) is a common valvular heart disease worldwide, and current guidelines for TR treatment are relatively conservative, as well as with detrimental outcomes. Restoration of sinus rhythm was reported to improve the TR severity in those TR patients with atrial fibrillation (AF). However, relevant research was limited. The aim of this meta-analysis was to evaluate the clinical outcomes of restoration of sinus rhythm in TR patients with AF.MethodsIn this study, PubMed, Web of Science, and Scopus databases were searched for study enrollment until July 2023. This study was designed under the guidance of Preferred Reporting Items for Systematic Reviews and Meta-Analyses. These studies containing the patient’s baseline characteristics, surgical procedure, and at least one of the clinical outcomes were included. The primary endpoint was TR grade during follow-up after restoration of sinus rhythm.ResultsOut of 1074 records, 6 were enrolled. Restoration of sinus rhythm is associated with a reduction of TR severity (TR grade, odds ratio 0.11, 95% confidence interval (CI): 0.01 to 1.28, P = 0.08, I2 = 83%; TR area, mean difference (MD) -2.19 cm2, 95% CI: -4.17 to -0.21 cm2, P = 0.03, I2 = 96%). Additionally, remolding of right heart with a significant reduction of tricuspid valve annulus diameter (MD -0.36 cm, 95%CI: -0.47 to -0.26 cm, P < 0.00001, I2 = 29%) and right atrium volume index (MD -11.10 mL/m2, 95%CI: -16.81 to -5.39 mL/m2, P = 0.0001, I2 = 79%) was observed during follow-up.ConclusionsIn conclusion, rhythm-control therapy could reduce TR severity in AF patients with TR and is associated with right heart remodeling.

Determinants of Tricuspid Regurgitation Progression and Its Implications for Adequate Management

BackgroundTricuspid regurgitation (TR) is associated with an increased mortality. Previous studies have analyzed predictors of TR progression and the clinical impact of baseline TR. However, there is a lack of evidence regarding the natural history of TR: the pattern of change and clinical impact of progression. ObjectivesThe authors sought to evaluate predictors of TR progression and assess the prognostic impact of TR progression. MethodsA total of 1,843 patients with at least moderate TR were prospectively followed up with consecutive echocardiographic studies and/or clinical evaluation. All patients with less than a 2-year follow-up were excluded. Clinical and echocardiographic features, hospitalizations for heart failure, and cardiovascular death and interventions were recorded to assess their impact in TR progression. ResultsAt a median 2.3-year follow-up, 19% of patients experienced progression. Patients with baseline moderate TR presented a rate progression of 4.9%, 10.1%, and 24.8% 1 year, 2 years, and 3 years, respectively. Older age (HR: 1.03), lower body mass index (HR: 0.95), chronic kidney disease (HR: 1.55), worse NYHA functional class (HR: 1.52), and right ventricle dilation (HR: 1.33) were independently associated with TR progression. TR progression was associated with an increase in chamber dilation as well as a decrease in ventriculoarterial coupling and in left ventricle ejection fraction (P < 0.001). TR progression was associated with an increased cardiovascular mortality and hospitalizations for heart failure (P < 0.001). ConclusionsMarked individual variability in TR progression hindered accurate follow-up. In addition, TR progression was a determinant for survival regardless of initial TR severity.

Disproportionate MR and 5-year mortality following acute heart failure hospitalisation

Abstract Background The clinical implications of disproportionate mitral regurgitation (DispMR) is contentious and uncertainty remains if this cohort of patients benefit from intervention. Its prognostic significance in acute heart failure remains incompletely investigated. Purpose To examine whether DispMR, defined by the ratio of the effective regurgitant orifice area (ERO)/LVEDV &amp;gt;0.14mm2/ml, is an independent predictor of long-term mortality following hospitalisation for AHF. Methods 418 consecutive AHF patients were recruited and followed up for the primary outcome of all-cause, 5-year mortality. A key secondary outcome was cardiovascular (CV) death. Patients were recruited if they displayed signs and symptoms of AHF, had point-of-care brain-natriuretic peptide &amp;gt;100pg/ml and had evidence of AHF on comprehensive bedside transthoracic echocardiography. 30 variables encompassing age, gender, BMI, a history of COPD, CKD, hypertension, diabetes, previous CVA, CAD, AF on admission ECG, admission systolic BP, NYHA classification, heart rate, Na, BNP, urea, anaemia, LA size, RA size, TR severity, lateral E/e’ &amp;gt;14, RV diastolic area, TAPSE, SPAP, LVEF phenotype, a loop diuretic, MRA, beta-blocker, ARB/ACE-I, CCB or statin prescribed on discharge were included. Multivariate Cox-proportional hazard models were constructed to test for an independent prognostic role of DispMR. Missing outcome data was right-censored. Results 313/418 (74.8%) displayed secondary MR and had quantifiable ERO and LVEDV (median age 81, 53.4% male) and were included in analysis. 217/313 (66.5%) displayed DispMR. Kaplan-Meier curve analysis revealed worse all-cause mortality in DispMR vs. proportionate MR (HR 1.72 95% CI 1.31-2.27 [p&amp;lt;0.001]). On multivariable analysis DispMR was independently associated with all-cause mortality (HR 1.77 (95% CI 1.26-2.51 [p=0.0012]). 284/313 (90.7%) had CV mortality data available. DispMR was associated with increased risk of 5-year, unadjusted, CV mortality compared to proportionate MR (HR 1.72 95% CI 1.31-2.27 [p&amp;lt;0.001]). These effects were present across all ejection fraction phenotypes. Conclusions Among patients with quantifiable MR in AHF, the presence of DispMR was independently associated with long-term outcome. These results suggest assessment of MR within the context of LV volumes can identify patients at increased risk and should have implications for future guidelines.

Reduction of moderate to severe tricuspid regurgitation after catheter ablation for atrial fibrillation

ObjectiveTricuspid regurgitation (TR) is a progressive disease with high mortality and limited medical treatment options, and its association with atrial fibrillation (AF) has been documented. This study aimed to investigate...

Functional tricuspid regurgitation after transcatheter closure of atrial septal defect

Abstract Funding Acknowledgements Type of funding sources: None. Main funding source(s): none Background Significant functional tricuspid regurgitation (FTR) often improves during the long-term follow-up after transcatheter atrial septal defect (ASD) closure. However, the timing of TR improvement and its relationship with right ventricle (RV) reverse remodeling are unknown. Methods A total of 50 patients (age: mean age 58 +/- 16 years old, range:18–88; male: 66%) who underwent transcatheter ASD closure were enrolled. Echocardiography was performed at baseline, 1month and 1year after transcatheter ASD closure. Results TR improved significantly 1month after treatment compared to baseline, but no further significant improvement in TR severity was observed up to 1 year after treatment. Tricuspid annulus diameter decreased gradually over 1 year, while RV diameter decreased significantly at 1 month and throughout 1 year after treatment. (Figure). Conclusion Reverse remodeling of the RV was achieved immediately after ASD closure and continued thereafter, whereas significant improvement in TR severity was demonstrated only immediately after ASD closure. Meticulous follow-up with more intensive therapies should be considered for patients with residual significant TR after ASD closure.

PO-03-019 ECHOCARDIOGRAPHIC OUTCOMES OF HIS BUNDLE AND LEFT BUNDLE BRANCH AREA PACING: A SINGLE CENTER EXPERIENCE

Traditional right ventricular apical pacing is associated with risk of pacing induced cardiomyopathy (PICM), atrial fibrillation, and heart failure. Conduction system pacing (CSP) via the His or left bundle branch area (HBP, LBBAP) may mitigate or even prevent the development of these complications. To evaluate the effects of CSP on cardiac function as measured by standard 2D-echocardiography. Consecutive patients undergoing HBP or LBBAP implantation between Feb 2014 and July 2022 at Virginia Commonwealth University were analyzed. Ejection fraction (EF), left ventricular diastolic dimension (LVIDd), left ventricular systolic dimension (LVIDs), tricuspid regurgitation severity, and mitral regurgitation severity were compared pre- and post- CSP. Only patients with echo data at 90 days or greater from time of implant were included. A total of 340 patients with CSP had echocardiographic data available. Mean clinical follow up time was 810 days from implant, and median time until post-implant EF was 483 days (IQR 324-763). 77 had reduced EF (<50%) at baseline. Pacing burden exceeded 20% across the cohort. The mean pre- and post- CSP implantation EF in the overall group was 53.8% ±10.9% vs 54.7% ±9.1% (p=0.08). Mean pre- and post- CSP implant LVIDd was 4.59±0.73cm vs 4.37 ±0.72 cm (p<0.001). Mean pre- and post- CSP implant LVIDs was 3.23± 0.79cm vs 3.05± 0.76cm (p<0.001). TR and MR severity were unchanged after pacemaker implantation. In the subset of patients with reduced EF, mean pre-implant EF was 37% ±9.4% and post-implant EF was 47% ±11.6% (p<0.001). Mean pre-implant LVIDd was 5.02cm ±0.86cm and post-implant LVIDd was 4.60cm ±0.75cm (p<0.001). Mean pre-implant LVIDs was 4.05cm ±1.0cm and post-implant this dropped to 3.44cm ±0.96 (p<0.001). CSP via HBP or LBBAP is not associated with PICM in patients requiring high ventricular pacing burdens. In patients with a reduced EF, it may significantly improve systolic function along with positive structural remodeling.

Tricuspid repair in mitral regurgitation surgery: a systematic review and meta-analysis

BackgroundConcomitant tricuspid repair in MR surgery is indicated in patients with severa tricuspid regurgitation, however, concomitant repair in less-than-severe TR patients is still a matter of debate.MethodsIn December 2021, we systematically searched PubMed, Embase and Cochrane databases for randomised control trials (RCTs) comparing isolated MR surgery versus MR surgery with concomitant TR annuloplasty. Four studies were included, resulting in 651 patients (323 in the prophylactic tricuspid intervention group and 328 in the no tricuspid intervention group).ResultsOur meta-analysis showed a similar all-cause mortality and perioperative mortality for concomitant prophylactic tricuspid repair when compared with no tricuspid intervention (pooled odds ratio (OR), 0.54; 95% confidence interval (CI): 0.25–1.15, P = 0.11; I2 = 0% and pooled OR, 0.54; 95% CI: 0.25–1.15, P = 0.11; I2 = 0%, respectively) in patients undergoing MV surgery. despite a significantly lower TR progression (pooled OR, 0.06; 95% CI: 0.02–0.24, P < 0.01; I2 = 0%). Additionally, similar New York Heart Association (NYHA) classes III and IV were identified in both concomitant prophylactic tricuspid repair and no tricuspid intervention, despite a lower trend in the tricuspid intervention group (pooled OR, 0.63; 95% CI: 0.38–1.06, P = 0.08; I2 = 0%).ConclusionsOur pooled analyses suggested that TV repair at the time of MV surgery in patients with moderate or less-than-moderate TR did not impact on perioperative or postoperative all-cause mortality, despite reducing TR severity and TR progression following the intervention.

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

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

897 PEAK RIGHT ATRIAL LONGITUDINAL STRAIN: A NEW PARAMETER IN PREDICTING VENOUS CONGESTION

Abstract Background tricuspid regurgitation (TR) of either organic or functional etiology can lead to systemic venous congestion particularly in its more severe forms. Little is known about the role of the right atrium (RA) which acts as an intermediate player between TR and systemic veins. Purpose to assess the influence of right atrial size and function on venous congestion in TR patients. Methods 101 stable patients with at least mild to moderate TR were enrolled at the time of echocardiography (age 74±13 years, 37% male). Systemic congestion was assessed by inferior vena cava (IVC) diameter and right atrial pressure (RAP) estimated according to inferior vena cava diameter and collapsibility. TR severity was quantified by means of proximal isovelocity surface area (PISA) derived effective regurgitant orifice area (EROA) and regurgitant volume (RVol). RA and right ventricular (RV) function were assessed respectively by peak atrial longitudinal strain (PALS) and free wall longitudinal strain (FWLS) while indexed RA volume (RAVi) by Simpson's disk summation method. Results TR was quantified mild or moderate in 52 patients and more than moderate in 49 patients (mean EROA 37±31 mm2; mean RVol 34±23 ml). Mean indexed RA volume was 58±31 ml/m2; mean RA strain was 18±11% and mean RV strain (free wall) was -21 ± 7%. Mean IVC diameter was 20±6 mm; estimated RAP was ≤5 mmHg in 32 patients, 6-10 mmHg in 26, 11-15 mmHg in 26 and greater than 15 mmHg in 17 patients. In univariate analysis both IVC diameter and RAP correlated significantly with EROA, RVol, RAVi and RA strain (p&amp;lt;0.0001 for all); only RAP correlated with RV strain. In linear multivariate analysis only RAVi and RA strain were independent predictors of IVC diameter (p=0.01 and &amp;lt;0.0001, respectively), and only RVol and RA strain were independent predictors of RAP (p=0.001 and 0.002, respectively). We found a RA strain cut-off of -15% to have a sensitivity of 82% and specificity of 70% to identify a RAP greater than 15 mmHg (area under the curve-AUC 0.842). Conclusions RA size and function together with the TR-related volume overload were independent predictors of venous congestion. Among these variables, only RA strain predicted both parameters of venous congestion.

394 PROGNOSTIC POWER OF A NEW INDEX OF RIGHT VENTRICLE-PULMONARY ARTERY COUPLING BASED ON RIGHT VENTRICULAR VOLUMES IN PATIENTS WITH SECONDARY TRICUSPID REGURGITATION

Abstract Background Echocardiographic surrogates of right ventricle (RV) to pulmonary artery (PA) coupling have been reported to be associated with outcomes in secondary tricuspid regurgitation (STR). However, pulmonary artery systolic pressure (PASP) is difficult to be estimated using echocardiography in patients with severe STR and 3D-derived indexes are loading dependent. Objectives To evaluate the predictive power of a new surrogate of RV-PA coupling obtained using RV volumes measured by three-dimensional echocardiography (3DE), accounting for regurgitant volume of STR. Methods Patients with moderate or severe STR were enrolled. The primary outcome was the composite endpoint of death from any cause and heart failure hospitalization. Results 180 patients were included with a median follow up of 24 months (IQR: 2-48); 72 patients (40%) reached the primary endpoint. Among the tested RV-PA coupling indexes, the ratio between (RV stroke volume [SV]-regurgitant volume)/ RV End-systolic volume (ESV) (i.e. RV forward SV/ESV) showed the highest predictive power of the combined endpoint (AUC 0.85 [IC 95% 0.78-0.93]), with a threshold value of 0.40. It was followed by RV ejection fraction/PASP (AUC 0.75 [IC 95% 0.67-0.84]), and TAPSE/PASP (AUC 0.76 [IC 95% 0.68-0.85]). Severe TR (HR 2.04 [CI 95%: 1.10-3.78], p=0.02), TAPSE/PASP &amp;lt;0.36 mm/mmHg (HR 2.39 [CI 95%: 1.26-4.54], p=0.01), and RV forward SV/ESV &amp;lt;0.40 (HR 5.45 [CI 95% 2.47-12.00], p&amp;lt;0.001) were independently associated with the combined endpoint. Conclusions RV forward SV/ESV is able to stratify the risk of death and HF hospitalization in patients with STR when added to TR severity, RV ejection fraction and TAPSE/PASP

The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype.

We sought to evaluate the differences in prognosis between the atrial (A-STR) and the ventricular (V-STR) phenotypes of secondary tricuspid regurgitation. Consecutive patients with moderate or severe STR referred for echocardiography were enrolled. A-STR and V-STR were defined according to the last ACC/AHA guidelines criteria. The primary endpoint was the composite of all-cause death and heart failure (HF) hospitalizations. A total of 211 patients were enrolled. The prevalence of A-STR in our cohort was 26%. Patients with A- STR were significantly older and with lower NYHA functional class than V-STR patients. The prevalence of severe STR was similar (28% in A-STR vs. 37% in V-STR, p = 0.291). A-STR patients had smaller tenting height (TH) (10 ± 4 mm vs. 12 ± 7 mm, p = 0.023), larger end-diastolic tricuspid annulus area (9 ± 2 cm2 vs. 7 ± 6 cm2/m2, p = 0.007), smaller right ventricular (RV) end-diastolic volumes (72 ± 27 ml/m2 vs. 92 ± 38 ml/m2; p = 0.001), and better RV longitudinal function (18 ± 7 mm vs. 16 ± 6 mm; p = 0.126 for TAPSE, and -21 ± 5% vs. -18 ± 5%; p = 0.006, for RV free-wall longitudinal strain, RVFWLS) than V-STR patients. Conversely, RV ejection fraction (RVEF, 48 ± 10% vs. 46 ± 11%, p = 0.257) and maximal right atrial volumes (64 ± 38 ml/m2 vs. 55 ± 23 ml/m2, p = 0.327) were similar between the two groups. After a median follow-up of 10 months, patients with V-STR had a 2.7-fold higher risk (HR: 2.7, 95% CI 95% = 1.3-5.7) of experiencing the combined endpoint than A-STR patients. The factors related to outcomes resulted different between the two STR phenotypes: TR-severity (HR: 5.8, CI 95% = 1, 4-25, P = 0.019) in A-STR patients; TR severity (HR 2.9, 95% CI 1.4-6.3, p = 0.005), RVEF (HR: 0.97, 95% CI 0.94-0.99, p = 0.044), and RVFWLS (HR: 0.93, 95% CI 0.85-0.98, p = 0.009) in V-STR. Almost one-third of patients referred to the echocardiography laboratory for significant STR have A-STR. A-STR patients had a lower incidence of the combined endpoint than V-STR patients. Moreover, while TR severity was the only independent factor associated to outcome in A-STR patients, TR severity and RV function were independently associated with outcome in V-STR patients.

Prevalence and prognostic impact of tricuspid regurgitation in patients with cardiac implantable electronic devices: From the national echocardiography database of Australia

AimsWe sought to analyse the distribution of TR severity and survival in a large cohort of adults with CIED leads. MethodsThe distribution of TR severity was analysed in 18,797 adults (mean age 73.8+/-13.9, 63.3% men) with CIED leads undergoing echocardiography across 25 centres. Survival status and cause of death were linked and the relationship between TR severity and mortality during 2.6 (interquartile range 1.1-4.6) years follow-up examined. Data from 439,558 individuals (mean age 62.1 ±17.8 years, 51.5% men) without a CIED were subsequently incorporated in a pooled cohort analysis. ResultsOverall, 8,824/18,797 individuals (47%) with a CIED had no/trivial TR; 5,490 (29.2%) mild TR; 3,068 (16.3%) moderate TR; and 1,415 (7.5%) severe TR. Moderate or greater TR was independently associated with age, female sex, atrial fibrillation and significant left heart disease (p<0.001 for all). 8,868 individuals (47.2%) died from any cause (43.2% from cardiovascular causes). Individuals with moderate or severe TR had a 1.6 to 2.5-fold increased risk of all-cause mortality in adjusted models, compared to those with no TR (p<0.001 for both). In the pooled cohort analysis, CIEDs were associated with a near 2-fold (95% CI 1.81-1.99; p<0.001) increased probability of moderate or greater TR, on adjusted basis. However, the mortality associated with moderate or greater TR did not differ significantly with respect to the presence or absence of a device lead. ConclusionsModerate or greater TR is more prevalent in those with CIED’s, even in adjusted models, and was independently associated with incremental risks for all-cause and cardiovascular mortality.

Tricuspid regurgitation worsening after transcatheter or surgical aortic valve replacement

Abstract Background Tricuspid regurgitation (TR) often occurs concomitantly with severe aortic stenosis. Post-operative worsening of tricuspid regurgitation has been observed after surgical and transcatheter aortic valve replacement (SAVR, TAVR) [1,2]. Purpose Pre-procedural severe tricuspid regurgitation has been shown to be a predictor of all-cause mortality in patients undergoing transcatheter aortic valve replacement (TAVR) [3,4]. However, little is known about the incidence of worsening tricuspid regurgitation after SAVR and TAVR and the impact on post-procedural outcomes. This study aims to evaluate, characterize and compare the incidence of worsening TR after TAVR and SAVR. Methods Retrospective single-center study of patients undergoing Transcatheter and Surgical Aortic Valve Replacement for severe aortic stenosis between 2014 and 2020. Incidence of tricuspid regurgitation was noted on echocardiogram at baseline and 1 year after TAVR or SAVR. This study enrolled 430 patients in the TAVR group and 237 patients in the SAVR group. The SAVR group only included patients who underwent isolated SAVR without any other valve intervention. Patients with severe TR at baseline were excluded from the study. Progression of TR severity was defined as deterioration by at least 1 grade of severity compared to baseline on echocardiography. Multivariable logistic regression analysis was performed to identify associations with worsening TR. Results Mean age of TAVR patients was higher than the SAVR patients (79±9 vs 68±12 years, p&amp;lt;0.0001). TAVR patients also had a significantly higher EuroSCORE than the SAVR patients (8.0±7 vs 3.5±4, p&amp;lt;0.0001). TAVR group was more likely to have atrial fibrillation than the SAVR group (34% vs 24%, p=0.006). Baseline right ventricular dysfunction and right ventricular enlargement were significantly higher in the TAVR group compared to the SAVR group [9% vs 4%, (p=0.009) and 10% vs 6%, (p=0.04), respectively]. Progression of TR severity occurred in 21.8% (94/430) of TAVR patients and 31.2% (74/237) of SAVR patients. Majority of these patients progressed from absent TR to mild TR [13.2% (57) in TAVR group vs 19.8% (47) in SAVR group (p=0.02)]. 6.3% (27) of patients in the TAVR group and 8.8% (21) of patients in the SAVR group had mild to moderate worsening of TR (p=0.22). 1.63% (7) in the TAVR group and 2.1% (5) in the SAVR group had progression from moderate to severe TR (p=0.65). On multivariable analysis, SAVR (Odds ratio, 2.46 [CI, 1.6–3.7]) and age (Odds ratio, 1.03 [CI, 1.03–1.05]) were associated with worsening TR severity. Conclusions In this retrospective observational study, SAVR and age were found to be associated with worsening tricuspid regurgitation. Majority of these patients progressed from absent TR to mild TR after SAVR. Further studies are necessary to determine long term outcomes of worsening tricuspid regurgitation after TAVR and SAVR. Funding Acknowledgement Type of funding sources: None.

Right ventricular reverse remodeling after mitral valve transcatheter edge-to-edge repair

Abstract Background Right ventricular dysfunction (RVD) is an important predictor for outcome in patients undergoing transcatheter mitral or tricuspid valve edge-to-edge repair (M/T-TEER). Due to the unique anatomy and contraction pattern of the RV, three-dimensional echocardiography (3DE) has emerged as a valuable tool in the assessment of RV function. While 3DE data showed RV reverse remodeling (RVRR) following T-TEER, respective data are absent in the setting of M-TEER. Purpose We sought to assess RVRR after M-TEER using 3DE comparing baseline and follow-up RV measurements. Methods Patients undergoing M-TEER treatment for relevant MR between August 2016 and February 2021 with eligible transthoracic 3DE of the RV at baseline and follow-up were included in the study. 3DE comprised RV end-diastolic and end-systolic volumes (RVEDV3D, RVESV3D), total RV stroke volume (RVSV3D) and RV ejection fraction (RVEF3D). Further, RV length (RVL3D) as well as RV basal (RVbase3D) and mid-ventricular diameters (RVmid3D) were derived from 3DE. RVRR was assessed as change in the respective 3DE parameters of RV dimensions between baseline and follow-up. Results A total of 66 patients (45.5% female; age 78.5±8.2 years; EuroScore II 4.6±3.6%) were included in the study. From baseline to latest available follow-up (median interval 364 days, interquartile range 180–728 days), a significant reduction of RVEDV3D and RVESV3D was observed (RVEDV3D 140.2±50.2 ml to 128.1±46.1 ml, p&amp;lt;0.01 and RVESV3D 93.1±37.8ml to 87.1±34.7ml, p=0.04). The decrease in 3D-derived linear RV dimensions primarily occurred in the septolateral direction, while RV length did not change significantly. The observed RVRR was associated with significant reduction of TR severity. Of note, patients with RVRR showed also left ventricular reverse remodeling (LVRR). Conclusion M-TEER is an effective treatment option for patients with MR which leads to LVRR and RVRR. Funding Acknowledgement Type of funding sources: None.

Concomitant tricuspid repair in mitral regurgitation surgery: a systematic review and meta-analysis

Abstract Background Tricuspid Regurgitation (TR) is common in patients with severe mitral disease. However, the evidence is insufficient to inform a decision about whether to perform prophylactic tricuspid-valve repair during mitral-valve surgery in patients who have moderate TR or less-than-moderate regurgitation. Purpose To compare the outcomes of concomitant tricuspid repair in mitral valve surgery versus no concomitant tricuspid repair in less-than-severe TR patients. Methods We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for interventional studies comparing concomitant tricuspid repair in mitral valve surgery versus no tricuspid intervention. Random-effects meta-analysis was performed. Results Four randomised trials were included, providing a total of 651 patients (323 in prophylactic tricuspid intervention group and 328 patients in conservative group). Our meta-analysis showed a similar all-cause mortality for concomitant prophylactic tricuspid repair compared with no tricuspid intervention (pooled OR, 0.54; 95% CI [0.25, 1.15], P=0.11; I2=0%). Additionally, there is a similar New York Heart Association (NYHA) III–IV classes in both groups, despite a lower trend in the tricuspid intervention group (pooled OR, 0.63; 95% CI [0.38, 1.06], P=0.08; I2=0%) (Figure 3). However, there was a significant lower progression of TR (pooled OR, 0.06; 95% CI [0.02, 0.24], P&amp;lt;0.01; I2=0%) and moderate-severe TR (pooled OR, 0.23; 95% CI [0.11, 0.46], P&amp;lt;0.01; I2=27%). Conclusions Our pooled analysis suggests that a tricuspid-valve repair at the time of mitral-valve surgery in patients with moderate or less-than-moderate TR does not impact perioperative or postoperative all-cause mortality, despite reducing TR severity and progression of TR following intervention. Funding Acknowledgement Type of funding sources: None.

Prognostic power of a new index of right ventricle-pulmonary artery coupling based on right ventricular volumes in patients with secondary tricuspid regurgitation

Abstract Background Although echocardiographic surrogates of right ventricular -arterial coupling (RVAC) have been reported to be associated with outcome in patients with moderate or severe secondary tricuspid regurgitation (STR), pulmonary artery systolic pressure (SPAP) is difficult to be estimated using echocardiography in patients with severe STR. Purpose Accordingly, we evaluated the predictive power of indexes of RVAC obtained using RV volumes measured using three-dimensional echocardiography (3DE). Methods We prospectively enrolled 180 patients with moderate or severe STR and complete two-dimensional, Doppler and 3DE data. The composite endpoint of death for any cause and heart failure hospitalization was used as primary outcome. Results After a median follow up of 24 months (IQR: 2–48), 72 patients (40%) reached the primary endpoint. Most of the echocardiographic parameters of RV function were associated with outcomes. Among the different parameters of RVAC, the receiver operating curve (ROC) analysis selected the ratio between (RV stroke volume [SV]-RegVol)/ RV End-systolic volume (ESV) (i.e. the RV forward SV/ESV) as the best predictor of the combined endpoint (AUC 0.80 [IC 95% 0.73–087]), with a threshold value of 0.49. Event-free survival of patients with RV forward SV/ESV higher and lower 0.49 has been performed (Figure 1). Multivariable Cox proportional hazards models were constructed (Figure 2). Adding sequentially the 3D-RVEF, TAPSE/SPAP and the forward RV SV/RV ESV on top of a basal model made of TR severity, New York Heart Association (NYHA) functional class and tricuspid anulus plane systolic excursion (TAPSE), the χ2 of the model increased from 40 to 43 (p=0.13) by adding 3D RVEF, from 43 to 46 (p=0.04) by adding TAPSE/SPAP, and from 46 to 51 (p=0.02) by adding RV forward SV/ESV. Severe TR (HR 3.53 [CI 95%: 1.84–6.78], p&amp;lt;0.001) and RV forward SV/ESV &amp;lt;0.49 (HR 2.45 [CI 95% 1.16–5.18], p=0.02) were the only parameters independently associated with outcome. Conclusions The RV forward SV/ESV is an index of RVAC obtained by 3DE which is independent from SPAP and it is strongly associated with the occurrence of death or heart failure hospitalization in patients with STR. Funding Acknowledgement Type of funding sources: None.