Tricuspid Annular Diameter Research Articles

Unenhanced computed tomography as a diagnostic tool in suspected pulmonary hypertension: a retrospective cross-sectional pilot study

Background: Computed tomography pulmonary angiography (CTPA) has been proposed to be diagnostic for pulmonary hypertension (PH) in multiple studies. However, the utility of the unenhanced CT measurements diagnosing PH has not been fully assessed. This study aimed to assess the diagnostic utility and reproducibility of cardiac and great vessel parameters on unenhanced computed tomography (CT) in suspected pulmonary hypertension (PH). Methods: In total, 42 patients with suspected PH who underwent unenhanced CT thorax and right heart catheterization (RHC) were included in the study. Three observers (a consultant radiologist, a specialist registrar in radiology, and a medical student) measured the parameters by using unenhanced CT. Diagnostic accuracy of the parameters was assessed by area under the receiver operating characteristic curve (AUC). Inter-observer variability between the consultant radiologist (primary observer) and the two secondary observers was determined by intra-class correlation analysis (ICC). Results: Overall, 35 patients were diagnosed with PH by RHC while 7 patients were not. Main pulmonary arterial (MPA) diameter was the strongest (AUC 0.79 to 0.87) and the most reproducible great vessel parameter. ICC comparing the MPA diameter measurement of the consultant radiologist to the specialist registrar’s and the medical student’s were 0.96 and 0.92, respectively. Right atrial area was the cardiac measurement with highest accuracy and reproducibility (AUC 0.76 to 0.79; ICC 0.980, 0.950) followed by tricuspid annulus diameter (AUC 0.76 to 0.79; ICC 0.790, 0.800). Conclusions: MPA diameter and right atrial areas showed high reproducibility. Diagnostic accuracies of these were within the range of acceptable to excellent, and might have clinical value. Tricuspid annular diameter was less reliable and less diagnostic and was therefore not a recommended diagnostic measurement.

Causal relation of tricuspid regurgitation for heart failure outcomes: a mediation analysis of echocardiographic predictors.

AimsAlthough significant tricuspid regurgitation (TR) is critically associated with heart failure (HF) prognosis, the predictors for large TR impact on HF outcomes remain unknown. This study aimed to identify echocardiographic predictors for a causal relation of TR to HF outcomes.Methods and resultsIn a retrospective, acute HF cohort of 462 patients, multivariate logistic regression analysis was performed to determine subgroups with strong association of greater-than-moderate TR with HF readmission or cardiovascular death in a year. We then conducted causal mediation analysis according to persistent atrial fibrillation (Af) or mitral regurgitation (MR) to identify the echocardiographic predictors. The association of TR with HF outcomes was prominent in subgroups of females, with Af, the enlarged indexed tricuspid annular diameter (TADi) or right atrial area, or within certain ranges of the left ventricular ejection fraction, indexed right ventricular end-systolic area, or fractional area change (FAC). Causal mediation analysis found that the TR impact was significant in patients with Af. Furthermore, combination of TADi ≥2.1 cm/m2 and FAC ≥30%, which accounted for half of TR patients, predicted a much larger TR impact irrespective of Af and MR. Its prediction ability was superior to that of the modified Model for End-stage Liver Disease score.ConclusionThe causal impact and burden of TR on HF outcomes was significant in patients with Af, and combining TADi ≥2.1 cm/m2 with FAC ≥30% could provide superior echocardiographic prediction of larger TR impact in HF patients.

Outcome of consistent guideline-based tricuspid management in patients undergoing degenerative mitral regurgitation correction

ObjectivesDespite coherent guidelines, management of functional tricuspid regurgitation (FTR) consequences on outcome in the context of degenerative mitral regurgitation (DMR) remains controversial due to lacking series of large magnitude with rigorous application of tricuspid guidelines and strict long-term echocardiographic follow-up. Thus, we aimed at gathering such a cohort to examine outcomes of patients undergoing DMR surgery following tricuspid surgery guidelines. MethodsAll consecutive patients with isolated DMR 2005-2015 operated on with baseline FTR assessment and tricuspid annulus diameter measurement were identified. Operative complications, postoperative tricuspid regurgitation incidence, and survival were assessed overall and stratified by guideline-based tricuspid annuloplasty (TA) indication (severe FTR or tricuspid annulus diameter ≥40 mm). ResultsAmong 441 patients with DMR undergoing mitral repair (66 ± 13 years, 30% female, ejection fraction 66 ± 10%, systolic pulmonary artery pressures 39 ± 12 mm Hg) followed 6 [3-9] years, patients with TA (n = 234, 53%) had generally similar presentation versus without TA (n = 207, 47%; all P ≥ .2) except for more atrial fibrillation and larger left ventricle (both P ≥ .0003). Patients with TA showed longer bypass time, more maze procedures (all P ≤ .001), but hospital stay, renal-failure, pacemaker implantation, and operative mortality (overall 0.9%) were comparable (all P ≥ .2). Postoperative incidence of moderate/severe FTR (0% at 1 year) became over time greater among patients without TA (5-year 8% [4%-13%] vs 3% [1%-11%] and 10-year 10% [6%-16%] vs 4% [1%-16%], P = .01). Survival (95% confidence interval) throughout follow-up was 85% (77%-89%) at 10 years, with hazard ratio 0.57 (0.29-1.10), P = .09. for patients with TA versus without. ConclusionsIn this large surgical DMR cohort, guideline-based FTR management was safe and effective. While long-term mortality did not reach significance, postoperative incidence of moderate/severe FTR, overall low, was nevertheless greater in patients who did not appear to require TA at surgery and linked to tricuspid annular dimension. Thus, future multicenter prospective cohorts with long-term follow-up are warranted to re-examine thresholds for TA performance and impact on survival.

Continuous positive airway pressure treatment in sleep apnea: patient compliance and impact on the right heart

Obstructive sleep apnea syndrome (OSAS) is considered to be an important predisposing factor for cardiovascular diseases. The main objective of this study was to investigate the impact of CPAP treatment on cardiac structure and function and to assess patient compliance over a long-term course of CPAP treatment. A total of 50 patients diagnosed with moderate-to-severe OSAS based on overnight study, without relevant concomitant diseases were enrolled. Patient compliance, along with echocardiographic and CPAP parameters, was assessed. The average time to follow-up was 38 ± 4.2 months. An increase in tricuspid annular plane systolic excursion (TAPSE) (22.1 ± 4.3–25.5 ± 4.6 mm, p = 0.005) and peak early systolic tricuspid annular velocity (S’) (14 ± 3.2–17.2 ± 5.2 cm/s, p = 0.005) after CPAP treatment was noted. In patients without CPAP, no significant change in right ventricular (RV) contractility was found. There were no significant differences regarding right atrial (RA) and RV diameters, as well as tricuspid regurgitant peak gradient (TRPG) in both groups; however, a predisposition to increased RA size along with RV and tricuspid annulus diameters was revealed. The mean duration of nightly CPAP use was 3 ± 2.3 h/night in all-day analysis and 4.7 ± 2.1 h/night on days with device usage. The non-adherence rate was 57%. The use of effective CPAP therapy may lead to increased RV systolic function in patients with OSAS in long-term observation. However, long-term patient compliance is generally poor. Regardless of CPAP therapy, a gradual increase in heart size is observed.

Echocardiographic Determinants of Ventricular Arrhythmia in Sickle Cell Disease Adults

Unexplained sudden death remains one of the leading causes of death in sickle cell disease (SCD) adults. Ventricular arrhythmia is a well-known risk factor for sudden death but its prevalence and determinants in the context of SCD remain understudied. From January 2019 to March 2021, consecutive adult patients with SCD referred to ambulatory cardiology department for possible cardiac involvement were prospectively included (Drepacoeur cohort). All patients that had 24-hour ECG monitoring (24h-holter) and thransthoracic echocardiography (TTE) on the same day were analysed. The primary end point was the occurrence of ventricular arrhythmia, defined as sustained or non-sustained ventricular tachycardia (VT), more than 500 premature ventricular contractions (PVC) on 24h-holter, or history of VT ablation. Overall, 90 patients were included and 54 (60%) were analysed. Mean age was 47.6 ± 11.6 years (range 21-69), 53% were male. Heart function was mainly preserved with a mean left ventricular ejection fraction (LVEF) of 57.9 ± 4.9% and a mean global longitudinal strain (GLS) of -18 ± 2.8%. Mean tricuspid regurgitation velocity was 2.6 ± 0.4 m/s. Ventricular arrhythmia was observed in 13 (24.1%) patients (4 non-sustained VT, 9 with more than 500 PVC and 1 history of VT ablation). Ventricular arrhythmia was associated with lower GLS (−15.8 ± 1.8% vs. −19 ± 2.7%, P < 0,001), lower tricuspid annular plane systolic excursion (TAPSE, 23 ± 5.7 mm vs. 26.9 ± 4.6 mm, P = 0,02) and more dilated right ventricle assessed by tricuspid annulus diameter (38.2 ± 6.1 mm vs. 34.2 ± 4.5 mm, P = 0,02). In multivariate analysis, GLS was independently associated with ventricular arrhythmia (OR = 2,1 CI95% [1,3; 3,3], P = 0,004) with a moderate exponential correlation with PVC load on 24h-holter (R = 0,5, P < 0,001). In SCD adults with preserved LVEF, GLS was the only independent echocardiographic predictor of ventricular arrhythmia.

Original Article--Predictors of Persistent Functional Tricuspid Regurgitation After Transcatheter Closure of Atrial Septal Defect and its Relationship to Tricuspid Valve Remodeling.

ObjectivesThe aim of this study is assessment of persistent functional tricuspid regurgitation in patients with atrial septal defect before and after successful device closure and its relationship to tricuspid valve remodeling.MethodsThe current study was conducted on 60 patients referred to Tanta University Hospital Cardiology Department with the provisional diagnosis of atrial septal defect secundum type for transcatheter closure from December 2017 to December 2019. All patients were subjected to history taking, clinical examination, 12 lead electrocardiography, plain chest X-ray, full two dimension transthoracic echocardiography (for assessment of tricuspid regurgitation severity) before and at 3, 6 months after transcatheter closure.ResultsTricuspid regurgitation was decreased significantly after atrial septal defect closure due to remodeling in the right side. Age, estimated systolic pulmonary artery pressure, right atrium end systolic area, right ventricular end diastolic area, tricuspid valve tenting area and height, tricuspid septal leaflet angle and tricuspid annular diameter were predictors of persistent tricuspid regurgitation after 3 and 6 months of closure. Only estimated systolic pulmonary artery pressure, tricuspid septal leaflet angle and tricuspid annular diameter were independent predictors of persistent tricuspid regurgitation after 3, and 6 months of closure.ConclusionTricuspid regurgitation significantly improved after transcatheter atrial septal defect closure despite its significance at baseline due to remodeling in right side and tricuspid valve.

Ratio between Vena Contracta Width and Tricuspid Annular Diameter: Prognostic Value in Secondary Tricuspid Regurgitation

Conventional approaches for the assessment of secondary tricuspid regurgitation (STR) severity do not correct for right heart dimensions. The authors hypothesized that STR severity can be proportional or disproportional to the dilation of the tricuspid annulus (TA) and investigated the prognostic impact of this novel definition. A total of 334 patients with moderate to severe STR and preserved left ventricular systolic function were included. The ratio between vena contracta (VC) width and tricuspid annular diameter was calculated. The cutoff value for VC/TA ratio associated with increased risk for all-cause death was identified using spline-curve analysis. The cutoff value of VC/TA ratio associated with a mortality excess was 0.24, and 165 patients (49%) had VC/TA ratios≥0.24. Compared with those with VC/TA ratios < 0.24, patients with VC/TA ratios ≥ 0.24 had a higher prevalence of moderate to severe mitral regurgitation, had higher pulmonary pressures, and were more frequently treated with diuretics. During a median follow-up period of 62months (interquartile range, 28-101months), 128 patients (38%) died. The cumulative 5-year survival rate was significantly worse in patients with VC/TA ratios ≥ 0.24 (55% vs 71%, P=.001). VC/TA ratio ≥ 0.24 was independently associated with poor outcomes on multivariate analysis (hazard ratio, 1.567; 95% CI, 1.044-2.352; P=.030) together with coronary artery disease, renal impairment, right ventricular systolic function (evaluated using either tricuspid annular plane systolic excursion or right ventricular free wall strain), and pulmonary pressures. VC/TA ratio≥0.24 is independently associated with poor prognosis in patients with STR. This parameter may be considered as a marker of disproportionate STR and could improve risk stratification and clinical decision-making.

Application of a Series of Two-Dimensional Transesophageal Echocardiographic (2D TEE) Views Across Multiple Axes Improves the Accuracy of Tricuspid Annular Measurements

Quantification of the tricuspid annulus (TA) is an important factor in determining the requirement for tricuspid annuloplasty in cardiac surgery. Three-dimensional echocardiography (3DE) has shown that the TA is biplanar with an antero-posterior longaxis and septo-lateral shortaxis, and that the commonly used 2D TEE (two-dimensional transesophageal echocardiography) four-chamber view (4ChV) underestimates the true TA longaxis. The authors hypothesized that the use of multiple 2D TEE TA views could attain greater TA long-axis measurements and smaller TA short-axis measurements than the 4ChV, and that the 4ChV has a significant but inconsistent bias relative to the maximal TA diameter measured by these views. Prospective observational study. Adult tertiary teaching hospital. 45 adult patients. Multiplanar 2D TEE assessment of the tricuspid annulus. Multiplanar assessment reliably produced larger TA long-axis measurements (93% of patients, 95% confidence interval: 81-98%) of (mean [95% confidence interval]) 40 mm (28-50 mm) compared with the 4ChV (34mm [25-44 mm], p < 0.0001) and smaller TA short-axis measurements (29 mm [20-38 mm], p < 0.0001) compared with the 4ChV. TA diameter by 4ChV assessment yielded an average bias of -5.6 mm, with 95% limits of agreement -15 to +3.9 mm compared with the largest TA long-axis measurement by multiplanar assessment. Multiplanar 2D TEE assessment of the TA long- and short-axis consistently achieves larger and smaller measurements, respectively, than the 4ChV. The 4ChV also is not a reliable index of the TA longaxis. If the time, proficiency, or equipment required for 3DE TA assessment are unavailable, the use of multiple standard and non-standard 2D TEE TA views may offer an alternative for TA assessment.

Morphological variability of the atrioventricular valve cusps in the equine heart.

The morphometric studies of the atrioventricular valves are still limited in the horse. To investigate the anatomy of the atrioventricular valves in the horse, focusing on the morphometric features of the valvular leaflets and the tendinous cords. We hypothesised that accessory leaflets occur commonly and exist as independent structures in the atrioventricular valves of the horse. Descriptive anatomical study. Twenty normal hearts from slaughtered half-bred horses were used. The cardiac weight and circumference were recorded. The atrioventricular valves were exposed by excision of the atria, and the tricuspid and mitral annular diameters and circumferences were measured; the number of leaflets and tendinous cords for each atrioventricular ostium were then counted. The atrioventricular valves were isolated and the width, height and thickness of each leaflet were measured. In addition to the principal leaflets, accessory leaflets were identified in 39 of 40 cardiac valves, 2 to 6 accessory leaflets for the mitral valve and 1 to 4 for the tricuspid valve. All the accessory leaflets were separated from the adjacent leaflets at their insertion. They were narrower and thinner than the principal leaflets, and were attached to a single papillary muscle; 95% of the accessory leaflets had two tendinous cords shared with the adjacent leaflets while a minority (34%) had their own specific tendinous cord. Lack of signalment data from the study population. Supernumerary leaflets occurred commonly in the atrioventricular valves of the horse and appeared as independent structures. The clinical relevance of increased numbers of commissures that result from accessory leaflets and their relationship with valvular regurgitation are currently unknown.

Transfemoral Transcatheter Tricuspid Valve Replacement With the EVOQUESystem: AMulticenter, Observational, First-in-Human Experience.

The purpose of this observational first-in-human experience was to investigate the feasibility and safety of the EVOQUE tricuspid valve replacement system and its impact on short-term clinical outcomes. Transcatheter tricuspid intervention is a promising option for selected patients with severe tricuspid regurgitation (TR). Although transcatheter leaflet repair is an option for some, transcatheter tricuspid valve replacement (TTVR) may be applicable to a broader population. Twenty-five patients with severe TR underwent EVOQUE TTVR in a compassionate-use experience. The primary outcome was technical success, with NYHA (NYHA) functional class, TR grade, and major adverse cardiac and cerebrovascular events assessed at 30-day follow-up. All patients (mean age 76 ± 3 years, 88% women) were at high surgical risk (mean Society of Thoracic Surgeons risk score 9.1 ± 2.3%), with 96% in NYHA functional class III or IV. TR etiology was predominantly functional, with mean tricuspid annular diameter of 44.8 ± 7.8mm and mean tricuspid annular plane systolic excursion of 16 ± 2mm. Technical success was 92%, with no intraprocedural mortality or conversion to surgery. At 30-day follow-up, mortality was 0%, 76% of patients were in NYHA functional class I or II, and TR grade was≤2+ in 96%. Major bleeding occurred in 3 patients (12%), 2 patients (8%) required pacemaker implantation, and 1 patient (4%) required dialysis. This first-in-human experience evaluating EVOQUE TTVR demonstrated high technical success, acceptable safety, and significant clinical improvement. Larger prospective studies are needed to confirm durability and safety and the impact on long-term clinical outcomes.

Characteristics of idiopathic tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Science and Technology, Executive Yuan, Taiwan Background Tricuspid regurgitation (TR) were traditionally classified as primary and secondary TR. Recently a new category of TR was developed and named as idiopathic TR. However, diagnosis and characteristics of idiopathic TR were not consisted. We tried to identify idiopathic TR by a new systemic approach and studied its characteristics. Methods 207 consecutive patients (mean age 71.2 ± 14.7 years, 40.6% male) identified as significant TR (moderate and severe) by echocardiography were recruited. We classified TR by a new systemic approach. The classification process started from identified primary TR, then pacemaker related TR, left heart disease related TR, congenital heart related TR, right ventricular (RV) myopathy, pulmonary hypertension and, finally idiopathic TR step by step. Results There were 29 (14%) primary TR, 18 (8.7%) pacemaker related, 81 (39.1 %) left heart diseases, 6 (2.9%) congenital heart diseases, 3 (1.4%) RV myopathy, 27 (13%) pulmonary hypertension, and 43 (20.8%) idiopathic TR. Mean age of idiopathic TR was 72.9 ± 11.4 years and 39.5% was male which were not different from other groups. Atrial fibrillation was presented highest in patients with pacemaker related TR (77.8%) and left heart disease (55.6%), lowest in primary TR (24.1%) and pulmonary HT (25.9%), and modest in idiopathic TR (44.2%). Among the echocardiographic characteristics of right heart measurements, idiopathic TR had lowest TR maximal velocity (3.0 ± 0.3 m/s), pulmonary (41.2 ± 8.7 mmHg) and right atrium pressure (5.3 ± 0.3 mmHg; all p &amp;lt;0.001). Idiopathic TR had smallest RV wall thickness (4.5 ± 1.4 mm; p = 0.008), tricuspid annulus diameter (3.2 ± 0.7 cm; p = 0.001), and right atrial area (18.9 ± 8.4 cm2; p &amp;lt;0.001). RV function represented as tricuspid annulus velocity S’ (12.8 ± 3.3 cm/s; p = 0.011) and RV fractional area change FAC (42.6 ± 16.0 %; p &amp;lt;0.001) were best in idiopathic TR. RV dysfunction (FAC &amp;lt; 35%) was lowest (14%) in idiopathic TR. Conclusions Idiopathic TR had better RV function then other types of TR. Idiopathic TR can be regarded as a unique disease category in studying TR.

Tricuspid leaflet kinematics after annular size reduction in ovine functional tricuspid regurgitation

ObjectiveTricuspid annular size reduction with annuloplasty rings represents the foundation of surgical repair of functional tricuspid regurgitation. However, the precise effect of annular size reduction on leaflet motion and geometry remains unknown. MethodsTen sheep underwent surgical implantation of a pacemaker with an epicardial lead and were paced 200-240 beats/min to achieve biventricular dysfunction and functional tricuspid regurgitation. Subsequently, sonomicrometry crystals were implanted on the right ventricle, the tricuspid annulus, and on the belly of anterior, posterior, and septal tricuspid leaflets. Double-layer polypropylene suture was placed around the tricuspid annulus and externalized to a tourniquet. Simultaneous echocardiographic, hemodynamic, and sonomicrometry data were acquired with functional tricuspid regurgitation and during 5 consecutive annular reduction steps. Annular area, tenting height, and volume, together with each leaflet strain, radial length, and angles, were calculated from crystal coordinates. ResultsRapid pacing reduced both left ventricle and right ventricle function and induced functional tricuspid regurgitation (0-3+) in all animals (from 0 ± 0 to 2.4 ± 0.7, P = .002), whereas tricuspid annulus diameter increased from 2.6 ± 0.3 cm to 3.3 ± 0.3 cm (P = .001). Tricuspid annular size reduction 1 to 5 resulted in 16% ± 7%, 37% ± 11%, 55% ± 11%, 66% ± 10%, and 76% ± 8% tricuspid annulus area reduction, respectively, and successively decreased tricuspid regurgitation. Tricuspid annular size reduction 2 to 5 induced anterior and posterior leaflet restricted motion and lower diastolic motion velocities. Tricuspid annular size reduction 5 perturbed septal leaflet range of motion but preserved its angle velocities. Tricuspid annular size reduction 3-5 generated compressive strains in all leaflets. ConclusionsTricuspid annular area reduction of 55% perturbed anterior and posterior leaflet motion while maintaining normal septal leaflet movement. More extreme reduction triggered profound changes in anterior and posterior leaflet motion, suggesting that aggressive undersizing impairs leaflet kinematics.

Progression of Tricuspid Regurgitation After Surgery for Ischemic Mitral Regurgitation

BackgroundWhether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain. ObjectivesThe goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery. MethodsPatients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years. ResultsPatients’ mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04). ConclusionsAfter IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart’s Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040)

Cardiac remodelling in secondary tricuspid regurgitation: Should we look beyond the tricuspid annulus diameter?

A better understanding of the mechanism of tricuspid regurgitation severity would help to improve the management of this disease. We sought to characterize the determinants of isolated secondary tricuspid regurgitation severity in patients with preserved left ventricular ejection fraction. This was a prospective observational multicentre study. Patients with severe tricuspid regurgitation were asked to participate in a registry that required a control echocardiogram after optimization of medical treatment and a follow-up. Patients had to have at least mild secondary tricuspid regurgitation when clinically stable, and were classified according to five grades of tricuspid regurgitation severity, based on effective regurgitant orifice area. One hundred patients with tricuspid regurgitation (12 mild, 31 moderate, 18 severe, 17 massive and 22 torrential) were enrolled. Right atrial indexed volume and tethering area were statistically associated with the degree of tricuspid regurgitation (P<0.001 and P=0.005, respectively). When the tricuspid annular diameter was≥50mm, the probability of having severe tricuspid regurgitation or a higher grade was>70%. For an increase of 10mL/m2 in right atrial volume, the effective regurgitant orifice area increased by 4.2mm2, and for an increase of 0.1cm2 in the tethering area, the effective regurgitant orifice area increased by 2.35mm2. The degree of right ventricular dilation and changes in tricuspid morphology were significantly related to tricuspid regurgitation severity class (P<0.001). No significant difference in right ventricular function variables was observed between the tricuspid regurgitation classes. For tricuspid regurgitation to be severe or torrential, both right atrial dilatation and leaflet tethering are needed. Interestingly, right cavities dilated progressively with tricuspid regurgitation severity, without joint degradation of right ventricular systolic function variables.

Early Feasibility Study of Cardioband Tricuspid System for Functional Tricuspid Regurgitation: 30-Day Outcomes.

The study reports for the first time the 30-day outcomes of the first U.S. study with the Cardioband tricuspid valve reconstruction system for the treatment of functional tricuspid regurgitation (TR). Increasing severity of TR is associated with progressively higher morbidity and mortality; however, treatment options for isolated significant disease are limited. In this single-arm, multicenter, prospective Food and Drug Administration-approved early feasibility study (EFS), 30 patients with severe or greater symptomatic functional TR were enrolled who were deemed candidates for transcatheter tricuspid repair with the Cardioband tricuspid system by the local heart team and multidisciplinary screening committee. The mean patient age was 77 years, 80% were women, 97% had atrial fibrillation, 70% were in New York Heart Association functional class III to IV with mean left ventricular ejection fraction of 58%, and 27% had severe, 20% massive, and 53% torrential TR. Device success was 93% and all patients were alive at 30days. Between baseline and 30days, septolateral tricuspid annular diameter was reduced by 13% (p<0.001), 85% of patients had≥1 grade TR reduction and 44% had≤moderate TR, 75% were in New York Heart Association functional class I to II (p<0.001), and overall Kansas City Cardiomyopathy Questionnaire score improved by 16 points (p<0.001). In patients with severe symptomatic functional TR, this is the first study in the United States with the Cardioband tricuspid system for direct transcatheter annular reduction. This early feasibility study demonstrates high procedural feasibility with no 30-day mortality. There is significant reduction of functional TR with clinically significant improvements in functional status and quality of life. (Edwards Cardioband Tricuspid Valve Reconstruction System Early Feasibility Study; NCT03382457).

Impact of tricuspid regurgitation on survival in patients with cardiac amyloidosis

Tricuspid regurgitation (TR) is a common finding and has been associated with poorer outcome in patients with heart failure. This study sought to investigate the prognostic value of TR in patients with cardiac amyloidosis (CA). Two-hundred and eighty-three patients with CA – 172 (61%) wild-type transthyretin–amyloidosis (ATTRwt) and 111 (39%) light-chain amyloidosis (AL) – were consecutively enrolled between December 2010 and September 2019. Transthoracic echocardiographies at time of diagnosis were reviewed to establish the presence and severity of TR and its relationship with all-cause mortality during patients’ follow-up. Seventy-four (26%) patients had a moderate-to-severe TR. Moderate-to-severe TR was associated with NYHA status (P < 0.001), atrial fibrillation (P = 0.003), greater levels of natriuretic peptides (P = 0.002), worst renal function (P = 0.03), lower left ventricular ejection fraction (P = 0.02), reduced right ventricular systolic function (P = 0.001), thicker tricuspid leaflets (P = 0.019), greater tricuspid annulus diameter (P = 0.001), greater pulmonary artery pressure (P = 0.001), greater doses of furosemide (P = 0.001) and anti-aldosterone (P = 0.01) and more anticoagulant treatment (P = 0.001). One hundred and thirty-four (47%) patients met the primary endpoint of all-cause mortality. After multivariate Cox analysis, moderate-to-severe TR was significantly associated with mortality (hazard ratio [HR]: 1.89, 95% confidence interval [CI]: [1.01–3.51], P = 0.044) in patients with ATTRwt. There was no correlation between TR and death (HR: 0.84, 95% CI: [0.46–1.51], P = 0.562) in patients with AL. Moderate-to-severe TR is frequent in CA and it is an independent prognosis factor in patients with ATTRwt but not in patients with AL.

Echocardiographic Follow-Up of Right Ventricular Function After Tetralogy of Fallot Operation

Aim: Although limited in assessing right ventricular (RV) function, echocardiography is widely used after correction for tetralogy of Fallot (TOF). The change in echocardiographic measurements of RV in asymptomatic patients after TOF repair over a long follow-up time is not explored yet. The variation in simple echocardiographic measurements during follow-up of our TOF patients are presented. The predictive value of those parameters in determining a future pulmonary valve replacement is sought. Method: Asymptomatic patients surviving the first year after correction for simple TOF from February 2007 to December 2019 at Başkent University, Istanbul Hospital are enrolled. Patients are followed annually with echocardiography including: RV area, volume, length, RV outflow tract (RVOT) diameter and gradient, tricuspid annulus diameter, tricuspid lateral annular tissue velocities, tricuspid annular plane systolic excursion, TEI index RV ejection fraction (EF) measurements. The change in the consecutive echocardiographic measurements during follow-up is analysed. Patients are evaluated with a cardiac magnetic resonance (CMR) imaging when deemed necessary and compared with echocardiographic measurements. Results: A total of 66 patients (54.5% males) are operated at age 14.4±9.3 months (78.8% with transannular patch). Twelve patients had pulmonary valve replacement (PVR) operation at an age 10.1±3.1 years. During follow-up of 7.2±4.3 years, tricuspid annulus diameter, RV area, RV inlet length, RV volume, RV volume index significantly increased (p=0.001 for all), whereas RV inlet length index, TEI and TEI z score decreased (p&lt;0.0001 for all). When means are compared, tricuspid annulus (28.8mm vs 25.0mm; p=0.013), RV volume (72.2ml vs 52.2ml; p=0.042), RV inlet length index (77.9mm/m2 vs 60.2mm/m2 ; p=0.013), RVOT diameter (28.7 vs 23.0; p=0.007) are increased. RV EF is decreased (51.3% vs 60.5%; p=0.011) in those requiring PVR. Those with higher RV area index, RV volume index, tricuspid annulus diameter and tricuspid annular z score in their first echocardiography after the TOF repair, are more likely to have a PVR operation later on (p&lt;0.05 for all). RV volume index ≥39ml/m2 predicts a PVR within 7 years with 100% sensitivity and 74% specificity. Tricuspid annular z score less than -0.43 seems to eliminate the possibility of having a PVR within 7 years with a sensitivity of 44% and specificity of 100%. Conclusion: Observing the sequential change in echocardiographic parameters like RV volume index, RV area index, tricuspid annulus z score is reliable in determining right ventricular function and can limit the costly CMR applications. Cut off values of RV volume index &gt;39ml/m2 and tricuspid annulus z score ≥ - 0.43 after the initial TOF repair may determine patients with higher possibility of having early PVR and indicate a closer follow-up.

Cardiovascular magnetic resonance reference values of mitral and tricuspid annular dimensions: the UK Biobank cohort

BackgroundMitral valve (MV) and tricuspid valve (TV) apparatus geometry are essential to define mechanisms and etiologies of regurgitation and to inform surgical or transcatheter interventions. Given the increasing use of cardiovascular magnetic resonance (CMR) for the evaluation of valvular heart disease, we aimed to establish CMR-derived age- and sex-specific reference values for mitral annular (MA) and tricuspid annular (TA) dimensions and tethering indices derived from truly healthy Caucasian adults.Methods5065 consecutive UK Biobank participants underwent CMR using cine balanced steady-state free precession imaging at 1.5 T. Participants with non-Caucasian ethnicity, prevalent cardiovascular disease and other conditions known to affect cardiac chamber size and function were excluded. Absolute and indexed reference ranges for MA and TA diameters and tethering indices were stratified by gender and age (45–54, 55–64, 65–74 years).ResultsOverall, 721 (14.2%) truly healthy participants aged 45–74 years (54% women) formed the reference cohort. Absolute MA and TA diameters, MV tenting length and MV tenting area, were significantly larger in men. Mean ± standard deviation (SD) end-diastolic and end-systolic MA diameters in the 3-chamber view (anteroposterior diameter) were 2.9 ± 0.4 cm (1.5 ± 0.2 cm/m2) and 3.3 ± 0.4 cm (1.7 ± 0.2 cm/m2) in men, and 2.6 ± 0.4 cm (1.6 ± 0.2 cm/m2) and 3.0 ± 0.4 cm (1.8 ± 0.2 cm/m2) in women, respectively. Mean ± SD end-diastolic and end-systolic TA diameters in the 4-chamber view were 3.2 ± 0.5 cm (1.6 ± 0.3 cm/m2) and 3.2 ± 0.5 cm (1.7 ± 0.3 cm/m2) in men, and 2.9 ± 0.4 cm (1.7 ± 0.2 cm/m2) and 2.8 ± 0.4 cm (1.7 ± 0.3 cm/m2) in women, respectively. With advancing age, end-diastolic TA diameter became larger and posterior MV leaflet angle smaller in both sexes. Reproducibility of measurements was good to excellent with an inter-rater intraclass correlation coefficient (ICC) between 0.92 and 0.98 and an intra-rater ICC between 0.90 and 0.97.ConclusionsWe described age- and sex-specific reference ranges of MA and TA dimensions and tethering indices in the largest validated healthy Caucasian population. Reference ranges presented in this study may help to improve the distinction between normal and pathological states, prompting the identification of subjects that may benefit from advanced cardiac imaging for annular sizing and planning of valvular interventions.

Impact of tricuspid regurgitation on survival in patients with cardiac amyloidosis.

AimsTricuspid regurgitation (TR) is a common finding and has been associated with poorer outcome in patients with heart failure. This study sought to investigate the prognostic value of TR in patients with cardiac amyloidosis (CA).Methods and resultsTwo‐hundred and eighty‐three patients with CA—172 (61%) wild‐type transthyretin amyloidosis (ATTRwt) and 111 (39%) light‐chain amyloidosis (AL)—were consecutively enrolled between December 2010 and September 2019. Transthoracic echocardiographies at time of diagnosis were reviewed to establish the presence and severity of TR and its relationship with all‐cause mortality during patients' follow‐up. Seventy‐four (26%) patients had a moderate‐to‐severe TR. Moderate‐to‐severe TR was associated with New York Heart Association status (P < 0.001), atrial fibrillation (P = 0.003), greater levels of natriuretic peptides (P = 0.002), worst renal function (P = 0.03), lower left ventricular ejection fraction (P = 0.02), reduced right ventricular systolic function (P = 0.001), thicker tricuspid leaflets (P = 0.019), greater tricuspid annulus diameter (P = 0.001), greater pulmonary artery pressure (P = 0.001), greater doses of furosemide (P = 0.001), and anti‐aldosterone (P = 0.01) and more anticoagulant treatment (P = 0.001). One hundred and thirty‐four (47%) patients met the primary endpoint of all‐cause mortality. After multivariate Cox analysis, moderate‐to‐severe TR was significantly associated with mortality [hazard ratio 1.89, 95% confidence interval (1.01–3.51), P = 0.044] in patients with ATTRwt. There was no correlation between TR and death [hazard ratio 0.84, 95% confidence interval (0.46–1.51), P = 0.562] in patients with AL.ConclusionsModerate‐to‐severe TR is frequent in CA, and it is an independent prognosis factor in patients with ATTRwt but not in patients with AL.

Abstract 14868: Promises of Transcatheter Tricuspid Valvular Interventions in Patients With Clinically Significant Tricuspid Regurgitation: A Meta-analysis

Introduction: Clinically significant tricuspid regurgitation is common especially in patients with structural heart disease and is independently associated with poor outcomes. Several transcatheter interventions for tricuspid valve repair are under investigation. We aimed to illustrate and summarize the efficacy and safety of these interventions. Methods: We conducted a literature search for relevant clinical registries and trials published until April 2020. We searched PubMed, Scopus, Web of Science, and Cochrane CENTRAL. We performed the analysis of continuous outcomes using the mean difference (MD) while used the risk ratio (RR) for analysis of dichotomous outcomes. We included the following outcomes: Tricuspid annular plane systolic excursion (TAPSE), Vena Contracta (VC), Tricuspid Annulus diameter (TAD), Tricuspid regurgitation volume (TRV), Left ventricular ejection fraction (LVEF), and mortality rates. The random-effects model was used for the analysis of heterogeneous data, while homogeneous data were analyzed under the fixed-effects model. Results: We obtained fifteen clinical registries/trials and included a total of 1329 patients. We found that tricuspid valve interventional devices improved LVEF (MD = 1.46%, 95% CI [0.45, 2.47], p=0.005), led to smaller VC (MD = -4.69, 95% CI [-5.50, -3.88], p=0.005), lower TRV (MD = -11.68, 95% CI [-21.25, -2.11], p=0.02), and smaller TAD (MD = -3.78mm, 95% CI [-5.09, -2.47], p&lt;0.001). No significant difference was noted regarding TAPSE (MD=0.07mm, 95% CI [-0.29, 0.44], p=0.7). Results of the six minutes walking test showed that patients could walk 40 more meters after intervention (MD = 40.64, 95% CI [23.89, 57.40], p&lt;0.001). Pooled mortality rate was 8.2%, stroke 1%, and bleeding 5% during the mean 12 months follow up. Conclusions: Transcatheter tricuspid valve repair devices prove to be effective interventions in decreasing regurgitation and improving functional capacity in patients with clinically significant TR. Mortality (8% during mean 12 months follow up) seems to be related to underlying cardiovascular disease.