Tricuspid Annular Dilatation Research Articles

Abstract 11994: Proteomic Evaluation And Biomarker Identification In Tricuspid Regurgitation

Introduction: Not only are mechanisms involved in tricuspid regurgitation (TR) incompletely understood, there is no established means of risk stratification for patients undergoing tricuspid valve interventions. A better understanding of underlying biological mechanisms allows for identification of therapeutic targets as well as biomarkers for disease staging, monitoring, and prediction following intervention. Methods: Preoperatively, 276 patients undergoing tricuspid annuloplasty, divided into training and validation cohorts, were assessed and followed-up for adverse events defined as death or heart failure requiring hospitalisation. Preoperative plasma samples were analysed for levels of cardiac troponin-T, NTproBNP, as well as 91 other markers (Olink multiplex assay). Correlated network analysis was used for clustering plasma markers. The relations of clusters to echocardiographic parameters and adverse outcomes were assessed by linear and Cox regression respectively. Pathway overrepresentation analysis was conducted to ascertain biological mechanisms overrepresented in relevant clusters by enrichment with reference to existing knowledge. Results: Over a median follow-up period of 3.7 years, 83 adverse events occurred. Two clusters of biomarkers in the training cohort significantly correlate with right chamber and tricuspid annular dilatation, regurgitant jet area, effective regurgitant orifice area and/or adverse outcomes following tricuspid annuloplasty (P<0.05). The two clusters are represented by hub proteins TNF Receptor Superfamily Member 10A and TRAIL receptor 2. Overrepresented biological pathways in the two clusters include immunological responses, cytokine production regulation, and responses to lipids. Both clusters are conserved in the validation cohort. Conclusion: Immunoinflammatory pathways may be implicated in tricuspid regurgitation, and markers related to such pathways show prognostic significance.

52-Year-Old Woman With Palpitations, Abdominal Distension, and Severe Abdominal Pain

52-Year-Old Woman With Palpitations, Abdominal Distension, and Severe Abdominal Pain

Impact of tricuspid annular shape on late worsening tricuspid regurgitation after transcatheter aortic implantation: insight from multidetector row computed tomography assessment

Abstract Background Worsening of tricuspid regurgitation (TR) in patients undergoing transcatheter aortic valve implantation (TAVI) is associated with adverse clinical outcomes. The geometrical factors that determine the occurrence of significant TR after TAVI are uncertain. Multi-detector row computed tomography (MDCT) may provide additional geometrical insights in the pathophysiology of worsening TR after TAVI. Purpose To investigate the impact of right atrial and tricuspid annular (TA) geometryassessed by MDCT on the occurrence of significant TR (≥ moderate) at 1-year after TAVI. Methods Patients without significant TR who had undergone a full-beat MDCT prior to TAVI were included. Right and left atrial and ventricular volumes and TA parameters including the anterior-posterior (AP) and septal-lateral (SL) diameters, area and circularity (AP/SL ratio) were measured and correlated to the occurrence of significant TR at 1-year after TAVI. Results A total of 205 patients (80±7 years, 51% male) who underwent TAVI for severe aortic stenosiswere included. Moderate or severe TR at 1-year follow-up occurred in 59 patients (29%). Patients who developed significant TR were more likely to have atrial fibrillation and lower left ventricular (LV) volumes, but larger right and left atrial volumes and TA dimensions at baseline. After adjusting for atrial fibrillation and LV and right atrial volumes, larger end-diastolic TA SL diameter (odds-ratio 1.182 95% CI 1.047–1.334, P=0.007) and more circular TA shape were independently associated with the occurrence of significant TR. Conclusion In patients without significant TR prior to TAVI, TA dilation and loss of the elliptical shape of the TA at baseline are associated with of the occurrence of significant TR 1-year after TAVI. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC research grant 2018 Representative cases

The tricuspid annulus in cardiac amyloidosis – a three-dimensional speckle-tracking echocardiographic study

Abstract Introduction Amyloidosis is a rare condition due to extracellular deposition of excessive amount of protein in parenchymal tissues including the heart. The present study aimed to test whether cardiac amyloidosis (CA) is associated with morphological and functional abnormalities of the tricuspid annulus (TA). For this aim, the results of patients having CA were compared to age- and gender-matched healthy controls by three-dimensional speckle-tracking echocardiography (3DSTE). Moreover, differences in TA parameters between light-chain CA (AL-CA) and transthyretin CA (TTR-CA) were studied as well. Methods The study comprised 27 CA patients (mean age: 62.7±9.1 years, 21 males), their results were compared to those of 20 age- and gender-matched healthy volunteers (59.3±3.8 years, 13 males). Current consensus criteria were used for the definition of CA. Biopsy was carried out in all patients to confirm the diagnosis of CA. The first positive biopsy site was the myocardium in 7 cases, bone marrow in 6 cases, duodenum and rectum in 5 cases, salivary gland in 1 case, skin and subcutaneous tissue in 2 cases and kidney in 10 cases in the CA patients. In 5 CA patients, biopsy samples were collected from more than one organ. CA proved to be AL-CA in 21 subjects and TTR-CA in 6 patients. Complete two-dimensional Doppler echocardiography and 3DSTE were performed in all CA patients and controls. Results CA patients had significantly higher left atrial diameter, left ventricular (LV) end-diastolic diameter, thicker interventricular septum and LV posterior wall and increased E/A ratio compared to the results of healthy controls. None of the 27 CA patients and their matched controls had atrial fibrillation in their medical history. Dilated 3DSTE-derived end-diastolic and end-systolic TA diameter (3.0±0.6 cm vs. 2.1±0.2 cm, p<0.05 and 2.6±0.6 cm vs. 1.6±0.2 cm, p<0.05, respectively), area (10.7±3.5 cm2 vs. 6.1±1.1 cm2, p<0.05 and 8.0±3.2 cm2 vs. 4.1±1.0 cm2, p<0.05, respectively) and perimeter (12.5±2.0 cm vs. 9.8±1.0 cm, p<0.05 and 10.6±2.1 cm vs. 8.0±1.0 cm, p<0.05, respectively) could be detected in all CA patients and in the AL-CA and TTR-CA subgroups, as well. Although only a few TTR-CA patients were involved, morphologic TA parameters proved to be tendentiously higher as compared to those of AL-CA patients. Functional parameters of TA represented by TA fractional area change (TAFAC, 26.1±11.2% vs. 32.0±11.1%, p=0.07) and TA fractional shortening (TAFS, 12.8±10.3% vs. 21.6±7.4%, p<0.05) were found to be reduced in CA patients, which were more enhanced in TTR-CA patients (TAFAC for TTR-CA: 27.1±14.3% vs. TAFAC for AL-CA:25.7±10.5%, p=ns; TAFS for TTR-CA: 16.0±9.8% vs. TAFS for AL-CA: 11.9±10.4%, p=ns). Conclusions Dilated TA is associated with its functional deterioration in CA. Patients with TTR-CA have tendentiously more dilated TA with more enhanced TA functional parameters. Funding Acknowledgement Type of funding sources: None.

Novel computed-tomography derived prognostic markers in patients undergoing TAVI with a self-expanding valve

Abstract Introduction Transcatheter aortic valve implantation is the treatment of choice in a consistently expanding group of patients with severe aortic valve stenosis. Tricuspid and mitral annular dilatation with consequent valvular regurgitation are associated with adverse outcome. Computed tomography angiography (CTA) is routinely performed for preprocedural evaluation of vascular access and prosthesis sizing. Purpose To evaluate the impact of mitral and tricuspid annular dimensions in preprocedural CTA on prognosis of patients undergoing TAVI with a self-expanding valve. Methods CTAs of consecutive patients undergoing TAVI in a single high-volume center between 2016 and 2019 were retrospectively evaluated. Maximal septolateral tricuspid annular diameters (TAD) and mitral annular diameters (MAD) were obtained and measured from properly angulated three dimensional CTA datasets. Moreover, maximal pulmonary artery diameter perpendicular to the long axis was measured in every patient. Patients were followed up by clinical visits or telephone contacts. As clinical events were defined all-cause mortality, stroke and heart failure hospitalization. Results In total 123 patients were included in the study. The mean follow-up duration was 875±383 days and 21 clinical events were recorded. There was a moderate but statistical significant correlation between TAD and both pulmonary artery diameter (r=0.39, p<0.001) and pulmonary artery systolic pressure by echocardiography (r=0.23, p=0.015). In univariate logistic regression analysis pulmonary artery diameter and TAD were both associated with heart failure hospitalization (p=0.03 and 0.02 respectively). In addition, MAD was associated with total events (OR: 0.43, 95% CI 0.19–0.99, p=0.048). The relationship of MAD with events remained significant after adjustment for sex, age and tricuspid annular dimensions (OR: 0.28, 95% CI 0.1–0.79, p=0.02). Conclusions TAD and MAD were associated with heart failure rehospitalization and clinical events respectively in patients undergoing TAVI with a self-expanding valve. Further larger prospective studies are warranted to evaluate the prognostic value of these CTA markers. Funding Acknowledgement Type of funding sources: None.

Prognostic value of right ventricular systolic function by speckle tracking echocardiography beyond conventional echocardiography in significant tricuspid regurgitation

Abstract Background Right ventricular (RV) systolic function is determinant in the evaluation of patients with significant tricuspid regurgitation (TR). Timely detection of RV dysfunction with conventional 2D echocardiography is limited by the geometry and position of the RV. RV strain has emerged as an accurate and sensitive tool for evaluation of RV function with the capability of detect subclinical RV dysfunction Purpose This study was aimed to evaluate the prognostic value of RV strain in consecutive patients with significant TR, in comparison with conventional parameters of RV systolic function. Methods Consecutive patients in stable clinical status with significant TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic were included. RV systolic function was measured with conventional echocardiographic parameters (RV fractional area change [FAC], tricuspid annular plane systolic excursion [TAPSE]), DTI S wave (S') and with STE derived automatic peak global and free wall longitudinal strain (GLS, FW-LS respectively) using the EPIQ system (Philips Medical Systems, Andover, Massachusetts). A combined endpoint of hospital admission due to right heart failure or cardiovascular mortality was defined. Results A total of 130 patients were included (mean age was 75±17 years, 69% females, 93% in NYHA I/II). According to etiology, 14% were primary TR and 86% were functional (49% due to corrected left valve disease and 37% due to tricuspid annulus dilatation). Mean values of RV function parameters are shown in the table. During a mean follow up of 18±8 months, n=39 patients (30%) reached the combined endpoint. Patients with events showed impaired RV GLS and FW-LS. Both parameters were predictive of the combined endpoint (table 1). Conventional parameters of RV systolic function were not associated with outcomes (p>0.05 for all). Conclusion In patients with severe TR, RV strain values are superior to conventional parameters to detect RV dysfunction. Among different measurements of RV function, RV GLS and FW-LS were the only predictors of poor prognosis. These parameters should be included in the serial evaluation of these patients. Funding Acknowledgement Type of funding sources: None. RV parameters

Prognostic value of serum biomarkers in patients with severe tricuspid regurgitation

Abstract Background Significant tricuspid regurgitation (TR) is related to significant morbimortality. Given the lack of strong evidence, optimal timing for intervention remains controversial. Surgery is often performed late mainly because symptoms might go unnoticed until advance stages of the disease. The clinical impact of serum biomarkers evaluation in the serial evaluation of patients with significant TR is unknown. Purpose This study was aimed to evaluate the prognostic value of brain natriuretic peptide (BNP) and serum hepatic enzymes assessment in stable patients with significant tricuspid regurgitation Methods Consecutive patients in stable clinical status with significant TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic were included. Patients with previous episodes of heart failure were excluded. BNP levels and liver function enzymes were measured in all patients in their first visit. A combined endpoint of hospital admission due to right heart failure and cardiovascular (CV) mortality was defined. Results A total of 163 patients were included (mean age was 75±17 years, 69% females, 93% in NYHA I/II). According to etiology, 14% were primary TR and 86% were functional (49% due to corrected left valve disease and 37% due to tricuspid annulus dilatation). During a median follow up of 28 months (IQR: 15–49 months), n=59 patients (36%) reached the combined endpoint (n=12 patients died). Differences in BNP and liver function enzymes values in patients with or without events are shown in figure 1. BNP values and both cholestasis enzymes (alkaline phosphatase and gamma-glutamyl transferase) were independent predictors of the combined endpoints (Figure 2). In a multivariable Cox analysis (forward selection) in a model including BNP, alkaline phosphatase and gamma-glutamyl transferase, alkaline phosphatase remained as the sole independent predictor of outcome (HR: 1.01, [1.004–1.014], p<0.001). Conclusion Serum biomarkers held prognostic value in patients with significant TR. BNP values and colestasis enzymes are predictive of heart failure and CV death in stable patients with TR. Given the low clinical expression of the disease, these serum biomarkers should be considered in the serial evaluation of these patients. Funding Acknowledgement Type of funding sources: None. Comparison of serum biomarkersCox regression analysis

Predicting procedural success in patients treated with Cardioband system for severe tricuspid regurgitation by employing a random forest algorithm

Abstract Background Severe tricuspid regurgitation (TR) is associated with high morbidity and mortality despite optimal medical treatment. Transcatheter tricuspid valve intervention (TTVI) is therefore emerging as a novel treatment option, fueling the hope to prolong survival and reduce rehospitalization for heart failure. Obviously, procedural success of TTVI is an important determinant of survival, but predictors for procedural success in patients treated with Cardioband system, which mimics the surgical approach by implanting an annular reduction system and hence targets tricuspid annulus dilatation as the central pathology in most patients, are largely elusive. Purpose This study aims to refine prediction of procedural success in patients with severe TR undergoing TTVI with Cardioband system by employing a random forest algorithm. Methods Procedural success was evaluated in 72 patients enrolled at two tertiary centers in Germany between 2018 and 2020. Key inclusion criterion was TR ≥ III/V° with high symptomatic burden despite optimal medical treatment. Procedural success war defined as patient alive at the end of the procedure, successful Cardioband implantation, and TR reduction ≥ II/V° as assessed on transthoracic echocardiography before discharge. Since 66.7% of patients were classified as “success”, a synthetic minority over-sampling technique was applied in order to train the random forest algorithm on a balanced data set. Results A random forest algorithm reached 85.4% accuracy (AUC: 0.923) in predicting procedural success in a balanced data set using eight parameters from pre-procedural echocardiography as input variables. Partial dependence analysis revealed that enlargement of the tricuspid valve (TV) anteroseptal diameter was most important for model accuracy. Applied to the real-world data set (24 patients classified as “failure” and 48 patients classified as “success”), the now trained random forest algorithm predicted procedural success with high sensitivity (70.8%) and specificity (100.0%), significantly outperforming the no information rate (p-value: 0.0069). Patients with low probability for success were characterized by impaired right ventricular function (TAPSE: 15.5±3.63 mm) and enlarged right sided cardiac diameters (basal right ventricular diameter: 51.6±3.79 mm; TV anteroseptal diameter: 45.0±5.10 mm). Notably, systolic pulmonary artery pressure (sPAP) and TV effective regurgitant orifice area were negatively correlated (R: −0.3004, p-value: 0.0322), and elevation in sPAP was attenuated in patients with low probability for procedural success (sPAP: 34.0±11.7 mmHg). Conclusion A random forest algorithm enables precise prediction of procedural success in patients treated with Cardioband system. TR reduction ≥ II/V° appears less achievable in patients with advanced stages of right heart failure, emphasizing the importance of adequate patient selection and timing of intervention. Funding Acknowledgement Type of funding sources: None.

The impact of tricuspid annular geometry on outcome after percutaneous edge-to-edge repair for severe tricuspid regurgitation.

Percutaneous tricuspid repair using the edge-to-edge technique is a novel treatment option. More data are needed to better understand which aspects predict a favorable outcome. Twenty high-risk patients (78.6 ± 8.3 years, EuroScore II 9.1 ± 7.7%, STS score 8.8 ± 4.3) with severe symptomatic tricuspid regurgitation (TR) were treated with the MitraClip® system. All patients underwent standardized pre-, peri-, and post-procedural evaluation. Acute success was defined as successful edge-to-edge repair with TR reduction of ≥ 1 grade and survival until hospital discharge. Fifteen (75%) patients showed acute success until discharge and 12 (60%) at 30-day followup. In 5 (25%) patients repair failed due to either unsuccessful clip implantation (n = 2), single leaflet device attachment (n = 1), TR reduction < 1 grade (n = 1), or in-hospital death (n = 1). Comparing patients with successful procedure versus those with failed repair revealed similar comorbidities but more severe right heart failure, lower left ventricular ejection fraction, worse renal function, and higher diuretic equivalent doses in the failed repair group. No differences in conventional echocardiographic parameters for TR severity but more dilated tricuspid annulus geometry (tricuspid valve annulus, coaptation depth, tenting area) in the failed repair group were observed. The success rate of non-central/non-anteroseptal jet location was only 25%. Tricuspid annulus geometry assessment may be of crucial importance and seems to impact procedural outcomes in patients undergoing edge-to-edge tricuspid valve repair. Further investigations including advanced imaging are needed to better understand and treat this complex valve disease.

An Unusual Cause of Profound Tricuspid Annular Dilatation Resulting in Severe Regurgitation

An Unusual Cause of Profound Tricuspid Annular Dilatation Resulting in Severe Regurgitation

Assessment of tricuspid annulus: anatomic and echocardiographic correlation.

Tricuspid regurgitation is associated with a poor outcome and its quantification remains a challenge. Tricuspid annulus dilatation is one of the parameters that influences clinical decision-making. The aim of this study was to compare the use of 2D transoesophageal echocardiography with surgical assessment for the measurement of the tricuspid annulus. Sixty-one cardiac patients (median age 64years) were included in the study. Echocardiographic tricuspid annulus measurements were obtained from four chamber and transgastric short axis views and compared with the surgical measurements of this valve. The study was approved by the Ethics Committee of our institution. The tricuspid annulus measurements were obtained from the four chamber and the short axis views in 57 and 49 patients, respectively, while surgical measurement was performed in all 61 patients. Bland-Altman analysis of 49 tricuspid annulus-matched dimensions of the short axis view and surgical values showed a mean bias of 0.223mm/m2, with limits of agreement of -5.86 to 6.31mm/m2. Echocardiographic measurements of the tricuspid annulus dimension were accurate (90% sensitivity and 90% specificity for a four chamber view cut-off value ≥ 24.5mm/m2, and 89% sensitivity and 97% specificity for a short axis view cut-off value ≥ 37.6mm/m2, P < 0.0001; both cases) for detecting directly assessed annular dilatation by the surgeon in the operative field. Echocardiographic values of tricuspid annulus dimension have a good predictive value to detect surgically assessed annular dilatation and may help identify patients who require surgical tricuspid intervention.

Tricuspid annular dilation in patients undergoing early mitral valve surgery: is it an old story?

Patients with mitral valve prolapse (MVP), undergoing early surgery for severe regurgitation, are usually characterized by a low degree of right chambers' remodeling. In this selected population, the mechanisms leading to tricuspid annular (TA) dilatation (TAD) are not well understood. In this setting, we aimed to evaluate, using three-dimensional echocardiography (3DE), how right chambers affect TA size and might contribute to functional tricuspid regurgitation (FTR) progression. We studied 159 patients treated with early isolated surgery for MVP, characterized by: sinus rhythm; normal biventricular function; normal or elevated pulmonary artery pressure; tricuspid regurgitation (TR) ≤ mild; no concomitant cardiac disease. All patients reached a 3-year echocardiographic follow-up. Based on two-dimensional echocardiography, patients were divided in Group 1 (N = 68, 43%, TAD, TA ≥ 21mm/m2) and Group 2 (N = 91, 57%, no TAD, TA < 21mm/m2). By 3DE, Group 1 showed larger TA size, right atrial (RA) volume and right ventricular (RV) conical remodeling compared to Group 2 (p < 0.05). The multivariate analysis revealed that RA volume, RV basal diameter and function were independently correlated to TA size (p < 0.05). At the 3-year follow-up there was a low incidence of FTR, with a trend towards FTR progression in Group 1 (p = 0.07). In patients undergoing early surgery for MVP, TAD seems to result from distinctive early-onset geometrical changes of the right chambers, preceding TR, RV dilatation and pulmonary hypertension at rest. An integrated approach, including right chambers' assessment by 3DE, might help to better recognized patients at higher risk for TAD and, potentially for FTR.

Role of the tricuspid annulus in functional tricuspid regurgitation development after early isolated mitral valve surgery: is it an old story?

Abstract Funding Acknowledgements Type of funding sources: None. Background. Functional Tricuspid Regurgitation (FTR) has been described as a common condition after isolated mitral valve (MV) surgery, affecting patients’ prognosis. Thus, in cases without significant tricuspid regurgitation (TR) but tricuspid annular (TA) dilatation, TV annuloplasty is currently recommended. Studies suggesting the currently used cut-off for definition of TA dilatation were based on 2D echocardiography (2DE) and included patients treated with MV surgery with heterogeneous MV disease, degree of cardiac remodeling and heart rhythm. As the management of severe MR has moved towards an earlier surgical treatment, few data are available about the incidence of FTR in the population undergoing early isolated MV surgery without TR, but 2DE satisfying criteria for TA dilatation. Aims. To test, in patients treated with early isolated MV surgery for MV prolapse (MVP), without TR and either normal or dilated TA (i) if the currently used 2D TA cut-off is predictive of FTR and cardiac events development (ii) how right chambers’ remodeling assessed by 3D echocardiography (3DE) affects TA dimension. Methods. We studied 159 patients (age 61 ± 11) treated with early isolated MV surgery between 2010 and 2017. Eligible patients were those with 3DE images; normal left and right ventricular (LV and RV) function; sinus rhythm; normal or elevated right ventricular systolic pulmonary artery pressure (sPAP); normal or dilated TA by 2DE; absent TR. The decision to not perform TV annuloplasty in patients with TA dilatation was based on the surgical inspection. All patients underwent a complete 2DE, 3DE analysis was performed using custom software, including LV, RV, left atrial (LA) and right atrial (RA) assessment. 3D TA dimension were obtained using MPR. Clinical and 2DE follow-up was performed at 36 ± 6 months after surgery, major adverse cardiac events (MACEs, including cardiac hospitalization, cardiac death, arrhythmias) and FTR were recorded. Results. Based on 2DE TA dimensions, patients were divided in group 1 (N = 68, 43%, TA≥21 mm/m²) and group 2 (N= 91, 57%, normal TA). Patients in group 1 showed larger RA volume, RV basal diameter and TA area (p &amp;lt; 0.05) by 3DE compared to group 2 (Table). At the multivariate analysis, only the 3D RA volume, RV basal diameter and RV function were independently correlated to the TA area (p &amp;lt; 0.05). At the follow-up, no differences were noted between groups in FTR development and MACEs at the Kaplan-Meier analysis (Fig.). At the COX analysis, 2DE TA dilatation failed to result a predictor of cardiovascular events (model’s X2, p &amp;gt; 0.05). Conclusions. In patients undergoing early MV surgery, the currently defined TA dilatation by 2DE may not necessarily evolve in FTR, and a larger cut-off may be needed. In this population, the evaluation of right chambers’ dimension and function may better define the probability to develop FTR. Abstract Figure. Fig

State-of-the-Art Review: Anatomical and Imaging Considerations During Transcatheter Tricuspid Valve Repair Using an Annuloplasty Approach.

Transcatheter techniques for the treatment of tricuspid regurgitation (TR) are being more frequently used and several new devices are in development. Since 90% of patients with TR have secondary TR, catheter based systems which reduce the dilated tricuspid annulus area are of particular interest. In order to perform an annuloplasty procedure effectively and safely, knowledge about the anatomy of the tricuspid valve apparatus and especially of the annulus in relation to the important neighboring structures such as the aortic root, the RCA, the electrical pathways and the CS is fundamental. In addition, comprehensive understanding of the device itself, the delivery system, its maneuverability and the individual procedural steps is required. Furthermore, the use of multi-modality imaging is important. For each step of the procedure the appropriate imaging modality as well as the optimal; imaging planes are crucial to provide the necessary information to best guide the individual procedural step.

Risk factors for postoperative recurrent tricuspid regurgitation after concomitant tricuspid annuloplasty during left heart surgery and the association between tricuspid annular circumference and secondary tricuspid regurgitation

BackgroundTo identify the association between tricuspid annular circumference and secondary tricuspid regurgitation and analyze the risk factors of recurrent tricuspid regurgitation after concomitant tricuspid annuloplasty during left heart surgery.MethodsFrom October 2018 to June 2019, a total of 117 patients receiving concomitant tricuspid annuloplasty within left heart surgery were enrolled. Severity of tricuspid regurgitation was classified as 4 subtypes: normal, mild, moderate and severe. Perioperative data and mid-term outcome were collected. Tricuspid annular circumference (TAC) was measured under cardiac arrest during surgery procedure by cardioplegia. Optimal TAC and TAC index (TAC/body surface area, BSA) cutoffs of significant tricuspid annulus dilatation (moderate and severe) were obtained. Univariable and multivariable logistic regression analyses were performed to identify the risk factors of postoperative recurrent tricuspid regurgitation. The follow up period is 13–19 months (mean 15.5 ± 3.2 months).ResultsThere was 1 patient was excluded who died after surgery. A total of 116 patients receiving tricuspid annuloplasty were included. Optimal cutoffs of significant tricuspid annulus dilatation were recommended (TAC 11.45 cm, Sensitivity 82.89%, Specificity 73.68%, AUC 0.915; TAC index 7.09 cm/m2, Sensitivity 73.68%, Specificity 85%, AUC 0.825, respectively). Based on findings of multivariable logistic regression, it has been showed that TAC index and postoperative atrial fibrillation were the independent risk factors of recurrent regurgitation after surgery. Optimal TAC index cutoff to predict recurrent tricuspid regurgitation was 7.86 cm/m2ConclusionsThe severity of secondary tricuspid regurgitation is associated with the tricuspid annular circumference. The cut-offs of significant tricuspid regurgitation (more than moderate) were TAC 11.45 cm and TAC index 7.09 cm/m2, respectively. Clinically, concomitant tricuspid annuloplasty is relative safe and effective. TAC index ≥ 7.86 cm/m2 and postoperative atrial fibrillation are the risk factors of recurrent significant tricuspid regurgitation after concomitant tricuspid annuloplasty during left heart surgery.

The Pathophysiological Link between Right Atrial Remodeling and Functional Tricuspid Regurgitation in Patients with Atrial Fibrillation: A Three-Dimensional Echocardiography Study

Atrial fibrillation (AF) itself may lead to functional tricuspid regurgitation (FTR) through tricuspid annulus (TA) dilation. However, the pathophysiological determinants of TA enlargement in AF patients remain to be clarified. The objectives of this study were (1) to compare the TA size and function in AF patients versus healthy subjects; (2) to identify the determinants of TA remodeling in patients with AF and FTR; and (3) to assess the relationships among right heart structures and severity of FTR in AF patients. Eighty-three consecutive patients with long-term persistent AF and FTR (61±9.9years, 67% women) were prospectively enrolled and compared with 83 sex and body surface area-matched healthy subjects. Heart chamber size and function and TA geometry were analyzed using three-dimensional echocardiography. Among AF patients, 33%, 34%, and 33% had mild, moderate, and severe FTR, respectively. Right atrial (RA) dilation was detected in 93% of AF patients, while only 27% and 12% of them showed dilated or dysfunctional right ventricle (RV), respectively. End-diastolic TA area had the strongest correlation with the minimum volume of the RA (RAVmin r=0.6981, P<.0001) but only mild correlation with RV end-diastolic volume and sex (r=0.3405, P=.0019; r=0.2914, P=.0075). At multivariable analysis, only RAVmin was independently associated with TA area in AF patients (r=0.665, P<.0001). The RAVmin and TA area were the only predictors of FTR severity. In patients with AF, RA dilation seems to be more important than RV dilation to determine TA enlargement and subsequent FTR development. The RAVmin and TA area were directly correlated to FTR severity.

Surgical treatment of tricuspid valve disease due to permanent pacemaker lead

Objective: To summarize the etiology and surgical treatment experience of tricuspid valve disease due to permanent pacemaker lead. Methods: The medical records of 22 patients who underwent tricuspid valve operation for tricuspid valve disease due to permanent cardiac pacemaker lead from January 2008 to December 2017 were retrospectively reviewed. There were 12 males and 10 females, with a mean age of (62.6±12.1) years old (45-82 years old). All patients underwent tricuspid valve surgery via open thoracotomy under general anesthesia, including 8 patients through median thoracotomy approach, 4 patients through right mini-thoracotomy approach, and 10 patients with endoscopy-assisted and totally endoscopic technique. Moreover, 8 patients underwent tricuspid valve replacement, and 14 patients received tricuspid valve repair. Results: During the operation, 10 cases of severe tricuspid regurgitation were detected due to valve and subvalvular structures dysfunction involved in the pacing electrode, 7 cases showed tricuspid annulus dilation, and pacing electrode-related infective endocarditis were involved in the tricuspid valve of 5 cases. Compared with conventional median thoracotomy surgery, the amount of postoperative drainage fluid and hospitalization time after minimally invasive surgery (including right mini-thoracotomy and endoscopic surgery) were significantly reduced [281(120, 489) ml vs 368(180, 560) ml, P=0.02; 9.2(4.8, 14.5) d vs 11.2(6.3, 16.9) d, P=0.03]. Postoperative echocardiographic data showed that the size of the right atrium and ventricle in these patients was significantly reduced compared with preoperative data, and their cardiac function were normal. There was no difference of pacing electrode parameters between pre-and postoperative period. All 22 patients were cured and discharged, with no valve-and pacemaker-related complications. Conclusions: Patients with tricuspid valve disease due to permanent cardiac pacemaker lead should actively undergo surgery including tricuspid replacement or repair according to different etiologies, which exhibit satisfactory outcomes. Minimally invasive endoscopic tricuspid surgery is a new technique for the treatment of isolated tricuspid valve disease, with less surgical trauma and faster recovery.

Incremental prognostic value of tricuspid annular dilatation over the STS score

Abstract Background Transcatheter aortic valve replacement (TAVR) is the treatment of choice in most patients with severe aortic stenosis. The Society of Thoracic Surgeons (STS) score is a well established risk score to estimate morbidity, mortality and procedural risk of patients undergoing TAVR. However, tricuspid annular Dilatation (TAD), which is an increasingly recognized pathology associated with increased mortality, is not implemented in the STS Score. Purpose The purpose of this analysis was to investigate the incremental prognoctic value of TAD over the STS score. Methods Maximal septo-lateral diameter of the tricuspid annulus was measured in 923 patients on 3-dimensional MDCT datasets. A cut-off of 23 mm/m2 body-surface area was revealed by receiver-operating curve statistics and used to define TAD. Incremental prognostic Information was tested with c-index statistics and continuous net reclassification improvement (NRI). Patients were followed for 2 years and all-cause mortality was defined as study endpoint. Results Of 923 patients included in this analyis, TAD was found in 370 patients (40%). Patients with TAD had a significantly higher mortality (hazard ratio 2.18 with 95% CI 1.71 and 2.78, p&amp;lt;0.001). The mean STS score in the investigated patient cohort was 5.6±5.0. TAD provided incremental prognostic Information over the STS score when assessed with c-index statistics (rise from 0.63 to 0.66, p&amp;lt;0.01) or continuous NRI (0.209 with 95% CI 0.127 and 0.292, p&amp;lt;0.001). Estimated survival rates at 2 years were 88.2% (95% CI 84.5 and 92.1) in patients with a low STS score (&amp;lt;4) and no TAD and 57.5% (95% CI 51.1 and 64.7) in patients with a high STS score (&amp;gt;4) and TAD. Estimated survival rates in patients with a low STS score and TAD and patients with a high STS score and no TAD were similiar (75.8% with 95% CI 68.9 and 83.5 and 74.8% with 95% CI 69.2 and 80.7, respectively). Kaplan-Meier curves are shown in Figure 1. Conclusion TAD is a common entity in patients undergoing TAVR for severe aortic stenosis. It is associated with significantly higher mortality and provides incremental prognostic Information over the STS score. Funding Acknowledgement Type of funding source: None

A novel quantitative grading system to further characterize the prognosis of patients with functional tricuspid regurgitation

Abstract Background Recent studies have suggested that current grading of tricuspid regurgitation (TR) has significant limitations and specifically cannot identify the various grades of severe TR (such as torrential). New cut-off values for the recommended measures of vena contracta (VC) width and effective regurgitant orifice area (EROA) have been proposed but not yet validated. Purpose To test the prognostic utility of new cut-offs for VC width and EROA in a large registry of patients with functional TR (FTR) and to integrate them into a novel comprehensive grading system. Methods FTR severity was evaluated in 1148 patients (mean age: 69±13 years, 50% male) with significant FTR (≥ moderate). Patients with congenital heart disease or who underwent tricuspid valve repair during follow-up were excluded. The primary endpoint was all-cause mortality. Based on Kaplan-Meier survival analyses, VC width significantly differentiated the prognosis of patients with moderate FTR vs severe FTR (with a cut-off value of 7 mm), whereas EROA was able to further stratify patients with more than severe (torrential) FTR. Therefore these two parameters were combined into a novel grading system (Figure: Upper Panel) to define: moderate FTR (VC &amp;lt;7 mm), severe FTR (VC ≥7 mm, EROA &amp;lt;80 mm2) and torrential FTR (VC ≥7 mm, EROA ≥80 mm2). Results According to our novel grading system a total of 146 patients (13%) showed moderate FTR, 547 patients (48%) had severe FTR and 454 patients (39%) presented with torrential FTR. Patients with torrential FTR had greater right ventricular (RV) dimensions, lower RV systolic function and were more likely to receive diuretics. The cumulative 10-year survival rates were significantly different among the groups: 54% for moderate FTR, 43% for severe FTR and 32% for torrential FTR (P=0.004 Figure – Lower Panel). After adjusting for potential confounders, torrential FTR retained its association with worse prognosis compared with other FTR grades (HR 1.28; 95% CI 1.07–1.54; P=0.007) together with age, coronary artery disease, diabetes, severe renal impairment, lower RV or left ventricular systolic function, higher pulmonary artery pressures, and dilated tricuspid annulus. Differently, severe FTR graded according to current guidelines did not show any association with the primary outcome (HR for severe FTR vs moderate FTR 1.17; 95% CI 0.96–1.42; P=0.128). Conclusion The proposed novel grading system combining measures of VC width and EROA is able to further risk stratify patients with FTR and specifically to identify patients with torrential FTR, a new clinical condition associated with even worse mortality than severe FTR. Figure 1 Funding Acknowledgement Type of funding source: None

CT-Determined Tricuspid Annular Dilatation Is Associated With Increased 2-Year Mortality in TAVR Patients

The aim of this study was to investigate the prevalence and prognostic impact of tricuspid annular dilatation (TAD) measured in multislice computed tomography datasets in patients undergoing transfemoral transcatheter aortic valve replacement for severe aortic stenosis. TAD is an increasingly recognized entity associated with poor outcomes in patients with valvular heart disease. The maximal septolateral diameter of the tricuspid annulus was measured in consecutive patients with 3-dimensional multidetector row computed tomographic datasets undergoing transfemoral transcatheter aortic valve replacement. Receiver-operating curve characteristic analysis was performed to obtain an ideal, body surface area-normalized cutoff for TAD. Ethical approval was obtained from the institutional ethics board. The study included 1,137 patients, of whom 299 died within a mean follow-up period of 1.8 ± 1.0 years. TAD was identified in 446 patients (39.2%) on the basis of a receiver-operating characteristic cutoff of 23mm/m2. TAD had no impact on procedural outcomes, including device failure defined according to Valve Academic Research Consortium-2 criteria. Patients with TAD experienced significantly greater mortality (hazard ratio: 1.99; 95% confidence interval: 1.59 to 2.51; p<0.001). Multivariate analysis including clinical and echocardiographic parameters confirmed the predictive value of TAD (hazard ratio: 1.78; 95% confidence interval: 1.33 to 2.38; p<0.001), while echocardiographic variables, including estimated pulmonary artery pressure and the severity of tricuspid regurgitation, did not reach statistical significance. The predictive value of TAD was incremental to a baseline model of clinical and echocardiographic parameters (continuous net reclassification improvement 0.204; p<0.01) and incremental to the Society of Thoracic Surgeons score (continuous net reclassification improvement 0.209; p<0.001). TAD is an independent predictor of all-cause mortality in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement.