Tricuspid Regurgitation Fraction Research Articles

Tricuspid Regurgitation Stratification Predicts the Time Course of Systemic Right Ventricle Dysfunction Among Patients on ACE-I/ARB

BackgroundProgressive systemic right ventricle (sRV) dysfunction is a significant challenge in adult congenital heart disease. Current guidelines do not specify effective heart failure medications for patients with sRV; however, previous studies have relied on semiquantitative assessments. The advancement of cardiac magnetic resonance (CMR) imaging as the gold-standard modality offers quantitatively accurate assessments even for complex cardiac anomalies. Therefore, we aimed to investigate prognostic factors associated with sRV dysfunction in patients on angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACE-I/ARB), using CMR-derived quantitative values. MethodsWe conducted a retrospective cohort study of 17 adult patients with sRV treated with ACE-I/ARB and performed logistic regression analysis, with the primary outcome defined as sRV ejection fraction (sRVEF) deterioration. ResultsOver an average follow-up period of 68.7 months, sRVEF deterioration occurred in 3 patients (17%). Logistic regression analysis identified tricuspid regurgitation (TR) as a potential independent prognostic factor for the primary outcome (odds ratio = 1.11; 95% confidence interval, 1.00-1.31). Furthermore, patients with mild TR (TR fraction ≤15%; N = 12) experienced improvements in sRVEF between the initial and last CMR assessments (from 49.1% ± 8.4% to 56.7% ± 8.0%, P = 0.0029), with increased stroke volume from 68.2 ± 18.6 to 79.5 ± 17.2 mL (P = 0.0029). In contrast, these changes were not observed in patients with moderate or severe TR (TR fraction >16%) (N = 5). ConclusionsOur CMR-based evaluation highlights the potential utility of TR stratification in predicting the changes in sRVEF among patients with sRV on ACE-I/ARB. Future randomized controlled trials that consider TR severity are required to elucidate the significance of ACE-I/ARB therapy.

Prevalence and determinants of tricuspid regurgitation after repair of tetralogy of Fallot

BackgroundThe prevalence and determinants of tricuspid regurgitation (TR) in patients with repaired Tetralogy of Fallot (rTOF) remain incompletely understood. ObjectivesTo explore the prevalence of and factors associated with TR in patients with rTOF, specifically, the relationship of right ventricular (RV) dilatation with TR severity. MethodsPatients (≥17 yrs) with rTOF referred to our service (2000–2019) were identified. Those with severe pulmonary stenosis, significant shunt, or previous tricuspid valve surgery were excluded. Using standard cardiac MRI protocols, RV, right atrial (RA) and tricuspid valve (TV) parameters were measured and compared. Results68 consecutively eligible patients with rTOF were included in the study (27 ± 9 yrs., 35% female). Despite substantial RV volume overload (mean RVEDVi 153 mL/m2), the majority of the cohort (78%) had no or only mild TR. RA volumes, tenting height/area and annular diameter were normal (4.9 ± 2.0 mm, 1.1 ± 1.0 cm2 and 32.4 ± 6.2 mm, respectively). There was no significant correlation of TR fraction with RVEDVi (r = 0.13; p = 0.30), RVEF (r = 0.09; p = 0.44) or tricuspid annular diameter (r = 0.07; p = 0.62). Only RAVi showed a weak but significant correlation with TR fraction (0.29; p = 0.03). In a pooled cohort analysis, including both rTOF patients and adults with a dilated RV from pre-tricuspid shunt lesions, only rTOF was independently associated with higher TR fraction (p = 0.017). ConclusionDespite substantial RV dilatation in a cohort with rTOF, there was surprisingly little TR. We found poor correlation between RVEDVi, RA volumes, tricuspid annular dilatation and the presence of significant TR. These findings question commonly held notions regarding the pathophysiology of functional TR in these patients.

Prognostic value of functional tricuspid regurgitation quantified by cardiac magnetic resonance in heart failure.

Quantitative assessment of tricuspid regurgitation (TR) is challenging, and the prognostic implications of cardiac magnetic resonance (CMR)-quantified measures of TR remain unclear in patients with heart failure with reduced ejection fraction (HFrEF). This study investigated the prognostic value of functional TR quantified by CMR in patients with HFrEF. A total of 262 patients with HFrEF who underwent CMR were analysed. Patients who had primary TR, who had acute HF, or for whom cardiac surgery was planned were excluded. TR volume and fraction were indirectly calculated via subtracting methods. The primary outcome was defined as a composite of all-cause death and hospitalization for HF. Renal outcome was defined as a composite of a decrease in estimated glomerular filtration rate ≥50% or progression to end-stage renal disease. During the follow-up period (median 921 days), 62 primary outcomes and 48 renal outcomes occurred. When divided into two or three groups based on TR fraction in Kaplan-Meier analysis, patients with higher TR fractions showed worse primary outcomes and renal outcomes than those with lower TR fractions. In Cox regression analysis, a 10% increase in TR fraction was significantly associated with primary outcome [hazard ratio (HR) 1.49, 95% confidence interval (CI) 1.29-1.73, P < 0.001] and renal outcome (HR 1.31, 95% CI 1.12-1.55, P = 0.001). TR fraction exhibited a strong positive linear relationship with primary outcomes and renal outcomes in restricted cubic spline curves. CMR-quantified measures of TR were independently associated with adverse clinical outcomes in patients with HFrEF.

Abstract 14737: Right Heart Remodeling After Pulmonary Valve Replacement in Patients With Pulmonary Atresia With Intact Ventricular Septum and Critical Pulmonary Stenosis

Background: Patients with pulmonary atresia with intact ventricular septum (PA/IVS) and critical pulmonary stenosis (CPS) managed to a biventricular circulation may eventually require pulmonary valve replacement (PVR) for pulmonary regurgitation (PR). Right ventricular (RV) remodeling after PVR has been well described in tetralogy of Fallot (TOF); we sought to investigate RV volumetric and functional changes in PA/IVS using CMR. Methods: A retrospective cohort of PA/IVS and CPS patients who underwent PVR at Boston Children’s Hospital from 1995-2021 with CMR before and after PVR was matched 1:3 with TOF patients by age at PVR. Patients with initial intervention &gt;2 weeks of age or 1.5 ventricle circulation were excluded. Median regression modeling accounting for matching was performed with reduction in indexed right ventricular end diastolic volume (RVEDVi) post PVR as the primary outcome, adjusting for covariates including tricuspid regurgitation (TR) and PVR valve size. Results: Twenty PA/IVS or CPS patients (cases) were matched with 60 TOF (controls), with median age at PVR 14 years; at median follow-up 8 years post PVR, 95% were NYHA Class I. Pre-PVR RVEDVi was similar between groups (165 vs 167 ml/m 2 , p=0.7), although cases had higher RV EF (51.4 vs 48.6%, p=0.03), TR fraction (23 vs 9%, p=0.008), and a trend toward lower RV mass; PR fraction, LV volumes and EF were similar. Pre-PVR RV free wall and LV longitudinal strain were similar, although LV circumferential strain was worse in cases (-15.6 vs -17.1, p=0.01). At median 2 years after PVR, RVEDVi was similarly reduced from 166 to 118 ml/m 2 (p=0.73), although cases had higher RV EF (52.3% vs 46.9%, p=0.007) with less reduction in indexed RV mass (Δ4.5 vs 9.6 g/m 2 , p=0.02); LV volumes and EF were similar. Post PVR, RV and LV longitudinal strain remained unchanged both within and between groups; LV circumferential strain was similar post PVR and remained lower in cases vs controls. Conclusion: Patients with PA/IVS after PVR demonstrate similar RV remodeling to TOF patients, with lesser reduction in RV mass and comparatively better post RV EF. CMR strain imaging found no significant pre-post differences in RV or LV systolic parameters. Further investigation is needed to evaluate for changes in diastolic parameters.

CMR assessment of right ventricular remodeling after transcatheter therapy for severe tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: Private hospital(s). Main funding source(s): Helios Clinical Research Institute Background/Introduction Patients with severe tricuspid regurgitation (TR) are characterized from severe dilatation and negative remodeling of the right heart chambers causing functional right ventricular (RV) failure and increased mortality and morbidity. The transcatheter tricuspid edge-to-edge repair (TTVR) is a new treatment option associated with symptom improvement and reduced hospitalization. The cardiac magnetic resonance imaging (CMRI) remains the gold standard for evaluating the right ventricular morphology and function and could be a useful in assessing the RV reverse remodeling after TTVR. The Tricuspid Regurgitation REgistry (TRuE) is an ongoing national prospective register of patients with severe TR that aims to identify morphofunctional parameters of the right heart chambers related to improve outcomes after TTVR. Purpose The present is a subanalysis of patients with serial CMRI examinations recruited in the ongoing prospective TRuE registry. Methods After excluding patients with intracardiac RV leads, seven patients (age 70 ±12 years) with completed thirty-day follow up were included in the present analysis. Retrospective gated steady state free precession cine images were acquired in the long and short-axis views covering the entirety of both ventricles. Aortic and pulmonary flow data were acquired with a flow-sensitive gradient echo sequence. Assessment of left ventricular (LV) and RV volumes was performed manually in the short-axis cine images (Circle Cardiovascular Imaging, Calgary, Alberta, Canada). The TR fraction was calculated as: ({total RV stroke volume (SV) – total pulmonary forward flow}/total RVSV) × 100. All volumes and flow measurements were indexed for body surface area and expressed in ml/m2. The ratio between the diameter of pulmonary artery (PA) and ascending aorta (AA) was used as indirect measurement of pulmonary arterial hypertension (PAH). CMRI parameters assessing TR quantification, RV morphology and function were analyzed at baseline and follow-up with Fisher´s test or paired t-test. Results At thirty days there was a significant reduction of the TR fraction (45% to 20%, p &amp;lt; 0.001), RV dilatation (RV-end diastolic volume (EDV): 106 ± 12ml/m2 to 86 ± 9.4ml/m2, p = 0.002, RV- end sistolic volume (ESV):55 ± 6.5 to 43 ± 6.6ml, p = 0.003) and improvement of function (RVEF: 47 ± 3.6 to 53 ± 2.4 %, p = 0.006). On the left heart side, there was an improvement of LV filling, with increased LVEDV and LVESV and of the LVSV (36 ± 5.3 to 41 ± 3.7ml/m2, p = 0.040), causing an improvement of the cardiac index (2.2 ± 0.9 l/min/m2 to 2.9 ± 0.7 l/min/m2; p = 0.019. Furthermore, the PA/AA ratio improved significantly (0.91 ± 0.15 to 0.81 ± 0.14, p = 0.006). Conclusion TTVR is associated with positive reverse remodeling of the RV with reduction of dilatation, PAH and function improvement.

Natural history of functional tricuspid regurgitation: impact of cardiac output.

Tricuspid regurgitation (TR) was long forgotten until recent studies alerting on its prognostic impact. Cardiac output (CO) is the main objective of heart mechanics. We sought to compare clinical and echocardiographic data of patients with TR from inclusion to 1-year follow-up according to initial CO. Patients with isolated secondary TR and left ventricular ejection fraction (LVEF) ≥40% were prospectively included. All patients had a clinical and echocardiographic evaluation at baseline and after 1 year. Echocardiographic measurements were centralized. The patients were partitioned according to their CO at baseline. The primary outcome was all-cause death. Ninety-five patients completed their follow-up. The majority of patients had normal CO (n = 64, 67.4%), whereas 16 (16.8%) patients had low-CO and 12 (12.6%) had high-CO. right ventricular function was worse in the low-CO group but with improvement at 1 year (30% increase in tricuspid annular plane systolic excursion). LVEF and global longitudinal strain were significantly worse in the low-CO group. Overall, 18 (19%) patients died during follow-up, of which 10 (55%) patients had abnormal CO. There was a U-shaped association between CO and mortality. Normal CO patients had significantly better survival (87.5% vs. 62.5% and 66.67%) in the low- and high-CO groups, respectively, even after adjustment (heart rate 2.23 for the low-CO group and 9.08 for high-CO group; P = 0.0174). Significant isolated secondary TR was associated with 19% of mortality. It is also associated with higher long-term mortality if CO is abnormal, suggesting a possible role for evaluating better and selecting patients for intervention.

Cone reconstruction for Ebstein anomaly: Late biventricular function and possible remodeling

ObjectivesTo evaluate late-term tricuspid valve competence and biventricular function following cone reconstruction for Ebstein anomaly, and to explore biventricular remodeling. MethodsConsecutive adult and pediatric patients who underwent cone reconstruction from 2009 to 2019 were reviewed for inclusion in this retrospective cardiac magnetic resonance imaging study. Tricuspid valve competence was assessed with tricuspid regurgitation fraction. Biventricular systolic function was assessed by ejection fraction, cardiac index, indexed stroke volume, and indexed aortic and pulmonary artery beat volume. Biventricular remodeling was assessed by planimetered areas (right atrium, functional right ventricle, left heart), and indexed end-diastolic and end-systolic ventricular volumes. Paired t tests or Wilcoxon signed-rank tests were used for analyses. ResultsOf 58 included patients, 50 underwent cardiac magnetic resonance imaging. Twelve patients had both preoperative and late postoperative cardiac magnetic resonance imaging with a median follow-up of 5.11 years (interquartile range, 3.12-6.07 years). Focusing on these, tricuspid regurgitation fraction decreased (from 69% to 10%; P = .014), right ventricle ejection fraction remained stable, and antegrade pulmonary artery beat volume increased (from 26.7 to 41.6 mL/beat/m2; P = .037). The left ventricle stroke volume (from 30.4 to 44.1 mL/m2; P = .015) and antegrade aortic beat volume (from 28.5 to 41.1 mL/beat/m2; P = .014) also increased, and the left ventricle stroke volume improved progressively with time since surgery (P = .048). Whereas the right atrium area decreased (P = .004), the functional right ventricle and left heart area increased (cm2, P = .021 and P = .004). Right ventricle volumes showed a tendency to normalize and left ventricle indexed end-diastolic volume increased (from 50 to 69 mL/m2; P = .03) over time. ConclusionsCone valve integrity was sustained. Biventricular function improved progressively during follow-up, and there are positive signs of biventricular remodeling late after cone reconstruction.

Risk assessment in PAH using quantitative CMR tricuspid regurgitation: relation to heart catheterization.

AimsImproved risk stratification is of value for decision making in pulmonary arterial hypertension (PAH). Right heart catheterization combined with quantitative tricuspid regurgitation (TR) by cardiovascular magnetic resonance (CMR) may provide this. The aims were to study: (i) to what extent quantitative TR is associated with event‐free survival; (ii) how quantitative TR is related to known prognostic markers in PAH; and (iii) to what extent quantitative TR and right atrial pressure determine right atrial dilation.Methods and resultsFifty patients (63 ± 17 years) with PAH referred for CMR were included. Volumes and pulmonary artery flow by CMR and pressure and vascular resistance by right heart catheterization were obtained. Composite outcome was lung transplantation or death. Four transplantations and 27 deaths occurred over a median of 2.7 years. A trend towards higher hazard ratio was shown for TR volume (TRV; 2.1, 95% CI 1.0–4.4) and TR fraction (TR%; 1.6, 95% CI 0.8–3.3) above median. TRV and TR% correlated with right ventricular (RV) end‐diastolic (TRV r = 0.50; TR% r = 0.39) and end‐systolic (TRV r = 0.35; TR% r = 0.30) volumes, pulmonary vascular resistance (TRV r = 0.28; TR% r = 0.43), N terminal pro brain natriuretic peptide (TRV r = 0.65; TR% r = 0.68), cardiac index (TRV r = −0.32; TR% r = −0.54), pulmonary artery stroke volume (TRV r = −0.32; TR% r = −0.58) and effective RV ejection fraction by pulmonary artery quantitative flow (TRV r = −0.56; TR% r = −0.69), but not RVEF. Both TR% and right atrial pressure determined right atrial volumes (r 2 = 0.38; r 2 = 0.48).ConclusionsA clear trend towards worse outcome with larger TRV or TR% was shown; however, the number of events was insufficient for significant outcome differences. Prognostic value of quantitative TR should be investigated in a larger multicentre cohort. Effective RV ejection fraction may be considered an improved measure of RV function in PAH.

Left Ventricular Volume is an Important Determinant of Exercise Capacity in Patients with Ebstein's Anomaly

Background: Mechanisms for impaired exercise capacity in Ebstein's anomaly (EA) remain unclear. We performed cardio-pulmonary exercise testing, rest and exercise cardiac magnetic resonance (CMR) to explore associations between disease severity and exercise capacity. Methods: In 13 un-operated EA patients (median age 13.5 years; M:F = 42:58%) percent predicted VO2 max (%VO2max) was determined. From rest CMR, indexed end diastolic volumes were calculated: right atrium (RA), atrialised RV (aRV), functional RV (fRVEDV), left atrium (LA), left ventricle (LVEDV). Three CMR based severity indices [A:(RA+aRV)/(fRVEDV+LA+LV), B:(RA+aRV+fRVEDV)/(LA+LV), C:(fRVEDV)/(LVEDV)] and tricuspid regurgitation fraction (TRF = fRV stroke volume-PA flow) were calculated. Pulmonary artery (PA) and aortic flow (AO) were measured at rest and peak exercise and cardiac index (CI) calculated. Results: Univariate associations were found between %VO2max and all measures of disease severity (A:r = −0.66, p = 0.02; B:r = −0.67, p = 0.02; C:r = −0.71, p = 0.01), TRF (r = −0.62; p = 0.03) and LVEDV (r = 0.76, p = 0.004) but not with fRVEDV (r = −0.31, p = 0.33) or age. LVEDV was associated with CI at rest (r = 0.84, p = 0.001) and exercise (r = 0.83, p = 0.001). fRVEDV and TRF were not associated with rest or peak exercise CI. aRV was associated with CI at peak exercise (r = −0.57, p = 0.05); RA was associated with CI at rest (r = −0.58; p = 0.05) and peak exercise (r = −0.53; p = 0.08). Only severity index C was associated with CI at rest (r = −0.61, p = 0.04) and peak exercise (r = −0.57, p = 0.05). LVEDV was the only variable independently associated with %VO2max, rest and peak exercise CI on multivariate analysis. Conclusions: Our data highlight the importance of maintenance of LV volume on exercise capacity in EA and suggest interactions between the RA, aRV and LV rather than between fRV and LV as seen in other congenital cardiac abnormalities.

Association of Tricuspid Regurgitation With Transcatheter Aortic Valve Replacement Outcomes: A Report From The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry

The purpose of this study is to evaluate the association of tricuspid regurgitation (TR) severity with outcomes after transcatheter aortic valve replacement (TAVR). We analyzed data from 34,576 patients who underwent TAVR at 365 US hospitals from November 2011 through March 2015 submitted to The Society of Thoracic Surgeon/American College of Cardiology Transcatheter Valve Therapy Registry. We examined unadjusted mortality and heart failure readmission stratified by degree of preoperative TR and used multivariable models for 1-year mortality and heart failure readmission. Tricuspid regurgitation was present in 80% (n= 27,804) of TAVR patients, with mild TR in 56% (n= 19,393), moderate TR in 19% (n= 6687), and severe TR in 5% (n= 1,724). Increasing TR severity was associated with a number of comorbidities and The Society of Thoracic Surgeons predicted risk of mortality increased (p < 0.001): no TR (7.3 ± 5.4); mild TR (8.0 ± 5.7); moderate TR (9.6 ± 6.8); and severe TR (10.7 ± 7.4). In unadjusted analysis, moderate and severe TR were associated with increased use of cardiopulmonary bypass, longer intensive care unit and hospital stays, new dialysis, inhospital major adverse cardiac event, inhospital mortality, observed-to-expected inhospital mortality ratio, long-term heart failure readmission, and mortality (p < 0.001). Adjusted mortality at 1 year was significantly worse for patients with severe TR when left ventricular ejection fraction greater than 30% (hazard ratio 1.29, 95% confidence interval: 1.11 to 1.50) as was heart failure readmission (hazard ratio 1.27, 95% confidence interval: 1.04 to 1.54). Tricuspid regurgitation was common among patients undergoing TAVR. Increasing TR severity was associated with higher risk patients and increased mortality and readmission-particularly for patients with severe TR and left ventricular ejection fraction greater than 30%. The effectiveness of TAVR alone in patients with aortic stenosis and concomitant severe TR may warrant further consideration, particularly for lower risk patients.

Clinical aspects of myocardial fibrosis in adults with Ebstein\u2019s anomaly

Heart failure and arrhythmia are common complications in adults with Ebstein’s anomaly. They may result not only from hemodynamic alterations, but also from myocardial fibrosis. Late gadolinium enhancement (LGE) by CMR enables the evaluation of myocardial fibrosis. The aim of the study was to asses the presence of LGE and its relation to clinical outcome. We studied a group of 37 unoperated adults aged 43.0 ± 14.4 years with Ebstein’s anomaly from the congenital heart disease outpatient clinic. Study protocol included: cardiopulmonary test, assessment of supraventricular arrhythmia (SVA), and CMR with evaluation of cardiac chambers’ morphology and function, and presence of LGE. Variables following normal distribution were shown as mean ± SD if otherwise median (range) was applied. Fibrosis was found in 18 patients (48.6%) and was distributed as follows: 12 patients (32.4%) in the right atrium, 12 (32.4%) in the atrialized right ventricle, and 2 (5.4%) in the functional right ventricle. In patients with fibrosis, the tricuspid regurgitation fraction was bigger (48.3 ± 19.7 vs. 36.1 ± 22.6%, p = 0.048) and SVA was more frequent [12 (66.7%) vs. 6 (31.6%), p = 0.046] when compared to patients without fibrosis. However, exercise capacity did not differ between patients with and without LGE (peak VO2 24.0 ± 4.7 vs. 23.7 ± 4.4, p = 0.87). In adults with Ebstein’s anomaly fibrosis estimated by LGE-CMR was localized in the right atrium and the right ventricle only. Volume overload resulting from tricuspid regurgitation might be a factor conducive to fibrosis. Myocardial fibrosis did not influence exercise capacity. Association between myocardial fibrosis and supraventricular arrhythmia was confirmed.

Transcatheter pledget-assisted suture tricuspid annuloplasty (PASTA) to create a double-orifice valve.

Pledget-assisted suture tricuspid valve annuloplasty (PASTA) is a novel technique using marketed equipment to deliver percutaneous trans-annular sutures to create a double-orifice tricuspid valve. Tricuspid regurgitation is a malignant disease with high surgical mortality and no commercially available transcatheter solution in the US. Two iterations of PASTA were tested using trans-apical or trans-jugular access in swine. Catheters directed paired coronary guidewires to septal and lateral targets on the tricuspid annulus under fluoroscopic and echocardiographic guidance. Guidewires were electrified to traverse the annular targets and exchanged for pledgeted sutures. The sutures were drawn together and knotted, apposing septal and lateral targets, creating a double orifice tricuspid valve. Twenty-two pigs underwent PASTA. Annular and chamber dimensions were reduced (annular area, 10.1 ± 0.8 cm2 to 3.8 ± 1.5 cm2 (naïve) and 13.1 ± 1.5 cm2 to 6.2 ± 1.0 cm2 (diseased); septal-lateral diameter, 3.9 ± 0.3 mm to 1.4 ± 0.6 mm (naïve) and 4.4 ± 0.4 mm to 1.7 ± 1.0 mm (diseased); and right ventricular end-diastolic volume, 94 ± 13 ml to 85 ± 14 ml (naïve) and 157 ± 25 ml to 143 ± 20 ml (diseased)). MRI derived tricuspid regurgitation fraction fell from 32 ± 12% to 4 ± 5%. Results were sustained at 30 days. Pledget pull-through force was five-fold higher (40.6 ± 11.7N vs 8.0 ± 2.6N, P < .01) using this strategy compared to single puncture techniques used to anchor current investigational devices. Serious complications were related to apical access. PASTA reduces annular dimensions and tricuspid regurgitation in pigs. It may be cautiously applied to selected patients with severe tricuspid regurgitation and no options. This is the first transcatheter procedure, to our knowledge, to deliver standard pledgeted sutures to repair cardiac pathology.

Quantification of tricuspid regurgitation using two-dimensional velocity encoding cine: optimal plane and reproducibility.

To determine the optimal plane of two-dimensional velocity-encoding cine (VENC) magnetic resonance (MR) imaging at the tricuspid annulus for quantification of tricuspid regurgitation (TR) and to assess the reproducibility of VENC tricuspid flow measurements. We conducted a retrospective review of MR images of 25 consecutive patients (M:F=8:17; mean age, 58.5±10.5years) with TR. VENC was performed twice orthogonal to the tricuspid annulus plane during the end-diastolic (ED) and end-systolic (ES) phases. The TR fraction was quantified at each plane as retrograde flow/antegrade flow and additionally as retrograde flow of the ED plane/antegrade flow of the ES plane (combined plane method). The conventional method to determine the TR amount [right ventricular stroke volume (RVSV)-pulmonary antegrade flow] and TR fraction (TR amount/RVSV) was used as the reference standard. There were no differences between TR amount and retrograde flow of the ED plane (65.3±43.4 vs. 70.5±36.1ml, P=0.361) between the RVSV and the antegrade flow of the ES phase (124.2±46.1 vs. 128.0±45.0ml, P=0.612) or in TR fraction between the conventional and combined plane methods (48.8±19.2 vs. 56.3±24.3%, P=0.08). The retrograde flow of the ED phase was best correlated with TR amount [intraclass correlation coefficient (ICC)=0.859] and antegrade flow of ES with RVSV (ICC=0.808). The TR fraction of the combined plane method was best correlated with the conventional method (ICC=0.694). Interobserver agreement of VENC flow measurements was excellent (ICC, 0.939-0.993). The optimal method for quantification of TR using tricuspid annular VENC was the combined plane method, which divides the retrograde flow of the ED plane by the antegrade flow of the ES plane. Tricuspid flow measurements using VENC showed excellent reproducibility.

Assessment of acute changes in ventricular volumes, function, and strain after interventional edge-to-edge repair of mitral regurgitation using cardiac magnetic resonance imaging.

Whereas haemodynamic and echocardiographic studies suggest benefits for left ventricular (LV) function and cardiac output following reduction in LV preload by interventional edge-to-edge repair for mitral regurgitation (MR), there is limited data on volumetric and functional LV and right ventricular (RV) changes using cardiac magnetic resonance (CMR) imaging. Patients with moderate to severe MR and high surgical risk underwent MitraClip-implantation and CMR imaging before and within 7 days after the procedure. In addition to volumetric and flow studies, myocardial feature tracking (FT) technology for quantification of myocardial strain was applied. Twenty patients (age: 76 ± 8 years) with functional (n = 15) or degenerative MR (n = 5) with a mean logistic Euroscore I of 33 ± 16 underwent both successful MitraClip implantation and CMR imaging. MR fraction (36 ± 10 vs. 19 ± 12%; P < 0.001) and LV end-diastolic volume (115 ± 36 vs. 105 ± 41 mL/m2; P = 0.002) decreased significantly, whereas LV ejection fraction (42 ± 15 vs. 41 ± 16%, P = 0.8) and cardiac index (1.7 ± 0.5 vs. 1.8 ± 0.4 L/min/m2, P = 0.4) remained unchanged. MitraClip implantation resulted in a significant impairment of circumferential (-12.8 ± 4.8 vs. -8.2 ± 3.3; P = 0.002) and radial strain (15.4 ± 7.7 vs. 9.6 ± 5.3; P = 0.02) on basal short-axis view. On RV level, there were no significant changes in end-diastolic volume (83 ± 19 vs. 84 ± 18 mL/m2, P = 0.8), ejection fraction (42 ± 9 vs. 43 ± 11%, P = 0.8), or tricuspid regurgitation fraction (24 ± 17 vs. 25 ± 19%, P = 0.7). MitraClip implantation led to a significant improvement in New York Heart Association functional class (patients in functional class III-IV pre 100% vs. post 45%; P < 0.001). In severely compromised patients, marked reduction in MR by MitraClip implantation might not result in immediate improved cardiac output and effective biventricular forward flow.

Athlete’s Heart with a Systemic Right Ventricle?

Objective: High load of regularly vigorous exercise leads to multiple physiological adaptations. The major cardiovascular effects are hypertrophy and dilation, predominantly of the left ventricle, and bradycardia. However, there are no reports on an athlete’s heart in a systemic right ventricle. Subject: We report on a 23 year old male endurance athlete (177cm, 69kg) with a systemic subaortic right ventricle after atrial redirection (Senning procedure) for simple transposition of the great arteries in infancy. Albeit medical doctors had imposed activity restriction to him, he has lead an active lifestyle from early childhood on, intensifying his sport activities over the years especially in cycling and running to a training volume of about 10 hours per week in winter and about 15 hours per week in summer. In 2009 he performed 1:50h on the half marathon distance. In 2013 he finished his first Marathon in 4:34h. Results: Cardiopulmonary exercise testing revealed a maximum oxygen uptake of 52.3ml/min/kg and a peak work load of 353 Watt, corresponding to 5.1Watt per kilogram body mass. Cardiovascular Magnetic Resonance showed a cardiac index of 2.9ml/min/m2, a tricuspid regurgitation fraction of 4%, and a systemic right ventricle enddiastolic volume of 109ml/m2 with an ejection fraction of 53%. Conclusions: With regular exercise training a systemic right ventricle can become very efficient comparable to healthy amateur athletes. Case Study Muller et al.; CA, 2(4): 293-297, 2014; Article no. CA.2014.4.014 294

Assessment of acute changes in biventricular volumes, systolic function and strain after MitraClipTM-implantation using magnetic resonance imaging and feature tracking

MitraClipTM-implantation has been shown to significantly reduce mitral regurgitation (MR) in patients with high surgical risk. Whereas hemodynamic and echocardiographic studies suggest a reduction in left ventricular (LV) volumes and an increase in cardiac output following the intervention, there is very limited data on assessment of volumetric and functional changes after MitraClipTM-implantation using cardiac magnetic resonance (CMR) imaging, the considered method of choice in such a scenario. Methods Patients with moderate to severe MR, high surgical risk and absence of contraindications to CMR imaging underwent MitraClipTM-implantation and CMR imaging on a 1.5 Tesla scanner (Intera, CV, Philips Medical Systems) before and within seven days after the procedure. In addition to volumetric and flow studies, myocardial feature tracking (FT) technology for quantification of myocardial wall mechanics was applied. From steady-state free precession images of short axis views LV maximal circumferential (ECCSAX) and radial (ERRSAX) and of the 4-chamber view LV longitudinal (ELL4CH) and radial (ERR4CH) strain was calculated using dedicated prototype software (TomTec, Germany). Results Twenty patients (age: 76 ± 8 years) with functional MR (n = 15) or degenerative MR (n = 5) with a median Euroscore of 33 (range 17-62) underwent the MitraClipprocedure and CMR imaging. Detailed results of volumetric assessment of the LV and right ventricle (RV) as well as calculated mitral and tricuspid regurgitation fraction are summarized within the table. There was a 44% relative reduction in MR fraction after MitraClipTMimplantation. In this severely compromised patient population (mean pre-implant cardiac index of 1.7 L/min/m2), there were smaller LV enddiastolic volumes after the intervention, but reduced total stroke volume at unchanged effective LV stroke volume (=net aortic forward flow) and

Assessment of haemodynamic effects of surgical correction for severe functional tricuspid regurgitation: cardiac magnetic resonance imaging study

There has been growing attention for the development of functional tricuspid regurgitation (TR) long after left-sided valve surgery. We attempted to determine the long-term haemodynamic effects of corrective surgery for severe functional TR in patients who had prior left-sided valve surgery using cardiac magnetic resonance imaging (CMR). Thirty-one patients with severe functional TR (TR fraction of 46.0+/-16.2% by CMR) were analysed. CMR was performed within 1 month before and at a median 27.0 months after surgery. Long after TR surgery, 28 of the 31 patients had no or mild residual TR, two had mild-to-moderate TR, and one showed moderate TR. Remarkable reductions in the right ventricular (RV) end-diastolic volume index (RV-EDVI) (177.4+/-59.1 mL/m(2) vs. 118.2+/-31.2 mL/m(2), P<0.001) and end-systolic volume index (RV-ESVI) (88.5+/-30.1 mL/m(2) vs. 67.2+/-31.0 mL/m(2), P=0.002) were observed, whereas RV ejection fraction (RV-EF) showed no change (49.7+/-8.3% vs. 44.9+/-12.5%, P=0.09). Pre-operative RV-EDVI (R=-0.86, P<0.001) and RV-ESVI (R=-0.55, P=0.001) were significantly associated with their respective changes after corrective surgery. Post-surgery, a normal RV-EF was achieved in 14 patients (42.5%). Pre-operative RV-EDVI of 164 mL/m(2) effectively discriminated patients with normal RV-EF from those without post-surgery, with a sensitivity of 77% and a specificity of 72% (P=0.01). A significant rise in the left ventricular (LV) EDVI and cardiac index (CI) was found after surgery (from 92.9+/-24.4 to 123.2+/-31.6 mL/m(2) for LV-EDVI, P<0.001; from 3.8+/-1.3 to 4.2+/-0.8 L/min/m(2) for CI, P=0.03). Functional capacity as assessed by NYHA class showed a significant improvement from 2.7+/-0.6 before surgery to 2.0+/-0.6 long after surgery (P<0.001). Successful TR surgery can remarkably reduce RV volumes and preserve RV systolic function. In addition, successful TR surgery led to a significant rise in LV preload and CI, which may significantly contribute to a significant amelioration in the functional capacity of the patients. It seems that RV volume measurement by CMR is helpful for determining optimal timing for TR surgery.

Reduction in right ventricular pressure and/or volume overload by percutaneous pulmonary valve implantation improves tricuspid valve function as assessed by MR imaging

Methods Magnetic resonance (MR) imaging including biventricular volumes and great vessel blood flow assessment was performed prior to and immediately after PPVI in 137 patients. Retrospectively, out of this patient population, we selected patients who had a tricuspid regurgitation fraction (TRF) > 10% on MR prior to valve implantation. TRF was calculated from right ventricular stroke volume and pulmonary artery forward flow.

Changes in right ventricular dimensions and performance after passive cardiac containment

Background Previous studies have shown that the cardiac support device (CSD) improves left ventricular structure and function in patients with heart failure by preventing further cardiac enlargement. The aim of this study was to identify effects on the right ventricle (RV). Methods Ten male patients with idiopathic dilated cardiomyopathy underwent electron-beam computed tomographic (CT) examination within 1 month before, and 6 to 9 months after CSD implantation. The RV end-diastolic and end-systolic volumes (EDV, ESV) and diameters (EDD, ESD), stroke volume (SV), ejection fraction (EF), total and forward RV output (RVO, fRVO), and tricuspid regurgitation fraction (TRF) were calculated. Results The EDV measurements decreased from 182.1 ± 49.6 to 137.5 ± 37.0 mL, ESV from 114.8 ± 47.0 to 68.3 ± 23.8 mL, EDD from 48.2 ± 6.6 to 41.6 ± 7.1 mm, and ESD from 39.6 ± 6.9 to 32.7 ± 6.5 mm ( p < 0.05 for each). Ejection fraction increased from 38.5 ± 8.9 to 52.0% ± 7.7% and fRVO from 4.0 ± 0.8 to 4.6 ± 1.1 L/min (each with p < 0.05). TRF decreased from 18.2 ± 14.1 to 10.4% ± 13.5%, whereas SV and RVO remained nearly unchanged. Postoperatively, RV volumes, EF, and fRVO were not different from 15 age- and gender-matched normal control patients. Conclusions Implantation of a CSD leads to a decrease in RV size and improved RV performance. These data together with the results of previous studies demonstrating improved left ventricular structure and function confirm the biventricular nature of recovery with the CSD.