Tricuspid Regurgitation Grade Research Articles

Prognostic Implications of Residual Tricuspid Regurgitation Grading After Transcatheter Tricuspid Valve Repair.

The safety profile of transcatheter tricuspid valve (TTV) repair techniques is well established, but residual tricuspid regurgitation (TR) remains a concern. The authors sought to assess the impact of residual TR severity post-TTV repair on survival. We evaluated the survival rate at 2 years of 613 patients with severe isolated functional TR who underwent TTV repair in TRIGISTRY according to the severity of residual TR at discharge using a 3-grade (mild, moderate, and severe) or 4-grade scheme (mild, mild to moderate, moderate to severe, and severe). Residual TR was none/mild in 33%, moderate in 52%, and severe in 15%. The 2-year adjusted survival rates significantly differed between the 3 groups (85%, 70%, and 44%, respectively; restricted mean survival time [RMST]: P= 0.0001). When the 319 patients with moderate residual TR were subdivided into mild to moderate (n=201, 33%) and moderate to severe (n=118, 19%), the adjusted survival rate was also significantly different between groups (85%, 80%, 55%, and 44%, respectively; RMST: P = 0.001). Survival was significantly lower in patients with moderate to severe residual TR compared to patients with mild to moderate residual TR (P = 0.006). No difference in survival rates was observed between patients with no/mild and mild to moderate residual TR (P = 0.67) or between patients with moderate to severe and severe residual TR (P = 0.96). The moderate residual TR group was heterogeneous and encompassed patients with markedly different clinical outcomes. Refining TR grade classification with a more granular 4-grade scheme improved outcome prediction. Our results highlight the importance of achieving a mild to moderate or lower residual TR grade during TTV repair, which could define a successful intervention.

First-in-man Experience of a New Transcatheter Edge-to-edge Repair System Neoblazar in Patients With Severe Tricuspid Regurgitation

Objective: Severe tricuspid regurgitation frequently leads to increased mortality and a poor prognosis. Transcatheter edge-to-edge repair (TEER) for tricuspid valve regurgitation has been reported as a safe alternative to traditional open-heart surgery. This study endeavors to assess the efficacy and safety of a newly designed Neoblazar TEER system in this high-risk population. Methods: This investigation was structured as a prospective, single-arm, first-in-man trial in China (ClinicalTrials.gov number: NCT05497141). From August 2022 to October 2022, patients with severe tricuspid regurgitation were enrolled from 3 centers (Xiamen Cardiovascular Hospital, Fuwai Yunnan Cardiovascular Hospital, and Wuhan Union Hospital). The primary endpoint was achieving a minimum 1-grade reduction in tricuspid regurgitation at the 6-month post-TEER intervention, in addition to the pertinent New York Heart Association class. Scheduled echocardiographic evaluations were conducted at the following distinct intervals: baseline, discharge, 1 month, and 6 months post-TEER intervention. Results: A total of 10 patients were enrolled in the study. Immediately after the TEER procedure with the Neoblazar system, massive tricuspid regurgitation (grade 5+) at baseline decreased to moderate-severe tricuspid regurgitation (grade 3+) in 2 patients and the optimal tricuspid regurgitation reduction (severe tricuspid regurgitation (grade 4+) to mild tricuspid regurgitation (grade 1+)) were achieved in 6 patients. After 6 months of follow-up, tricuspid regurgitation reduction was found to be durable in all enrolled patients, among whom at least 1 grade of tricuspid regurgitation reduction was sustained, even without reintervention. Consistently, the New York Heart Association class among these subjects significantly improved, with the percentage of patients categorized as class I–II increasing from 0/10 at baseline to 5/10 after 1 month (P = 0.015) and 8/10 after 6 months (P < 0.001). Conclusion: Tricuspid TEER with the newly designed Neoblazar system appears to be a feasible and safe alternative in treating patients with severe tricuspid regurgitation. However, the implementation of larger and more robust randomized trials is still necessary for further verification of the potential benefits.

Refining the Grading of Tricuspid Regurgitation: Enhancing Outcome Prediction and Patient Management.

Refining the Grading of Tricuspid Regurgitation: Enhancing Outcome Prediction and Patient Management.

Severe lead induced tricuspid regurgitation - clinical impact of repair or replacement of tricuspid valve

Abstract The prevalence of lead-induced tricuspid regurgitation (LITR) ranges between 7 to 45%. The most frequent mechanism of LITR is the impingement of the leaflets, but right ventricle remodelling, pacing-induced cardiomyopathy and tricuspid annular dilatation also can contribute to the severity of tricuspid regurgitation (TR). Different studies concluded that LITR was associated with an increased risk of all-cause mortality and heart failure hospitalizations. Beyond diuretics, patients (P) may be candidates for interventional treatment, including lead extraction, surgery, or percutaneous tricuspid trans-catheter ‘edge-to-edge’ repair (TEER) and heterotopic bicaval devices (HBD). Despite its importance, there is a scarcity of data concerning the management and clinical impact of severe LITR. The purpose of the current analysis is to improve the knowledge regarding the impact of interventional treatment on the outcomes in this population. Methods A retrospective, single-centre analysis was made including P with severe LITR referred to evaluation regarding eligibility for tricuspid percutaneous intervention in a tertiary hospital. All P were evaluated using both transthoracic echocardiography (TTE) and transoesophageal echocardiography (TEE). Data were collected regarding clinical characterization, management, intervention and follow-up. Results From January 2020 to September 2023, of the 97 P referred for tricuspid intervention eligibility, 36 (37%) had LITR, with 14 cases (39%) presenting lead impingement as the TR mechanism. The majority of P were female (58%), with a median age of 78 [IQR 72-83] years. Median Euroscore II was 6 % [IQR 3-9]), with 51% of the P having a previous heart surgery, and 97% presenting atrial fibrillation. Prior to cardiac electronic device (CIED) implantation, 14% already presented TR. When analysing post-CIED TR, 30% increased 1 grade of TR at 1-year follow-up, and 68% increased 2 grades of TR at 5 years. According to TTE, ventricular desynchrony was present in 30% of the P. After evaluation of TR, 30% underwent intervention (22% percutaneous - TEER or HBD - and 8% surgical). All P remained with the previous electrodes. Mortality was 21.1% in the intervention population and 78.9% on the remaining pts (p=0.027). The type of intervention had no statistically significant differences in outcome. Conclusions In our study, more than 1/3 of the cases referred due to severe TR presented lead impingement as the mechanism underlying TR. As previously reported, the intervened population had better outcomes than the remaining pts.

Cardiovascular crossroads - exploring the impact of atrial fibrillation on mitral valve regurgitation and MitraClip treatment

Abstract Introduction The use of the MitraClip technique is becoming increasingly popular as a treatment option for patients suffering from mitral valve regurgitation who are not suitable for surgery. It is unclear how pre-existing atrial fibrillation impacts patients during the procedure. Purpose The question arises: What is the underlying cause of atrial fibrillation in patients with significant mitral valve involvement and why do some patients remain unaffected? This study aims to compare and identify differences in cohorts of patients with and without atrial fibrillation before the MitraClip procedure. Methods We analyzed a register of 279 patients who underwent MitraClip treatment. The study classified the patients according to the presence (n=140, 50%) or absence (n=139, 50%) of atrial fibrillation prior to the procedure. We utilized univariate analysis to compare demographic, clinical, and echocardiographic parameters. Multivariate logistic regression was also performed to determine significant predictors. Results Both cohorts were of similar size, but there were significant differences in certain parameters. Women were more frequent in the group without atrial fibrillation (45% compared to 34%, p=0.045). The group with atrial fibrillation was slightly older (73 years compared to 70 years, p<0.001) and had a lager body surface area (1.95 compared to 1.87, p=0.005). Parameters such as Euroscore II, NT-proBNP and creatinine levels were not significantly different. Nevertheless, it is important to note that the group with atrial fibrillation had a greater transverse dimension of the left atrium (55 compared to 50, p<0.001). Additionally, the atrial fibrillation group exhibited a higher degree of tricuspid regurgitation (2.9 vs 2.0, p=0.007) and a slightly lower baseline VO2 max (11.63 vs 12.59, p<0.001). Multivariate logistic regression revealed that baseline tricuspid regurgitation is a significant predictor of atrial fibrillation, with and odds ratio of 2.066 (95% CI: 1.041-4.097, p=0.038). Conclusion During the MitraClip procedure, patients with atrial fibrillation demonstrate certain specific characteristics, including older age, increased body surface area, larger left atrial size, and higher grade of tricuspid regurgitation. The significant association of tricuspid regurgitation with atrial fibrillation emphasizes its potential role in clinical evaluation and subsequent treatment.

Improvement in atrial functional and ventricular functional tricuspid regurgitation following catheter ablation or cardioversion of atrial fibrillation

Abstract Background The majority of cases of significant tricuspid regurgitation (TR) are secondary to tricuspid annular dilation and leaflet tethering in the context of RV remodeling due to pressure or volume overload, as seen in patients with pulmonary hypertension (primary or secondary to left-sided heart disease) or dilated cardiomyopathies. Secondary TR induced by tricuspid valve annular dilatation secondary to right atrial dilatation is referred to as atrial functional TR, while secondary TR caused by RV remodeling is referred to as ventricular functional TR. In current guidelines, GDMT (Guideline-Directed Medical Therapy) is effective for secondary TR attributable to HF with reduced LVEF. Normal sinus rhythm should be restored for secondary TR caused by AF-related annular dilatation. In patients with ventricular functional TR, however, AF may also accompany the clinical condition. It is unknown whether restoring sinus rhythm will reduce tricuspid regurgitation in these patients. Purpose The objective of this study was to investigate the degree of tricuspid regurgitation change in patients with atrial and ventricular functional tricuspid regurgitation after sinus rhythm restoration. Methods A retrospective cohort study of patients undergoing AF ablation and cardioversion at a single center between 2019 and 2023 was performed. Patients with at least grade 1 TR on echocardiography and a baseline echocardiogram and a follow-up echocardiogram after ablation were included. A-FTR and V-FTR were defined according to the latest ACC/AHA guidelines. According to the latest guidelines, patients with mild to severe FTR were classified as A-FTR if they had atrial fibrillation, left ventricular ejection fraction >60%, pulmonary artery systolic pressure (PASP) <50 mm Hg, no left-sided valve disease, and normal-appearing tricuspid leaflets. FTR patients who did not meet at least one of these three criteria were defined as ventricular FTR (V-FTR). Results A total of 88 patients were enrolled. The prevalence of A-FTR in our cohort was 62% (53 patients), and 38% of the patients were in the V-FTR group. There was no significant difference between the A-FTR and V-FTR groups regarding age, gender, and NYHA class. 21 of the patients underwent DCCV, and 67 underwent catheter ablation. The prevalence of severe FTR was similar (%17 in A-FTR vs. %8,6 in V-FTR, p= 0.205). There was no difference in preintervention TR grade between the two groups. TR severity improved significantly from baseline to follow-up in both V-FTR and A-FTR patients. These outcomes were observed in patients who underwent both DCCV and catheter ablation. Conclusion The degree of tricuspid regurgitation is reduced with sinus rhythm restoration in patients with both ventricular functional and atrial functional TR.Changes in TR severity with interventionGraph of changes in severity of TR

Clinical and echocardiographic characterization of patients hospitalized for severe tricuspid valve regurgitation: a single tertiary-care center experience with two-year follow-up.

Tricuspid regurgitation (TR) is a common acquired valvular heart disease. Recently new transcatheter treatment options for severe TR have emerged that could change the management of this condition, which warrants better characterization of this specific patient group. The aim of the study was to describe the clinical and echocardiographic characteristics of patients with severe TR and to evaluate their short- and mid-term prognosis. This retrospective, observational single-center study enrolled consecutive patients with severe TR hospitalized between January 2016 and September 2021 in the 1st Chair and Department of Cardiology, Medical University of Warsaw, Poland. The severity of heart failure (HF) was evaluated using New York Heart Association (NYHA) classification. Echocardiographic assessment was performed by experienced sonographer. EuroSCORE II and TRI-SCORE were computed for each patient. 12- and 24-month clinical outcomes were reported. There were 172 patients [93 female (54.1%)] included. The mean age was 76.4 (± 10.5) years. The most common comorbidities included: atrial fibrillation (84.9%), hypertension (68.0%), chronic kidney disease (54.1%), coronary artery disease (45.3%), diabetes mellitus (30.9%). The median EuroSCORE II and TRI-SCORE values were 4.68% and 14.0%, respectively. The median follow-up was 24 months. The overall mortality was 29.7% at 1 year and 47.3% at 2 years. TR grade, TAPSE <17 mm, TAPSE/SPAP <0.26 and right atrial area were significant factors associated with mortality. Patients presenting with severe TR are characterized by a large comorbidity burden and poor prognosis, despite intensive heart failure management.

Personalized Guidance of Edge-to-Edge Transcatheter Tricuspid Valve Repair by Multimodality Imaging.

Background: Transcatheter edge-to-edge tricuspid valve repair (T-TEER) for tricuspid regurgitation (TR) is always guided by transesophageal echocardiography (TEE). As each patient has unique anatomy and acoustic window, adding transthoracic echocardiography (TTE) and cardiac CT could improve procedural planning and guidance. Objectives: We aimed to assess T-TEER success and outcomes of a personalized guidance approach, based on multimodality imaging (MMI) of patient-tailored four right-sided chamber views (four-right-ch), as depicted by CT, TTE, TEE and fluoroscopy. Methods: Patients were assigned to MMI or classical TEE guidance, depending on TTE acoustic window. In MMI patients, planning included cardiac CT, which determined the fluoroscopic angulations of the specific four-right-ch, while guidance relied heavily on TTE, with minimal intermittent TEE for leaflet grasping and result confirmation. Both TTE and TEE were matched to respective CT and fluoroscopy four-right-ch. TR severity and quality of life (QoL) parameters were assessed from baseline to 12 months. Results: A total of 40 T-TEER patients were included, with 17 procedures guided by MMI and 23 solely by TEE. Baseline characteristics were similar between groups, e.g., age (83.1 ± 4.1 vs. 81 ± 5.3, p = 0.182) or STS-Score (11.1 ± 7.4% vs. 10.6 ± 5.9%, p = 0.813). The primary efficacy endpoint of ≥one-grade TR reduction at 30 days was 94% (16/17) in MMI vs. 91% (21/23) in TEE patients, with two or more TR grade reduction in 65% vs. 52% (p = 0.793). Device success was overall 100%, with no device-related complications, but three TEE-associated cases of gastrointestinal bleeding in the TEE-only group. By 12 months, all 15 MMI and 19 TEE survivors improved NYHA functional class and QoL, e.g., Kansas City Cardiomyopathy Questionnaire Score Δ29.6 ± 6.7 vs. 21.9 ± 5.8 (p = 0.441) pts., 6-min walk distance Δ101.5 ± 36.4 vs. 85.7 ± 32.1 (p = 0.541) meters. Conclusions: In a subset of patients with good TTE acoustic window, MMI guidance of T-TEER is effective and seems to avoid gastroesophageal injuries caused by TEE probe manipulation. TR reduction, irrespective of guidance method, impacts long-term QoL.

Real-world 1-Year Results of Tricuspid Edge-to-Edge Repair from the bRIGHT Study.

Severe tricuspid regurgitation (TR) is known to be associated with poor quality of life and increased risk of death when left untreated. To report the 1-year clinical outcomes of subjects treated by tricuspid transcatheter edge-to-edge repair (TEER) with the TriClip system in a contemporary, real-world setting. The bRIGHT post-approval study is a prospective, single-arm, open-label, multicenter, post-market registry conducted at 26 sites in Europe with central event adjudication and echocardiographic core-lab assessment. Enrolled subjects were elderly (79±7 years) with significant comorbidities. Eighty-eight percent had baseline massive or torrential TR and 80% percent of subjects were in NYHA class III/ IV. TR was reduced to moderate or less in 81% at 1 year. Significant improvements in NYHA class (21% to 75% I/II, P<0.0001) and KCCQ score (19±26-point improvement, P<0.0001) were observed at 1 year. One-year mortality was significantly lower in subjects who achieved moderate or lower TR at 30 days; however, there was no difference in mortality among subjects that achieved moderate, mild, or trace TR at 30 days. In addition to TR reduction at 30 days, baseline serum creatinine and baseline RV TAPSE were independently associated with mortality at 1 year (OR: 2.169, 95% CI: [1.494, 3.147], P<0.0001; OR: 0.636, 95% CI: [0.415, 0.974], P=0.0375). Mortality was not associated with baseline TR grade, nor with center volume. Tricuspid TEER using the TriClip system was safe and effective through 1 year for subjects with significant TR and advanced disease in a diverse, real-world population.

Predictors of late outcomes after concomitant tricuspid valve repair with left-sided valve surgery.

Concomitant tricuspid valve (TV) repair is a safe and effective procedure to protect against late moderate or greater tricuspid regurgitation (TR) after left-sided valve surgery, but studies regarding its late outcomes and recurrent TR are limited. This study aimed to reveal the late outcomes and explore the predictors of mortality and recurrent TR among patients who underwent concomitant TV repair with left-sided valve surgery. This study included 645 patients (mean age, 69.7years; 44% male) who underwent concomitant TV repair with left-sided valve surgery (mitral valve surgery in 594 cases, aortic valve surgery in 172 cases) from 2006-2020. Preoperative TR was grade 4, 3, and less than 2 in 85, 235, and 325 patients, respectively. The median follow-up period was 4.6 (IQR 1.7-7.8) years. The in-hospital or 30-day mortality was 1.7% (n = 11). Regarding long-term outcomes after TV repair, 90.3% and 80.8% achieved 5- and 10-year survival, respectively, while 96.1% and 88.8% achieved 5- and 10-year freedom from recurrent TR, respectively. The following were independent predictors of overall mortality on multivariate analysis in patients with preoperative TR grade ≥ 3: prior pacemaker implantation, preoperative renal dysfunction, diabetes mellitus and NYHA class ≥ 3. Also, suture annuloplasty and ring type of ring annuloplasty were not independent risk factors for recurrent TR, classified as grade ≥ 3. Concomitant TV repair with left-sided valve surgery had acceptable outcomes in terms of survival and TR durability. In patients with preoperative TR grade ≥ 3, preoperative patient status had negative impacts on prognosis.

Tricuspid repair: short and long-term results of suture annuloplasty techniques and rigid and flexible ring annuloplasty techniques

BackgroundFunctional tricuspid regurgitation may arise from left heart valve diseases or other factors. If not addressed concurrently with primary surgical intervention, it may contribute to increased morbidity and mortality rates during the postoperative period. This study investigates the impact of various repair techniques on crucial factors such as systolic pulmonary artery pressure (SPAP), tricuspid valve regurgitation, and New York Heart Association (NYHA) functional capacity class in the postoperative period.Materials and methodsFrom April 2007 to June 2013, 379 adults underwent open-heart surgery for functional tricuspid regurgitation. Patients were categorized into four groups: Group 1 (156) with De Vega suture annuloplasty, Group 2 (60) with Kay suture annuloplasty, Group 3 (122) with Flexible Duran ring annuloplasty, and Group 4 (41) with Semi-Rigid Carpentier-Edwards ring annuloplasty. Demographic, clinical, operative, and postoperative data were recorded over a mean follow-up of 35.6 ± 19.1 months. Postoperative SPAP values, tricuspid regurgitation grades, and NYHA functional capacity classes were compared among the groups.ResultsNo statistically significant differences were observed among the groups regarding age, gender, preoperative disease diagnoses, history of previous cardiac operations, or echocardiographic characteristics such as preoperative ejection fraction, SPAP, and tricuspid regurgitation. Hospital and intensive care unit length of stay and postoperative complications also showed no significant differences. However, patients in Group 3 exhibited longer Cardio-Pulmonary Bypass duration, cross-clamp duration, and higher positive inotrope requirements. While the mortality rate within the first 30 days was higher in Group 1 compared to the other groups (p: 0.011), overall mortality rates did not significantly differ among the groups. Significant regression in functional tricuspid regurgitation and a notable decrease in SPAP values were observed in patients from Group 3 and Group 4 (p: 0.001). Additionally, patients in Group 3 and Group 4 showed a more significant reduction in NYHA functional capacity classification during the postoperative period (p: 0.001).ConclusionAmong the repair techniques, ring annuloplasty demonstrated superiority in reducing SPAP, regressing tricuspid regurgitation, and improving NYHA functional capacity in functional tricuspid regurgitation repairs.

Outcomes of tricuspid regurgitation after lead extraction.

Transvenous leads have been implicated in tricuspid valve (TV) dysfunction, but limited data are available regarding the effect of extracting leads across the TV on valve regurgitation. The aim of this study is to quantify tricuspid regurgitation (TR) before and after lead extraction and identify predictors of worsening TR. We studied 321 patients who had echocardiographic data before and after lead extraction. TR was graded on a scale (0 = none/trivial, 1 = mild, 2 = moderate, 3 = severe). A change of >1 grade following extraction was considered significant. A total of 321 patients underwent extraction of a total of 338 leads across the TV (1.05 ± 0.31 leads across the TV per patient). There was no significant difference on average TR grade pre- and postextraction (1.18 ± 0.91 vs. 1.15 ± 0.87; p = 0.79). TR severity increased after extraction in 84 patients, but was classified as significantly worse (i.e., >1 grade change in severity) in only 8 patients (2.5%). Use of laser lead extraction was associated with a higher rate of worsening TR postextraction (44.0% vs. 31.6%, p = 0.04). In our single-center analysis, extraction of leads across the TV did not significantly affect the extent of TR in most patients. Laser lead extraction was associated with a higher rate of worsening TR after extraction.

Tricuspid Regurgitation and TAVR: Outcomes, Risk Factors and Biomarkers.

Background. The significance of concomitant tricuspid regurgitation (TR) in the context of transcatheter aortic valve replacement (TAVR) remains unclear. This study aimed to analyze the severity of TR before and after TAVR with regard to short- and long-term survival and to analyze the influencing factors. Methods. In our retrospective analysis, TR before and after TAVR was examined and patients were classified into groups accordingly. Special attention was paid to patients with post-interventional changes in TR. Mortality after TAVR was considered the primary endpoint of the analysis and major complications according to the Valve Academic Research Consortium 3 (VARC3) were compared. Moreover, biomarkers and risk factors for worsening or improvement of TR through TAVR were analyzed. Results. Among 775 patients who underwent TAVR in our center between January 2009 and December 2019, 686 patients (89%) featured low- and 89 patients (11%) high-grade TR. High-grade pre-TAVR TR was associated with worse short- (30-day), mid- (2-year) and long-term survival up to 8 years. Even though in nearly half of the patients with high-grade TR the regurgitation improved within seven days after TAVR (n = 42/89), this did not result in a survival benefit for this subgroup. On the other hand, a worsening of low-grade TR was seen in more than 10% of the patients (n = 73/686), which was also associated with a worse prognosis. Predictors of worsening of TR after TAVR were adipositas, impaired right ventricular function and the presence of mild TR. Age, atrial fibrillation, COPD, impaired renal function and elevated cardiac biomarkers were risk factors for mortality after TAVR independent from the grade of TR. Conclusions. Not only pre-interventional, but also post-TAVR high-grade TR is associated with a worse prognosis after TAVR. TAVR can change concomitant tricuspid regurgitation, but improvement does not have any impact on short- and long-term survival. Worsening of TR after TAVR is possible and impairs the prognosis.

Tricuspid regurgitation: Frequency, clinical presentation, management and outcome among patients with severe left-sided valvular heart disease in Europe. Insights from the ESC-EORP Valvular Heart Disease II survey.

Tricuspid regurgitation (TR) is commonly observed in patients with severe left-sided valvular heart disease (VHD). This study sought to assess TR frequency, management and outcome in this population. Among 6883 patients with severe native left-sided VHD or previous left-sided valvular intervention enrolled in the EURObservational Research Programme prospective VHD II survey, moderate or severe TR was very frequent in patients with severe mitral VHD (30% when mitral stenosis, 36% when mitral regurgitation [MR]), especially in patients with secondary MR (46%), and rare in patients with severe aortic VHD (4% when aortic stenosis, 3% when aortic regurgitation). An increase in TR grade was associated with a more severe clinical presentation and a poorer 6-month survival (p < 0.0001). Rates of concomitant tricuspid valve (TV) intervention at the time of left-sided heart valve surgery were high at the time of mitral valve surgery (50% when mitral stenosis, 41% when MR). Concordance between class I indications (patients with severe TR) for concomitant TV surgery at the time of left-sided valvular heart surgery according to guidelines and real-practice decision-making was very good (88% overall, 95% in patients operated on for MR). In this large international prospective survey among patients with severe left-sided VHD, moderate/severe TR was frequent in patients with mitral valve disease and was associated with a poorer outcome as TR grade increased. In patients with severe TR, compliance to guidelines for class I indications for concomitant TV surgery at the time of left-sided heart valve surgery was very good.

Mitral-Tricuspid Regurgitation Change After Transcatheter Aortic Valve Implantation and Its Effect on Mortality and Hospitalization.

Moderate to severe mitral regurgitation (MR) and tricuspid regurgitation (TR) are present in approximately 20-60% of patients undergoing transcatheter aortic valve implantation (TAVI). This study aims to evaluate the impact of TAVI on MR and TR, pulmonary hypertension, and reverse cardiac remodeling in these patients. Methods: Out of 240 patients who underwent TAVI, 79 who met the inclusion and exclusion criteria were analyzed. In our study, 46.8% (n = 37) of the patients were male. Nineteen (24.1%) patients died within two years. Before TAVI, 34 (43%) patients had moderate-to-severe MR, which decreased to 18 (22.7%) after the procedure (P < 0.05). Similarly, the number of patients with moderate-to-severe TR decreased from 26 (32.9%) before TAVI to 12 (15%) after the procedure (P < 0.05).Of the patients, 50.6% (n = 40) did not require hospitalization after the procedure, while 25 were hospitalized once, 12 twice, and 2 three times. The mean systolic pulmonary artery pressure (sPAP) values of the patients decreased from 44.30 ± 14.42 mmHg before the procedure to 39.09 ± 11.77 mmHg after the procedure (Z=-3.506, P < 0.001). No correlation was found between changes in MR and TR grades after TAVI and mortality or hospitalization during follow-up. Furthermore, there was no statistically significant difference in tricuspid annular plane systolic excursion (TAPSE), free wall annular S' velocity, left atrial volume (LAV), or LAV index (LAVI) before and after TAVI. Conclusion: There was a significant decrease in moderate-to-severe MR and TR after TAVI; however, this did not impact hospitalization or mortality rates. Additionally, no significant differences were observed in right ventricular systolic function or in LAV and LAVI before and after TAVI.

The Occurrence of Infection and TP53 Mutation Are Risk Factors for Cardiovascular Toxicity of Acute Myeloid Leukemia Induction Therapy

Introduction: For almost 50 years,induction therapy (IT) is the standard of care for acute myeloid leukemia (AML) patients. Nevertheless, little is known about cardiovascular (CV) toxicity during IT. We aimed to describe CV events (CVE)occurring during IT and to identify clinical, hematological and molecular risk factors of such events. Methods: Two hundred and twenty-four patients of 18 years or more (median age 61 (51;67) years, 58% males), treated with ITbetween 2014 and 2021 were enrolled in this study. Two hundred and one (90%) received an anthracycline-based IT, the others received gemtuzumab ozogamicin as part of a clinical protocol research. Survival from the time from initiation of IT until death or until the initiation of the second course of therapy (either salvage regimen in case of primary refractory or relapsed AML, or intensive consolidation therapy in case of response) was considered. The primary endpoint was the time to occurrence of the first CVE after IT initiation, with death as a competing event. Multivariate analysis included significant covariate, identified by univariate models among initial characteristics and occurrence of infection (coded as time dependent covariate). Results: Hematological characteristics were as follows: European LeukemiaNet (ELN) 2022 risk of myelodysplastic neoplasm (MDS)/AML was low, intermediate and adverse in 13%, 29% and 58% of patients respectively. Main mutations encounters were: DNMT3A, FLT3, NPM1, TET2, NRAS, RUNX1, ASXL1, IDH2, PTPN11, BCOR, SRSF2, WT1 and TP53. Main CV risk factors were tobacco (36%), arterial hypertension (35%), obesity (24%), hyperlipidemia (22%), diabetes mellitus (11%). Baseline left ventricular ejection fraction (assessed by transthoracic echocardiography) was &amp;gt;45% in all patients, &amp;gt;55% in 95% of patients. Seventy-five patients (33%) presented a CVE during IT. Eighty-six percent of CVE were severe (grade 3 or more). Patients presenting CVE during IT were significantly older (p=0.02) and presented more often a past history of dilated cardiomyopathy (p=0.04), arterial hypertension (p=0.005) or dyslipidemia (p=0.005). At baseline, CVE patients presented a greater left auricle volume (p=0.005), higher tricuspid regurgitation grade (p=0.01), and more often a right ventricular dilatation or a significative valvopathy (respectively p=0.01 and p=0.03). There was no difference in CVE occurrence between patients treated with and without anthracyclin (p=0.2). Competing risk models identified the following adverse characteristic for the risk of first CVE, namely the occurrence of the first infectious event (Hazard ratio [HR]= 2.43, p=0.005), TP53 mutation (HR=1.79, p=0.04). No other clinical characteristics nor mutation (including TET2 and DNMT3A) were identified. Multivariate analyses demonstrated that TP53 mutation (HR=1.78, p=0.04) and occurrence of infection (HR=2.29, p=0.008) retained independent prognostic value, see Table 1. In a response stratified model, only TP53 mutation was a risk factor of first CVE (HR=2.46, p=0.008). Conclusions: CVE occurred in 33% of patients during IT and were severe. The major adverse role of onset of infection for CVE occurrence after IT could overcome the prognostic value of mutations usually associated with CV risk in the healthy population (i.e. TET2, DNMT3A, ASXL1, ...). TP53 mutation was the only molecular abnormality associated with CVE, in agreement with the increased risk of doxorubicin-induced cardiac toxicity in a mouse model of TP53 clonal hematopoiesis developed by Sano et al. These results suggest that TP53 mutated patients could benefit from careful CV monitoring and optimization of primary prevention treatment.

Chronic kidney disease and survival of patients with tricuspid regurgitation

Abstract Introduction Chronic kidney disease (CKD) patients are under-represented in clinical trials examining transcatheter interventions for tricuspid regurgitation (TR). The purpose of the current analysis was to investigate how CKD modifies the association of severe TR with overall survival. Methods Consecutive echocardiographic reports linked to clinical data from the largest medical center in Israel (2007-2022) were reviewed. Patients were dichotomized into four mutually exclusive TR groups (none/trivial, mild, moderate and severe), following by stratification according to CKD stage classification. The primary outcome was all-cause mortality. Kaplan Meier, Multivariate Cox regression and interaction analysis models were applied. Results Final study population included 78,147 patients with a median age of 67 (IQR: 55-78 years), 2,989 (4%) of whom had severe TR. There were 19,910 (25%) patients with estimated glomerular filtration rate [eGFR] &amp;lt; 60 mL/min/1.73 m2, 14,359 (18%) with eGFR between 30-60 and 5,551 (7%) with eGFR &amp;lt;30. During a median follow-up period of 4 years (IQR: 1-7 years), 28,112 patients (36%) died. Kaplan-Meier survival analysis demonstrated an increased risk of death with both increasing severity of TR and/or CKD grade (log-rank p&amp;lt;.001 for both). Multivariate Cox analysis with adjustment for age, sex, left heart disease and pulmonary pressures demonstrated that compared to the none/trivial group, patients with severe TR were 38% more likely to die during follow up (95% CI 1.30-1.47, p&amp;lt;.001). The association of tricuspid regurgitation with poor survival was CKD-dependent, such that in the eGFR&amp;gt;60 group severe TR was associated with 19% increased risk of death, whereas among patients with eGFR&amp;lt;60 the risk was significantly higher and reached 34% in the same multivariate model (p for interaction &amp;lt;.001). Interestingly, the modification effect of CKD was mediated by RV function, such that the interaction analysis was no longer significant when RV function was incorporated into the multivariate model. Sub analysis limited to patients with isolated TR yielded consisted results. Conclusions While the association of severe TR with poor survival is consistent across all CKD groups, it is more pronounced among patients with advanced CKD. This association may be modulated through right ventricular function. When examining data and outcome of tricuspid clinical trials , special emphasis should be given to CKD status.Consort like figureHR modification by CKD

Hemodynamic implications of transcatheter tricuspid valve repair in HFpEF Patients - HERACLES-HFpEF

Abstract Background Patients with severe tricuspid regurgitation (TR) and heart failure with preserved ejection fraction (HFpEF) have been suggested to respond favourably to transcatheter edge-to-edge tricuspid valve repair (TEER), but the mechanisms remain poorly understood. Purpose The aim of this study was to investigate the pathophysiological implications of TV-TEER in patient with HFpEF and severe TR. Methods This was a prospective interventional single arm trial that included 20 HFpEF patients with invasive evidence of increased filling pressures (i.e. left-ventricular enddiastolic pressure [LVEDP] &amp;gt;15 mmHg and preserved ejection fraction i.e. LVEF ≥50%) at a single centre. All patients received transthoracic echocardiography and cardiac magnetic resonance imaging (MRI) immediately before and 1-month after TV-TEER. During the TV-TEER procedure LV pressure-volume loops were recorded by using a conductance catheter (Figure 1A). The primary outcome was the periprocedural change in the ratio of LVEDP to left-ventricular end-diastolic volume (LVEDV) as surrogate for preload independent diastolic function. The secondary outcomes included single-beat estimated end-diastolic pressure volume-relationships (EDPVRs), and LV distending pressure (calculated as LVEDP-mean right atrial pressure) as well as changes at 1-month in LVEDV and right ventricular EDV (RVEDV) as surrogates for ventricular interdependence. Results Between 02/2021 to 12/2022 20 patients (median age 78, IQR 72 to 83 years, 65% ♀) were included in the prospective HERACLES-HFpEF trial. All patients successfully underwent TV-TEER with a median TR grade reduction of 2 (IQR 2 to 1) on a five-grade scaling. Despite a periprocedural increase in LVEDV (p&amp;lt;0.001), LVEDP remained stable after successful TV-TEER (p=0.12). This led to a significant reduction of the primary endpoint LVEDP/LVEDV (p=0.001, Figure 1B). Load independent diastolic function improved with a rightward shift of the EDPVR (Figure 1C). LV distending pressure increased implying stronger LV distension in the restricted pericardial space. At one-month follow-up MRI (available for 17 patients) LVEDV increased (∆ median +5 ml, p=0.017), while RVEDV decreased (∆ median -17 ml, p=0.031). Interestingly, there was a significant inverse correlation between the change of LVEDV and RVEDV, again implying more favourable LV to RV interaction (Figure 1C). Conclusion TV-TEER in HFpEF patients leads to an immediate periprocedural increase in LV volume at maintained filling pressures. The improved diastolic function is possibly attributable to a more favourable LV to RV interaction where RV volumes are reduced to allow for the LV to better distend in the limited pericardial space. TV-TEER might pose a potential therapy for a subgroup of HFpEF patients with severe TR, meriting validation in prospective endpoint driven clinical trials.Figure 1

Early deterioration of right ventricular strain in patients undergoing transcatheter tricuspid valve intervention

Abstract Background Severe tricuspid regurgitation (TR) leads to volume overload and increased wall stress causing detrimental right ventricular (RV) remodelling and dysfunction and is associated with excess mortality. Transcatheter tricuspid valve interventions (TTVI) emerged to treat patients with severe TR and high surgical risk, but predictors of outcome remain largely unknown. RV free wall longitudinal strain (RVFWLS) is a sensitive parameter for RV dysfunction and has shown prognostic value in patients with functional TR treated conservatively. Periinterventional changes in RVFWLS and right atrial (RA) strain have not been evaluated in patients undergoing TTVI. Purpose To analyse the effect of transcatheter tricuspid valve annuloplasty (TTVA) and transcatheter edge-to-edge repair (TEER) on RVFWLS and RA strain, assessed by speckle tracking echocardiography, and their association with outcome. Methods We retrospectively analysed consecutive patients with severe TR that underwent TTVI at our centre between 2020 and 2022. 126 patients were included (n=48 underwent TTVA with the Cardioband system, n=78 underwent TEER with the PASCAL system). Established parameters for RV function (TAPSE, FAC) as well as RVFWLS and RA reservoir strain (RASR) were analysed at baseline and one month after TTVI. Results All patients (median age 80 years, 69% female, 79% in NYHA III/IV functional class) were at prohibitive surgical risk. RV function at baseline was slightly reduced according to FAC (34% [29-39]) and preserved according to TAPSE (18mm [15-20]), whereas RVFWLS (-18.6±5.7%) and RASR (10.0% [7.0-14.0]) were severely reduced in markedly dilated right heart chambers (RV basal 45mm [41-49], RA area 34 cm2 [28-41]). TR reduction following TTVI to TR grade ≤ 2 was achieved in 77%. Right heart chamber size significantly decreased after one month (RV basal 41mm [38-45], RA area 29cm2 [25-38], P&amp;lt;0.001), with no improvement of FAC (37% [30-40], P=0.668) or RASR (10% [7-13], P=0.143) but deterioration of RV longitudinal function (TAPSE 17mm [13-20], P=0.002; RFWLS -16.1±5.7%, P=0.001) compared to baseline. RVFWLS reduction occurred irrespective of the procedure performed (TEER [-9.2±41.4] vs. TTVA [-7.0±31.3], P=0.783). RVFWLS deterioration occurred in 63%, whereas it improved in 37% of patients. Symptomatic and clinical outcome did not differ in patients with deteriorated vs. improved RVFWLS (improvement of at least one NYHA class 61.9% vs. 58.3%, P=0.569, one-year mortality 13.7% vs. 12.3%, P=0.940, one-year heart failure rehospitalization 10.8% vs. 17.1%, P=0.701). Conclusion Deterioration of RVFWLS after TTVI possibly reflects the decreased wall stress due to TR and consecutive preload reduction. However, symptomatic and clinical outcomes did not differ in patients with deteriorated RVFWLS vs. patients with improved RVFWLS. Reduction of RA size after TTVI did not translate into improvement of RASR, indicating an already advanced pre-existing RA dysfunction.

Right ventricular-arterial coupling and exercise-induced tricuspid regurgitation

Abstract Background Right Ventricular-pulmonary Artery (RV-PA) coupling is prognostic in a variety of cardiovascular disorders, including heart failure with preserved ejection fraction, pulmonary hypertension and severe aortic stenosis. The functional aspects of RV-PA coupling are less investigated than rest ones especially in what is their interaction with tricuspid regurgitation (TR). Purpose We sought to understand the association of RV-PA coupling with extent of exercise induced TR by combining gas exchange abnormalities through cardiopulmonary exercise test (CPET) imaging. Methods We prospectively studied patients with indication to perform a CPET imaging test due to dyspnoea and underlying heart disease of any left ventricular ejection fraction. Demographics, baseline characteristics, echo and CPET parameters [(e.g. VE/VCO2 slope and peak oxygen consumption (pVO2)] were evaluated across 3 sub-cohorts phenotyped according to TR severity pattern at rest and at peak exercise . Mitral and tricuspid regurgitation degree were adjudicated accordingly to ESC guidelines. RV-PA coupling function was assessed through the ratio between tricuspid annular plane systolic excursion (TAPSE), and non-invasive pulmonary artery systolic pressure (PASP) with echocardiography. Dynamic TR was defined as detection of at least moderate TR grade from rest to stress. Results A total of 73 patients (age 67±13 years, 52% men), with a mean LVEF of 50±14% were studied. Overall 50 (69%) patients had less than moderate TR which did not increase during stress (Controls), 11 (15%) patients exhibited a dynamic TR pattern (Group 1), and 12 (16%) already had significant TR at rest (Group 2). TAPSE/PASP at rest and peak exercise were significantly lower in Group 1 and 2 compared to Controls (Figure), while the mean PAP/cardiac output (CO) ratio at rest and at peak exercise were significantly higher (Table). As to gas exchange data, Group 1 and 2 exhibited a lower median peak VO2, while Group 2 patients had also a higher median VE/VCO2 slope compared to Controls (Table). 10 (14%) patients showed at least moderate mitral regurgitation (significant MR) at rest and the prevalence of significant MR at peak was higher in group 1 and 2 compared to Controls (Table). A weak negative correlation was found between TAPSE/PASP slope and E/e’ ratio at peak exercise (r =-0.435, p&amp;lt;0.01). Conclusion In presence of exercise dyspnoea, patients with dynamic TR during maximal exercise exhibit a worse degree of RV-PA coupling and gas exchange profile compared to the group without significant exercise-induced TR. Moreover, the exercise-induced TR profile behaves similarly to the one of those presenting with moderate to severe TR already detectable at rest. Phenotyping dynamic TR and RV-PA warrants further evidence on therapies and outcomes prediction in exertional dyspnoea patients.FigureTable