Tricuspid Regurgitation Group Research Articles

Tricuspid Regurgitation after Orthotopic Heart Transplantation: Trajectories and Association With Mortality.

Tricuspid regurgitation (TR) is common immediately after orthotopic heart transplantation (OHT), though the expected outcomes of TR over time remain undefined. In this study, we examined the natural trajectory of TR in the first 120 days post-transplantation. We observed the clinical phenotypes of trajectories of TR after OHT, and assessed trajectory correlation with 1-year mortality and degree of right ventricular (RV) dysfunction. All patients who underwent OHT at a single institution from January 2009 to July 2019 were included, unless death occurred during the index hospitalization. TR and RV dysfunction on follow-up transthoracic echocardiograms were tracked on 4-point scales and latent-class mixed modeling (LCMM) identified classes of TR trajectories. Fisher's exact test was used to compare 1-year mortalities between classes. Based on LCMM, four distinct classes of TR trajectories emerged, characterized as sustained (n = 40), variable (n = 172), stable (n = 175), and recovered (n = 189) TR. Significant differences in mortality rates were found amongst classes at 10.0%, 8.1%, 4.0%, and 2.6%, respectively (p = 0.025). The degree of RV dysfunction mirrored TR severity in all subsets except the sustained TR group. The trajectory of TR in the first 120 days post-OHT is associated with 1-year mortality. In many subsets, there is a close association with TR grade and RV function improvement. However, in the sustained TR group, RV function improved without subsequent improvement in TR severity. These findings could identify patients with higher mortality risk for whom more frequent follow-up or intervention is warranted.

Preoperative Predictors of Recurrent Tricuspid Regurgitation After Annuloplasty: Insights into the Role of 3D Echocardiography.

While tricuspid annuloplasty (TAP) is an effective treatment option for tricuspid regurgitation (TR), understanding the echocardiographic factors contributing to recurrent TR can help in developing more effective preventive measures to reduce the rate of recurrent TR after TAP. This study was designed as a prospective observational cohort study to investigate factors contributing to recurrent TR following surgical tricuspid valve (TV) repair in patients with moderate or severe functional TR caused by left heart valvular disease, with severe mitral regurgitation as the dominant pathology. The study included 66 patients who underwent preoperative two-dimensional (2D) and three-dimensional (3D) echocardiographic assessments. Patients were divided into two groups based on TAP outcomes: the effective TAP group and the recurrent TR group. The analysis revealed that 3D-derived both septal-lateral diastolic and systolic tricuspid annulus (TA) diameter (odds ratio (OR) 1.77; 95% confidence interval (CI) 1.17-2.68 and OR 1.62; 95% CI 1.14-2.29, respectively), and major axis diastolic TA diameter (OR 1.59; 95% CI 1.15-2.2) had the highest OR among all echocardiographic parameters. The further univariate analysis of predefined echocardiographic values unveiled that the combined effect of heightened 3D-measured TA major axis diastolic diameter and increased right ventricle (RV) basal diameter exhibited the highest OR at 12.8 (95% CI 2.3-72.8) for a recurrent TR. Using ROC analysis, diastolic major axis (area under the curve (AUC) 0.848; cut-off 48.5 mm), septal-lateral systolic (AUC 0.840; cut-off 43.5 mm) and diastolic (AUC 0.840; cut-off 46.5 mm) TA diameter demonstrated the highest predictive value for recurrent TR from all TV parameters. Recurrent moderate or severe TR after TAP is associated with preoperative TA size, right atrium and RV geometry, but not with changes of RV function. The predictive capacity of 2D-assessed echocardiographic parameters was found to be lower when compared to their corresponding 3D parameters.

Predictive factors for recurrent tricuspid regurgitation after tricuspid annuloplasty: 3D echocardiography study

Abstract Introduction There is growing concern about the recurrence of tricuspid regurgitation (TR) after tricuspid annuloplasty (TA) in individuals with functional tricuspid regurgitation (FTR). While TA is effective in treating FTR, a comprehensive understanding of the echocardiographic factors influencing TR recurrence is crucial. Aim This study aims to employ multivariate regression analysis to investigate the prognostic significance of tricuspid valve (TV) geometry and echocardiographic parameters associated with both RV geometry and function. The focus is on comprehending these relationships in the context of recurrent TR subsequent to TA. Methods This prospective observational cohort study aimed to explore factors contributing to recurrent tricuspid regurgitation (TR) after tricuspid annuloplasty (TA). The focus was on patients with moderate or severe functional TR due to left heart valvular disease, particularly severe mitral regurgitation, excluding those with ischemic heart disease. The cohort included 66 individuals undergoing preoperative assessments with 2D and 3D echocardiography, quantifying RV and right atrial (RA) geometry, functional, and tricuspid valve (TV) parameters. TR severity followed ESC guidelines. Patients were categorized into effective TA (50 patients) and recurrent TR (16 patients) groups, defined by mild-moderate TR and significant moderate-severe TR one year post-surgery, respectively. SPSS software facilitated statistical analysis, with adjusted logistic regression considering parameters such as age and gender. Results Among the patients (54% male, mean age 68±9 years), no significant differences were found in gender, left ventricular and atrial parameters, or preoperative TV orifice area between groups (recurrent TR vs. effective TA: 38 [33] mm2 vs. 29 [15] mm2, p=0.117). Univariate logistic regression analysis identified Septal-Lateral Systolic TA Diameter (OR 1.62), Septal-Lateral Diastolic TA Diameter (OR 1.99), and Major Axis Diastolic TA Diameter (OR 1.59) as key predictors. For diagnostic efficacy, ROC analysis revealed Major Axis Diastolic TA Diameter (AUC 0.848; cut-off 52.5 mm), TV Leaflet Tenting Volume (AUC 0.778; cut-off 5.1 ml), and RV Basal Diameter (AUC 0.763; cut-off 47.5 mm) as the most predictive parameters. The combined use of predefined RV basal diameter and Major Axis Diastolic TA Diameter showed the highest odds ratio for recurrent TR. Conclusion Key predictors, including Septal-Lateral Systolic and Diastolic TA Diameters, and Major Axis Diastolic TA Diameter, were identified, emphasizing their significance in understanding TR recurrence after tricuspid annuloplasty. The combination of predefined RV basal diameter and Major Axis Diastolic TA Diameter showed the highest odds ratio for recurrent TR, offering valuable insights for clinical assessment and preventive strategies.

Prognostic preoperative factors for recurrence of tricuspid regurgitation following annuloplasty: examining the influence of 3d echocardiography

Abstract Introduction The increasing worry revolves around the reappearance of tricuspid regurgitation (TR) following tricuspid annuloplasty (TA) among individuals dealing with functional tricuspid regurgitation (FTR). Despite TA's efficacy as a treatment, a complete understanding of the echocardiographic elements influencing the recurrence of TR is pivotal. This knowledge holds the potential to guide the development of more robust preventive strategies, aiming to ease the incidence of recurrent TR after TA. Aim The aim of this study was to examine the prognostic value of tricuspid valve (TV) and echocardiographic parameters related to both right ventricular (RV) geometry and function. Specifically, our focus is on understanding these relationships in the context of recurrent TR following TA. Methods This prospective observational cohort study aimed to investigate determinants of recurrent TR post-surgical TV repair. The focus was on patients with moderate or severe functional TR related to left heart valvular disease, primarily severe mitral regurgitation, excluding those with ischemic heart disease. The study involved 66 participants, assessed preoperatively with 2D and 3D echocardiography, examining RV and right atrial (RA) geometry, functional, and TV parameters. TR severity followed ESC guidelines. Two groups were formed: effective TA group (50 patients) and recurrent TR group (16 patients), defined by mild to moderate TR and significant moderate-severe TR one year post-surgery, respectively. Statistical analysis employed SPSS software, with adjusted univariate logistic regression considering age and gender. Results Of the patients, 54% were male, with a mean age of 68±9 years. Echocardiography parameters in Table 1 showed no significant differences in gender, left ventricular, atrial geometrical, functional parameters, or preoperative effective regurgitant TV orifice area between groups (recurrent TR vs. effective TA: 38 [33] mm2 vs. 29 [15] mm2, p=0.117). Univariate logistic regression analysis highlighted RV and RA geometry, along with TV diameter, as predictors for recurrent TR. Notably, 3D TV geometrical parameters had prognostic significance, as confirmed by univariate adjusted logistic regression analysis. Functional RV parameters did not exhibit statistical significance in this analysis. Conclusion In conclusion, the recurrence of moderate-severe functional tricuspid regurgitation following tricuspid annuloplasty is linked to the tricuspid annulus size, as well as the geometry of the right atrium and right ventricle before surgery. Notably, no correlation was identified between the recurrence of TR and alterations in RV function.

Lead-related tricuspid regurgitation: an important phenotype seen through the lens of computed tomography

Abstract Background The imaging diagnostic approach of patients with cardiac implantable electronic devices (CIED)-related tricuspid regurgitation (TR) is undefined. Functional cardiac computed tomography angiography (4D-CTA) provides a complementary role to echocardiography in the evaluation of tricuspid valve (TV) apparatus and right ventricle (RV) remodeling, but the capability to assess lead-leaflet interaction is unknown. Purpose To evaluate the role of 4D-CTA anatomical and morphological diagnostic assessment in a cohort of patients with severe TR and CIED vs those without. Methods Clinical, echocardiographic and CTA data were collected from two quaternary centers for patients with severe TR and a CIED evaluated between January 2017 to October 2023. Functional and morphological CTA information assessed lead-leaflet relationship to divide patients in those with lead-related TR, those with no lead-TR causal relationship, and those with severe isolated TR but without CIED. Primary end-point was the occurrence of all-cause death. Results A total of 143 patients were identified, roughly dividng the cohort into thirds. Baseline characteristics and imaging characteristics of these 3 groups revealed important differences suggesting a more advanced patophysiology phenotype for those with lead-related TR, particularly presenting both the largest 4D-CTA-derived TV maximum coaptation gap and anatomical regurgitant orifice area (see Figure 1). At regression analysis, time from CIED implantation (OR 1.01, CI 1.00-1.09, p=0.031) and >3 leaflets valve morphology (OR 2.90, CI 1.01-8.32, p=0.040) were independently associated with lead-related TR. After a median follow-up of 18 months, the primary end-point occurred in 36 patients (25%) and was more common among patients with lead-related TR (p-value overall= 0.007, see Figure 2). While no differences in the rate of TV intervention were found, excessive mortality persisted for lead-related TR group even after adjustement for age and gender (HR 6.49, CI 1.72-14.47, p=0.006). Conclusion Systematic 4D-CTA in patients with severe TR and presence of a CIED, identified a large number of patients with lead-related TR with important functional and anatomical implications including greater TR severity and > 3 leaflets. These findings appear to have prognostic relevance that might have decision-making implications for patient management.Figure 1Figure 2

Comprehensive Dynamic 3-Dimensional Analysis of the Tricuspid Valve in Functional Tricuspid Regurgitation: Implications for Prophylactic Tricuspid Valve Intervention

ObjectivesUnderstanding of changes in tricuspid annulus (TA) during secondary or functional tricuspid regurgitation (TR) is currently limited and its surgical management relies on limited 2-dimensional (2D) imaging. The aims of the study were to: 1) track and measure changes in TA using 3-dimensional (3D) echocardiography during complete cardiac cycle in patients with functional TR when compared to no TR, and 2) compare TAPSE derived from 2D and 3D coordinates as a measure of RV function when compared to standard method of fractional area change (FAC). DesignIntraoperative 3D echocardiography data was collected prospectively followed by post processing software analysis to track and reconstruct changes throughout the cardiac cycle. SettingData was collected from 108 patients undergoing left sided heart surgery at two large academic centers – Beth Israel Deaconess Medical Center in Boston, MA and Rhode Island Hospital, Providence, RI between from November 2018 to April 2020. ParticipantsFinal dataset (n=92) included two groups: no significant functional tricuspid regurgitation (NTR) group (n=74), defined as ≤ mild tricuspid regurgitation (TR) and TA < 35 mm, and a significant functional TR (FTR) group (n=18), defined as ≥ moderate TR. Interventions3D TEE datasets were analyzed, and the motion of TA coordinates was tracked during complete cardiac cycle in 2D and 3D planes using post-processing and software analysis. Computational modeling of TA motion was performed using computer-aided design. In further analysis, reconstructed and 3D printed models of TV were developed for the two groups. Measurements and Main ResultsPatients in FTR group had larger TA size during the cardiac cycle with less overall excursion and reduced annular dynamism. 3D motion of TA for lateral (L), anterolateral (AL) and posterolateral (PL) coordinates was lower in FTR group compared to NTR group [(18±6.8 vs 13.6±8.5, p=0.02), (15.2±5.5 vs 11.3±6.0, p=0.009) and (17.6±6.6 vs 12.3±5.2, p=0.002) respectively]. TAPSE derived from 3D planes was more accurate for RV function assessment (AUC 0.704, p = 0.011) than 2D TAPSE (AUC 0.625, p = 0.129). Finally, in the FTR group, the anteroseptal-posterolateral (AS-PL) diameter was consistently larger during all phases of cardiac cycle, in comparison with septo-lateral (S-L) diameter. Conclusion3D echocardiographic assessment of TA helps better understand its geometry and dynamism in functional TR, and is more accurate than 2D measurements for RV function assessment.

Effects of Implantable Cardioverter-Defibrillator Leads on the Tricuspid Valve and Right Ventricle: A Randomized Trial

BackgroundThere are no randomized data to inform the extent to which transvenous cardiac leads cause tricuspid regurgitation (TR). ObjectivesThis study sought to determine the effect of a transvenous implantable cardioverter-defibrillator (TV-ICD) on TR severity, and secondarily, on right ventricular (RV) size and function. MethodsWe evaluated TR severity before and 6 months after implantable cardioverter-defibrillator insertion in a post hoc analysis of adults randomized to receive a transvenous (n = 252) or subcutaneous implantable cardioverter-defibrillator (S-ICD) (n = 251) device. TR and RV size and systolic function were assessed by echocardiographic images analyzed in a core laboratory. ResultsAt baseline, at least mild TR was present in 30% of individuals. At 6 months, the proportion of participants with any TR in the TV-ICD group was 42% vs 19% in the S-ICD group (P < 0.001). The proportion with moderate or severe TR was 7% in the TV-ICD group vs 2% in the S-ICD group (P = 0.021). At 6 months, the OR of at least 1 grade worsening of TR in the TV-ICD group as compared with the S-ICD group was 7.2 (95% CI: 3.3-15.8; P < 0.001). There were no differences between groups with respect to RV size or systolic function. ConclusionsSix months following TV-ICD insertion, there was a 7-fold increase in the risk of at least 1 grade worsening of TR, with 7% of individuals having TR that was moderate or severe. There was no detectable difference in RV size or function; however, longer follow-up is needed.

Tricuspid regurgitation in the context of severe left-sided valvular disease: Patients characteristics and outcome

BackgroundWe aimed to assess the characteristics, management and long-term prognosis of a cohort of patients with multiple valvular disease, focusing on the context of severe mitral or aortic disease with concomitant significant tricuspid regurgitation (TR). MethodsAfter using a propensity score matching for age, 975 patients with ≥ moderate TR, diagnosed at our centers from 2012 to 2020, were included and divided in four groups, including isolated TR patients as reference group. Primary endpoint was all-cause death (ACD), secondary endpoint was the composite of heart failure (HF) hospitalization + any valvular intervention. ResultsPatients with isolated TR (356, 37 %) had more history of atrial fibrillation and were more often asymptomatic and with preserved left-ventricular ejection fraction (LVEF). Patients with severe mitral regurgitation (MR) + TR (466, 48 %) showed higher rates of concomitant coronary artery disease, advanced functional class symptoms and larger left atrial volumes. Severe aortic stenosis (AS) patients (131, 13 %) were older, with more comorbidities and lower LVEF. Patients with severe aortic regurgitation and TR (22, 2 %) were younger, with larger LV dimensions and higher pulmonary arterial pressures.After a median follow-up of 2.8 years, both endpoints were univariably more frequent in patients with severe AS + TR (all p < 0.001), but after comprehensive adjustment difference in the primary endpoint became insignificant, underscoring the serious outcomes of all significant TR groups significantly. Overall, in 44 (5 %) patients tricuspid intervention was performed, with no differences between groups in term of frequency of concomitant or staged tricuspid valve surgical treatment. ConclusionsIn the context of severe left-sided VD, concomitant significant TR is common, and each subtype presents with different clinical and echocardiographic features: patients with severe AS and TR have considerable worse prognosis, although comprehensive adjustment reflected the poor outcomes affecting all types of patients with significant TR. In this scenario, TR was profoundly undertreated.

Concomitant tricuspid valve regurgitation repair in patients with minimally invasive mitral valve surgery: a single-centre experience in Vietnam

Background: This study aims to present the early and mid-term outcomes of combining minimally invasive mitral valve surgery (MIMVS) with tricuspid valve repair (TVR) at the authors’ centre. Methods: From January 2017 to March 2022, our centre treated a total of 67 patients with both MIMVS and TVR. Among these patients, 41 were women (61.2%), and 26 were men (38.8%). The average Euro SCORE II was 2.67±1.54%, and the patients had an average follow-up period of 25.45±16.2 months. Results: Pre-discharge echocardiography revealed no or mild TR in 82.8% of cases. The overall 30-day mortality rate was 4.5%, with 3 deaths. Five-year survival was 94.5%±3.2%. In patients with mild or moderate preoperative tricuspid regurgitation (TR), the 5-year survival rate was 95.7%±4.3%, while for those with severe TR, it was 93.7%±4.5% (P=0.947). Conclusions: The authors’ 5-year experience demonstrates that the combination of MIMVS and TVR can be routinely performed with favourable perioperative and postoperative outcomes in patients undergoing non-high-risk surgery. Additionally, there is no significant difference in five-year survival between the severe TR and mild to moderate TR groups preoperatively.

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

BackgroundThe safety profile of transcatheter tricuspid valve (TTV) repair techniques is well established, but residual tricuspid regurgitation (TR) remains a concern. ObjectivesThe authors sought to assess the impact of residual TR severity post–TTV repair on survival. MethodsWe 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). ResultsResidual 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). ConclusionsThe 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.

Impact of Tricuspid Regurgitation on Outcomes After Transcatheter Mitral Valve Replacement

Development of functional tricuspid regurgitation (TR) due to chronic mitral disease and subsequent heart failure is common. However, the effect of TR on clinical outcomes following transcatheter mitral valve replacement (TMVR) remains unclear. We aimed to evaluate the impact of baseline TR on outcomes after TMVR. This was a single-center retrospective analysis of patients who received valve-in-valve or valve-in-ring TMVR between 2012 and 2022. Patients were categorized into none/mild TR and moderate/severe TR based on baseline echocardiography. Primary outcome was 3-years all-cause death and secondary outcomes were in-hospital events. Among the 135 patients who underwent TMVR, 64 (47%) exhibited none/mild TR at baseline, while 71 (53%) demonstrated moderate/severe TR. There were no significant differences in in-hospital events among the groups. At 3-years, the moderate/severe TR group exhibited a significantly elevated risk of all-cause death (adjusted HR 3.37, 95% CI 1.35-8.41, p = 0.009). When patients with baseline moderate/severe TR were stratified by echocardiography at 30 days into improved (36%) and non-improved (64%) TR groups, although limited by small sample size, there was no significant difference in 3-year all-cause mortality (p = 0.48). In conclusion, this study investigating the impact of baseline TR on clinical outcomes revealed that moderate/severe TR is prevalent among those undergoing TMVR, and was an independent predictor of 3-years all-cause mortality. Earlier mitral valve intervention, prior to the development of significant TR, may play a pivotal role in improving outcomes following TMVR.

Preoperative predictors of recurrent tricuspid regurgitation after annuloplasty: insights into the role of 3D echocardiography

Abstract Introduction There is a growing concern regarding the recurrence of tricuspid regurgitation (TR) after tricuspid annuloplasty (TA) in patients with functional tricuspid regurgitation (FTR). While TA is an effective treatment option, understanding the echocardiographic factors contributing to recurrent TR can help in developing more effective preventive measures to reduce the rate of recurrent TR after TA. Aim The aim is to investigate the relationship between tricuspid valve (TV) and right ventricular geometry and function parameters with recurrent TR after TA. Methods This study was designed as a prospective observational cohort study to investigate factors contributing to recurrent TR following surgical TV repair in patients with moderate or severe functional TR caused by left heart valvular disease, with severe mitral regurgitation as the dominant pathology. Patients with ischemic heart disease were excluded from the analysis. The study included 65 patients who underwent preoperative 2D and 3D echocardiographic assessments, which included the quantification of right ventricular (RV) and right atrial (RA) geometry, functional and TV parameters. The severity of TR was measured according to the recent ESC guidelines, and patients were divided into two groups based on the outcomes of TA: effective TA (43 patients) and recurrent TR group (22 patients). Effective TA was defined as mild TR one year after surgery, while recurrent TR group was defined as moderate or severe TR. Statistical analysis was conducted using SPSS statistical software. Results Of the patients, 54% were male, and the mean age was 68±9 years. The distribution of echocardiography parameters among the study groups are shown in Table 1. Analysis revealed that gender, left ventricular and atrial geometrical and functional parameters, or preoperative effective regurgitant TV orifice area did not differ between the groups (recurrent TR vs. effective TA: 33 [28] mm2 vs. 29 [18] mm2, p=0.113 respectively). However, recurrent TR was associated with dilated RV and RA parameters and an increased septal-lateral diameter of tricuspid annulus. RV functional parameters did not show significant associations. Of all preoperative parameters, RV middle (sensitivity 82%, specificity 63%; AUC 0.731) and basal (sensitivity 73%, specificity 65%; AUC 0.725) diameters, tricuspid annulus sphericity index (sensitivity 59%, specificity 70%; AUC 0.718), septal-lateral systolic (sensitivity 59%, specificity 76%; AUC 0.686) diameter, have the highest predictive value for recurrent TR. Conclusion Recurrent moderate or severe functional TR after TA is associated with preoperative tricuspid annulus size, RA and RV geometry, but not with changes of RV function. This information can guide surgical decision-making. To conclude with, improving our understanding of the factors contributing to recurrent TR after TA can improve patient outcomes and reduce the need for reoperations.

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

Natural course and prognostic impact of lead-related tricuspid regurgitation

Abstract Aim Direct injury from Cardiac Implantable Electrical Device (CIED) leads is one of the most common causes of tricuspid regurgitation (TR), with a reported prevalence up to 40%. Little is known about the natural history of CIED-related TR and the prognostic impact of worsening TR detected at different time points after CIED implantation. Methods The CIED-IT registry retrospectively included patients who underwent CIED implantation in a tertiary referral center in Italy, as long as they had been performed repeated transthoracic echocardiograms (TTE) and at least one chest CT after the implantation. TR severity was graded using a pre-specified 4-class grading scheme: mild, moderate, severe and massive. The primary endpoint for outcome analysis was major adverse clinical events (MACE), defined as the composite of all-cause death or heart failure (HF) hospitalizations. Results 249 patients undergoing CIED implantation from January 2015 to December 2021 were included. Median time to last available TTE was 1593 days (IQR 857-2089). TR prevalence was 71.8% (178/248) at baseline and 88.7% (220/248, p&amp;lt;0.001) at last available TTE. Worsening TR was observed in 48.4% (120/248) of cases. Mean age was 74.5±10.1 years, 35% of patients were females, 45.6% had atrial fibrillation and 41.9% had a LVEF &amp;lt;40%. Baseline RV dysfunction was present in 23.8% of patients, while a worsening RV function was observed in 24.2% of patients with worsening TR and 10.1% of those without worsening TR (p=0.003). Median follow-up time was 4.2 years (IQR: 2.4-5.6). At Kaplan Maier analysis, the cumulative 5-year MACE incidence was 39.4% (95% CI: 30.4-50%) in patients with worsening TR and 18.9% (95% CI: 12.5-28.1%) in those with no worsening TR (Log-Rank p = 0.01). This difference was mainly driven by a higher rate of heart failure hospitalizations in the worsening TR group (36.5% vs, 10 at 5y, Log-Rank p&amp;lt;0.001), while the rate of all-cause death was comparable between the two groups (Log-Rank p=0.313). At multivariable stepwise Cox regression analysis, worsening TR was an independent predictor of both MACE (HR 1.89, 95% CI: 1.15-3.11, p=0.012) and HF hospitalizations (HR 2.77, 95% CI: 1.49-5.16, p=0.001). In a subgroup analysis including patients who also received a 1-year TTE (median time 182 days, IQR: 74-286), worsening TR at last available TTE was still an independent MACE predictor (HR 1.75, 95% CI: 1.0-3.1, p=0.05), while worsening TR at 1y was not (HR 1.66, 95% CI: 0.9-3.06). Conclusions CIED-related TR is a strong determinant of long-term adverse cardiovascular outcomes in patients undergoing CIED implantation. Lead-induced injury is sometimes not evident in the first months after the procedure and might require years to develop clinically significant TR. Serial echocardiographic assessments are therefore pivotal to implement risk stratification, while further knowledge of the pathophysiology of CIED-related TR is required to prevent its occurrence.Kaplan Maier Curves for MACEKaplan Maier curves for HHF

Tricuspid Regurgitation (TR) after Implantation of a Cardiac Implantable Electronic Device (CIED)-One-Year Observation of Patients with or without Left Ventricular Dysfunction.

The frequency of tricuspid regurgitation (TR) progression after cardiac implantable electronic devices (CIEDs) implantation varies from 7.2% to 44.7%. TR is associated with increased mortality and hospitalizations due to heart failure (HF) decompensation. The aim of this study was to assess the rate of early TR progression after CIED implantation and the frequency of HF decompensation and mortality. The 101 patients, who received a CIED between March 2020 and October 2021, before the procedure were divided into two groups-one with left ventricle ejection fraction (LVEF) ≥ 40% (n = 60) and one with LVEF < 40% (n = 41). Lead-related tricuspid regurgitation (LRTR) was defined as an increase of TR by at least one grade. The follow-up period was similar between both groups and was on average 13 (12-16) months. In the whole study group, TR progression by one grade was 34.6% and by two or more grades 15.8%. The significant changes in the dynamic of TR degree were as follows before and after implantation: none/trivial TR in group 1 (61.7% vs. 28.3%, p = 0.01) and severe/massive TR in group 2 (0.0% vs. 14.6%, p = 0.03). The groups did not differ from each other in terms of survival from decompensation of HF (18.3% vs. 36.6%, p = 0.70) and survival from death (1.7% vs. 4.9%, p = 0.16). At the one-year follow-up, the baseline LVEF did not affect the survival rate from death or HF decompensation among patients with a progression of TR after CIED implantation. In this study, a progression by one grade was more common in group 1, but the occurrence of severe/massive TR after implantation was more specific for group 2.

Association of Functional Tricuspid Regurgitation and All-Cause Mortality in Ischemic Heart Failure Varies by Left Atrial Size: A Prospective Cohort Study

This study aimed to evaluate whether the mortality risk of tricuspid regurgitation (TR) varies by left atrial (LA) size in patients with heart failure (HF). In total, 2,234 patients with ischemic HF were included. Participants were categorized as normal LA group and LA enlargement group based on the guideline recommendations, and in each group, patients were further classified as non/mild TR group and moderate/severe TR group according to echocardiographic examination. All-cause mortality was used as the only end point, and comparisons were conducted between the TR degree groups stratified by LA size status. Propensity-matched analyses and restricted cubic splines were performed to verify the robustness of the results. Of 2,234 patients with ischemic HF participants, 1,002 (44.9%) had LA enlargement and 294 (13.2%) had moderate/severe TR. After a median follow-up of 3.02 years (7,140 person-years), 453 patients (20.3%) died. After adjusting for the covariates, the higher mortality risk of moderate/severe TR was only observed in the normal LA diameter group (hazard ratio 1.64, 95% confidence interval 1.02 to 2.65) rather than the LA enlargement group (hazard ratio 0.96, 95% confidence interval 0.69 to 1.34). A significant interaction of TR degree was observed between the normal LA size group and the LA enlargement group. The relation was consistent in the propensity-matching cohort and in the restricted cubic splines analysis. In conclusion, mortality rate and prevalence of moderate/severe TR were high in patients with ischemic HF. Moderate/severe TR is significantly associated with all-cause mortality in those with normal LA diameter. The mechanisms underlying these observations merit further investigation.

Fate of concomitant tricuspid regurgitation in patients undergoing coronary artery bypass grafting

ObjectiveOwing to a lack of supportive data, tricuspid regurgitation (TR) is usually not addressed in patients undergoing coronary artery bypass grafting (CABG). Here we evaluated changes in TR degrees over time and its impact on survival in patients undergoing CABG. MethodsWe reviewed the data of 9726 patients who underwent isolated CABG between January 2000 and January 2021. According to preoperative TR severity, patients were stratified into nonsignificant (none to trivial, mild) and significant (moderate to severe) TR groups. We excluded patients who had undergone previous tricuspid valve surgery, pacemaker placement, and concomitant valve or ablative surgery. Propensity score matching and Cox proportional hazards models were used to identify associations between TR grade and the primary outcome of all-cause mortality. The secondary outcome was change in TR severity on the last echocardiogram. ResultsAfter propensity score matching, 380 patients in each group were identified. At baseline, 359 patients had moderate TR (94.5%) and 21 (5.5%) had severe TR. On the last follow-up echocardiogram, TR had improved in 40.5% of the patients in the significant TR group. Kaplan–Meier survival curves showed significantly lower survival in patients with significant preoperative TR compared to those with nonsignificant TR (P < .001). After adjusting for other confounders, survival was no worse in the patients with significant TR group (hazard ratio, 1.05; 95% confidence interval, 0.80-1.38; P = .70). ConclusionsSignificant preoperative TR improved in 40.5% of patients after isolated CABG. After adjusting for other factors, significant TR did not affect long-term survival.

Body mass index, frailty and outcome of patients with significant tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Background Body weight is associated with frailty and is an independent strong predictor of adverse outcomes among patients with cardiovascular diseases. Purpose To evaluate how body mass index (BMI) and frailty modify the association of significant tricuspid regurgitation (TR) with poor survival. Methods Consecutive echocardiographic reports linked to clinical data from a tertiary medical center (2007–2021) were reviewed. Patients with BMI between 14 and 45 Kg/m2 were included, with the first echocardiography as the index case. Significant TR was defined as moderate-to-severe or severe. BMI categories included underweight, normal weight, overweight and obesity with cutoffs of 18.5, 25 and 30, respectively. Frailty was stratified into 3 groups. The primary outcome was all-cause mortality and was available for all patients. Multivariable Cox regression and interaction analysis models were applied. Results Final study population included 109,927 patients with a median age of 65 (IQR 52–76) years of whom 63,368 (58%) were males. 3,352 (3.1%) patients had significant TR. There were 2,384 (2%), 39,638 (36%), 43,086 (39%), and 24,700 (24%) individuals with underweight, normal weight, overweight, and obesity, respectively, with 3% of significant TR in each weight group. During a median follow-up of 4.7 (1.8–8.5) years 28,917 (26%) patients died. Interaction analysis of the multivariable model demonstrated that the association of significant TR with poor survival was significantly modified by BMI such that the association of significant TR with mortality differed across BMI groups (not significant for underweight groups, HR of 1.27 1.32 and 1.34 for normal weight, overweight and obesity, p&amp;lt;.0001 for all three groups: Figure 1A). Interaction analysis between TR and frailty was not significant, as in all frailty groups the TR was similarly associated with mortality. Sub-analysis of 67,188 (61%) patients who were hospitalized, with adjustment of the model to baseline comorbidities (heart failure, ischemic heart disease, diabetes etc.) yielded similar point estimates to the main analysis (Figure 1B). Conclusions The association of significant TR with poor survival is not modified frailty, whereas it is modified by body weight. Among underweight patients, significant TR is not an independent predictor of mortality.

Chronic kidney disease and outcome of patients with tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Although chronic kidney disease (CKD) is common among patients with tricuspid regurgitation (TR), these patients are under-represented in clinical trials examining tricuspid transcatheter interventions, and data regarding their outcome are limited. Methods Consecutive echocardiographic reports linked to clinical data from the largest medical center in Israel (2007–2022) were reviewed. Patients were dichotomized into three groups TR groups (mild, moderate and severe), following by stratification according to renal function. The primary outcome was all-cause mortality. Kaplan Meier, Multivariate Cox regression and interaction analysis models were applied. Results The final study population included 78,461 patients with a mean age of 65 (IQR: 55–78 years), 2,998 (4%) of whom had severe TR. There were 11,443 (15%) patients with at least moderate CKD (estimated glomerular filtration rate [eGFR] &amp;lt; 45 mL/min/1.73 m2), 5573 (7%) with eGFR&amp;lt;30 and 1853 (2%) with eGFR&amp;lt;=15. During a median follow-up period of 4 years (IQR: 1–7 years), 28,228 patients (36%) died. Kaplan-Meier survival analysis demonstrated an increased risk for death with both increasing severity of TR and/or CKD grade (log-rank p&amp;lt;.001 for both;). The association of severe TR with poor survival was consistent among all CKD subgroups (FIGURE). Multivariate Cox analysis with adjustment for age, sex, ejection fraction, estimated pulmonary pressure and eGFR demonstrated that compared to mild TR, patients with severe TR were 56% more likely to die during follow up (95% CI 1.47–1.66, p&amp;lt;.001). Interaction analysis demonstrated that the association of severe TR degree with survival was consistent in all subgroups but dependent on renal function, such that it was more pronounced as renal function declined, with adjusted HR of 1.6 among patients with eGFR&amp;lt;=15 (P for intercation &amp;lt;.001). Conclusions While the association of TR with poor survival is consistent across all CKD groups, it is more pronounced among patients with advanced CKD. When examining data and outcome of tricuspid clinical trials, special emphasis should be given to CKD status.

Venae Cavae Anatomic Characteristics in Severe Tricuspid Regurgitation: Implications for Transcatheter Interventions

Venae Cavae Anatomic Characteristics in Severe Tricuspid Regurgitation: Implications for Transcatheter Interventions