Reduction Of Tricuspid Regurgitation Research Articles

Initial experience with transcatheter tricuspid valve repair in patients with cardiac amyloidosis.

Wildtype transthyretin amyloid cardiomyopathy is an under-recognized cause of heart failure in elderly patients. Transcatheter tricuspid valve repair is a newly emerging therapeutic option for severe tricuspid regurgitation (TR). We present first insights into safety and possible benefits of this procedure in patients with cardiac amyloidosis. Eight patients with cardiac non-hereditary (wildtype) transthyretin (ATTRwt) amyloidosis and severe to torrential TR, undergoing successful transcatheter tricuspid valve repair, were included in the analysis and compared to a control group of 21 patients without cardiac amyloidosis. All patients presented with an advanced stage of amyloid cardiomyopathy. Primary endpoint was reduction in TR at 3months follow-up. Secondary endpoints were feasibility, safety, hospitalization or death, clinical improvement, cardiac biomarkers, and structural and functional right heart parameter obtained by echocardiography. Transcatheter tricuspid valve repair resulted in a significant reduction of TR (IV to II, P=0.008) in all eight patients with cardiac amyloidosis (100%). Device success (amyloidosis 75% vs. control group 86%, P=0.597) and overall probability of hospitalization or death (amyloidosis 13% vs. control group 25%, P=0.646) were similar compared with those in the control group at 3months follow-up. Transcatheter tricuspid valve repair led to an improvement of New York Heart Association functional class (P=0.031) and 6min walking distance (from 313±118 to 337±106, P=0.012). TR reduction in amyloidosis patients was less extensive compared with that in control group (TR-reduction 1.6±0.3, P=0.008 vs. control group 2.3±0.3, P<0.0001). Furthermore, these patients showed no significant improvement of structural right heart parameters. Transcatheter tricuspid valve repair is a safe and feasible new treatment option in patients with amyloid cardiomyopathy and has the potential to improve TR-grade and clinical status. However, the benefit appears to be less pronounced compared with patients without cardiac amyloidosis.

Sex-related characteristics and short-term outcomes of patients undergoing transcatheter tricuspid valve intervention for tricuspid regurgitation.

The impact of sexuality in patients with significant tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve intervention (TTVI) is unknown. The aim of this study was to investigate sex-specific outcomes in patients with significant TR treated with TTVI vs. medical therapy alone. The Transcatheter Tricuspid Valve Therapies (TriValve) registry collected data on patients with significant TR from 24 centres who underwent TTVI from 2016 to 2021. A control cohort was formed by medically managed patients with ≥severe isolated TR diagnosed in 2015-18. The primary endpoint was freedom from all-cause mortality. Secondary endpoints were heart failure (HF) hospitalization, New York Heart Association (NYHA) functional status, and TR severity. One-year outcomes were assessed for the TriValve cohort and compared with the control cohort with the inverse probability of treatment weighting (IPTW). A total of 556 and 2072 patients were included from the TriValve and control groups, respectively. After TTVI, there was no difference between women and men in 1-year freedom from all-cause mortality 80.9% vs. 77.9%, P = 0.56, nor in HF hospitalization (P = 0.36), NYHA Functional Classes III and IV (P = 0.17), and TR severity >2+ at last follow-up (P = 0.42). Multivariable Cox-regression weighted by IPTW showed improved 1-year survival after TTVI compared with medical therapy alone in both women (adjusted hazard ratio 0.45, 95% confidence interval 0.23-0.83, P = 0.01) and men (adjusted hazard ratio 0.42, 95% confidence interval 0.18-0.89, P = 0.03). After TTVI in high-risk patients, there were no sex-related differences in terms of survival, HF hospitalization, functional status, and TR reduction up to 1 year. The IPTW analysis shows a survival benefit of TTVI over medical therapy alone in both women and men.

Abstract 12654: Reduction of Tricuspid Regurgitation as Predictor of Successful Percutaneous Edge-to-Edge Repair: Clinical Outcomes Comparison Between Patients With Residual Severe and Moderate-or-Less Regurgitation

INTRODUCTION: Transcatheter tricuspid valve repair (TTVR) for high-grade regurgitation (TR) is emerging as a viable option, but defining procedure-related clinical success is challenging, as considerable reduction is not possible in all patients with massive or torrential TR. This study compared clinical outcomes of edge-to-edge TTVR, in patients with residual severe vs moderate-or-less TR. Methods: Eligible patients had chronic symptomatic functional TR despite diuretic therapy, and were deemed inoperable by the local Heart Team. TR was assessed by the current five-grade classification. Efficacy and safety outcomes were compared at baseline and 6 months, with follow-up between January 2021 and May 2022. Results: Forty-three patients had ≥severe (III/V) functional TR, 65% presenting with massive (IV/V) and 14% with torrential (V/V) TR. Mean age was 81.8±4.9 years, with 10.8±6.3% STS-Score. The primary efficacy endpoint of at least one-grade TR reduction was recorded in 91% of all patients, with no device related complications.Residual severe TR (STR subgroup) was present in 15 patients, while 20 (MTR subgroup) had moderate-or-less (≤II/V). By 6 months, 4 patients died, 4 patients had no TR reduction, and MACE rate was 18.6%. Improvement in initial NYHA class III/IV occurred in 61% of STR and 77% of MTR patients. KCCQ Score increased by 17±10.6 pts. (p&lt;0.001) vs 21±11.8 (p&lt;0.001), and six-minute walk test by 69.6±48.7 meters (p&lt;0.001) vs 74.2±63 (p&lt;0.001). Renal and liver function equally improved in both groups [GFR 50±16ml/min/1,73m 2 to 57.8±20.4 (p=0.012) vs 57.4±18.5 to 65.5±21.2 (p=0.002); AST 27.5±9.3U/L to 22.9±7.3 (p=0.039) vs 37.2±25.6 to 26.8±7.3 (p=0.069)]. CONCLUSIONS: Although TTVR should always aim for trace to mild TR, considerable reduction is not always possible. This study indicates that even one-grade TR reduction can significantly impact quality of life, functional capacity and multiorgan involvement, similarly in STR and MTR patients.

Abstract 11155: Recovery of Tricuspid Valve Function After Resection of a Primary Ovarian Carcinoid Tumor

Case Presentation: A 51-year-old woman presented with a &gt;1-year history of bilateral leg edema, diarrhea, and facial flushing. Examination revealed a large abdominal mass, which CT scan confirmed to be a 15x11x13 cm ovarian mass with solid and cystic components. She underwent hysterectomy and bilateral salpingo-oophorectomy. Histopathology revealed a 17 cm ovarian dermoid cyst containing an insular carcinoid tumor. Her post-operative urinary 5-hydroxyindoleacetate (HIAA) level was 23 umol/d (normal 10-40 umol/d) and chromogranin-A level was 95 ug/L (normal &lt;94 ug/L), but positron emission tomography (PET) scan showed lymph node metastasis, prompting initiation of lanreotide, a somatostatin analogue. A perioperative echocardiogram revealed thickened, fixed, and retracted tricuspid and pulmonic valves with severe tricuspid and pulmonary regurgitation consistent with carcinoid heart disease. The right ventricle was dilated but showed preserved systolic function. Valve intervention was considered but deferred as right heart catheterization 15 weeks after surgery showed normal right-sided pressures. A follow-up echo 8 months post resection showed unchanged pulmonary regurgitation but significant improvement in tricuspid valve mobility with a corresponding reduction in tricuspid regurgitation to a mild-to-moderate level. Discussion: Thickened and fixed tricuspid valve leaflets with significant regurgitation represents a hallmark of carcinoid heart disease that can lead to progressive right heart failure, often necessitating surgical intervention. This is a rare case of carcinoid heart disease where there was marked improvement in tricuspid valve function after surgical resection of a primary carcinoid tumor and initiation of somatostatin analog therapy. It highlights the potential for timely treatment to reverse the deleterious effects of carcinoid tumors on cardiac valves, which may ultimately spare the need for cardiac surgery.

Right ventricular function in transcatheter mitral and tricuspid valve edge-to-edge repair.

Since transcatheter edge-to-edge repair (TEER) has become a valuable therapy in the treatment of both, mitral (MR) and tricuspid regurgitation (TR), the question of optimized patient selection has gained growing importance. After years of attributing rather little attention to the right ventricle (RV) and its function in the setting of valvular heart failure, this neglect has recently changed. The present review sought to summarize anatomy and function of the RV in a clinical context and aimed at presenting the current knowledge on how the RV influences outcomes after TEER for atrioventricular regurgitation. The anatomy of the RV is determined by its unique shape, which necessitates to use three-dimensional imaging methods for detailed and comprehensive characterization. Complex parameters such as RV to pulmonary artery coupling (RVPAc) have been developed to combine information of RV function and afterload which is primary determined by the pulmonary vasculature and LV filling pressure. Beyond that, TR, which is closely related to RV function also plays an important role in the setting of TEER. While mitral valve transcatheter edge-to-edge repair (M-TEER) leads to reduction of concomitant TR in some patients, the prognostic value of TR in the setting of M-TEER remains unclear. Overall, this review summarizes the current state of knowledge of the outstanding role of RV function and associated TR in the setting of TEER and outlines the unsolved questions associated with right-sided heart failure.

Right ventricular ejection fraction assessed by computed tomography in patients undergoing transcatheter tricuspid valve intervention

Abstract Background The role of right-ventricular (RV) function in patients with tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve interventions (TTVI) is poorly understood. Although cardiac computed tomography (CCT) provides elaborate three-dimensional (3D) visualization of the entire anatomy of the RV and theoretically allows to assess the global RV systolic function. Nevertheless, the utility of the functional assessments of the RV using CCT remains unclear in patients undergoing TTVI. Purpose This study investigated the association of right-ventricular ejection fraction (RVEF) assessed by CCT with clinical outcome in patients undergoing TTVI. Methods We retrospectively assessed 3D-RVEF by using pre-procedural CCT images in patients undergoing TTVI with either edge-to-edge repair or annuloplasty device. RV dysfunction (RVD) was defined as a CT-RVEF &amp;lt;45%. The primary outcome was a composite outcome, consisting of all-cause mortality and hospitalization due to heart failure, within one year after TTVI. Results Of 157 patients, 58 (36.9%) presented with CT-RVEF &amp;lt;45%. Patients with CT-RVEF &amp;lt;45% were more likely to be male, to have a previous history of coronary artery disease, and had higher EuroSCORE II and a lower LVEF compared to those with CT-RVEF ≥45%, while the severity of TR was comparable between the groups. Among the patients with CT-RVEF &amp;lt;45%, acute procedural success was achieved in 93.1%, and in-hospital mortality was 1.7%, which were comparable to those with CT-RVEF ≥45%. Patients with CT-RVEF &amp;lt;45% had an improvement in New York Heart Association functional class at follow-up compared to baseline; however, CT-RVEF &amp;lt;45% was associated with a higher risk of the composite outcome (adjusted hazard ratio: 3.23; 95% confidence interval: 1.52–6.88; p=0.002) (Figure 1). Furthermore, CT-RVEF had an additional value to stratify the risk of the composite outcome beyond two-dimensional transthoracic echocardiographic (TTE) assessments (Figure 2). In addition, patients with CT-RVEF &amp;lt;45% exhibited an attenuated association between a reduction in TR to &amp;lt;3+ and a lower incidence of the composite outcome after TTVI compared to those with CT-RVEF ≥45%. Conclusions TTVI is safe and feasible regardless of baseline RV function, while RVD, defined as 3D-RVEF &amp;lt;45%, is associated with a higher risk of the composite outcomes within one year after TTVI. Furthermore, our findings suggest that the prognostic benefits of TR reduction might be attenuated in patients with RVD. Given the additional prognostic value of CT-RVEF to the conventional echocardiographic assessments, the assessments of 3D-RVEF with CCT may refine the patient selection for TTVI. Funding Acknowledgement Type of funding sources: None.

Transthoracic echocardiography guidance of transcatheter edge-to-edge percutaneous tricuspid valve repair: the TTE-TTVR pilot study and methodology proposal

Abstract Background Transcatheter tricuspid valve repair (TTVR) is an emerging option for treating high-grade tricuspid regurgitation (TR) [1], mostly performed by edge-to-edge repair, and always guided by transesophageal echocardiography (TOE). In patients with excellent acoustic window, transthoracic echocardiography (TTE) can also provide a comprehensive understanding of tricuspid valve (TV) morphology [2]. Also, in TTVR there is no need for transseptal puncture. Purpose We sought to determine if TTVR can be successfully conducted by a novel TTE guiding approach, in conjunction with fluoroscopy [3]. Methods 30 consecutive patients, scheduled for TTVR, were assigned to a TTE group (n=10), in the presence of excellent acoustic window, and a TOE group (n=20). On top of fluoroscopy, TTVR was guided exclusively by TTE in the first group, with TOE result confirmation solely upon clip release, due to safety reasons. The second group underwent classical TOE guidance. Understanding the 4 right heart chamber views (Fig. 1) and their respective fluoroscopic angulations was paramount. TR severity, parameters of quality of life and functional capacity were assessed and compared between-groups, at baseline and 30 days. Results Except for lower BMI (TTE 22.3±0.8 vs TOE 29.8±4.3, p&amp;lt;0.001), other baseline characteristics were very similar between groups, e.g., age (81.7±3.9 vs 82.8±4.1, p=0.483) or EuroSCORE II (11.9±10.3 vs 10.4±8, p=0.692).Device success was achieved in all patients, with a total of 15 implanted clips in the TTE group (mean no. of clips / patient 1.5±0.7) and 31 clips in the TOE group (1.5±0.6). Device time (75±37.1 vs 65.7±31.3 minutes, p=0.506) and fluoroscopy duration (16.3±10.5 vs 14.4±7.2 minutes, p=0.564) were also close. TR reduction was successful in all but one patient, in each group (90% vs 95%, p=1.000). TR improvement was equal between-groups, with 2 or more grade reduction in 60% of each group, at 30 days. Thus, grade IV/V and V/V TR, present in 60% of all patients at baseline, dropped to 10% (9/10 vs 18/20, p=1.000) by procedure end and follow-up (Fig. 2). No device associated complications occurred. By 30 days, there was one non-cardiac death and one major bleeding. At follow-up, all but one patient had at least one grade reduction in NYHA class (10/10 vs 19/20, p=1.000). Kansas City Cardiomyopathy Questionnaire score and 6-minute walk distance similarly improved (Δ20.7±14.9 vs 15.5±7.9 points, p=0.227; Δ80.5±60.1 vs 46.6±30.6 meters, p=0.121). A statistical in-group difference was also noticed in renal function improvement by follow-up [glomerular filtration rate (GFR) TTE group 56.8±18.7 vs 64.8±12.5 ml/m2/1.73 m2, p=0.028; TOE group 50.7±19.9 vs 62.2±25.9, p=0.001]. Conclusion TTE guidance of TTVR is feasible in selected patients with excellent acoustic window and could offer an alternative in case of high anesthetic risk. Similar procedural success and clinical outcomes, as with TOE guidance, can be achieved. Funding Acknowledgement Type of funding sources: None.

Influence of pacemaker leads on the severity of tricuspid regurgitation after successful mitral valve edge to edge repair

Abstract Background After percutaneous mitral-valve edge-to-edge repair (MVER) for mitral regurgitation (MR) in patients with baseline tricuspid regurgitation (TR), about one third of patients shows improvement in TR severity. It is unknown whether this improvement may depend on the presence of a right ventricular (RV) pacemaker (PM) lead. Aim We investigated whether the presence of an existing RV PM lead influences TR severity after successful MVER due to symptomatic secondary MR. Methods and results We retrospectively analyzed 115 consecutive patients with symptomatic secondary high-grade MR (age 78.1±9.4 years, 50 women (43%) and baseline TR grade &amp;gt; or =1 (semiquantitative grading from 0 to 5) treated with MVER using the MitraClipTM device (Abbott, Cardiovascular, USA) and separated them in 2 groups, 43 patients with a PM lead compared to 72 pts without (see Table). TR grading by echocardiography was performed before and 3 months after MVER. (median follow up duration was 3 months). Procedural success with reduction of MR to &amp;lt; or =2/4 grades was 100% in both groups (p&amp;lt;0,001 vs. baseline). There was an overall significant change in TR grade after MVER in 46 pts (p 0,032): but both increase in TR in 17 pts (16.7%, p=0.58), in 10 pts with and in 7 pts without PM lead (58.8% vs. 41.2%, respectively; p=0.84) was not significant; the decrease in TR in 29 patients (28.4%, p=0.57), in 20 pts with and in 9 pts without PM lead (69% and 31%, respectively; p=0.47) also failed to reach statistical significance. TR reduction was associated with RV dilatation at baseline (p=0.006) but not the presence of pulmonary hypertension (p=0.83). Conclusion There was an overall significant change in TR after successful MVER. Although there was a trend towards an increase in TR after MVER in pts with PM lead there was no overall significant correlation between changes in TR severity and the presence of an RV PM lead but rather with baseline RV dilatation. Funding Acknowledgement Type of funding sources: None.

1-Year Outcomes of Cardioband Tricuspid Valve Reconstruction System Early Feasibility Study.

Tricuspid regurgitation (TR) is prevalent and undertreated, with mortality and morbidity increasing with TR severity. Given poor outcomes with medical therapy and high in-hospital mortality for isolated tricuspid valve surgery, emerging transcatheter repair devices offer a promising alternative. The Edwards Cardioband Tricuspid Valve Reconstruction System Early Feasibility study (NCT03382457) evaluates the treatment of functional TR via annular reduction with the Cardioband Tricuspid Valve Reconstruction System (Edwards Lifesciences). Patients with≥ moderate functional TR were eligible for this prospective, single-arm multicenter study. At 1year, patients were evaluated for echocardiographic parameters, clinical and quality-of-life measures, and major adverse events. The 37 patients enrolled had a mean age of 78 years; 76% were female; and they had≥ severe functional (97.3%) or mixed (2.7%) TR, atrial flutter/fibrillation (97%), and New York Heart Association functional class III/IV (65%). At 1 year, 73.0% achieved≤ moderate TR (P< 0.0001), and 73.1% had≥2 grade reductions. Echocardiography showedsignificant reductions in the tricuspid annulus diameter (P< 0.0001), mean vena contracta (P< 0.0001), proximal isovelocity surface area effective regurgitant orifice area (P< 0.0001), right ventricular end-diastolic diameter (P< 0.0001), and inferior vena contracta (P = 0.0006). New York Heart Association functional class improved significantly (P< 0.0001), with 92.3% achieving class I/II, and Kansas City Cardiomyopathy Questionnaire scores improved by 19.0 points (P< 0.0001). One-year cardiovascular mortality was 8.1%, reinterventions were necessary in 5.4%, major access site complications occurred in 8.1%, and severe bleeding was noted in 35.1% of patients. Kaplan-Meier estimates of survival and freedom from heart failure rehospitalization were 85.9% and 88.7%, respectively. One-year experience using the Cardioband system for tricuspid valve repair shows high survival and low rehospitalization rates with durable outcomes in TR reduction and echocardiographic, clinical, and quality-of-life outcomes.

Right ventricle remodeling after transcatheter tricuspid leaflet repair in patients with functional tricuspid regurgitation: Lessons from the surgical experience.

Clinically significant tricuspid regurgitation (TR) is common and associated with excess mortality. At the same time right ventricular (RV) failure is a complex clinical syndrome that results from many causes, but is often associated with long-term prognosis. Whilst results of isolated tricuspid valve (TV) surgery are often unsatisfactory and limited by the prohibitive risk of most patients, the recent development of percutaneous recovery techniques has opened new scenarios. In consideration of the complexity of the mechanisms that lead to right heart failure and RV dysfunction it is important to understand the real advantages that percutaneous TV treatment can offer, more specifically the effect of TR reduction on RV remodeling in the setting of functional tricuspid regurgitation (fTR).

Transcatheter Tricuspid Valve Repair in Prohibitive Risk Patients: Impact on Quality of Life and Major Organ Systems

BackgroundPercutaneous repair for severe tricuspid regurgitation (TR) is emerging as a viable option, but patient selection is challenging and predetermined by comorbidities. This study evaluated mid-term outcomes of transcatheter tricuspid valve repair (TTVR) in very sick inoperable patients and explored the concept of risk-based therapeutic futility. MethodsTTVR patients treated in our centre were prospectively assigned to prohibitive-risk (PR) and high-risk (HR) subgroups, based on Society of Thoracic Surgeons (STS) Score, frailty indices, and major organ system compromise. Efficacy and safety outcomes were compared at baseline, 30 days, and 6 months. ResultsThirty-three patients (mean age 81.9 ± 5.1 years) completed follow-up from May 2021 to March 2022: 18 PR (mean STS Score 15.5 ± 7%) and 15 HR (mean STS Score 6.4 ± 1.7%). The primary efficacy end point of at least 1 grade of TR reduction by 30 days was recorded in 93.9% of all patients, with no device-related adverse events. Improvement in initial New York Heart Association functional class III/IV occurred in 74% of PR and 93% of HR patients. Six-minute walk test increased by 81 ± 43.6 metres (P < 0.001) and 85.8 ± 47.9 metres (P < 0.001), respectively. Renal function tests improved by 15% (P = 0.048) and 7% (P = 0.050), while liver enzymes decreased by 18% (P = 0.020) and 28% (P = 0.052). Right ventricular systolic function increased in both subgroups by at least 24% (P < 0.001). Six-month mortality was 12.1%, with 6 hospitalisations for acute heart failure. ConclusionsTR reduction significantly affected quality of life, functional capacity, cardiac remodelling, and multiorgan involvement similarly in PR and HR patients. TTVR is feasible in very sick symptomatic patients, regardless of predicted risk.

Multicenter Experience With the Transcatheter Leaflet Repair System for Symptomatic Tricuspid Regurgitation.

Transcatheter treatment techniques for tricuspid regurgitation (TR) have evolved in recent years, with leaflet repair being the most commonly used, but thus far evidence on the PASCAL and PASCAL Ace system is based mainly on compassionate use data. This is the first report on commercial use in a multicenter study with a large patient cohort investigating the safety and efficacy of the PASCAL and PASCAL Ace system in the treatment of TR. In a retrospective, multicenter, observational setting, data from all consecutive patients undergoing leaflet repair for TR at 8 centers was collected, including a centralized analysis of echocardiographic data. A total of 235 high-risk patients (mean age 78 ± 8 years, 49% women, mean Society of Thoracic Surgeons Predicted Risk of Mortality score 8.6% ± 6.8%) were included. TR was functional in 87% of patients and graded severe or higher in 91%. TR was successfully reduced to moderate or less in 78% of patients (P< 0.001). Procedural success was 78% (n=153). At the latest available follow-up (median 173days), TR reduction was sustained (78% with TR moderate orless; P< 0.001), and echocardiography showed indications of right ventricular remodeling (mean right ventricular end-diastolic diameter 56 ± 9mm vs 53 ± 9mm; P< 0.001). Patients' symptoms diminished significantly (63% were inNew York Heart Association functional class I or II at follow-up; P< 0.001). In a device-specific analysis, the PASCAL andPASCAL Ace showed no difference in TR reduction (postprocedural TR moderate or less in 77% vs 78%; P=0.82). In early clinical experience, the PASCAL (Ace) leaflet repair system has high technical and procedural success rates with efficient TR reduction and significant clinical and echocardiographic improvement at follow-up.

Invasive Hemodynamic Assessment and Procedural Success of Transcatheter Tricuspid Valve Repair-Important Factors for Right Ventricular Remodeling and Outcome.

IntroductionSevere tricuspid regurgitation (TR) is a common condition promoting right heart failure and is associated with a poor long-term prognosis. Transcatheter tricuspid valve repair (TTVR) emerged as a low-risk alternative to surgical repair techniques. However, patient selection remains controversial, particularly regarding the benefits of TTVR in patients with pulmonary hypertension (PH).AimWe aimed to investigate the impact of preprocedural invasive hemodynamic assessment and procedural success on right ventricular (RV) remodeling and outcome.MethodsAll patients undergoing TTVR with a TR reduction of ≥1 grade without precapillary or combined PH [mean pulmonary artery pressure (mPAP) ≥25 mmHg, mean pulmonary artery Wedge pressure ≤ 15 mmHg, pulmonary vascular resistance ≥3 Wood units] were assigned to the responder group. All patients with a TR reduction of ≥1 grade and precapillary or combined PH were classified as non-responders. Patients with a TR reduction ≥2 grade were directly classified as responders, and patients without TR reduction were directly assigned as non-responders.ResultsA total of 107 patients were enrolled, 75 were classified as responders and 32 as non-responders. We observed evidence of significant RV reverse remodeling in responders with a decrease in RV diameters (−2.9 mm, p = 0.001) at a mean follow-up of 229 days (±219 SD) after TTVR. RV function improved in responders [fractional area change (FAC) + 5.7%, p < 0.001, RV free wall strain +3.9%, p = 0.006], but interestingly further deteriorated in non-responders (FAC −4.5%, p = 0.003, RV free wall strain −3.9%, p = 0.007). Non-responders had more persistent symptoms than responders (NYHA ≥3, 72% vs. 11% at follow-up). Subsequently, non-response was associated with a poor long-term prognosis in terms of death, heart failure (HF) hospitalization, and re-intervention after 2 years (freedom of death, HF hospitalization, and reintervention at 2 years: 16% vs. 78%, log-rank: p < 0.001).ConclusionHemodynamic assessment before TTVR and procedural success are significant factors for patient prognosis. The hemodynamic profiling prior to intervention is an essential component in patient selection for TTVR. The window for edge-to-edge TTVR might be limited, but timely intervention is an important factor for a better outcome and successful right ventricular reverse remodeling.

El sistema TriClip para la reparación transcatéter de la válvula tricúspide. Estudio multicéntrico español

Introduction and objectivesIn patients with tricuspid regurgitation (TR), edge-to-edge transcatheter tricuspid valve repair (TTVR) is the strategy with the highest penetration worldwide. A dedicated edge-to-edge TTVR system has recently become available in Europe. The present study describes the initial experience with the system in Spain. MethodsThis multicenter study collected individual data from the centers accepted for the use of the novel system within an initial limited release. Between June 2020 and March 2021, all patients undergoing an edge-to-edge TTVR using the TriClip system in Spain were included in the study. The primary endpoint was the achievement of a TR reduction of at least 1 grade at discharge. ResultsWe included 34 patients. Most of them reported a previous history of atrial fibrillation (91%) and only 1 had a pacemaker lead. The primary endpoint (TR reduction of at least 1 grade at discharge) was met in all patients. Most of the patients required 1 (47%) or 2 clips (44%) with a clear predominance of XT (87%) over NT (13%). The location of the first clip was anteroseptal in >90% of the patients. Only 1 patient had a partial detachment, which was stabilized with additional clips in the same procedure. At discharge, TR severity was≤2 in 91% of patients. At 3 months, mortality was nil. Overall, 88% of patients were in New York Heart Association functional class≤2 and 80% had residual TR≤2. ConclusionsEdge-to-edge TTVR seemed to be effective and safe with a sustained TR reduction at 3 months. Further studies will be needed to confirm our findings.

The TriClip system for edge-to-edge transcatheter tricuspid valve repair. A Spanish multicenter study

Introduction and objectivesIn patients with tricuspid regurgitation (TR), edge-to-edge transcatheter tricuspid valve repair (TTVR) is the strategy with the highest penetration worldwide. A dedicated edge-to-edge TTVR system has recently become available in Europe. The present study describes the initial experience with the system in Spain. MethodsThis multicenter study collected individual data from the centers accepted for the use of the novel system within an initial limited release. Between June 2020 and March 2021, all patients undergoing an edge-to-edge TTVR using the TriClip system in Spain were included in the study. The primary endpoint was the achievement of a TR reduction of at least 1 grade at discharge. ResultsWe included 34 patients. Most of them reported a previous history of atrial fibrillation (91%) and only 1 had a pacemaker lead. The primary endpoint (TR reduction of at least 1 grade at discharge) was met in all patients. Most of the patients required 1 (47%) or 2 clips (44%) with a clear predominance of XT (87%) over NT (13%). The location of the first clip was anteroseptal in >90% of the patients. Only 1 patient had a partial detachment, which was stabilized with additional clips in the same procedure. At discharge, TR severity was≤2 in 91% of patients. At 3 months, mortality was nil. Overall, 88% of patients were in New York Heart Association functional class≤2 and 80% had residual TR≤2. ConclusionsEdge-to-edge TTVR seemed to be effective and safe with a sustained TR reduction at 3 months. Further studies will be needed to confirm our findings.

Transfemoral Tricuspid Valve Replacement in Patients With TricuspidRegurgitation: TRISCEND Study 30-Day Results.

The TRISCEND study (Edwards EVOQUE Tricuspid Valve Replacement: Investigation of Safety and Clinical Efficacy after Replacement of Tricuspid Valve with Transcatheter Device) is evaluating the safety and performance of transfemoral transcatheter tricuspid valve replacement in patients with clinically significant tricuspid regurgitation (TR) and elevated surgical risk. Transcatheter valve replacement could lead to a paradigm shift in treating TR and improving patient quality of life. In the prospective, single-arm, multicenter TRISCEND study, patients with symptomatic moderate or greater TR, despite medical therapy, underwent percutaneous transcatheter tricuspid valve replacement with the EVOQUE system. A composite rate of major adverse events, echocardiographic parameters, and clinical, functional, and quality-of-life measures were assessed at 30days. Fifty-six patients (mean age of 79.3 years, 76.8% female, 91.1% TR severe or greater, 91.1% atrial fibrillation, and 87.5% New York Heart Association functional class III or IV) were treated. At 30days, TR was reduced to mild or less in 98%. The composite major adverse events rate was 26.8% at 30days caused by 1 cardiovascular death in a patient with a failed procedure, 2 reinterventions after device embolization, 1 major access site or vascular complication, and 15 severe bleeds, of which none were life-threatening or fatal. No myocardial infarction, stroke, renal failure, major cardiac structural complications, or device-related pulmonary embolism were observed. New York Heart Association significantly improved to functional class I or II (78.8%; P< 0.001), 6-minute walk distance improved 49.8m (P< 0.001), and Kansas City Cardiomyopathy Questionnaire score improved 19 points (P< 0.001). Early experience with the transfemoral EVOQUE system in patients with clinically significant TR demonstrated technical feasibility, acceptable safety, TR reduction, and symptomatic improvement at 30days. The TRISCEND II randomized trial (NCT04482062) is underway.

Right Ventricular-Pulmonary Arterial Coupling and Afterload Reserve in Patients Undergoing Transcatheter Tricuspid Valve Repair

BackgroundThe right ventricular (RV)–pulmonary arterial (PA) coupling ratio relates the efficiency with which RV stroke work is transferred into the PA. Lower ratios indicate an inadequate RV contractile response to increased afterload. ObjectivesThis study sought to evaluate the prognostic significance of RV-PA coupling in patients with tricuspid regurgitation (TR) who were undergoing transcatheter tricuspid valve repair or replacement (TTVR). MethodsThe study investigators calculated RV-PA coupling ratios for patients enrolled in the global TriValve registry by dividing the tricuspid annular plane systolic excursion (TAPSE) by the PA systolic pressure (PASP) from transthoracic echocardiograms performed before the procedure and 30 days after the procedure. The primary endpoint was all-cause mortality at 1-year follow-up. ResultsAmong 444 patients analyzed, their mean age was 76.9 ± 9.1 years, and 53.8% of the patients were female. The median TAPSE/PASP ratio was 0.406 mm/mm Hg (interquartile range: 0.308-0.567 mm/mm Hg). Sixty-three patients died within 1 year of TTVR, 21 with a TAPSE/PASP ratio >0.406 and 42 with a TAPSE/PASP ratio ≤0.406. In multivariable Cox regression analysis, a TAPSE/PASP ratio >0.406 vs ≤0.406 was associated with a decreased risk of all-cause mortality (HR: 0.57; 95% CI: 0.35-0.93; P = 0.023). In 234 (52.7%) patients with echocardiograms 30 days after TTVR, a decline in RV-PA coupling was independently associated with reduced odds of all-cause mortality (odds ratio [OR]: 0.42; 95% CI: 0.19-0.93; P = 0.032). The magnitude of TR reduction after TTVR (≥1+ vs <1+; OR: 2.53; 95% CI: 1.06-6.03; P = 0.037) was independently associated with a reduction in post-TTVR RV-PA coupling. ConclusionsRV-PA coupling is a powerful, independent predictor of all-cause mortality in patients with TR undergoing TTVR. These data suggest that the TAPSE/PASP ratio can inform patient selection and prognostication following TTVR.

Anomalía de Ebstein en la edad pediátrica: algoritmos de manejo y cirugía de reconstrucción del cono de Da Silva

ObjectivesThe objective of this study is to report our casuistry in the Ebstein's anomaly surgery in the last 10 years, to analyze the considerations for surgical decision making in the neonate and present our results in da Silva's “cone” tricuspid reconstruction. MethodsRetrospective observational study that includes 11 patients diagnosed with Ebstein's anomaly operated on at our center from January 2011 to August 2021. Two neonates underwent Starnes procedure and 9 (beyond the neonatal period) Da Silva's “cone” surgery. ResultsThe 2 neonates in follow-up are in Fontan's situation and in functional class i (New York Heart Association). The mean age of patients operated beyond the neonatal period was 9.1±6.0 years. There was no hospital mortality or at follow-up. As postoperative complications, one patient was placed on ECMO for severe right ventricular dysfunction. There was no AV block. The mean follow-up was 5.3 years. Follow-up transthoracic echocardiogram demonstrated a significant reduction in tricuspid regurgitation from 3.7±0.6 to 1.1±0.9 (P<.0001), and the New York Heart Association class improved from 2.3±0.7 to 1.2±0.4 (P<.001). There has been no immediate or follow-up tricuspid valve replacement. ConclusionsThe “Cone” procedure can be performed safely with low morbidity and mortality. In the medium-term follow-up, the echocardiogram shows a significant reduction in the degree of tricuspid regurgitation, the patients have improved their functional class and none have required tricuspid valve replacement.

38 Transcatheter tricuspid valve edge-to-edge repair in patient with severe tricuspid regurgitation and previous mitraclip treatment: when four orifices are better than two

Abstract An 82 years old woman was admitted to our Division for worsening dyspnoea. Her past medical history showed: arterial hypertension, chronic atrial fibrillation on oral anticoagulation, a non-critical single-vessel coronary artery disease, previous mitral transcatheter edge-to-edge repair through 2 Mitraclip NTR. After an initial improvement in clinical symptoms following Mitraclip implantation, the patient was admitted several times for acute decompensated heart failure. Haematological exams at admission were normal, exception of NTproBNP (1909 pg/mL). The ECG documented atrial fibrillation with normal ventricular rate. Transthoracic echocardiography demonstrated mid-range heart failure (EF 45–50%) with D-shape morphology of the left ventricle. Colour-doppler analysis shows presence of Mitraclip devices in place with mild residual insufficiency, dilation of the right side, torrential tricuspid regurgitation (tTR) with estimated pulmonary arterial pressure of 45 mmHg. Preprocedural transesophageal echocardiography confirmed these findings showing dilation of the tricuspid annulus with two large regurgitating jets. After positioning Amplatzer Superstiff guide in superior vena cava through guide catheter TSGC0202, a Triclip XT was placed in commissural region between anterior and septal leaflets. A two-grade reduction in tricuspid regurgitation (TR) grade from torrential (5+) to moderate (3+) was achieved without significant transvalvular gradient. The patient was successful discharged after 2 days, asymptomatic and in good clinical conditions. A great reduction in NTproBNP values at discharge was observed (1612 pg/mL). We report a case of successful tricuspid transcatheter repair in patient with chronic decompensated heart failure and previous Mitraclip treatment. The clinical impact of TR reduction is probably due to a positive right ventricular (RV) remodelling, with a reduction in RV size. RV dysfunction and its implications (liver, renal, and haemostatic consequences) are definitely a matter of concern for fragile patients with TR. In fact, many patients with severe TR have a reduced RV function. The reduction in volume and pressure overload of the right heart side, the progressive anatomic and functional reverse of the RV disfunction, may lead to a significant clinical benefit and to a lower hospitalizations rates also through to an important improvement of the left ventricular function as a consequence of the reduction in pressure overload.

Health Status After Transcatheter Tricuspid Valve Repair in Patients With Functional Tricuspid Regurgitation.

The aim of this study was to investigate changes in quality of life (QoL) after transcatheter tricuspid valve repair (TTVR) for tricuspid regurgitation (TR). TTVR provides feasible and durable efficacy in reducing TR, but its clinical benefits on QoL still remain unclear. In 115 subjects undergoing TTVR for severe functional TR, QoL was evaluated using the 36-Item Short Form Health Survey (SF-36) and the Minnesota Living With HeartFailure Questionnaire (MLHFQ). All-cause mortality, heart failure (HF) rehospitalization, and a composite endpoint of all-cause mortality, HF rehospitalization, and repeat TTVR were recorded as clinical events. Successful device implantation was achieved in 110 patients (96%). Moderate or less TR at discharge was achieved in 95 patients (83%). Mean SF-36 physical component summary (PCS) score improved from 34 ± 9 to 37 ± 9 points (+3 points; 95% CI: 1-5 points; P=0.001), mean SF-36 mental component summary score improved from 49 ± 9 to 51 ± 10 points (+2 points; 95% CI: 0-4 points; P=0.017), and mean MLHFQ score decreased from 29 ± 14 to 20 ± 15 points (-8 points; 95% CI:-11 to-5 points; P< 0.001). Baseline PCS, moderate or less TR at discharge, and baseline massive or torrential TR were associated with 1-month change in PCS score (P< 0.05). Change in PCS score after 1month predicted HF rehospitalization after TTVR (adjusted HR: 0.74 [95% CI: 0.60-0.92] per 5-point increase in PCS score; P=0.008). This study demonstrates that TTVR provides improvement in QoL in patients with relevant TR. TR reduction to a moderate or less grade was associated with improvement of SF-36 and MLHFQ scores. Further, global QoL was associated with clinical outcomes and might serve as a future outcome surrogatefollowing TTVR.