Worsening Of Tricuspid Regurgitation Research Articles

MISDIAGNOSED PARTIAL ANOMALOUS PULMONARY VENOUS RETURN AS A CAUSE OF RIGHT VENTRICULAR DILATION IN TRICUSPID VALVE DYSPLASIA

Abstract A 38–year–old woman comes to our attention for regular follow–up of a known tricuspid valve dysplasia, diagnosed since she was 19 years old. The patient has been persistently asymptomatic and hemodynamically compensated. In previous cardiac assessments, there was moderate and stable tricuspid regurgitation (TR) that never reached the diagnostic criteria for Ebstein‘s anomaly (7 mm). The right atrium was dilated, and the right ventricle was at the upper limits of normal dimensions. However, our evaluation revealed a worsening of TR to a severe degree, associated with valvular annulus dilation and severe dilation of the right ventricle, which remained normokinetic, and evident diastolic overload of the interventricular septum. Therefore, a cardiac surgery intervention was indicated to correct the valvulopathy. During hospitalization, a transthoracic echocardiogram was repeated to investigate a possible cause of right ventricular overload, not fully explained by the relatively short duration of severe TR. During the exam, suspecting Partial Anomalous Pulmonary Venous Return (PAPVR) as one of the possible determinants, a vessel compatible with left superior pulmonary venous return was visualized, which converged into the anonymous vein and then into the right superior vena cava. Further diagnostic investigation with magnetic resonance angiography and computed tomography angiography confirmed the severe dilation of the right cardiac chambers and the presence of left upper pulmonary venous return and part of the left lower lobe into the left anonymous vein, with a Qp/Qs of 1.7 in relation to the pre–tricuspidal shunt. Therefore, a cardiac surgery intervention was indicated for PAPVR correction. However, previously unnoticed thrombocytosis was revealed in the hematological exams, leading to the initiation of a pertinent hematological workup and the cardiac surgery intervention was postponed to reduce the risk of perioperative complications. In conclusion, PAPVR is a rare congenital condition that can remain asymptomatic until adulthood due to a chronic adaptation of the right heart to volume overload and should, therefore, be considered in the differential diagnosis of right cardiac chambers dilation, especially when other causes do not justify its pathophysiology.

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.

Left bundle branch pacing lead for sensing ventricular arrhythmias in implantable cardioverter-defibrillator: A pilot study (LBBP-ICD study)

BackgroundLeft bundle branch pacing (LBBP) has been suggested as an alternative modality for biventricular pacing in cardiac resynchronization therapy (CRT)–eligible patients. As it provides stable R-wave sensing, LBBP has been recently used to provide sensing of ventricular arrhythmia in patients receiving implantable cardioverter-defibrillator (ICD) with CRT. ObjectiveThe aim of this study was to analyze the long-term safety and efficacy of the LBBP lead for appropriate detection of ventricular arrhythmia and delivery of antitachycardia pacing (ATP) in patients requiring defibrillator therapy with CRT. MethodsCRT-eligible patients who underwent successful LBBP-optimized ICD and LBBP-optimized CRT with defibrillator were enrolled. The LBBP lead was connected to the right ventricular-P/S port after capping the IS-1 connector plug of the DF-1–ICD lead. LBBP-optimized ICD or LBBP-optimized CRT with defibrillator was decided on the basis of correction of conduction system disease. Documented arrhythmic episodes and therapy delivered were analyzed. ResultsThirty patients were enrolled. The mean age was 59.7 ± 10.5 years. LBBP resulted in an increase in left ventricular ejection fraction from 29.9% ± 4.6% to 43.9% ± 11.2% (P < .0001). During a mean follow-up of 22.9 ± 12.5 months, 254 ventricular arrhythmic events were documented. Appropriate events (n = 225 [89%]) included nonsustained ventricular tachycardia (VT) (n = 212 episodes [94%]), VT (n = 8 [3.5%]), and ventricular fibrillation (n = 5 [2.5%]). ATP efficacy in terminating VT was 75%. Eleven percent of episodes (n = 29) were inappropriately detected because of T-wave oversensing. Inappropriate therapy (ATP) was delivered for 14 episodes (5.5%). Three patients (10%) had worsening of tricuspid regurgitation. ConclusionSensing from the LBBP lead for arrhythmia detection is safe as ∼90% of the episodes were detected appropriately. Future studies with a dedicated LBBP-defibrillator lead along with algorithms to avoid oversensing can help in combining defibrillation with conduction system pacing.

Abstract 12595: Vascular and Cardiac Ultrasound as the Primary Imaging Tool to Safely Deliver Pacing Leads While Implanting Single Chamber Cardiac Implantable Electronic Devices. RADICAI USE Investigators

Introduction: Conventional Cardiac implantable electronic devices (CIEDs) implantation requires fluoroscopy. Risks involved with implantation include pneumothorax, lead dislodgement, and perforation of the right ventricular wall. In addition, there are long-term risks of malignancy associated with prolonged and repeated use of radiation over the decades of operators’ employment and mechanical injuries related to heavy personal protection equipment. To reduce these risks, we aimed to study the utilization and safety of ultrasound (US) for the entire procedure to implant single-chamber devices. Methods: The RADICAI USE study (Reduction or Elimination of Radiation Use in Single Chamber Cardiac Devices using ultrasound) is a prospective, single-arm and multi-operator case series enrolled patients awaiting a single-chamber CIED. A fluoroscopic cut-off time of 20 seconds was used to define the success (Group A) or failure (Group B) of using the US for the entire implant duration. Patients were followed up at 1 week, 1 month and 1-year post-implant. Results: The study enrolled 63 patients, with 50 pacemakers and 13 ICDs, a mean age of 79.5 ± 13.8 years (95% CI = 76.1 - 82.9), and a mean weight of 74.1 ± 14.6 (95% CI = 70.5 - 77.7). Overall, 53 (84.1%) CIEDs were successfully implanted with a radiation time of less than 20 seconds (Group A). Fluoroscopic over 20 seconds was required due to poor echocardiographic windows, challenging access, or anatomy. No iatrogenic new or worsening of tricuspid regurgitation was noted. The mean procedure time including US setup time was 65.2 ± 20.2 (95% CI = 60.2 -70.2) minutes. Fluoroscopic time was significantly reduced in Group A compared to Group B (5.8 ± 4.5s vs 109.5 ± 92.9s, p = 0.004). Follow-up showed no device-related complications, with only two patients requiring lead revisions due to poor sensitivity, one unrelated to US use and another probably related. Conclusions: US-guided implantation of single-chamber CIEDs is feasible and safe, reducing the need for fluoroscopic guided implantation and subsequent risks of higher radiation exposure. Further studies are required to evaluate the cost-effectiveness and to explore fluoroscopic-free single-chamber CIED implantations using the US.

Identification of Pacemaker Lead Position Using Fluoroscopy to Avoid Significant Tricuspid Regurgitation.

Permanent pacemaker implantation improves survival but can cause tricuspid valve dysfunction in the form of tricuspid regurgitation (TR). The dominant mechanism of pacemaker-mediated TR is lead impingement. This study evaluated the association between the location of the pacemaker leads crossing the tricuspid valve and the incidence of worsening TR and lead impingement using fluoroscopy. Lead positions were evaluated using perpendicular right anterior oblique (RAO) and parallel left anterior oblique (LAO) fluoroscopic angulation views of the tricuspid annulus. A two-dimensional transthoracic echocardiogram (TTE) was performed to evaluate the maximum TR jet area-to-right atrium ratio and define regurgitation severity. A three-dimensional TTE was performed to evaluate lead impingement. A worsening of TR was observed in 23 of 82 subjects. Most leads had an inferior position in the RAO view and a septal position in the LAO view. The mid position in the RAO view and septal position in the LAO view were risk factors for lead impingement. Mid and septal positions were associated with higher risks of significant TR and lead impingement. Lead impingement was associated with a high risk of significant TR. Pacemaker-mediated TR remains a significant problem after lead implantation.

Outcomes and survival of patients undergoing percutaneous vegetectomy for right heart endocarditis

BackgroundsAngioVacis used for the percutaneous removal of vegetations and fordebulking of large vegetations in patients who are not surgical candidates.This study aims to identify thedemographics, echocardiographic features, indications, improvement of the tricuspid valve regurgitation, and survival outcomes of patients who have undergone AngioVac vegetectomy reported in the literature. MethodsA systematic review was performed to identify articles reporting suction thromectomy or vegetation removal using the AngioVac system for RSIE (right sided infective endocarditis). Survival on discharge was our primary outcome. Additionally, we evaluated indications for suction thrombectomy and TR improvement.Categorical variables were expressed as percentages and ratios. ResultsA total of 49 studies were identified. The most common risk factor was intravenous drug abuse seen in 45% (20/49) and cardiovascular implantable electronic device (CIED) in 45% (20/49). Circulatory shock was seen in 35% of patients. The causative organism was gram positive cocci (86%).Moderate to severe TRwas present in 74% of cases with documented echocardiograms. Indications for AngioVacwerepoor surgical candidacy (81%) or to reduceseptic emboli risk(19%). Survival at dischargewas 93%.TR improvement was reported only in 16% cases and remained unchanged/worsened in 84%. ConclusionAngioVac procedure is an alternative treatment for critically ill patients who cannot undergo surgery. To understand the survival, safety and candidacy of patients undergoing this procedure, further randomized control studies and literature reviews are needed. The improvement or worsening of tricuspid regurgitation in patients with TR valve involvement is another factor to be investigated.

Prognostic Predictors of Tricuspid Regurgitation Worsening after Mitral Regurgitation Surgery with Mild Tricuspid Regurgitation

We aimed to investigate the prevalence and predictors of postoperative tricuspid regurgitation (TR) worsening in patients with mitral regurgitation (MR) and concomitant ≤mild TR. A total of 620 patients underwent surgery for MR from 2013 to 2017. Of these, 260 had ≤mild preoperative TR and no concomitant tricuspid valve surgery and were enrolled in this single-center retrospective study. The primary endpoint was postoperative worsening of ≥moderate TR. The primary endpoint occurred in 28 of 260 patients (11%) during the follow-up period [median: 4.1 years (interquartile range: 2.9-6.1 years)]. In the multivariable analysis, age, female sex, and left atrial volume index (LAVI) were significant predictors of the primary outcome during intermediate-term follow-up (age: hazard ratio [HR] 1.05 per 1-year increment, 95% confidence interval [CI] 1.02-1.10, p = 0.003; female sex: HR 3.53, 95% CI 1.61-7.72, p = 0.002; LAVI: HR 1.17 per 10-mL/m2 increment, 95% CI 1.07-1.26, p < 0.001). The optimal LAVI cut-off value for predicting postoperative TR worsening was 79 mL/m2 (area under the curve: 0.69). A high LAVI (>79 mL/m²) was significantly associated with a low rate of freedom from postoperative TR worsening compared with a low LAVI (≤79 mL/m²) (82.6% vs. 93.9% at 5 years, respectively; log-rank p = 0.008). In patients with ≤mild preoperative TR and no concomitant tricuspid surgery, the rate of postoperative TR worsening was 11% during intermediate-term follow-up. LA enlargement in patients with MR and ≤mild preoperative TR was significantly associated with postoperative TR worsening.

The differences between conventional lead, thin lead, and leadless pacemakers regarding effects on tricuspid regurgitation in the early phase.

Trans-venous pacemaker leads are associated with worsening of tricuspid regurgitation (TR) after pacemaker implantation (PMI) in some cases. Recently, leadless pacemakers and thin ventricular pacemaker leads without a stylet lumen have become popular. However, the differences in the effects of these leads on TR are unclear. We investigated differences in the changes in TR in the early phase after PMI in patients with conventional leads, thin leads, and leadless pacemakers. We enrolled 65 patients who underwent PMI (32 males, 79 ± 8years), including 48 with trans-venous PMI (29 with conventional 6.0-Fr leads and 19 with 4.1-Fr thin leads) and 17 with leadless pacemakers. Transthoracic echocardiography was performed before and 1month after PMI for assessment of conventional echocardiographic parameters and severity of TR by quantitative assessment. Atrial fibrillation was the most frequent indication for PMI in patients with leadless pacemakers (p = 0.015). In the before and 1month after PMI comparison, left ventricular ejection fraction decreased after PMI only in the conventional lead group (p = 0.022). The TR effective regurgitant orifice area (EROA) decreased post PMI in the leadless (p = 0.002) and thin lead groups (p = 0.001), but not in the conventional lead group (p = 0.596). The change in TR EROA was greater in the leadless and thin lead groups as compared with the conventional lead group (p < 0.05). The decrease in TR EROA in the early phase after PMI differed according to the type of pacemaker lead. The thin lead might be beneficial for reduction of TR after PMI.

1132 CATHETER INTERVENTION TO TREAT MIGRATED TEMPORARY EPICARDIAL PACING WIRE INTO THE PULMONARY ARTERY

Abstract Catheter intervention to treat migrated temporary epicardial pacing wire into the pulmonary artery Introduction Temporary epicardial pacing wires (TEPW) are routinely inserted postoperatively for treating electrophysiological disturbances after open-heart surgeries. They are typically placed on the surface of the right ventricle and the right atrial appendage. They are usually removed before discharge, but in case of difficult removal, they are cut flush to the skin, and thus retained. Leaving TEPW can be associated to complications, especially with wires migration. As described in literature, TEPW migration is rare and typically involves the right side of the heart, even if any part of the body can be involved. A review proposed an algorithm for removal decision making, based on the risk of serious complications like infection, dissection and perforation. We present a case of a transcatheter removal of a TEPW migrated into the pulmonary artery, in an asymptomatic patient. Case presentation A 52 year-old man, with previous history of Hodgkin Lymphoma treated with radiotherapy and Chemotherapy; CAD (inferior AMI treated with CABG); constrictive pericarditis causing many on-hospital admissions for heart failure; valvular disease: together with the CABG intervention, in 2012, he underwent mitral valvular repair and aortic valvuloplasty; in 2018, because of mitral valve repair failure, he underwent mitral valve substitution with a mechanic valve together with tricuspid repair; in the same year, because of worsening aortic regurgitation, he underwent TAVI. During routine follow-up exams, three years later, in 2021, the patient underwent a total body CT scan that showed the presence of a hyperintensity signal in the region between the right atrium and the right ventricle, crossing the tricuspid valve, with a final loop in the right ventricle infundibulum, suspected to be a TEPW. A transthoracic echocardiogram confirmed the position of the extraneous body, that was causing no impingement to the leaflets of the tricuspid valve, without worsening tricuspid regurgitation. A fluoroscopy showed the presence of a metallic wire, divided into two segments, the former extended from the right atrium till the right subclavian vein passing through the superior cava vein; the latter extended from the right ventricle till the left pulmonary artery. The patient underwent a transcatheter intervention with a right femoral vein access, to try to remove the TEPWs. The former located in the right atrium had a extravascular location, so it was left inside. The other one was removed. After advancing a Swan-Ganz catheter into the pulmonary artery, it was exchanged with a multipourpose catheter and a Multi-Snare 20 mm retrieval system captured the wire and dragged till the inferior cava vein; a second retrieval system, a Snare STD 12-20 mm, was finally able to anchor firmly the wire and to carry it outside. No complications occurred after the procedure; an echocardiogram excluded intracardiac problems. The patient was discharge the day after the procedure, in good clinical conditions. Discussion In this case, a transcatheter removal of the TEPW was performed, even if the presence of the wires caused no symptoms and/or complications to the patient. Anyway, because of the presence of both a prosthetic valve and a mechanic valve, in a setting of constrictive pericarditis and the consequent possibility of several in-hospital admission in conditions of acute heart failure with worsening of tricuspid regurgitation, the persistence of the wire could represent a risk factor for infective endocarditis and for severe tricuspid regurgitation. Removing it with a fast and safe transcatheter femoral approach, a potential cause of other complications was avoided.

Tricuspid regurgitation worsening after transcatheter or surgical aortic valve replacement

Abstract Background Tricuspid regurgitation (TR) often occurs concomitantly with severe aortic stenosis. Post-operative worsening of tricuspid regurgitation has been observed after surgical and transcatheter aortic valve replacement (SAVR, TAVR) [1,2]. Purpose Pre-procedural severe tricuspid regurgitation has been shown to be a predictor of all-cause mortality in patients undergoing transcatheter aortic valve replacement (TAVR) [3,4]. However, little is known about the incidence of worsening tricuspid regurgitation after SAVR and TAVR and the impact on post-procedural outcomes. This study aims to evaluate, characterize and compare the incidence of worsening TR after TAVR and SAVR. Methods Retrospective single-center study of patients undergoing Transcatheter and Surgical Aortic Valve Replacement for severe aortic stenosis between 2014 and 2020. Incidence of tricuspid regurgitation was noted on echocardiogram at baseline and 1 year after TAVR or SAVR. This study enrolled 430 patients in the TAVR group and 237 patients in the SAVR group. The SAVR group only included patients who underwent isolated SAVR without any other valve intervention. Patients with severe TR at baseline were excluded from the study. Progression of TR severity was defined as deterioration by at least 1 grade of severity compared to baseline on echocardiography. Multivariable logistic regression analysis was performed to identify associations with worsening TR. Results Mean age of TAVR patients was higher than the SAVR patients (79±9 vs 68±12 years, p&amp;lt;0.0001). TAVR patients also had a significantly higher EuroSCORE than the SAVR patients (8.0±7 vs 3.5±4, p&amp;lt;0.0001). TAVR group was more likely to have atrial fibrillation than the SAVR group (34% vs 24%, p=0.006). Baseline right ventricular dysfunction and right ventricular enlargement were significantly higher in the TAVR group compared to the SAVR group [9% vs 4%, (p=0.009) and 10% vs 6%, (p=0.04), respectively]. Progression of TR severity occurred in 21.8% (94/430) of TAVR patients and 31.2% (74/237) of SAVR patients. Majority of these patients progressed from absent TR to mild TR [13.2% (57) in TAVR group vs 19.8% (47) in SAVR group (p=0.02)]. 6.3% (27) of patients in the TAVR group and 8.8% (21) of patients in the SAVR group had mild to moderate worsening of TR (p=0.22). 1.63% (7) in the TAVR group and 2.1% (5) in the SAVR group had progression from moderate to severe TR (p=0.65). On multivariable analysis, SAVR (Odds ratio, 2.46 [CI, 1.6–3.7]) and age (Odds ratio, 1.03 [CI, 1.03–1.05]) were associated with worsening TR severity. Conclusions In this retrospective observational study, SAVR and age were found to be associated with worsening tricuspid regurgitation. Majority of these patients progressed from absent TR to mild TR after SAVR. Further studies are necessary to determine long term outcomes of worsening tricuspid regurgitation after TAVR and SAVR. Funding Acknowledgement Type of funding sources: None.

Tricuspid Valve Damage Related to Transvenous Lead Extraction.

Background: Damage to the tricuspid valve (TVD) is now considered either a major or minor complication of the transvenous lead extraction procedure (TLE). As yet, the risk factors and long-term survival after TLE in patients with TVD have not been analyzed in detail. Methods: This post hoc analysis used clinical data of 2631 patients (mean age 66.86 years, 39.64% females) who underwent TLE procedures performed in three high-volume centers. The risk factors and long-term survival of patients with worsening tricuspid valve (TV) function after TLE were analyzed. Results: In most procedures (90.31%), TLE had no negative influence on TV function, but in 9.69% of patients, a worsening of tricuspid regurgitation (TR) to varying degrees was noted, including significant dysfunction in 2.54% of patients. Risk factors of TLE relating to severe TVD were: TLE of pacing leads (5.264; p = 0.029), dwell time of the oldest extracted lead (OR = 1.076; p = 0.032), strong connective scar tissue connecting a lead with tricuspid apparatus (OR = 5.720; p < 0.001), and strong connective scar tissue connecting a lead with the right ventricle wall (OR = 8.312; p < 0.001). Long-term survival (1650 ± 1201 [1–5519] days) of patients with severe TR was comparable to patients without tricuspid damage related to TLE. Conclusions: Severe tricuspid valve damage related to TLE is relatively rare (2.5%). The main risk factors for the worsening of TV function are associated with a longer lead dwell time (more often the pacing lead), causing stronger connective tissue scars connecting the lead to the tricuspid apparatus and right ventricle. TVD is unlikely to affect long-term survival after TLE.

Evolution of tricuspid regurgitation after transcatheter edge-to-edge mitral valve repair for secondary mitral regurgitation and its impact on mortality.

To evaluate short-term changes in tricuspid regurgitation (TR) after transcatheter edge-to-edge mitral valve repair (M-TEER) in secondary mitral regurgitation (SMR), their predictors and impact on mortality. This is a retrospective analysis of SMR patients undergoing successful M-TEER (post-procedural mitral regurgitation ≤2+) at 13 European centres. Among 503 patients evaluated 79 (interquartile range [IQR] 40-152) days after M-TEER, 173 (35%) showed ≥1 degree of TR improvement, 97 (19%) had worsening of TR, and 233 (46%) remained unchanged. Smaller baseline left atrial diameter and residual mitral regurgitation 0/1+ were independent predictors of TR ≤2+ after M-TEER. There was a significant association between TR changes and New York Heart Association class and pulmonary artery systolic pressure decrease at echocardiographic re-assessment. At a median follow-up of 590 (IQR 209-1103) days from short-term echocardiographic re-assessment, all-cause mortality was lower in patients with improved compared to those with unchanged/worsened TR (29.6% vs. 42.3% at 3 years; log-rank p=0.034). Baseline TR severity was not associated with mortality, whereas TR 0/1+ and 2+ at short-term follow-up was associated with lower all-cause mortality compared to TR 3/4+ (30.6% and 35.6% vs. 55.6% at 3 years; p<0.001). A TR ≤2+ after M-TEER was independently associated with a 42% decreased risk of mortality (p=0.011). More than one third of patients with SMR undergoing successful M-TEER experienced an improvement in TR. Pre-procedural TR was not associated with outcome, but a TR ≤2+ at short-term follow-up was independently associated with long-term mortality. Optimal M-TEER result and a small left atrium were associated with a higher likelihood of TR ≤2+ after M-TEER.

Tricuspid insufficiency after cardiac-implantable electronic device placement

ABSTRACT Objective Device-related estimates of incidence and significance of tricuspid regurgitation (TR) is mainly based on case reports and small observational studies. We sought to determine whether right-heart device implantation increased the risk of TR in this interventional study. Methods All patients who underwent permanent pacemaker (PPM) or other device implantation were assessed for degree of TR at one year. The data collected was analyzed on IBM SPSS version 26. Descriptive statistics were applied for qualitative variables. Mean and standard deviation were applied for quantitative variables. Regression analysis and paired t-tests were applied for the degree of change and predictors of TR. Results Out of 165 participants, 73.94% were male. The mean age of the participants was 59.86 ± 12.03 years. Dual-chamber pacemaker (DDDR) was the most common device implanted (78.18%) causing significant TR and drop in left ventricular ejection fraction as compared to other devices (p-value < 0.05). The paired t-test for changes in ejection fraction (LVEF) and TR were also significant (p-value < 0.05). A regression model predicted significant TR to depend on baseline LVEF (p-value < 0.05). Conclusion Device-related worsening of TR is related to mechanical mechanisms. It is significantly associated with DDDR pacemakers after a 1-year follow-up.

Prevention of pacemaker lead induced tricuspid regurgitAtion by transesophageal eCho guidEd implantation (PLACE Pilot)

Abstract Background Lead-induced tricuspid regurgitation (TR) is a frequent complication after pacemaker- and ICD-implantation that is associated with increased mortality and hospitalizations. Purpose The aim of this pilot study was to investigate if lead implantation guided by transesophageal echocardiography (TEE) is feasible and might be able to reduce lead-associated TR. Methods 21 patients with indication for new pacemaker/ICD including a trans-tricuspid lead implantation and TR &amp;lt; grade 2+ were prospectively enrolled and underwent TEE-guided lead implantation in addition to fluoroscopy. Leads were placed according to a dedicated echo protocol with focus on a transgastric en face view of the tricuspid valve targeting a lead position in a tricuspid valve commissure (preferentially postero-septal) and an apical ventricular lead position. (Figure 1) Transthoracic echocardiography (TTE) was performed before implantation and at discharge. 121 consecutive patients with standard lead implantation guided by fluoroscopy only served as a historical control group. TR was assessed by an experienced cardiologist and graded according to current guidelines. Results Key baseline characteristics of overall 124 patients with a mean age of 74 years didn't differ between groups. Of note, there was no significant difference regarding device type and baseline TR. TEE-guided lead implantation was possible in all 21 patients in the TEE-group in deep conscious sedation without occurrence of serious adverse events. Lead placement in a commissure, mostly postero-septal, was possible in 95.2% of patients without worsening of TR (20/21 pts). Based on TEE-guidance, lead position or length was altered in 52.4% of patients (11/21 pts, 6 pts with lead repositioning, 5 pts with modification of lead length). Compared to baseline, the 21 patients in the TEE-group did not show worsening of TR at discharge. In contrast, TR worsening by one grade occurred in 13.6% of patients (14/103 pts) with new onset of TR ≥2+ in 6.8% of patients (07/103 pts) in the control group (p=0.001). At discharge, lead position was evaluated using 2D and 3D TTE in a subset of patients. In all examined patients (14/14 pts) lead position was unchanged compared to intraprocedural position and stable during inspiration vs. expiration as well as in upright vs. horizontal position. Conclusion TEE-guidance during PM/ICD-implantation was safe and feasible and resulted in steps to optimize lead position in a relevant number of patients. At discharge lead position remained stable and TEE-guided lead implantation was associated with less worsening of TR than standard lead implantation guided by fluoroscopy. Funding Acknowledgement Type of funding sources: None. TEE view with targeted lead position

Potential Candidates for Transcatheter Tricuspid Valve Intervention After TranscatheterAorticValve Replacement: Predictors and Prognosis.

The aims of this study were to document the prevalence of concomitant tricuspid regurgitation (TR) before and after transcatheter aortic valve replacement (TAVR), to quantify potential eligibility for transcatheter tricuspid valve intervention (TTVI), and to report clinical outcomes as a function of the severity of TR and potential candidacy for TTVI. The importance of concomitant TR in patients with severe aortic stenosis undergoing TAVR remains unclear. In a prospective TAVR registry, the severity of TR before and after TAVR was retrospectively evaluated in an echocardiography core laboratory. Among 2,008 eligible patients, 1,659 patients (82.6%) had mild or less TR, 242 (12.1%) had moderate TR, 57 (2.8%) had severe TR, and 50 (2.5%) had massive TR. More than one-half of patients with moderate or greater TR had a reduction in TR, while a small proportion of patients with severe or less of TR had worsening of TR after TAVR. In contrast to TR at baseline, severe TR (adjusted HR [HRadjusted]: 1.90; 95% CI: 1.03-3.49) and massive TR (HRadjusted: 2.17; 95%CI: 1.10-4.30) after TAVR conferred an increased risk for mortality compared with mild or less TR at 1 year after TAVR. After TAVR, 63 patients (3.1%) were deemed potential candidates for TTVI. They had a 2-fold increased risk for mortality between 30days and 1 year (HRadjusted: 1.93; 95%CI: 1.15-3.25) and a higher risk for persistent heart failure symptoms (adjusted risk ratio: 2.80; 95%CI: 1.78-4.40). A non-negligible proportion of patients were considered potential candidates for TTVI after TAVR and had impaired prognosis and persistently impaired functional status at 1 year. (SwissTAVI Registry; NCT01368250).

Assessment of the effects of cardiac rhythm device implantation on right sided heart function and tricuspid valve

Abstract Objective To assess the effects of trans-tricuspid placement of permanent pacemaker (PPM), on the right-sided heart function and tricuspid valve function. Background Over the last decade there has been a significant increase in the number of cardiac device implantation as permanent pacemakers (PPM) worldwide in patients with cardiac rhythm disorders. Tricuspid regurgitation (TR) due to the endocardial lead is a known complication of this procedure, however the incidence of new or worsening TR had not been well studied. Patients and Methods We reviewed patients who underwent permanent pacemaker implantation in our cardiology department in Ain Shams University. Patients who had pacemaker implantation less than one year ago, had severe tricuspid regurgitation before implantation or had previous tricuspid valve repair were excluded. A total of one hundred patients with an echocardiographic study before and another echocardiographic study at least one year after device implantation were included in our study. TR severity was graded as (0 none/trace, 1 mild, 2 moderate, 3 severe). Results Of the 100 patients (Mean age: 53.10 ± 16.04, 50% of patients were males) 65 had DDD and 35 had VVI. Before implantation 25 patient had trace TR (grade 0) vs. 6 patients after, 75 patients had mild TR (grade 1) vs. 82 after, with no patient had moderate TR (grade 2) vs. 12 patients after. TR worsened by one grade in 25 patients, (16 patients from grade 0 to grade 1 and 9 patients from grade 1 to grade 2) and by 2 grades in 3 patients (from grade 0 to grade 2), Pvalue &amp;lt; 0.01. TR jet area size (Mean ± SD: 2.80 ± 0.77 before vs. 4.15 ± 1.29 after, P-value &amp;lt; 0.01). Also, 99 patients had normal RV size and one had dilated RV before implantation vs. 95 patient had normal RV and 5 had dilated RV (p-value= 0.097). RV size, LVEF (Mean ± SD: 56.41% ± 7.52 before vs. 55.77% ± 8.00 after), RV function by TASPE (Mean ± SD: 19.15 ± 1.00 before vs. 18.96 ± 0.96 after), RVSP (Mean ± SD: 29.48mmHg ± 5.54 before vs. 29.81 ± 5.09 after) and diastolic function by E/A ratio (Mean ± SD: 1.60 ± 0.39 before vs. 1.57 ± 0.38 after implantation) did not show significant change. Conclusion Permanent pacemaker (PPM) implantation is associated with worsening of tricuspid regurgitation. Echocardiography plays an important role in assessing and grading this condition. Further studies are needed in order to illustrate the effects of these finding on patients outcomes.

Impact of tricuspid regurgitation on late right ventricular failure in left ventricular assist device patients ~can prophylactic tricuspid annuloplasty prevent late right ventricular failure? ~

BackgroundIn this study, we evaluated the prevalence of tricuspid regurgitation (TR) worsening in patients with left ventricular assist devices (LVADs) and its impact on late right ventricular (RV) failure.MethodsWe enrolled 147 patients of the 184 patients who underwent continuous-flow LVAD implantations from 2005 to March 2018. The prevalence of postoperative TR worsening and late RV failure were retrospectively evaluated.ResultsConcomitant tricuspid annuloplasty (TAP) was performed in 28 of 41 patients (68%) with preoperative TR greater than or equal to moderate (TR group) and in 23 of 106 patients (22%) with preoperative TR less than or equal to mild (non-TR group). Regarding the TR-free rates, despite receiving or not receiving concomitant TAP, there was no significant difference between the 2 groups (TR group: p = 0.37; non-TR group: p = 0.42). Of the 9 patients with postoperative TR greater than or equal to moderate, late RV failure developed in 3 patients, with TR worsening after RV failure in each case. During follow-up, 16 patients (11%) had late RV failure. As for the late RV failure-free rates, despite receiving or not receiving concomitant TAP, there was no significant difference between the 2 groups (TR group: p = 0.37; non-TR group: p = 0.96).ConclusionsTR prognosis was preferable regardless of a patient receiving concomitant TAP; however, the presence of postoperative TR seemed to unrelated to late RV failure. Prophylactic TAP might not be necessary to prevent late RV failure.

Pacemaker lead-induced progression of primary vs. secondary tricuspid regurgitation

Abstract Background Currently no data are available whether the implantation of right ventricular (RV) pacemaker (PM) lead worsens preexisting primary or secondary (functional due to RV dilatation, RVD) tricuspid regurgitation (TR). Purpose The aim of the present retrospective analysis was to assess TR after PM implantation with a RV lead. Methods Patients with PM implantation (n=990) were enrolled if they had routine echocardiography including assessment of TR before first implantation and immediately after. RVD and severity of TR were characterized visually. Based on RVD in baseline echocardiography, patients were divided into 2 groups: with primary TR (without preexisting RVD, n=743) or secondary TR (with preexisting RVD, n=243). Results Lead-induced worsening of TR was present in both groups (Table 1). Progression from mild/moderate to severe TR was observed in 6.7% of patients with primary TR, compared to 25.6% of patients with secondary TR (P=0.001). Using an ordinal regression model, the probability to progress to severe TR with primary TR was 14.8% (95% CI 11.0%-19.7%), compared to 41.6% (95% CI 40.3%-42.8%) with secondary TR (P&amp;lt;0.001). Conclusion Preexisting secondary TR was associated with higher rates of lead-induced progression to severe TR compared to primary TR. Leadless pacing or tricuspid valve clipping post-PM implantation could be an option for patients with preexisting secondary TR and indication for a PM. Table 1. Patient characteristics. Funding Acknowledgement Type of funding source: Public grant(s) – EU funding. Main funding source(s): This study was supported by the European Union's Horizon 2020 Future and Emerging Technologies Programme [Grant number 732170].

Prognostic impact and post-procedural development of severe tricuspid regurgitation in patients undergoing transcatheter edge-to-edge mitral valve repair

Abstract Purpose The aim of this study was to investigate the clinical impact and post-procedural development of tricuspid regurgitation (TR) in patients undergoing the MitraClip procedure for severe mitral regurgitation. Methods In this present multicentre study, we included 940 patients undergoing MitraClip implantation for symptomatic mitral regurgitation from August 2010 to September 2018. Patients were categorized according to concomitant TR (none or mild vs moderate vs severe) and the prognostic impact of TR on 1-year mortality was evaluated. Moreover, in 377 patients, we assessed 3-months echocardiographic controls to further analyse the post-procedural development of TR. Results At baseline, concomitant TR was graded none/mild in 393 (42%), moderate in 316 (34%), and severe in 231 (25%) patients. During 1-year follow-up, 141 of 940 (15%) patients died. According to mild/none, moderate and severe TR, mortality rates were 13%, 12%, and 23%, respectively, revealing a higher prevalence of death in patients with severe TR (p=0.001). Kaplan-Meier analysis and log-rank test confirmed inferior survival rates for patients with severe TR (p=0.001), while there were no significant difference in survival rates between patients with none/mild vs moderate TR (p=0.561). Regarding 1-year mortality, multivariate cox regression analysis, revealed an odds ratio of 1.739 (1.024–2.953; p=0.041), associated with severe TR. After 3-months follow-up, echocardiography in 377 patients showed following TR grade distributions: 44% none/mild, 37% moderate and 19% severe TR. In 100 patients (27%), TR improved by one or more grades, while 64 patients (17%) showed a TR worsening. In patients with severe TR at baseline, 42 of 91 (46%) patients showed a reduction in TR of one or more grades. Patients with severe TR at baseline, who showed a TR improvement during 3-months follow-up, had lower rates of 1-year mortality (p=0.025). For these patients, in regression analysis, right atrial area was revealed as only predictor of TR improvement after MitraClip procedure [odds ratio 0.958 (0.918–0.999); p=0.046]. Conclusion One-fourth of patients undergoing MitraClip procedure for mitral regurgitation had concomitant severe tricuspid regurgitation which was predictive for worse prognosis. Post-procedural TR improvement of one or more grades was frequent in these patients and was associated with higher survival-rates. Funding Acknowledgement Type of funding source: None

Prevalence, predictors, and prognosis of tricuspid regurgitation following permanent pacemaker implantation.

This study aimed to investigate the prevalence and clinical significance of lead-related tricuspid regurgitation (TR) in patients with permanent pacemaker (PM). A total of 2,533 patients who underwent permanent PM implantation between January 2008 and December 2017 in a single center were retrospectively reviewed. Among them, 429 patients who underwent transthoracic echocardiography within 90 days before implantation and were followed up at least 3 months after PM implantation were included. Patients who had pre-existing grade 3 or 4 TR, had a single atrial lead, or had undergone tricuspid valve surgery before PM implantation were excluded. Occurrence of PM-related TR (PMTR) was defined as worsening of TR by at least 2 grades on follow-up echocardiography. Cardiovascular outcomes were defined as the composite of cardiovascular death and hospitalization for heart failure. During the median follow-up of 855 days, 42 (9.8%) patients had PMTR and 86 (20.0%) presented with cardiovascular outcomes. In the multivariate logistic regression analysis, the presence of atrial fibrillation (hazard ratio [HR]: 2.07, 95% confidence interval [CI]: 1.27–4.09, p = 0.037]) and history of open-heart surgery (HR: 3.34, 95% CI: 1.68–6.68, p<0.001) were independently associated with PMTR. Patients with PMTR showed significantly higher cardiovascular events than those without (45.2 vs. 17.3%, log-rank p<0.001). Furthermore, PMTR was independently associated with the primary outcome (HR: 2.45, 95% CI: 1.43–4.22, p = 0.001). In conclusion, the occurrence of TR in patients with permanent PM is not uncommon. PMTR is associated with atrial fibrillation, the history of open-heart surgery, and poorer cardiovascular outcomes.