Tricuspid Regurgitation Is Associated With Increased Risk of Mortality in Patients With Low-Flow Low-Gradient Aortic Stenosis and Reduced Ejection Fraction: Results of the Multicenter TOPAS Study (True or Pseudo-Severe Aortic Stenosis)

Most hospitalized patients with significant tricuspid regurgitation have advanced disease preventing transcatheter tricuspid valve intervention

BACKGROUND

More than moderate tricuspid regurgitation (TR) is associated with high mortality. Surgical tricuspid valve repair and replacements are rarely performed due to high operative mortality risk, mainly attributed to late presentation. Novel transcatheter tricuspid valve intervention (TTVI) devices are being developed as an alternative to surgery. The population of patients presenting to tertiary care centers who can benefit from TTVI has not been well defined.

METHODS

We retrospectively analyzed 12,677 consecutive 2D echocardiograms completed at our tertiary care center between March 2021 and March 2022 and identified hospitalized patients with more than moderate TR. A total of 569 patients were included in this study. Clinical and echocardiographic data were collected by individual chart review. We used the European Society of Cardiology (ESC) guidelines on the management of valvular disease to retrospectively assign patients to medical, surgical, or transcatheter therapy.

RESULTS

458 patients (80.5 %) were assigned to medical therapy, 57 (10.0 %) were assigned to TTVI, and 54 (9.5 %) were assigned to tricuspid valve surgery. Of note, 75.7 % (431/569) of patients were precluded from any intervention due to advanced disease, and only 4.7 % (27/569) presented too early for intervention, being both asymptomatic and without RV dilatation.

CONCLUSION

Only 10.0 % of patients presenting to a tertiary care center with significant TR would be candidates for TTVI when these technologies are approved in the United States. Earlier identification and treatment of TR could increase the number of patients who may benefit from interventions including TTVI.

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

Background

We 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).

Methods

After 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.

Results

Patients 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.

Conclusions

In 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.

Transcatheter treatment of the tricuspid valve: current status and perspectives

Transcatheter tricuspid valve interventions (TTVI) are emerging as alternatives to surgery in high-risk patients with isolated or concomitant tricuspid regurgitation. The development of new minimally invasive solutions potentially more adapted to this largely undertreated population of patients, has fuelled the interest for the tricuspid valve. Growing evidence and new concepts have contributed to revise obsolete and misleading perceptions around the right side of the heart. New definitions, classifications, and a better understanding of the disease pathophysiology and phenotypes, as well as their associated patient journeys have profoundly and durably changed the landscape of tricuspid disease. A number of registries and a recent randomized controlled pivotal trial provide preliminary guidance for decision-making. TTVI seem to be very safe and effective in selected patients, although clinical benefits beyond improved quality of life remain to be demonstrated. Even if more efforts are needed, increased disease awareness is gaining momentum in the community and supports the establishment of dedicated expert valve centres. This review is summarizing the achievements in the field and provides perspectives for a less invasive management of a no-more-forgotten disease.

Low-Flow, Low-Gradient Severe Aortic Stenosis in patients with preserved or reduced ejection fraction: a systematic literature review

OBJECTIVES

A systematic review of the literature was conducted to analyze the current evidence on low-flow, low-gradient severe aortic stenosis. This analysis aimed to differentiate between subgroups of patients with reduced and preserved left ventricular ejection fraction (LVEF).

METHODS

After conducting a systematic literature review, 35 observational studies were included. Out of these, 28 were prospective and 7 retrospective. The studies that included a mortality risk stratification of low-flow, low-gradient aortic stenosis (LF- LG AS) with both preserved and reduced LVEF were reviewed.

RESULTS

The importance of considering multiple clinical and echocardiographic variables in diagnostic evaluation and therapeutic decision-making was highlighted.

CONCLUSIONS

LF- LG AS, in any of its subgroups, is a common and challenging valve lesion. A careful assessment of severity and, in specific scenarios, a thorough reclassification is important. More high-quality studies are required to more precisely define the classification and prognosis of this entity.

Tricuspid Regurgitation: From Imaging to Clinical Trials to Resolving the Unmet Need for Treatment

Tricuspid regurgitation (TR) is a highly prevalent and heterogeneous valvular disease, independently associated with excess mortality and high morbidity in all clinical contexts. TR is profoundly undertreated by surgery and is often discovered late in patients presenting with right-sided heart failure. To address the issue of undertreatment and poor clinical outcomes without intervention, numerous structural tricuspid interventional devices have been and are in development, a challenging process due to the unique anatomic and physiological characteristics of the tricuspid valve, and warranting well-designed clinical trials. The path from routine practice TR detection to appropriate TR evaluation, to conduction of clinical trials, to enriched therapeutic possibilities for improving TR access to treatment and outcomes in routine practice is complex. Therefore, this paper summarizes the key points and methods crucial to TR detection, quantitation, categorization, risk-scoring, intervention-monitoring, and outcomes evaluation, particularly of right-sided function, and to clinical trial development and conduct, for both interventional and surgical groups.

Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints

Interest in the pathophysiology, etiology, management, and outcomes of patients with tricuspid regurgitation (TR) has grown in the wake of multiple natural history studies showing progressively worse outcomes associated with increasing TR severity, even after adjusting for multiple comorbidities. Historically, isolated tricuspid valve surgery has been associated with high in-hospital mortality rates, leading to the development of transcatheter treatment options. The aim of this first Tricuspid Valve Academic Research Consortium document is to standardize definitions of disease etiology and severity, as well as endpoints for trials that aim to address the gaps in our knowledge related to identification and management of patients with TR. Standardizing endpoints for trials should provide consistency and enable meaningful comparisons between clinical trials. A second Tricuspid Valve Academic Research Consortium document will focus on further defining trial endpoints and will discuss trial design options.

Impact of left ventricular end-diastolic pressure as a marker for diastolic dysfunction on long-term outcomes in patients undergoing transcatheter aortic valve replacement

OBJECTIVE

The aim of this study was to investigate the proportion of elevated left ventricular end-diastolic pressure (LVEDP) as an indicator of diastolic function after transcatheter aortic valve replacement (TAVR) and its implication in predicting long-term mortality.

METHODS

We analyzed retrospectively collected data on 3328 patients with severe aortic stenosis undergoing TAVR in our institution between July 2009 and June 2021. Patients were stratified into two groups based on invasive post-procedural LVEDP measurements: normal (<15 mmHg) vs. elevated (≥15 mmHg) LVEDP.

RESULTS

Mean age of the patients was 81.6 years, and 53.3% were female. Elevated post-procedural LVEDP was identified in 2408 (72.3%) patients. The 5-year mortality rates were higher in the group with elevated LVEDP compared with the group with normal LVEDP (27.4% vs. 8.3%, p = 0.01; hazard ratio [HR] 1.22, 95% CI 1.05-1.41). A multivariate model revealed the following independent predictors of mortality after TAVR: post-procedural elevated LVEDP (HR 1.24, 95% CI 1.01-1.53), pre-procedural significant tricuspid regurgitation (HR 1.24, 95% CI 1.02-1.52) and pulmonary hypertension (PH) (HR 1.53, 95% CI 1.26-1.86). In the present study, a significant paravalvular leak after TAVR was not associated with higher mortality (HR 1.45, 95% CI-0.95-2.19, p = 0.75).

CONCLUSION

Elevated post-procedural LVEDP in patients who undergo TAVR is an independent predictor of all-cause mortality. Furthermore, PH and tricuspid regurgitation were also identified as predictors of mortality. These data confirm that diastolic dysfunction is an important predictor of mortality in TAVR and should be considered to guide procedure timing, favoring an early interventional approach and management in aortic stenosis patients.

Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints

Interest in the pathophysiology, etiology, management, and outcomes of patients with tricuspid regurgitation (TR) has grown in the wake of multiple natural history studies showing progressively worse outcomes associated with increasing TR severity, even after adjusting for multiple comorbidities. Historically, isolated tricuspid valve surgery has been associated with high in-hospital mortality rates, leading to the development of transcatheter treatment options. The aim of this first Tricuspid Valve Academic Research Consortium document is to standardize definitions of disease etiology and severity, as well as endpoints for trials that aim to address the gaps in our knowledge related to identification and management of patients with TR. Standardizing endpoints for trials should provide consistency and enable meaningful comparisons between clinical trials. A second Tricuspid Valve Academic Research Consortium document will focus on further defining trial endpoints and will discuss trial design options.

Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints

Interest in the pathophysiology, etiology, management, and outcomes of patients with tricuspid regurgitation (TR) has grown in the wake of multiple natural history studies showing progressively worse outcomes associated with increasing TR severity, even after adjusting for multiple comorbidities. Historically, isolated tricuspid valve surgery has been associated with high in-hospital mortality rates, leading to the development of transcatheter treatment options. The aim of this first Tricuspid Valve Academic Research Consortium document is to standardize definitions of disease etiology and severity, as well as endpoints for trials that aim to address the gaps in our knowledge related to identification and management of patients with TR. Standardizing endpoints for trials should provide consistency and enable meaningful comparisons between clinical trials. A second Tricuspid Valve Academic Research Consortium document will focus on further defining trial endpoints and will discuss trial design options.

Isolated functional tricuspid regurgitation: how to define patients at risk for event?

AIMS

Functional tricuspid regurgitation (TR) is a turning point in cardiac diseases. Symptoms typically appear late. The optimal timing for proposing a valve repair remains a challenge. We sought to analyse the characteristics of right heart remodelling in patients with significant functional TR to identify the parameters that could be used in a simple prognostic model predicting clinical events.

METHODS AND RESULTS

We designed a prospective observational French multicentre study including 160 patients with significant functional TR (effective regurgitant orifice area > 30 mm² ) and left ventricular ejection fraction > 40%. Clinical, echocardiographic, and electrocardiogram data were collected at baseline and at the 1 and 2 year follow-up. The primary outcome was all-cause death or hospitalization for heart failure. At 2 years, 56 patients (35%) achieved the primary outcome. The subset with events showed more advanced right heart remodelling at baseline, but similar TR severity. Right atrial volume index (RAVI) and the tricuspid annular plane systolic excursion to systolic pulmonary arterial pressure (TAPSE/sPAP) ratio, reflecting right ventricular-pulmonary arterial coupling, were 73 mL/m² and 0.40 vs. 64.7 mL/m² and 0.50 in the event vs. event-free groups, respectively (both P < 0.05). None among all the clinical and imaging parameters tested had a significant group × time interaction. The multivariable analysis leads to a model including TAPSE/sPAP ratio > 0.4 (odds ratio = 0.41, 95% confidence limit 0.2 to 0.82) and RAVI > 60 mL/m² (odds ratio = 2.13, 95% confidence limit 0.96 to 4.75), providing a clinically valid prognostic evaluation.

CONCLUSIONS

RAVI and TAPSE/sPAP are relevant for predicting the risk for event at 2 year follow-up in patients with an isolated functional TR.

Low-flow, Low-gradient Severe Aortic Stenosis: A Review

Aortic stenosis (AS) is a common valve pathology experienced by patients worldwide. There are limited population-based studies assessing its prevalence; however, epidemiological studies emphasize that the burden of disease is growing. Recognizing AS relies on accurate clinical assessment and diagnostic investigations. Patients who develop severe AS are often referred to the heart team for assessment of aortic valve intervention. Although echocardiography has traditionally been used to screen and monitor the progression of AS, there can be discordance between measurements in a low-flow state. Such patients may have truly severe AS and potentially derive long-term benefit from aortic valve intervention. Accurately identifying these patients with the use of ancillary testing has been the focus of research for several years. In this article, we discuss the contemporary approaches and challenges in identifying and managing patients with low-flow, low-gradient severe AS.

Role of the mitral valve in left ventricular assist device pathophysiology

Functional mitral regurgitation (MR) in the setting of heart failure results from progressive dilatation of the left ventricle (LV) and mitral annulus. This leads to leaflet tethering with posterior displacement. Contrary to common assumptions, MR often does not resolve with LVAD decompression of the LV alone. The negative impact of significant (moderate-severe) mitral regurgitation in the LVAD setting is becoming better recognized in terms of its harmful effect on right heart function, pulmonary vascular resistance and hospital readmissions. However, controversies remain regarding the threshold for intervention and management. At present, there are no consensus indications for the repair of significant mitral regurgitation at the time of LVAD implantation due to the conflicting data regarding potential adverse effects of MR on clinical outcomes. In this review, we summarize the current understanding of MR pathophysiology in patients supported with LVAD and potential future management strategies.

Risk prediction in patients with low-flow, low-gradient aortic stenosis and reduced ejection fraction undergoing TAVI

OBJECTIVE

Patients with low-flow, low-gradient aortic stenosis (LFLG AS) and reduced left ventricular ejection fraction (LVEF) are known to suffer from poor prognosis after transcatheter aortic valve implantation (TAVI). This study aimed to develop a simple score system for risk prediction in this vulnerable subset of patients.

METHODS

All patients with LFLG AS with reduced EF and sufficient CT data for aortic valve calcification (AVC) quantification, who underwent TAVI at five German centres, were retrospectively included. The Risk prEdiction in patients with Low Ejection Fraction low gradient aortic stenosis undergoing TAVI (RELiEF TAVI) score was developed based on multivariable Cox regression for all-cause mortality.

RESULTS

Among all included patients (n=718), RELiEF TAVI score variables were defined as independent predictors of mortality: male sex (HR 1.34 (1.06, 1.68), p=0.013), underweight (HR 3.10 (1.50, 6.40), p=0.0022), chronic obstructive pulmonary disease (HR 1.55 (1.21, 1.99), p=0.001), pulmonary hypertension (HR 1.51 (1.17, 1.94), p=0.0015), atrial fibrillation (HR 1.28 (1.03, 1.60), p=0.028), stroke volume index (HR 0.96 (0.95, 0.98), p<0.001), non-transfemoral access (HR 1.36 (1.05, 1.76), p=0.021) and low AVC density (HR 1.44 (1.15, 1.79), p=0.0012). A score system was developed ranging from 0 to 12 points (risk of 1-year mortality: 13%-99%). Kaplan-Meier analysis for low (0-1 points), moderate (2-4 points) and high RELiEF TAVI score (>4 points) demonstrated rates of 18.0%, 29.0% and 46.1% (p<0.001) for all-cause mortality and 23.8%, 35.9% and 53.4% (p<0.001) for the combined endpoint of all-cause mortality or heart failure rehospitalisation after 1 year, respectively.

CONCLUSIONS

The RELiEF TAVI score is based on simple clinical, echocardiographic and CT parameters and might serve as a helpful tool for risk prediction in patients with LFLG AS and reduced LVEF scheduled for TAVI.

Tricuspid insufficiency after cardiac-implantable electronic device placement

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.

When Aortic Stenosis Is Not Alone: Epidemiology, Pathophysiology, Diagnosis and Management in Mixed and Combined Valvular Disease

Aortic stenosis (AS) may present frequently combined with other valvular diseases or mixed with aortic regurgitation, with peculiar physio-pathological and clinical implications. The hemodynamic interactions between AS in mixed or combined valve disease depend on the specific combination of valve lesions and may result in diagnostic pitfalls at echocardiography; other imaging modalities may be helpful. Indeed, diagnosis is challenging because several echocardiographic methods commonly used to assess stenosis or regurgitation have been validated only in patients with the single-valve disease. Moreover, in the developed world, patients with multiple valve diseases tend to be older and more fragile over time; also, when more than one valvular lesion needs to address the surgical risk rises together with the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. Therefore, when AS presents mixed or combined valve disease, the heart valve team must integrate various parameters into the diagnosis and management strategy, including suitability for single or multiple transcatheter valve procedures. This review aims to summarize the most critical pathophysiological mechanisms underlying AS when associated with mitral regurgitation, mitral stenosis, aortic regurgitation, and tricuspid regurgitation. We will focus on echocardiography, clinical implications, and the most important treatment strategies.

Natural history of functional tricuspid regurgitation: impact of cardiac output

AIMS

Tricuspid regurgitation (TR) was long forgotten until recent studies alerting on its prognostic impact. Cardiac output (CO) is the main objective of heart mechanics. We sought to compare clinical and echocardiographic data of patients with TR from inclusion to 1-year follow-up according to initial CO.

METHODS AND RESULTS

Patients with isolated secondary TR and left ventricular ejection fraction (LVEF) ≥40% were prospectively included. All patients had a clinical and echocardiographic evaluation at baseline and after 1 year. Echocardiographic measurements were centralized. The patients were partitioned according to their CO at baseline. The primary outcome was all-cause death. Ninety-five patients completed their follow-up. The majority of patients had normal CO (n = 64, 67.4%), whereas 16 (16.8%) patients had low-CO and 12 (12.6%) had high-CO. right ventricular function was worse in the low-CO group but with improvement at 1 year (30% increase in tricuspid annular plane systolic excursion). LVEF and global longitudinal strain were significantly worse in the low-CO group. Overall, 18 (19%) patients died during follow-up, of which 10 (55%) patients had abnormal CO. There was a U-shaped association between CO and mortality. Normal CO patients had significantly better survival (87.5% vs. 62.5% and 66.67%) in the low- and high-CO groups, respectively, even after adjustment (heart rate 2.23 for the low-CO group and 9.08 for high-CO group; P = 0.0174).

CONCLUSION

Significant isolated secondary TR was associated with 19% of mortality. It is also associated with higher long-term mortality if CO is abnormal, suggesting a possible role for evaluating better and selecting patients for intervention.

Risk assessment in patients with left ventricular systolic dysfunction following transcatheter aortic valve replacement

BACKGROUND

Mortality following transcatheter aortic valve replacement (TAVR) in patients with post-procedural left ventricular systolic dysfunction remains high. We investigated clinical variables associating with worse clinical outcomes following TAVR in patients with systolic dysfunction.

METHODS

We retrospectively investigated 2588 patients with severe aortic stenosis who received TAVR and were enrolled in the optimized transcatheter valvular intervention (OCEAN-TAVI) multicenter registry (UMIN000020423). The association between the clinical variables following TAVR and 2-year cardiovascular mortality was investigated among those with post-TAVR left ventricular ejection fraction less than 50%.

RESULTS

A total of 298 patients (median 85 years old, 131 men) were included. The presence of moderate or greater tricuspid regurgitation following TAVR was independently associated with 2-year mortality (adjusted hazard ratio 3.41, 95% confidence interval 1.15-10.1), and significantly discriminated 2-year cardiovascular mortality (30% vs. 12%, p = 0.001). No patients with any improvement in tricuspid regurgitation had cardiovascular death.

CONCLUSION

Following TAVR, the existence of significant tricuspid regurgitation was associated with cardiovascular mortality in patients with heart failure with reduced ejection fraction.

Postoperative outcome after reoperative isolated tricuspid valve surgery-is there a predictor for survival?

OBJECTIVES

Reoperative tricuspid valve (TV) surgery is considered high risk even in the absence of additional concomitant cardiac procedures. The purpose of this study was to evaluate preoperative clinical parameters as predictors for survival after isolated reoperative TV surgery.

METHODS

From January 2005 to January 2019, 85 patients (mean age: 66.7 ± 10.3 years, 34 male) with severe isolated TV regurgitation and prior cardiac surgery were referred to our centre for elective or urgent TV repair/replacement; patients with endocarditis were excluded. We retrospectively analysed preoperative hepatorenal function [reflected by widely used clinical and laboratory parameters and the Model of End-stage-Liver Disease excluding International Normalized Ratio (MELD-XI) score] as a predictor for postoperative survival.

RESULTS

At hospital admission, the patients' average preoperative New York Heart Association class was 2.9 ± 0.6, left ventricular ejection fraction 52.5 ± 10.6%, mean pulmonary artery pressure 24.7 ± 8.0 mmHg, creatinine 115.4 ± 66.6 μmol/l, bilirubin 20.0 ± 19.6 μmol/l and the mean MELD-XI score was 13.3 ± 4.0 μmol/l. The mean follow-up was 5.4 ± 4.2 years. Thirty-day mortality was 5%, 5-year survival was 60.6 ± 5.4% and 10-year survival was 42.9 ± 6.5%. The multivariable Cox regression analysis evaluated the MELD-XI score [hazard ratio (HR 1.144, confidence interval 95% 1.0-1.3, P = 0.005] and diabetes mellitus (HR 2.27, confidence interval 95% 1.0-5.0, P = 0.04) as significant predictors for excess mortality while age and mean pulmonary artery pressure did not reliably predict clinical outcome.

CONCLUSIONS

Hepatorenal dysfunction was one main factor accounting for limited postoperative survival in our patient cohort. The MELD-XI score is easy to calculate and seems to reliably predict the perioperative risk in patients with prior cardiac surgery and indication for TV surgery.

Burden of Tricuspid Regurgitation in Patients Undergoing Coronary Artery Bypass Grafting

BACKGROUND

Tricuspid regurgitation (TR) is associated with poor outcomes after cardiac surgery. Guidelines recommend correction of severe TR in patients undergoing left-sided valve surgery but not coronary artery bypass graft surgery (CABG). We sought to evaluate impact of TR on outcomes after CABG.

METHODS

All patients (n = 28,027) undergoing CABG in The Society of Thoracic Surgeons (STS) regional database (2011 to 2018) were stratified by TR severity. Primary outcomes included major morbidity or mortality, which were compared using univariate analysis.

RESULTS

Of patients undergoing CABG, 4837 (17%) had mild, 800 (3%) had moderate, and 81 (0.29%) had severe TR. Increased severity was associated with higher rate of preoperative heart failure (none 5162 [23.4%] vs mild 1697 [35%] vs moderate 427 [53%] vs severe 54 [67%], P < .001] and STS predicted risk of mortality (1.0 [0.6 to 1.9) vs 1.4 [0.8 to 2.9] vs 2.8 [1.4 to 5.4] vs 6.2 [2.2 to 11.4], P < .001). Increasing severity was associated with higher postoperative rate of renal failure (426 [1.9%] vs 145 [3%] vs 58 [7.3%] vs 7 [8.6%], P < .001), prolonged ventilation (1652 [7.5%] vs 495 [10.2%] vs 153 [19.1%] vs 22 [27.2%], P < .001), and mortality (344 [1.6%] vs 132 [2.7%] vs 58 [7.3%] vs 9 [11.1%], P < .001). After risk adjustment, mild, moderate, and severe TR remained associated with increased morbidity and mortality (all P < .05).

CONCLUSIONS

Increasing TR severity, although independently associated with higher surgical risk, is not accounted for entirely by STS risk calculator. This highlights the importance of TR on operative risk and supports consideration of concurrent tricuspid intervention for patients with significant TR undergoing CABG.

Right ventricular reserve post mitral valve repair is associated with heart failure hospitalization

Right ventricular impairment is a predictor of cardiovascular outcomes in patients with degenerative mitral regurgitation. However, the time course of right ventricular functional changes post-surgical mitral valve repair remains largely unknown. Herein, using right ventricular-focused echocardiography, we aimed to investigate right ventricular reserve and its impact on hospitalization for heart failure after mitral valve repair. In this prospective study, we enrolled 108 patients scheduled to undergo surgical repair of degenerative mitral regurgitation. Echocardiography, including right ventricular strain analysis, was performed prior to, and one month and six months post mitral valve repair. Right ventricular strain that improved one month post-surgery was defined as reserved right ventricular. In addition, any cardiovascular outcomes comprising heart failure that required admission were recorded. The median follow-up duration is 31 months. Despite a significant improvement in mitral valve regurgitant volume post-operatively, left ventricular ejection fraction (LVEF) at six months was similar to LVEF at baseline. There was a transient decrease in LV longitudinal strain at one month that was recovered six months post mitral valve repair. Regarding the right ventricular, in contrast with conventional right ventricular parameters, including right ventricular tissue Doppler S', fractional area change and tricuspid annular plane systolic excursion (TAPSE), only resolution of right ventricular strain at one month predicted the subsequent myocardial recovery. Furthermore, patients with reserved right ventricular had a lower risk of hospitalization for heart failure compared to those with non-reserved right ventricular. Collectively, the early resolution of right ventricular strain is associated with the improvement in right ventricular function (measured by TAPSE) and in heart failure hospitalization in patients who had undergone surgical mitral valve repair for degenerative mitral regurgitation.

Risk of mortality following transcatheter aortic valve replacement for low-flow low-gradient aortic stenosis

BACKGROUND

Low-flow low-gradient (LF-LG) aortic stenosis (AS) is associated with high mortality, even after transcatheter aortic valve replacement (TAVR). Further knowledge of risk indicators is needed and a clinical risk score would be desirable for optimizing patient selection and therapeutic strategy.

METHODS

The study cohort comprised of 219 consecutive LF-LG AS patients undergoing TAVR from 2008 to 2018 in two high-volume German centers. Predictive factors for one-year all-cause mortality were defined according to a Cox proportional hazard model.

RESULTS

At one-year follow-up after TAVR, 28% of patients had died. A multivariate model revealed six independent predictors of one-year mortality: history of myocardial infarction (HR 2.05, 95%CI 1.13-3.72), eGFR < 30 ml/min/1.73m² (HR 2.75, 95%CI 1.48-5.11), tricuspid regurgitation moderate or more (HR 2.06, 95%CI 1.14-3.72), stroke volume index < 25 mL/m² (HR 2.03, 95%CI 1.14-3.62), self-expandable device (HR 2.72, 95%CI 1.17-6.27), and non-transfemoral approach (HR 3.42, 95%CI 1.28-9.14). The Rhineland Risk Score (RRS) consisting of these variables (c statistic 0.75, 95%CI 0.68-0.82, p < 0.001) was superior to the EuroSCORE II (c statistic 0.63) and STS-PROM score (c statistic 0.69) at predicting one-year mortality. Patients with a RRS ≥ 8 had a prohibitive risk of one-year mortality of 67.6% (95%CI 52.0-82.4%).

CONCLUSION

In patients with LF-LG AS, history of myocardial infarction, renal dysfunction, tricuspid regurgitation, a low stroke volume index, self-expandable device, and non-femoral approach were associated with increased 1-year mortality after TAVR. The RRS might serve as a helpful tool for risk prediction and patient selection for TAVR in patients with LF-LG AS.

Role of 3-Dimensional Echocardiography in the Comprehensive Evaluation of the Tricuspid Valve in Patients With Tricuspid Regurgitation

Three-dimensional echocardiography is one of the most promising methods for the diagnosis of valvular heart disease, and recently has become an essential clinical tool owing to the continued development of real-time transesophageal echocardiography (TEE) technology. And now an era of renewed interest and enthusiasm surrounding the diagnosis and treatment of valvular heart disease has come, which is driven by emerging trans-catheter procedures. Nonetheless, little or no attention has been given to the treatment of tricuspid regurgitation (TR). The application of 3D-TEE is useful for simultaneous visualization of all 3 leaflets in order to grasp the whole picture of the tricuspid valve (TV; “en face” view). The implications of 3-D assessment of TV annulus, leaflets, and morphology involve an improved understanding of both the mechanics and treatment of TR. This method has been useful for surgical management, including accurate measurement of tricuspid annular diameter and prediction of the post-surgical outcome. Moreover, this method may be indispensable for detailed and comprehensive evaluation of the TV in patients with TR who are candidates for trans-catheter tricuspid procedures. In addition, color Doppler 3D-TEE has been valuable to identify the location of the regurgitant orifice and the severity of the TR. It is now clear that this method will enhance the diagnosis and management of TR patients.

Prognostic Value of Right Ventricular Dysfunction and Tricuspid Regurgitation in Patients with Severe Low-Flow Low-Gradient Aortic Stenosis

Long and mid-term data in Low-Flow Low-Gradient Aortic Stenosis (LFLG-AS) are scarce. The present study sought to identify predictors of outcome in a sizeable cohort of patients with LFLG-AS. 76 consecutive patients with LFLG-AS (defined by a mean gradient <40 mmHg, an aortic valve area ≤1 cm² and an ejection fraction ≤50%) were prospectively enrolled and followed at regular intervals. Events defined as aortic valve replacement (AVR) and death were assessed and overall survival was determined. 44 patients underwent AVR (10 transcatheter and 34 surgical) whilst intervention was not performed in 32 patients, including 9 patients that died during a median waiting time of 4 months. Survival was significantly better after AVR with survival rates of 91.8% (CI 71.1–97.9%), 83.0% (CI 60.7–93.3%) and 56.3% (CI 32.1–74.8%) at 1,2 and 5 years as compared to 84.3% (CI 66.2–93.1%), 52.9% (CI 33.7–69.0%) and 30.3% (CI 14.6–47.5%), respectively, for patients managed conservatively (p = 0.017). The presence of right ventricular dysfunction (HR 3.47 [1.70–7.09]) and significant tricuspid regurgitation (TR) (HR 2.23 [1.13–4.39]) independently predicted overall mortality while the presence of significant TR (HR 3.40[1.38–8.35]) and higher aortic jet velocity (HR 0.91[0.82–1.00]) were independent predictors of mortality and survival after AVR. AVR is associated with improved long-term survival in patients with LFLG-AS. Treatment delays are associated with excessive mortality, warranting urgent treatment in eligible patients. Right ventricular involvement characterized by the presence of TR and/or right ventricular dysfunction, identifies patients at high risk of mortality under both conservative management and after AVR.

Treatment Challenges in Patients with Acute Heart Failure and Severe Aortic Valve Stenosis

PURPOSE OF REVIEW

The goal of this paper is to describe the treatment challenges in patients with aortic stenosis in combination with a reduced left ventricular function.

RECENT FINDINGS

Since the risk of mortality is increased in this patient population, transcatheter aortic valve implantation emerged as an important treatment option. Concomitant factors such as mitral regurgitation or coronary artery disease are important co-factors that need to be evaluated and taken into account for treatment decision. Treatment of the severe aortic stenosis is key in this complex setting. Since several co-factors may exist in addition to aortic stenosis, treatment needs to be decided by a Heart Team.

Impact of tricuspid regurgitation and right ventricular dysfunction on outcomes after transcatheter aortic valve replacement: A systematic review and meta-analysis

Far less attention has been paid to the prognostic effect of right-side heart disease on outcomes after transcatheter aortic valve replacement (TAVR) when compared with the left side. Therefore, we performed a systematic review and meta-analysis on the impact of tricuspid regurgitation (TR) and right ventricular (RV) dysfunction on outcomes after TAVR. We hypothesized that TR and RV dysfunction may have a deleterious effect on outcomes after TAVR. Article revealing the prognostic effect of TR and RV dysfunction on outcomes after TAVR were being integrated. Random or fixed effect model was adopted in accordance with the heterogeneity. There were nine studies with a total of 6466 patients enrolled after a comprehensive literature search of the MEDLINE/PubMed, EMBASE, ISI Web of Science, and Cochrane databases. The overall analysis revealed that moderate or severe TR at baseline increased all-cause mortality after TAVR (HR = 1.79, CI 95% 1.52-2.11, P < 0.001). Both baseline RV dysfunction (HR = 1.53, CI 95% 1.27-1.83, P < 0.001) and presence of RV dilation (HR = 1.83, CI 95% 1.47-2.27, P < 0.001) were associated with all-cause mortality. Both baseline moderate or severe TR and RV dysfunction worsen prognosis after TAVR and careful assessment of right heart function should be done for clinical decision by the heart team before the TAVR procedure.

Contemporary Trends in the Use and Outcomes of Surgical Treatment of Tricuspid Regurgitation

Background

Tricuspid regurgitation (TR), if untreated, is associated with an adverse impact on long‐term outcomes. In recent years, there has been an increasing enthusiasm about surgical and transcatheter treatment of patients with severe TR. We aim to evaluate the contemporary trends in the use and outcomes of tricuspid valve (TV) surgery for TR using the National Inpatient Sample.

Methods and Results

Between January 1, 2003 and December 31, 2014, an estimated 45 477 patients underwent TV surgery for TR in the United States, of whom 15% had isolated TV surgery and 85% had TV surgery concomitant with other cardiac surgery. There was a temporal upward trend to treat sicker patients during the study period. Patients who underwent isolated TV repair or replacement had a distinctly different clinical risk profile than those patients who underwent TV surgery simultaneous with other surgery. Isolated TV replacement was associated with high in‐hospital mortality (10.9%) and high rates of permanent pacemaker implantation (34.1%) and acute kidney injury requiring dialysis (5.5%). Similarly, isolated TV repair was also associated with high in‐hospital mortality (8.1%) and significant rates of permanent pacemaker implantation (10.9%) and new dialysis (4.4%). Isolated TV repair and TV replacement were both associated with protracted hospitalizations and substantial cost.

Conclusions

In contemporary practice, surgical treatment of TR remains underused and is associated with high operative morbidity and mortality, prolonged hospitalizations, and considerable cost.

Clinical outcomes of tricuspid valve repair accompanying left-sided heart disease

AIM

To determine whether the need for additional tricuspid valve repair is an independent risk factor when surgery is required for a left-sided heart disease.

METHODS

One hundred and eighty patients (68 ± 12 years, 79 males) underwent tricuspid annuoplasty. Cox proportional-hazards regression model for multivariate analysis was performed for variables found significant in univariate analyses.

RESULTS

Tricuspid regurgitation etiology was functional in 154 cases (86%), organic in 16 cases (9%), and mixed in 10 cases (6%), respectively. Postoperative mortality at 30 days was 11.7%. Mean follow-up was 51.7 mo with survival at 5 years of 73.5%. Risk factors for mortality were acute endocarditis [hazard ratio (HR) = 9.22 (95%CI: 2.87-29.62), P < 0.001], ischemic heart disease requiring myocardial revascularization [HR = 2.79 (1.26-6.20), P = 0.012], and aortic valve stenosis [HR = 2.6 (1.15-5.85), P = 0.021]. Significant predictive factors from univariate analyses were double-valve replacement combined with tricuspid annuloplasty [HR = 2.21 (1.11-4.39), P = 0.003] and preoperatively impaired ejection fraction [HR = 1.98 (1.04-3.92), P = 0.044]. However, successful mitral valve repair showed a protective effect [HR = 0.32 (0.10-0.98), P = 0.046]. Additionally, in instances where tricuspid regurgitation required the need for concomitant tricuspid valve repair, mortality predictor scores such as Euroscore 2 could be shortened to a simple Euroscore-tricuspid comprised of only 7 inputs. The explanation may lie in the fact that significant tricuspid regurgitation following left-sided heart disease represents an independent risk factor encompassing several other factors such as pulmonary arterial hypertension and dyspnea.

CONCLUSION

Tricuspid annuloplasty should be used more often as a concomitant procedure in the presence of relevant tricuspid regurgitation, although it usually reveals an overly delayed correction of a left-sided heart disease.

Mechanism and Implications of the Tricuspid Regurgitation

The tricuspid valve was virtually ignored for a long time in the past. However, significant tricuspid regurgitation (TR) often accompanies left-side heart valve pathology and does not always reverse with its correction. If left untreated, TR can progress and result in progressive right ventricular failure. Current guideline recommendations still hold minor differences. Nevertheless, there is a consensus to operate on patients with severe TR undergoing left-sided valve surgery (class I) or those with mild to moderate TR with a dilated annulus (≥40 or ≥21 mm 2 , Class IIa). However, in case of the primary TR, surgical options is limited by a relatively high risk of mortality and morbidity. For these patients, new percutaneous approaches are becoming available but no long-term data are still available. In this review, we provide a comprehensive overview of the epidemiological and pathophysiological aspects of TR, and the current and future directions of therapy.

[Low-flow low-gradient aortic valve stenosis : Current evidence]

Many patients with severe aortic stenosis have a "low-flow, low-gradient" aortic stenosis. The management of these patients can be quite difficult, as these patients often show impairment of the left ventricle, which can lead to false measurements of the severity of stenosis and also leads to a higher risk during aortic valve replacement. More diagnostic tools than only standard echocardiography are needed to correctly differentiate true severe aortic stenosis from pseudo severe aortic stenosis.

Diagnosis and treatment of tricuspid valve disease: current and future perspectives

The assessment and management of tricuspid valve disease have evolved substantially during the past several years. Whereas tricuspid stenosis is uncommon, tricuspid regurgitation is frequently encountered and is most often secondary in nature and caused by annular dilatation and leaflet tethering from adverse right ventricular remodelling in response to any of several disease processes. Non-invasive assessment of tricuspid regurgitation must define its cause and severity; advanced three-dimensional echocardiography, MRI, and CT are gaining in clinical application. The indications for tricuspid valve surgery to treat tricuspid regurgitation are related to the cause of the disorder, the context in which it is encountered, its severity, and its effects on right ventricular function. Most operations for tricuspid regurgitation are done at the time of left-sided heart valve surgery. The threshold for restrictive ring annuloplasty repair of secondary tricuspid regurgitation at the time of left-sided valve surgery has decreased over time with recognition of the risk of progressive tricuspid regurgitation and right heart failure in patients with moderate or lesser degrees of tricuspid regurgitation and tricuspid annular dilatation, as well as with appreciation of the high risks of reoperative surgery for severe tricuspid regurgitation late after left-sided valve surgery. However, many patients with unoperated severe tricuspid regurgitation are also deemed at very high or prohibitive surgical risk. Novel transcatheter therapies have begun to emerge for the treatment of tricuspid regurgitation in such patients. Experience with such therapies is preliminary and further studies are needed to determine their role in the management of this disorder.

Low-gradient aortic stenosis

An important proportion of patients with aortic stenosis (AS) have a 'low-gradient' AS, i.e. a small aortic valve area (AVA <1.0 cm(2)) consistent with severe AS but a low mean transvalvular gradient (<40 mmHg) consistent with non-severe AS. The management of this subset of patients is particularly challenging because the AVA-gradient discrepancy raises uncertainty about the actual stenosis severity and thus about the indication for aortic valve replacement (AVR) if the patient has symptoms and/or left ventricular (LV) systolic dysfunction. The most frequent cause of low-gradient (LG) AS is the presence of a low LV outflow state, which may occur with reduced left ventricular ejection fraction (LVEF), i.e. classical low-flow, low-gradient (LF-LG), or preserved LVEF, i.e. paradoxical LF-LG. Furthermore, a substantial proportion of patients with AS may have a normal-flow, low-gradient (NF-LG) AS: i.e. a small AVA-low-gradient combination but with a normal flow. One of the most important clinical challenges in these three categories of patients with LG AS (classical LF-LG, paradoxical LF-LG, and NF-LG) is to differentiate a true-severe AS that generally benefits from AVR vs. a pseudo-severe AS that should be managed conservatively. A low-dose dobutamine stress echocardiography may be used for this purpose in patients with classical LF-LG AS, whereas aortic valve calcium scoring by multi-detector computed tomography is the preferred modality in those with paradoxical LF-LG or NF-LG AS. Although patients with LF-LG severe AS have worse outcomes than those with high-gradient AS following AVR, they nonetheless display an important survival benefit with this intervention. Some studies suggest that transcatheter AVR may be superior to surgical AVR in patients with LF-LG AS.

Pathophysiology and management of multivalvular disease

Multivalvular disease (MVD) is common among patients with valvular disease, and has a complex pathophysiology dependent on the specific combination of valve lesions. Diagnosis is challenging because several echocardiographic methods commonly used for the assessment of stenosis or regurgitation have been validated only in patients with single-valve disease. Decisions about the timing and type of treatment should be made by a multidisciplinary heart valve team, on a case-by-case basis. Several factors should be considered, including the severity and consequences of the MVD, the patient's life expectancy and comorbidities, the surgical risk associated with combined valve procedures, the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. The introduction of transcatheter valve therapies into clinical practice has provided new treatment options for patients with MVD, and decision-making algorithms on how to combine surgical and percutaneous treatment options are evolving rapidly. In this Review, we discuss the pathophysiology, diagnosis, and treatment of MVD, focusing on the combinations of valve pathologies that are most often encountered in clinical practice.