Multi-modality imaging assessment of native valvular regurgitation: an EACVI and ESC council of valvular heart disease position paper

Impact of Optimal Procedural Result After Transcatheter Edge-to-Edge Tricuspid Valve Repair: Results From TRI-SPA Registry

BACKGROUND

Procedural success following tricuspid transcatheter edge-to-edge repair (TEER) has been defined variably over time; however, the consequences of achieving a tricuspid regurgitation (TR) grade of 0/1+ are still unclear.

OBJECTIVES

This study aimed to assess the predictors and prognostic impact of achieving TR 0/1+ after TEER and its role in clinical events.

METHODS

This multicenter registry included patients undergoing tricuspid TEER in 15 Spanish centers from June 2020 and May 2023. Patients were categorized into the following groups based on the TR grade after procedure: optimal (0/1+), acceptable (2+), and not acceptable (≥3+). The primary endpoint was the 1-year composite of all-cause death, heart failure hospitalization, and tricuspid reintervention. Secondary endpoints included each component of the primary endpoint assessed separately, NYHA functional class, and TR grade at follow-up.

RESULTS

Among 280 enrolled patients, 120 (42.9%) had residual TR 0/1+, 111 (39.6%) had residual TR 2+, and 49 (17.5%) had residual TR ≥3+. Patients with TR 0/1+ experienced lower rates of the primary endpoint (13% vs 20% vs 31%; log-rank P = 0.036). Residual TR ≥3+ was an independent predictor of primary endpoint (HR: 2.277; P = 0.044). Higher rates of NYHA functional class I or II and sustained TR reduction were seen in the TR 0/1+ group (P < 0.001 for both). A small coaptation gap and absence of septal leaflet tethering were independent predictors of achieving TR 0/1+.

CONCLUSIONS

An optimal procedural result after TEER might be associated with improved outcomes. TR coaptation gap and leaflet restriction may aid in assessing suitability for TEER.

Racial and ethnic disparities in patients with severe tricuspid regurgitation: The Bronx-Valve registry

BACKGROUND

Severe tricuspid regurgitation (TR) is an adverse prognostic factor. The presence of potential racial/ethnic disparities in patient characteristics and outcomes remain unexplored. This study aimed to investigate the impact of race/ethnicity on the clinical course of severe TR.

METHODS

We conducted a retrospective cohort analysis of all adults diagnosed with severe TR between January 2017 and December 2019 at a quaternary-care health system. Clinical and echocardiographic features were evaluated according to race/ethnicity. TR was categorized into four etiologies: primary, cardiac implantable electronic device-induced, ventricular secondary (V-STR), and atrial secondary TR. V-STR subgroups included left-sided cardiac disease and pulmonary hypertension. The primary endpoint was 5-year all-cause mortality, with secondary endpoints being heart failure hospitalization (HFH) and cardiovascular (CV) mortality.

RESULTS

A total of 989 patients were analyzed: 47.8 %, 35.1 %, and 17.1 % were non-Hispanic Black, Hispanic, and non-Hispanic White, respectively, over a median follow-up of 14.8 (3-42.4) months. The mean age was 71.4 ± 15.6 years (60.9 % women) with non-Hispanic Black and Hispanic patients younger yet displaying higher comorbidity burden, worse functional class, and more pronounced right ventricular remodeling. Left-sided cardiac disease was the predominant etiology (65.9 %), with a higher prevalence among non-White individuals. All-cause mortality and CV mortality occurred in 575 (58.1 %) and 196 (19.8 %) of patients with no significant differences among groups. HFH presented in 334 (33.1 %) of patients with Black patients having an increased risk compared to White individuals (HR, 1.45; 95 %CI, 1.04-2.02).

CONCLUSIONS

At the time of severe TR detection, Black and Hispanic patients, despite being younger, had higher comorbidities and more advanced disease than White patients. While 5-year mortality rates showed no significant racial/ethnic differences, Black patients had a higher risk of HFH.

Sport PRactice and its Effects on aortic size and valve function in bicuspid Aortic valve Disease: a cross-sectional report from the SPREAD study

OBJECTIVE

Concerns exist about the possible detrimental effects of exercise training on aortic size and valve function in individuals with bicuspid aortic valve (BAV). This multicentre international study aimed to determine the characteristics of aortic size and valve function in athletes versus non-athletes with BAV and athletes with tricuspid aortic valve (TAV).

METHODS

We enrolled competitive athletes with BAV and age- and sex-matched athletes with TAV and non-athletes with BAV. We assessed valve function, aortic size and biventricular measures using echocardiography. Individuals with established moderate-severe AV stenosis, regurgitation or significant aortic dilation were excluded from the study.

RESULTS

The study population comprised 504 participants: 186 competitive athletes with BAV (84% males; age 30±11 years), 193 competitive athletes with TAV and 125 non-athletes with BAV. The aortic annulus was greater in athletes with BAV than athletes with TAV and non-athletes with BAV (p<0.001). Both athletic and non-athletic individuals with BAV had greater sinuses of Valsalva, sino-tubular junction and ascending aorta diameters than athletes with TAV (p<0.001). However, no significant differences were found between athletes and non-athletes with BAV. Left ventricular index volumes and mass were greater in athletes with BAV than in the other two groups (p<0.001). Individuals with BAV (athletes and non-athletes) had greater mean gradients than TAV athletes.

CONCLUSION

This multicentre international study demonstrates no differences between athletes with BAV and non-athletes with BAV regarding aortic valve function or aortic dimensions. However, athletes with BAV have larger aortic diameters and a relatively worse valvular function than athletes with TAV.

Bioimpedance analysis predicts worsening events in outpatients with heart failure and reduced ejection fraction

AIMS

Heart failure (HF) with reduced left ventricle ejection fraction (LVEF) is an entity with poor prognosis characterized by decompensations. Bioelectrical impedance analysis (BIA) is used to assess volume overload (VO) and may be useful to identify apparently stable HF outpatients at risk of decompensation. The aim of this study is to analyse whether VO assessed by BIA is associated with worsening heart failure (WHF) in stable outpatients with HF and reduced LVEF (HFrEF).

METHODS AND RESULTS

This is a prospective single-centre observational study. Consecutive stable HF outpatients with LVEF below 40% underwent BIA, transthoracic echocardiography, blood sampling, and physical examination and were followed up for 3 months. VO was defined as the difference between the measured weight and the dry weight assessed by BIA. Demographic, clinical, anthropometric, echocardiographic, and analytical parameters were recorded. The primary endpoint was WHF, defined by visits to the emergency department for HF or hospitalization for HF. A total of 100 patients were included. The median VO was 0.5 L (interquartile range 0-1.6 L). Eleven patients met the primary endpoint. Univariate binary logistic regression analysis showed that left ventricle filling pressures assessed by E/e', N-terminal pro B-type natriuretic peptide, inferior vena cava dilatation (≥21 mm), signs of congestion, and VO were associated with the primary endpoint. Binary logistic regression multivariate analysis showed that VO was the only independent predictor for the primary endpoint (adjusted OR 2.7; 95% CI 1.30-5.63, P = 0.008). Multivariate Cox regression analysis also showed an adjusted hazard ratio (HR) for VO of 2.03; 95% CI 1.37-3.02, P < 0.001. Receiver-operating characteristic curve analysis showed an area under the curve for VO of 0.88 (95% CI 0.79-0.97, P < 0.001) with an optimal cut-off of 1.2 L.

CONCLUSIONS

VO assessed by BIA is independently associated with WHF in stable outpatients with HFrEF at 3 months.

Multimodality Imaging for Transcatheter Tricuspid Regurgitation Interventions: Novel Approaches to the Forgotten Valve

Tricuspid regurgitation (TR) poses a significant healthcare burden and is a major concern for patients who experience debilitating symptoms and face a poorer prognosis. Cardiologists are showing renewed interest in TR, as the previous belief that it was merely a bystander of left-sided heart disease has evolved. As a result, more transcatheter techniques addressing TR are emerging. Although a clear impact on mortality from these transcatheter tricuspid valve interventions (TTVI) has not yet been demonstrated, the improvement in symptoms and quality of life for patients is substantial, leading to increased use of these procedures in clinical practice. In this review, we focus on multimodality imaging as an essential tool for quantifying TR severity, assessing right ventricular (RV) function, understanding the underlying mechanisms, selecting the appropriate intervention, and ensuring thorough and accurate preprocedural planning to minimize complications.

Insulin-Like Growth Factor Binding Protein 2 Predicts Right Ventricular Reverse Remodeling and Improvement of Concomitant Tricuspid Regurgitation After Transcatheter Edge-to-Edge Mitral Valve Repair

BACKGROUND

Concomitant right ventricular (RV) failure and tricuspid regurgitation (TR) are common comorbidities in patients undergoing mitral valve transcatheter edge-to-edge repair (M-TEER) and are associated with worse prognosis. Improvement of TR after M-TEER occurs frequently, however determinants of this course are poorly understood. This study aimed to analyze serum biomarkers that are differentially regulated in patients with TR and to identify biomarkers predictive of the course of TR after M-TEER.

METHODS AND RESULTS

Biomarker expression was analyzed in 242 prospectively included patients undergoing M-TEER. Patients with moderate-to-severe TR had significant comorbidities (median EuroSCORE II 5.2 in patients with severe TR, 4.9 in moderate TR, 3.2 in no/mild TR; p = 0.002) and a large number of biomarkers was upregulated including IGFBP-2 (1.4-fold in severe TR compared to no/mild TR, p = 0.005). Echocardiographic follow-up 3 months after M-TEER was carried out in 99 patients. RV reverse remodeling (RVRR) as defined by improvement of concomitant TR by at least one grade and/or RV diameter downsizing of at least 10% compared to baseline was seen in 50 patients (50.5%). IGFBP-2 (Odds Ratio 2.078) and presence of chronic pulmonary disease (Odds Ratio 15.341) proved independent predictors of non-development of RVRR within 3 months after M-TEER.

CONCLUSIONS

In patients undergoing M-TEER with concomitant moderate or severe TR, numerous cardiometabolic biomarkers including IGFBP-2 are upregulated. Higher levels of IGFBP-2 at baseline are independently associated with persistent TR and/or RV dilation after M-TEER.

Role of Cardiovascular Magnetic Resonance in the Assessment of Native Aortic Regurgitation With Insights on Mixed and Multiple Valvular Heart Disease: A Narrative Review

Cardiovascular magnetic resonance imaging (CMR) has received extensive validation for the assessment of valvular heart disease (VHD) and offers an accurate and direct method for the quantification of aortic regurgitation (AR). According to the current guidelines, CMR represents a useful second-line investigation in patients with poor acoustic windows or when echocardiography is inconclusive, for example, in cases of multiple or eccentric aortic jets. Without ionizing radiation exposure, CMR provides in-depth information not only on the severity degree of AR, providing a precise quantification of regurgitant volume and fraction, but also on cardiac structure and function, being recognized as the gold standard for the assessment of heart chamber size and systolic function. CMR allows a free choice of cardiac imaging planes and provides further information on the myocardium, thanks to the tissue characterization ability offered by several sequences, such as the late gadolinium enhancement technique. The possibilities offered by CMR become even more interesting in the context of mixed and multiple VHD, where the echocardiographic assessments often encounter difficulties in the quantification of each single valve lesion. The current scientific data support a greater expansion of CMR in this field, thanks to its additional advantages for the diagnosis, risk stratification, and to guide treatment. This review investigates the current CMR techniques and protocols in AR, with special insights into the evaluation of mixed aortic valve disease and multiple VHD including AR.

Noninvasive Imaging for Native Aortic Valve Regurgitation

Aortic regurgitation (AR) is associated with left ventricular (LV) volume and pressure overload, resulting in eccentric LV remodeling and enlargement. This condition may be well tolerated for years before the onset of myocardial dysfunction and symptoms. Echocardiography plays a crucial role in the diagnosis of AR, assessing its mechanism and severity, and detecting LV remodeling. The assessment of AR severity is challenging and frequently requires the integration of information from multiple different measurements to assess the severity. Recent data suggest that echocardiographically derived LV volumes (end-systolic volume index > 45 mL/m2), an ejection fraction threshold of <60%, and abnormal global longitudinal strain may help identify early dysfunction and may be used to improve clinical outcomes. Consequently, these parameters can identify candidates for surgery. Cardiac magnetic resonance imaging is emerging as a valuable tool for assessing severity when it remains unclear after an echocardiographic evaluation. This review emphasizes the importance of imaging, particularly echocardiography, in the evaluation of AR. It focuses on various echocardiographic parameters, including technical details, and how to integrate them for assessing the mechanism and severity of AR as well as LV remodeling.

Echocardiography Core Laboratory Methodology for TAVR: A Transatlantic Consensus

Inter-echocardiography core laboratory (ECL) harmonization is pivotal to consider data from different ECLs interchangeable. On the basis of the experience of the first trans-Atlantic harmonization of 2 established ECLs in the field of transcatheter aortic valve replacement (TAVR) trials, this review describes the harmonized ECL methodology in analyzing and adjudicating the post-TAVR echocardiographic endpoints according to Valve Academic Research Consortium 3 definitions. This review presents the feasibility and intra- and inter-ECL reproducibility, explains the root cause of potential important inter-ECL variability, and formulates ECL recommendations for optimal post-TAVR echocardiographic image acquisition. The implementation of inter-ECL harmonization may further define the best practice of ECLs and have logistic and regulatory implications for the realization of future TAVR trials.

Assessing right atrial size in patients with tricuspid regurgitation: importance of the right ventricular-focused view

AIMS

To assess the accuracy of measuring the right atrial volume (RAV) using two-dimensional echocardiography (2DE) in a right ventricular focused (RVF) view compared to the conventional apical four-chamber (4Ch) view in patients with secondary tricuspid regurgitation (STR). We also compared the clinical correlates of the measures obtained using different methods.

METHODS AND RESULTS

The accuracy of RAV measurements obtained between 2DE-4Ch and RVF views in 384 patients with STR were compared using three-dimensional echocardiography (3DE) as a reference. We used the analysis of variance to test the differences among RAVs obtained from the different 2DE and 3DE acquisitions and the receiving operating characteristics (ROC) curves to evaluate the association with the composite endpoint of hospitalization for heart failure or death. Compared to 3DE, RAV was significantly more underestimated when measurements were obtained from 4Ch rather than RVF (-24 vs. -14%, respectively, P < 0.001 for both). RAV underestimation in 4Ch and RVF view was relatively larger in lower grades of STR (-28 vs. -17% in mild, -23 vs. -14% in moderate, and -19 vs. -11% in severe STR, P = 0.001), and in the atrial compared to ventricular (-28 vs. -22%; P = 0.002) STR. RAV measured by 3DE and RVF showed the highest area under the curve (AUC = 0.67 for 3DE vs. 0.64 for RVF, P = 0.05), while 4Ch was significantly less related to the outcomes (AUC: 0.61, P = 0.021 vs. 3DE RAV).

CONCLUSION

In patients with STR, the use of RVF view improved the accuracy of 2DE RAV measurement as compared to the conventional 4Ch-derived measurements.

Relevance of residual tricuspid regurgitation for right ventricular reverse remodelling after tricuspid valve intervention in patients with severe tricuspid regurgitation and right-sided heart failure

AIMS

Right ventricular reverse remodelling (RVRR) is linked to improved survival in patients with severe tricuspid regurgitation (TR) and right-sided heart failure who underwent interventional treatment. However, the role of residual TR on RVRR remains unclear. In this analysis the impact of residual TR on RVRR after interventional TR treatment, which was validated by two independent cohorts at four sites using echocardiography or cardiac magnetic resonance (CMR) imaging, was investigated.

METHODS AND RESULTS

Overall, 253 patients who were treated for severe TR and right-sided heart failure using different treatment modalities (tricuspid transcatheter edge-to-edge repair [T-TEER], transcatheter tricuspid valve annuloplasty, orthotopic transcatheter TV replacement [TTVR], heterotopic TTVR) were included. Three-dimensional echocardiographic and CMR-based assessment of RVRR and clinical evaluation of decongestion or exercise capacity were performed at baseline and 30 days after the procedure. Mortality was analysed at 1 year after transcatheter tricuspid valve intervention (TTVI). In patients with residual TR ≤1+ pronounced reduction of right ventricular end-diastolic and end-systolic volumes was observed. In patients with residual TR ≥2+ the effect of RVRR gradually decreased with higher residual TR reinforcing the relevance of optimal procedural results for RVRR. These findings were validated in two independent cohorts. In contrast to RVRR, residual TR ≤1+ and 2+ were associated with similar 1-year survival. RVRR was only observed after T-TEER or orthotopic TTVR, but not after heterotopic TTVR as expected. However, all three treatment modalities were accompanied by significant decongestion and functional improvement at 30-day follow-up.

CONCLUSION

In patients with severe TR and right-sided heart failure undergoing TTVI, superior procedural results were associated with more pronounced RVRR.

Functional Mitral Regurgitation Post-Isolated Aortic Valve Replacement

Background: The management of mitral regurgitation during aortic valve replacement remains a complex question. Secondary mitral regurgitation often improves post-aortic valve replacement without mitral valve surgery, but residual mitral regurgitation can significantly affect long-term outcomes. This study investigates the natural history of mitral regurgitation following isolated aortic valve replacement and identifies prognostic factors for persistent mitral regurgitation. Methods: A retrospective study was conducted on 108 patients who underwent isolated aortic valve replacement. Patients were categorized based on mitral regurgitation improvement. Additionally, patients were divided into patient-prosthesis mismatch and non-patient-prosthesis mismatch groups based on the aortic prosthesis. Preoperative and postoperative echocardiographic data were analyzed. Results: In total, 63% of patients showed mitral regurgitation improvement. The improved functional MR group showed significant reductions in peak and mean transvalvular pressure gradients. In contrast, the patient-prosthesis mismatch group had persistent mitral regurgitation improvement in 59.2% of patients. The non-patient-prosthesis mismatch group exhibited significant structural improvements and a reduction in mitral regurgitation severity in 68.6% of patients. Conclusions: The study shows that aortic valve replacement could significantly improve MR when patient-prosthesis mismatch is avoided. This approach maximizes hemodynamic outcomes, mitigates the risk of residual or worsening mitral regurgitation, and potentially reduces the need for additional mitral valve interventions.

Visual grading of valvular regurgitation is inferior to measurement - results from the VIAVA-study (VIsual Assessment of VAlvular Regurgitation)

While the visual estimation of systolic left ventricular function by experienced examiners closely aligns with quantitative methodologies, the accuracy of visual estimation in determining the severity of valvular regurgitation using colour flow Doppler assessment of native heart valves remains largely unexplored. This study analysed the ability of 262 physicians to visually estimate the severity of 12 native valve regurgitations by grading colour Doppler transthoracic echocardiography loops in an online questionnaire. The assessments of the participants were compared to standardized quantitative evaluations conducted by certified echocardiography experts. Of the three valves to assess, evaluations by the participants showed the best correlation (Rs = 0.75, p < 0.0001) and agreement (percent agreement: 66.4%) with those of the experts in mitral valve regurgitation (MR). High agreement was observed for mild regurgitation across all valves (MR 94.5%, AR 80.3% and TR 88.7%), while consensus diminished in moderate (MR 55.9%, AR 49.5% and TR 55.0%) and severe regurgitation (MR 57.6%, AR 67.4%, TR 14.6%). The study underscores the potential utility of visual estimation of valvular regurgitation in clinical settings for identifying clinically relevant regurgitations. However, our findings also highlight the importance of integrating visual estimation with quantitative methods, particularly in moderate and severe cases of regurgitation.

Benefit of isolated surgical valve repair or replacement for functional tricuspid regurgitation and long-term outcomes stratified by the TRI-SCORE

BACKGROUND AND AIMS

Severe tricuspid regurgitation is associated with increased mortality rates, but benefit of its correction and ideal timing are not clearly determined. This study aimed to identify patient subsets who might benefit from the surgery.

METHODS

In TRIGISTRY, an international cohort study of consecutive patients with severe isolated functional tricuspid regurgitation (33 centres, 10 countries), survival rates up to 10 years were compared between patients who underwent isolated tricuspid valve surgery (repair or replacement) and those conservatively managed, overall and according to TRI-SCORE category (low: ≤3, intermediate: 4-5, and high: ≥6).

RESULTS

One thousand and two hundred seventeen were managed conservatively, and 551 underwent isolated tricuspid valve surgery (200 repairs and 351 replacements). TRI-SCORE distribution was 33% low, 32% intermediate, and 35% high. At 10 years, survival rates were similar between surgical and conservative management [41% vs. 36%; hazard ratio (HR) .97; 95% confidence interval (CI) .88-1.08, P = .57]. Surgery improved survival compared with conservative management in the low TRI-SCORE category (72% vs. 44%; HR .27; 95% CI .20-.37, P < .0001), but not in the intermediate (36% vs. 37%; HR 1.17; 95%CI .98-1.40, P = .09) or high categories (20% vs. 24%; HR 1.06; 95% CI .91-1.25, P = .45). Both repair and replacement improved survival in the low TRI-SCORE category (84% and 61% vs. 44%; HR .11; 95% CI .06-.19, P < .0001, and HR .65; 95% CI .47-.90, P = .009). Repair showed benefit in the intermediate category (59% vs. 37%; HR .49; 95% CI .35-.68, P < .0001) while replacement was possibly harmful (25% vs. 37%; HR 1.43; 95% CI 1.18-1.72, P = .0002).

CONCLUSIONS

Higher survival rates were observed with repair than replacement and benefit of intervention declined as TRI-SCORE increased with no benefit of any type of surgery in the high TRI-SCORE category. These results emphasize the importance of timely intervention and patient selection to achieve the best outcomes and the need for randomized controlled trials.

Prevalence and Prognostic Significance of Right Ventricular Dysfunction in Patients With Severe Low-Flow, Low-Gradient Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

Whether the presence of right ventricular (RV) dysfunction may influence the clinical outcome of patients with low-flow, low-gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve replacement (TAVR) has not yet been established.

METHODS AND RESULTS

This study included consecutive patients with LFLG-AS undergoing TAVR at 2 high-volume Italian centers. RV dysfunction before TAVR procedure was defined as tricuspid annular plane systolic excursion assessed by transthoracic echocardiography lower than <17 mm. The primary outcome was all-cause death at 1 year. The propensity score weighting technique was implemented to account for potential selection bias between patients with and without RV dysfunction. A prespecified subgroup analysis was conducted to evaluate the consistency of the results in patients with classical and paradoxical LFLG-AS forms. This study included 392 patients; of them, 97 (24.7%) patients showed RV dysfunction before TAVR. At propensity score-weighted adjusted Cox regression analysis, RV dysfunction, according to dichotomous definition, was associated with an increased risk for the primary outcome (adjusted hazard ratio [HR], 3.11 [95% CI, 1.58-6.13]), cardiovascular death (adjusted HR, 3.26 [95% CI, 1.58-6.72]), and major adverse cardiovascular and cerebrovascular events (adjusted HR, 3.39 [95% CI, 1.76-6.53]). Conversely, no difference was detected for the risk of stroke and of permanent pacemaker implantation. No significant interaction of the classical and paradoxical LFLG-AS subgroups was detected for all the outcomes of interest.

CONCLUSIONS

This study suggests that RV dysfunction echocardiographically assessed by tricuspid annular plane systolic excursion may improve the prognostic stratification of patients with LFLG-AS undergoing TAVR.

Association With Outcomes of Correcting the Proximal Isovelocity Surface Area Method to Quantitate Secondary Tricuspid Regurgitation

BACKGROUND

Although the correction of the proximal isovelocity surface area (PISA) method has been shown to improve the accuracy of assessing the severity of secondary tricuspid regurgitation (STR), its clinical impact remains to be investigated. The aim of this study was to compare the association of the quantitative parameters of STR severity obtained from the corrected and conventional PISA methods with outcomes.

METHODS

Both conventional and corrected effective regurgitant orifice area (EROA) (EROA vs corrected EROA [EROAc]), regurgitant volume (RegVol) (RegVol vs corrected RegVol [RegVolc]), and regurgitant fraction (RegFr) (RegFr vs corrected RegFr [RegFrc]) were measured in 519 consecutive patients (mean age, 75 ± 12 years; 44% men; 74% with ventricular STR) with moderate and severe STR. The end point was a composite of heart failure hospitalization and death.

RESULTS

EROAc, RegVolc, and RegFrc were significantly larger than EROA, RegVol, and RegFr (P < .001 for all). After a mean follow-up period of 19 ± 15 months, 210 patients reached the end point. Using time-dependent receiver operating characteristic curves, the parameters obtained from the corrected PISA method were more closely associated with outcomes at 2 years than those obtained with the conventional PISA method: EROAc vs EROA (P < .001), RegVolc vs RegVol (P = .001), and RegFrc vs RegFr (P < .001) for ventricular STR. Conversely, no significant differences were detected for atrial STR. After multivariable adjustment, both uncorrected and corrected EROA, RegVol, and RegFr were independently associated with the end point. Using the new five-grade severity scheme, patients reclassified using the corrected PISA method had a significantly higher rate of events compared with those not reclassified among those with ventricular STR (P = .0086). Conversely, this relationship was not statistically significant in patients with atrial STR (P = .061).

CONCLUSIONS

Correcting the PISA method provides larger quantitative parameters of STR severity that are more closely associated with outcomes in patients with ventricular STR.

Disparities in quantification of mitral valve regurgitation between cardiovascular magnetic resonance imaging and trans-thoracic echocardiography: a systematic review

Primary mitral regurgitation (MR) is a prevalent valvular heart disease. Therapy stratification for MR depends on accurate assessment of MR severity and left ventricular (LV) dimensions. While trans-thoracic echocardiography (TTE) has been the standard/preferred assessment method, cardiovascular magnetic resonance imaging (CMR) has gained recognition for its superior assessment of LV dimensions and MR severity. Both imaging modalities have their own advantages and limitation for therapy guidance. However, the differences between the two modalities for assessing/grade severity and clinical impact of MR remains unclear. This systematic review aims to evaluate the differences between TTE and CMR in quantifying MR severity and LV dimensions, providing insights for optimal clinical management. A literature search was performed from inception up to March 21st 2023. This resulted in 2,728 articles. After screening, 22 articles were deemed eligible for inclusion in the meta-analysis. The included study variables were, mitral valve regurgitation volume (MRVOL), regurgitation fraction (MRFRAC), LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LV stroke volume (LVSV), and LV ejection fraction (LVEF). TTE showed a significant higher MRVOL (10.4 ml, I2 = 88%, p = 0.002) and MRFRAC (6.3%, I2 = 51%, p = 0.05) compared to CMR, while CMR demonstrated a higher LVEDV (21.9 ml, I2 = 66%, p =  < 0.001) and LVESV (16.8 ml, I2 = 0%, p =  < 0.001) compared to TTE. Our findings demonstrate substantial disparities in TTE and CMR derived measurements for parameters that play a pivotal role in the clinical stratification guidelines. This discrepancy prompts a critical question regarding the prognostic value of both imaging modalities, which warrants future research.

Short-term outcome after isolated tricuspid valve surgery: prognostic role of right ventricular strain

OBJECTIVES

To assess the incremental prognostic value of right ventricular free wall longitudinal strain over conventional risk scores in predicting the peri-operative mortality in patients with severe tricuspid regurgitation (TR) undergoing isolated tricuspid valve (TV) surgery.

METHODS

We retrospectively enrolled 110 consecutive patients with severe TR who underwent isolated TV surgery between November 2016 and July 2022 at San Raffaele Hospital, Milan, Italy. Exclusion criteria were previous TV surgery, urgent surgery, complex congenital heart disease, active endocarditis and inadequate acoustic window. Baseline clinical data were included, as well as laboratory tests and clinical risk score, as TRI-SCORE and MELD-XI. The clinical outcome was peri-operative mortality, defined as all-cause mortality within 30 days.

RESULTS

The final cohort included 79 patients. The end-point occurred in 7 patients (9%), who died within 30 days after isolated TV surgery. Receiver operator characteristic curves analysis showed that, among parameters of right ventricular function, right ventricular free wall longitudinal strain was the best parameter to predict peri-operative mortality (AUC: 0.854, 95% CI 0.74-0.96, P = 0.005, sensitivity 68%, specificity 100%). At univariable analysis, left ventricular ejection fraction, diabetes mellitus, creatinine, estimated glomerular filtration rate, serum sodium, MELD-XI, TRI-SCORE, right ventricular areas, right ventricular global longitudinal strain, right ventricular free wall longitudinal strain, fractional area change and the ratio between right ventricular free wall longitudinal strain/pulmonary arterial systolic pressure were significantly associated with the end-point. The combination of TRI-SCORE and right ventricular Strain, evaluating right ventricular systolic function with speckle-tracking echocardiography, outperformed classic TRI-SCORE in outcome prediction (AUC 0.874 vs 0.787, P = 0.05).

CONCLUSIONS

Right ventricular free wall longitudinal strain has an incremental prognostic value over conventional parameters and significantly improves the ability of clinical scores to predict peri-operative mortality in patients undergoing isolated TV surgery.

In-hospital evolution of secondary mitral regurgitation in acutely decompensated heart failure

AIMS

Secondary mitral regurgitation (MR) negatively affects prognosis in acutely decompensated heart failure (ADHF), but can be rapidly sensitive to changes in volume status and medical interventions. We sought to assess the evolution of secondary MR in patients hospitalized for ADHF and its prognostic implications.

METHODS

We retrospectively enrolled 782 patients admitted for ADHF with at least two in-hospital echocardiographic evaluations of MR. We classified MR severity as none-mild or moderate-severe. Based on MR evolution, patients were divided into 'persistent moderate-severe MR', 'improved MR' (from moderate-severe to none-mild) and 'persistent none-mild MR'.

RESULTS

Four hundred and forty patients (56%) had moderate-severe MR at first evaluation, of whom 144 (33% of patients with baseline moderate-severe MR) had 'improved MR', while 296 (67%) had 'persistent moderate-severe MR'. Patients with improved MR had better clinical, laboratory and echocardiographic parameters of decongestion at discharge compared with those with persistent moderate-severe MR and showed a higher up-titration of recommended therapies. Left ventricular volume, ejection fraction and serum urea were the predictors of improved MR at multivariable analysis. After adjustment, no differences in 5-years survival (primary outcome) were observed according to baseline MR severity. When patients were stratified according to the in-hospital changes in MR severity, improved MR was associated with lower risk of 5-years mortality, compared with both persistent none-mild MR [hazard ratio (HR) = 0.505, P = 0.032] and persistent moderate-severe MR (HR = 0.556, P = 0.040).

CONCLUSIONS

The severity of MR frequently improved during hospitalization for ADHF; the extent and the changes in MR severity during the in-hospital stay identified distinct patient phenotypes, and seemed to portend different long-term outcomes, with higher 5-years survival associated with improvement in MR.

Advances in the Assessment of Patients With Tricuspid Regurgitation: A State-of-the-Art Review on the Echocardiographic Evaluation Before and After Tricuspid Valve Interventions

Tricuspid regurgitation (TR) can have a significant impact on the health and mortality of a patient. Unfortunately, many patients with advanced right-sided heart failure are not referred for isolated tricuspid valve (TV) surgery in a timely manner. This delayed referral has resulted in a high in-hospital mortality rate and significant undertreatment. Fortunately, transcatheter TV intervention (TTVI) has emerged as a safe and effective alternative to surgery, successfully reducing TR severity and improving patients' quality of life. Current guidelines emphasize the importance of assessing TR severity and its impact on the right heart chambers for selecting the appropriate intervention. However, the echocardiographic assessment of both right chambers and TV anatomy, along with TR severity, poses specific challenges, leading to the underestimation of TR severity. Recently, three-dimensional echocardiography has become crucial to enhance the characterization of TR severity. Moreover, it is essential to evaluate residual TR after TTVI to gauge the intervention's success and predict the patient's prognosis. This review provides a thorough evaluation of the echocardiographic parameters used to assess TR severity before and after TTVI. It presents a critical analysis of the accuracy and reliability of these parameters, highlighting their strengths and limitations to establish standardized diagnostic criteria and treatment protocols for TR, which will inform clinical decision-making and improve patient outcomes.

Dynamic evolution of tricuspid regurgitation during hospitalization in patients with acute decompensated heart failure

AIMS

Secondary tricuspid regurgitation (TR) is associated with poor prognosis in acute decompensated heart failure (ADHF). However, its dynamic evolution in response to volume status and treatment has never been previously investigated. In this study, we sought to explore the in-hospital evolution of TR in ADHF patients and to assess its prognostic implications.

METHODS AND RESULTS

We retrospectively enrolled patients admitted for ADHF with ≥2 in-hospital echocardiographic evaluations of TR. Patients were categorized, according to TR evolution, into persistent moderate-severe TR, improved TR (from moderate-severe to trivial-mild) and persistent trivial-mild TR. The primary endpoint was a composite of 5-year all-cause mortality and heart failure hospitalization (HFH). A total of 1054 patients were included. Of 318 patients (30%) with moderate-severe TR at admission, 49% improved TR severity and showed better trends of decongestion, whereas those who maintained persistent moderate-severe TR had characteristics of more severe heart failure at admission and discharge. Atrial fibrillation, previous heart failure and higher dosage of loop diuretics before admission were associated with a lower probability of improved TR. After adjustment, improved TR was associated with lower risk of 5-year all-cause mortality/HFH compared with persistent moderate-severe TR (hazard ratio [HR] 0.524, p = 0.008) and no different from persistent trivial-mild TR (HR 0.878, p = 0.575). Results were consistent across all subgroups of in-hospital variation of mitral regurgitation.

CONCLUSION

Among ADHF patients with moderate-severe TR at admission, 49% had an in-hospital improvement in TR severity, which was associated with a reduction in risk of 5-year all-cause mortality and morbidity outcomes.

Cardiac magnetic resonance imaging-derived right ventricular volume and function, and association with outcomes in isolated tricuspid regurgitation

BACKGROUND

In patients with significant tricuspid regurgitation, cardiac magnetic resonance imaging (CMR) is the preferred method for the evaluation of right ventricular function and volumes. However validated thresholds are lacking.

AIM

The aim of this study was to evaluate CMR assessment of right ventricular volumes in patients with significant (moderate or severe) tricuspid regurgitation, and to define its association with outcomes.

METHODS

The PRONOVAL study is a retrospective multicentre study using the clinical data warehouse of Greater Paris University Hospitals (AP-HP). Patients were screened for CMR in the PMSI (Programme de médicalisation des systèmes d'information). Hospitalization reports were analysed by natural language processing to include patients with tricuspid regurgitation. Exclusion criteria were left heart valvular disease, heart transplantation and cardiac amyloidosis. Primary outcome was a combined criterion of death or tricuspid surgery.

RESULTS

Between September 2017 and September 2021, 151 patients with isolated tricuspid regurgitation were screened. Right ventricular function and volumes were available in 86 (57.0%) CMR reports (the complete CMR group). In the complete CMR group, tricuspid regurgitation was severe in 62 patients (72.1%). Median age was 67.0 years (interquartile range 58.0-75.8). Median right ventricular indexed end-diastolic volume was 98.0 mL/m2 (interquartile range 66.8-118.5). At 2-year follow-up, six patients (9.2%) had undergone tricuspid valve surgery, and 12 patients (18.5%) had died. Right ventricular indexed end-diastolic volume was associated with death or surgery at 2years, with an area under the receiver operating characteristic curve of 0.76 (95% confidence interval 0.75-0.77) for a threshold of 119mL/m2.

CONCLUSION

Right ventricular indexed end-diastolic volume >119mL/m2 was found to be an independent indicator of death or surgery in patients with significant tricuspid regurgitation.

Findings from transoesophageal echocardiographic follow-up after mitral transcatheter edge-to-edge repair

BACKGROUND

Transoesophageal echocardiography (TOE) provides accurate evaluation of mitral valve (MV) function following mitral transcatheter edge-to-edge repair (M-TEER) and may better detect complications in case of suboptimal result.

AIMS

We aimed to evaluate midterm anatomical changes and structural complications after M-TEER using TOE and investigate their association with clinical outcomes at 2 years.

METHODS

A follow-up TOE at 6 months was systematically recommended to all patients included in our institutional prospective M-TEER registry until December 2021. We assessed changes in the incidence of mitral regurgitation (MR), MV stenosis (≥5 mmHg), and partial or complete single leaflet device attachment (SLDA) between the index procedure and follow-up and evaluated MV area and annular dimensions in a subset of patients with available three-dimensional (3D) datasets. The clinical endpoint was a composite of mortality and heart failure (HF) rehospitalisation at 2 years.

RESULTS

Among the 373 patients included in the registry between February 2012 and December 2021, 128 patients (34%) underwent elective TOE at 6 months. Using TOE, severe MR was observed in 13.3% (n=17) of the patients. The number of patients with an elevated MV gradient increased from 17 (13.3%) after the procedure to 23 (18%) at 6 months, and a new partial or complete SLDA was detected in 7.8% (n=10). Based on 3D TOE measurements, significant increases in MV area, annular area, annular perimeter, and intercommissural (but not anteroposterior) diameter were observed compared to intraprocedural images. A mean MV gradient ≥5 mmHg (hazard ratio [HR] 2.30, 95% confidence interval [CI]: 1.10-4.81; p=0.023) and the presence of severe MR at 6 months (HR 3.26, 95% CI: 1.18-8.99; p=0.023) were associated with the primary endpoint, which was met in 34 (26.6%) patients at 2 years.

CONCLUSIONS

TOE follow-up allowed the detection of complications that would not be diagnosed using transthoracic echocardiography only and should therefore be used liberally in the patients presenting with a suboptimal result. A mean MV gradient ≥5 mmHg and severe MR, diagnosed at the 6-month TOE follow-up, were associated with adverse clinical outcomes.

Mitral valve repair with resection and non-resection techniques in Barlow's disease: A multi-center study

BACKGROUND

Various mitral valve (MV) repair techniques are nowadays in use. Non-resection techniques, that rely exclusively on Gore-Tex® neochords and annuloplasty, have been popularized; however, their efficacy in Barlow's disease, characterized by large myxomatous leaflets, is yet unclear.

METHODS

Consecutive patients undergoing MV repair for Barlow's disease between 2011 and 2019 were selected on the basis of being eligible for resection and non-resection techniques. Study endpoints included overall survival, freedom from MV reintervention and recurrent regurgitation.

RESULTS

Of 209 patients meeting the inclusion criteria, 135 (65%) underwent MV repair with and 74 (35%) without resection. There was one early reoperation due to residual regurgitation (resection group). Mean clinical follow-up duration was 6.1 (IQR 3.9-8.5) years. At 6 years after surgery, there was no difference in overall survival or freedom from MV reintervention. Mean echocardiographic follow-up (95% complete) duration was 3.5 (IQR 2.3-5.8) years. At 6 years, there was no difference in freedom from recurrent regurgitation rate (86.1%, 95% CI 78.5-93.7% vs. 83.0%, 95% CI 71.6-94.4%, P = 0.20) between the groups. Inverse probability-of-treatment weighting adjusted analysis demonstrated no significant difference between groups (HR 0.535, 95% CI 0.212-1.349, P = 0.20). Uni- and multivariable Cox proportional regression analysis did not demonstrate an effect of valve repair technique on the occurrence of recurrent regurgitation.

CONCLUSIONS

At mid-term, the clinical and echocardiographic results of valve repair for Barlow's disease were very good and MV reintervention was rarely needed. At this time point, the results of non-resection techniques were comparable to the "gold standard" resection techniques.

Key Imaging Factors for Transcatheter Management of Tricuspid Regurgitation: Device and Patient Selection

The growing awareness of tricuspid regurgitation (TR) and the fast-expanding array of devices aiming to percutaneously repair or replace the tricuspid valve have underscored the central role of multi-modality imaging in comprehensively assessing the anatomical and functional characteristics of TR. Accurate phenotyping of TR, the right heart, and pulmonary vasculature via echocardiography, computed tomography, and, occasionally, cardiovascular magnetic resonance and right heart catheterization is deemed crucial in choosing the most suitable treatment strategy for each patient and achieving procedural success. In the first part of the present review, key imaging factors for patient selection will be discussed. In the ensuing sections, an overview of the most commonly used, commercially available systems for transcatheter repair/replacement will be presented, along with their respective selection criteria and information on intraprocedural imaging guidance; these are edge-to-edge repair, orthotopic and heterotopic replacement, and valve-in-valve procedures.

Sex-Specific Insights into Etiology, Diagnosis, Treatment, and Prognosis in Significant Tricuspid Regurgitation: A Narrative Review

In recent decades, a burgeoning interest in tricuspid regurgitation (TR) has been prompted by a heightened awareness of its prevalence and the advent of dedicated percutaneous treatment approaches. Despite considerable understanding of its intricate anatomy and response to varying pressure and loading conditions, the impact of biological sex remains a subject of investigation. While TR typically afflicts more women, significant differences in TR etiology and post-treatment outcomes have not been conclusively established. This narrative review seeks to consolidate the latest evidence concerning sex-related nuances in anatomy, pathophysiology, diagnosis, treatment, and prognosis of significant tricuspid regurgitation. Through synthesizing this information, we aim to provide a comprehensive understanding of how sex may influence the management and prognosis of this condition.

Rationale and design of the SPREAD study: Sport Practice and its Effects on Aortic Size and Valve Function in Bicuspid Aortic Valve Disease

The bicuspid aortic valve (BAV) is the most common congenital heart defect among adults, often leading to severe valve dysfunction and aortic complications. Despite its clinical significance, uncertainties persist regarding the impact of sports participation on the natural course of BAV disease. The SPREAD (Sport PRactice and its Effects on Bicuspid Aortic valve Disease) study is a multicenter and multinational project designed to investigate this relationship. This paper outlines the study's design, and objectives. The study is divided into two phases; phase one involves a cross-sectional analysis comparing aortic dimensions and valve function among competitive athletes with BAV, athletes with tricuspid aortic valves (TAV), and sedentary individuals with BAV. The second phase is a prospective, longitudinal follow-up aiming to evaluate the impact of regular sports training on disease progression. The SPREAD study seeks to provide evidence-based insights into the effects of sports participation on BAV disease progression, guiding clinical decision-making regarding sports eligibility and risk stratification for individuals with BAV.

Echocardiography-Derived Forward Left Ventricular Output Improves Risk Prediction in Systolic Heart Failure

BACKGROUND

Although it is widely used to classify patients with heart failure (HF), the prognostic role of left ventricular ejection fraction (LVEF) is debated. The aim of this study was to test the hypothesis that echocardiographic measures of forward left ventricular (LV) output, being more representative of cardiac hemodynamics, might improve risk prediction in a large cohort of patients with HF with systolic dysfunction.

METHODS

Consecutive stable patients with HF with LVEF <50% on guideline-recommended therapies undergoing echocardiography including the evaluation of forward LV output (i.e., LV outflow tract [LVOT] velocity-time integral [VTI], stroke volume index [SVi], and cardiac index) over a 6-year period were selected and followed for the end point of cardiac and all-cause death.

RESULTS

Among the 1,509 patients analyzed (mean age, 71 ± 12 years; 75% men; mean LVEF, 35 ± 9%), 328 (22%) died during a median follow-up period of 28 months (interquartile range, 14-40 months), 165 (11%) of cardiac causes. On multivariable regression analysis, LVOT VTI (P < .001), SVi (P < .001), and cardiac index (P < .001), but not LVEF (P > .05), predicted cardiac and all-cause death. The optimal prognostic cutoffs for LVOT VTI, SVi, and cardiac index were 15 cm, 38 mL/m2, and 2 L/min/m2, respectively. Adding each of these measures to a multivariable risk model (including clinical, biohumoral, and echocardiographic markers) improved risk prediction (P < .001). Among the different measures of forward LV output, cardiac index was less accurate than LVOT VTI and SVi.

CONCLUSIONS

The echocardiographic evaluation of forward LV output improves risk prediction in patients with HF across a wide LVEF spectrum over other well-established clinical, biohumoral, and echocardiographic prognostic markers.

Multimodality Imaging in the Management of Tricuspid Valve Regurgitation

Approximately 5% of elderly patients suffer from moderate or severe tricuspid valve regurgitation, which is an independent predictor of high morbidity and mortality. Surgical treatment of isolated tricuspid valve regurgitation has been associated with elevated fatality rate, leading to a growing interest in minimal invasive, transcatheter-based therapies such as transcatheter edge-to-edge repair and transcatheter valve replacement. Nevertheless, despite high procedural efficacy and safety of transcatheter-based therapies, a number of challenges limit their rapid adoption in routine clinical practice. In particular, the wide range of transcatheter approaches to address the significant variability in tricuspid valve pathology challenges the reproducibility of clinical outcomes. Multimodality imaging is pivotal for grading the regurgitation severity, determining the underlying pathology, assessing RV function and pulmonary pressures, identifying concomitant cardiac disease, and selecting the most beneficial treatment modality and access. This article reviews the role of different imaging modalities in guiding the management of patients with significant tricuspid valve regurgitation.

Potential Use of Systolic Pulmonary Artery Pressure/Pulmonary Artery Acceleration Time Ratio in Severe Functional Tricuspid Regurgitation with Pulmonary Hypertension

INTRODUCTION

To date, there is no specific evidence or criteria for the selection of patients with PH and severe tricuspid insufficiency that can be initiated into correction of tricuspid valvulopathy. Tricuspid regurgitation is a risk marker independent of mortality in patients with pulmonary hypertension. The critical factor for the procedure's success is to find the parameters to select patients so that they do not become just a futile act.

METHOD

From the initial group of 271 patients, a final group of 123 patients were selected, all diagnosed with precapillary PH confirmed by catheterization and with tricuspid regurgitation by echocardiography. Patients were in groups 1 and 2 according to the 2022 Pulmonary Hypertension Guidelines. Patients with right to left shunt were not excluded.

RESULTS

In patients with severe precapillary PH, the sPAP/PAAT ratio was close to 1 (0.89 ± 0.43), while in patients with mild precapillary PH or in the postcapillary group, the sPAP/PAAT ratio was considerably lower (0.47 ± 0.20, p < 0.001). The average sPAP/PAAT of deceased patients was 0.76. Among the 68 deceased patients, 42 (61.70%) had severe tricuspid regurgitation.

CONCLUSION

In our study, the average sPAP/PAAT ratio of the deceased patients with severe FTR was 0.76 mm Hg/ms; nevertheless, this knowledge could have a potential use but is not sufficient for full-informed qualification or disqualification for valve intervention, which requires specific TTVR-related data.

Multimodality imaging for the evaluation and management of patients with long-term (durable) left ventricular assist devices

Left ventricular assist devices (LVADs) are gaining increasing importance as therapeutic strategy in advanced heart failure (HF), not only as bridge to recovery or to transplant but also as destination therapy. Even though long-term LVADs are considered a precious resource to expand the treatment options and improve clinical outcome of these patients, these are limited by peri-operative and post-operative complications, such as device-related infections, haemocompatibility-related events, device mis-positioning, and right ventricular failure. For this reason, a precise pre-operative, peri-operative, and post-operative evaluation of these patients is crucial for the selection of LVAD candidates and the management LVAD recipients. The use of different imaging modalities offers important information to complete the study of patients with LVADs in each phase of their assessment, with peculiar advantages/disadvantages, ideal application, and reference parameters for each modality. This clinical consensus statement sought to guide the use of multimodality imaging for the evaluation of patients with advanced HF undergoing LVAD implantation.

Computational simulation model of transcatheter edge-to-edge mitral valve repair: a proof-of-concept study

AIMS

As transcatheter mitral valve (MV) interventions are expanding and more device types and sizes become available, a tool supporting operators in pre-procedural planning and the clinical decision-making process is highly desirable. We sought to develop a finite element computational simulation model to predict the results of transcatheter edge-to-edge repair (TEER) interventions.

METHODS AND RESULTS

We prospectively enrolled patients with secondary mitral regurgitation (MR) referred for a clinically indicated TEER. The 3D trans-oesophageal echocardiograms performed at the beginning of the procedure were used to perform the simulation. On the 3D dynamic model of the MV that was first obtained, we simulated the clip implantation using the same clip type, size, number, and implantation location that was used during the intervention. The 3D model of the MV obtained after the simulation of the clip implantation was compared with the clinical results obtained at the end of the intervention. We analysed the degree and location of residual MR and the shape and area of the diastolic MV area. We performed computational simulation on five patients. Overall, the simulated models predicted well the degree and location of the residual regurgitant orifice(s) but tended to underestimate the diastolic mitral orifice area.

CONCLUSION

In this proof-of-concept study, we present preliminary results on our algorithm simulating clip implantation in five patients with functional MR. We show promising results regarding the feasibility and accuracy in terms of predicting residual MR and the need to improve the estimation of the diastolic MV area.

TRIVALVE Score: A Risk Score for Mortality/Hospitalization Prediction in Patients Undergoing Transcatheter Tricuspid Valve Intervention

BACKGROUND

Transcatheter tricuspid valve intervention (TTVI) has been increasingly adopted in recent years for the treatment of patients with tricuspid regurgitation (TR). However, no dedicated risk stratification has been established for patients undergoing TTVI.

OBJECTIVES

The aim of the present study was to propose a dedicated risk score for patients affected by severe TR undergoing TTVI.

METHODS

The score was derived from the TRIVALVE (International Multisite Transcatheter Tricuspid Valve Therapies Registry; NCT03416166) registry, according to data availability. A stepwise model approach was used on predictor variables to develop a scoring system for predicting 12-month mortality or rehospitalization using multivariable logistic regression. Internal discrimination, calibration, and validation were assessed using receiver-operating characteristic curve analysis and bootstrapping with 1,000 resamples.

RESULTS

A total of 483 patients were included in the study, with an overall 12-month mortality or rehospitalization rate of 19% (n = 94). The final risk score, ranging from 0 to 4.5, included the following 5 parameters (adjusted for age and gender): 1) atrial fibrillation at baseline; 2) glomerular filtration rate <30 mL/min; 3) elevated gamma-glutamyl transferase/bilirubin levels; 4) signs of right heart failure; and 5) left ventricular ejection fraction <50%. The bias-corrected area under the receiver-operating characteristic curve was 68% (95% CI: 62%-75%). A cutoff value of 2.5 demonstrated sensitivity of 65.4% and specificity of 60.5% for the outcome.

CONCLUSIONS

The present study proposes a dedicated risk score for patients undergoing TTVI, providing an additional and simple tool for heart teams to select the best therapy for patients affected by severe TR.

EVOQUE Tricuspid Valve Replacement System: State-of-the-Art Screening and Intraprocedural Guidance

With the recent approval of the transcatheter EVOQUE tricuspid valve replacement system to treat severe, symptomatic tricuspid regurgitation, there is a need to define the appropriate patient population and anatomical considerations for this device. In this consensus document, the authors review these considerations, describe the procedural steps and imaging requirements to ensure technical success, and discuss management of complex intraprocedural circumstances.

Aortic regurgitation: from mechanisms to management

Aortic regurgitation (AR) is a common clinical disease associated with significant morbidity and mortality. Investigations based largely on non-invasive imaging are pivotal in discerning the severity of disease and its impact on the heart. Advances in technology have contributed to improved risk stratification and to our understanding of the pathophysiology of AR. Surgical aortic valve replacement is the predominant treatment. However, its use is limited to patients with an acceptable surgical risk profile. Transcatheter aortic valve implantation is an alternative treatment. However, this therapy remains in its infancy, and further data and experience are required. This review article on AR describes its prevalence, mechanisms, diagnosis and treatment.

Revisiting secondary mitral regurgitation threshold severity: insights and lessons from the RESHAPE-HF2 trial

Aims

This article revisits the severity threshold for secondary mitral regurgitation (MR), focusing on insights and lessons from the RESHAPE-HF2 trial. It aims to challenge the traditional effective regurgitant orifice area (EROA) threshold of ≥0.40 cm2 used for intervention, suggesting that earlier intervention may benefit patients with lower EROA. It also explores how transcatheter edge-to-edge repair (TEER) improves outcomes in patients with secondary MR and assesses the impact of left ventricular (LV) remodeling on treatment success.

Methods and Results

The RESHAPE-HF2 trial evaluated the use of TEER in patients with moderate-to-severe secondary MR, comparing outcomes in those with an EROA ≥0.2 cm2 and no extensive LV remodeling. TEER significantly reduced heart failure hospitalizations and improved quality of life in these patients. This supports the notion that patients with less severe MR, who still show symptoms despite optimal medical therapy, may benefit from earlier intervention. Comparisons with COAPT and MITRA-FR trials underscored the importance of selecting patients based on MR severity relative to LV dilatation.

Conclusions

The RESHAPE-HF2 trial highlights the need to reconsider the current EROA threshold for secondary MR intervention. TEER has shown to be beneficial even in patients with lower MR severity, suggesting that earlier intervention could improve outcomes. A more dynamic and integrated approach, considering both MR severity and LV remodeling, is essential for optimizing patient selection and treatment success.

Tricuspid Regurgitation Complicating Heart Failure: A Novel Clinical Entity

With the escalating incidence of heart failure, accurate diagnosis is paramount for tailored therapeutic interventions. The tricuspid valve, particularly tricuspid regurgitation, once relegated as the "forgotten valve", has gained prominence due to increasing evidence implicating severe tricuspid valve disease in the prognosis of diverse cardiovascular conditions. This review delineates recent significant advancements in imaging modalities, transcatheter interventions, and epidemiological and pathophysiological insights regarding tricuspid regurgitation complicating heart failure. A comprehensive understanding of these innovative concepts and technologies can significantly improve patient outcomes.

Stress echocardiography in heart failure patients: additive value and caveats

Heart failure (HF) is a clinical syndrome characterized by well-defined signs and symptoms due to structural and/or myocardial functional impairment, resulting in raised intracardiac pressures and/or inadequate cardiac stroke volume at rest or during exercise. This could derive from direct ischemic myocardial injury or other chronic pathological conditions, including valvular heart disease (VHD) and primary myocardial disease. Early identification of HF etiology is essential for accurate diagnosis and initiation of early and appropriate treatment. Thus, the presence of accurate means for early diagnosis of HF symptoms or subclinical phases is fundamental, among which echocardiography being the first line diagnostic investigation. Echocardiography could be performed at rest, to identify overt structural and functional abnormalities or during physical or pharmacological stress, in order to elicit subclinical myocardial function impairment e.g. wall motion abnormalities and raised ventricular filling pressures. Beyond diagnosis of ischemic heart disease, stress echocardiography (SE) has recently shown its unique value for the evaluation of diastolic heart failure, VHD, non-ischemic cardiomyopathies and pulmonary hypertension, with recommendations from international societies in several clinical settings. All these features make SE an important additional tool, not only for diagnostic assessment, but also for prognostic stratification and therapeutic management of patients with HF. In this review, the unique value of SE in the evaluation of HF patients will be described, with the objective to provide an overview of the validated methods for each setting, particularly for HF management.

Predictors of residual tricuspid regurgitation after interventional therapy: an automated deep-learning CT analysis

Computed tomography (CT) is used as a valuable tool for device selection for interventional therapy in tricuspid regurgitation (TR). We aimed to evaluate predictors of TR reduction using CT and automated deep learning algorithms. Patients with severe to torrential TR and CTs prior to either percutaneous annuloplasty (PA) or tricuspid transcatheter edge-to-edge repair (T-TEER) were enrolled. CTs were analyzed using automated deep learning algorithms to assess tricuspid valve anatomy, right heart morphology, and function. Outcome parameters comprised post-interventional TR ≤ 1 and all-cause mortality. 84 patients with T-TEER (n = 32) or PA treatment (n = 52) were enrolled. Patients with a post-interventional TR ≤ 1 presented lower tenting heights and smaller tenting angles compared to patients with a TR > 1. Tenting height showed the best accuracy for post-interventional TR > 1 with an AUC of 0.756 (95% CI 0.560-0.951) in the T-TEER and 0.658 (95% CI 0.501-0.815) in the PA group, consistent with a suggested threshold of 6.8 mm and 9.2 mm, respectively. Patients with a post-interventional TR ≤ 1 exhibited a mortality of 4% and those with a TR > 1 of 12% during a follow-up of 331 ± 300 and 370 ± 265 days, respectively (p = 0.124). To conclude, tenting is associated with procedural outcomes and should be considered during screening for interventional TR therapy.

Echocardiographic assessment of atrial, ventricular, and valvular function in patients with atrial fibrillation-an expert proposal by the german working group of cardiovascular ultrasound

Echocardiography in patients with atrial fibrillation is challenging due to the varying heart rate. Thus, the topic of this expert proposal focuses on an obvious gap in the current recommendations about diagnosis and treatment of atrial fibrillation (AF)-the peculiarities and difficulties of echocardiographic imaging. The assessment of systolic and diastolic function-especially in combination with valvular heart diseases-by echocardiography can basically be done by averaging the results of echocardiographic measurements of the respective parameters or by the index beat approach, which uses a representative cardiac cycle for measurement. Therefore, a distinction must be made between the functionally relevant status, which is characterized by the averaging method, and the best possible hemodynamic status, which is achieved with the most optimal left ventricular (LV) filling according to the index beat method with longer previous RR intervals. This proposal focuses on left atrial and left ventricular function and deliberately excludes problems of echocardiography when assessing left atrial appendage in terms of its complexity. Echocardiography of the left atrial appendage is therefore reserved for its own expert proposal.

Atrial Functional Mitral Regurgitation Subtypes Undergoing Transcatheter Edge-to-Edge Repair: Suboptimal Outcomes in Atriogenic Hamstringing

BACKGROUND

Two subtypes of atrial functional mitral regurgitation (AFMR) have been described, one is characterized by Carpentier type I and the other by Carpentier type IIIb leaflet motion.

OBJECTIVES

The authors sought to analyze echocardiographic characteristics and outcomes of AFMR subtypes undergoing mitral valve transcatheter edge-to-edge repair (M-TEER).

METHODS

Of 1,047 consecutive patients who underwent M-TEER, the authors identified those with isolated mitral annulus dilation (Carpentier I), termed AFMR-IAD, and those with atriogenic hamstringing characterized by restricted posterior mitral leaflet motion (Carpentier IIIb), termed AFMR-AH. Echocardiographic baseline characteristics and outcomes up to 1-year were analyzed.

RESULTS

A total of 128 patients (12.2%) met AFMR criteria; 75 (58.6%) were identified as AFMR-IAD and 53 (41.4%) as AFMR-AH. AFMR-AH displayed greater left atrial and left ventricular volumes, greater mitral annulus, shorter and steeper posterior mitral leaflet, and more pronounced MR (all P < 0.05). Technical success was achieved in 98.7% (AFMR-IAD) and 86.8% (AFMR-AH) of patients (P = 0.009). At discharge, device detachments were exclusively observed in AFMR-AH (10.0%). MR ≤II was achieved in 95.6% and 78.6% at 30 days (P = 0.009) and in 93.0% and 74.1% at 1 year (P = 0.038) in patients with AFMR-IAD and AFMR-AH, respectively. AFMR-AH was associated with procedural failure (OR: 1.17 [95% CI: 1.00-1.38]; P = 0.045) at 30 days (43.4% vs 24.0%; P = 0.023) and all-cause mortality (HR: 2.54 [95% CI: 1.09-5.91]; P = 0.031) at 1 year (77% vs 92%, Kaplan-Meier estimated 1-year survival; P = 0.017).

CONCLUSIONS

AFMR-AH shows worse procedural and clinical outcomes following M-TEER than AFMR-IAD. Thus, vigilance regarding this pathology is warranted and alternative mitral valve therapies might need to be considered.

Mitral Transcatheter Edge-to-Edge Repair and Clinical Value of Novel Echocardiographic Biomarkers: A Hypothesis-Generating Study

BACKGROUND

Longitudinal data on reverse cardiac remodeling and outcomes after transcatheter edge-to-edge repair (TEER) are limited.

METHODS

A total of 78 patients with severe mitral regurgitation (MR) were included retrospectively. All patients had echocardiography at baseline and again six months after TEER. They were monitored for a primary composite endpoint, consisting of heart failure hospitalization and cardiovascular death, over 13 months.

RESULTS

Significant decreases in the left ventricular ejection fraction (LVEF), all myocardial work indices (except global wasted work), and the left atrial reservoir were observed after TEER. Additionally, there was a decrease in the pulmonary artery systolic pressure and an increase in the tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio. A post-TEER TAPSE/PASP ratio of <0.47 (HR: 4.76, p-value = 0.039), and a post-TEER left atrial reservoir of <9.0% (HR: 2.77, p-value = 0.047) were associated with the primary endpoint.

CONCLUSIONS

Echocardiography post-TEER reflects impairment in ventricular performance due to preload reduction and right ventricle and pulmonary artery coupling improvement. Short-term echocardiography after TEER identifies high-risk patients who could benefit from a close clinical follow-up. The prognostic significance of LA strain and the TAPSE/PASP ratio should be validated in subsequent large-scale prospective studies.

Early Outcomes of Two Large Mitral Valve Transcatheter Edge-to-Edge Repair Devices-A Propensity Score Matched Multicenter Comparison

Background/Objectives: Previous trials reported comparable results with PASCAL and earlier MitraClip generations. Limited comparative data exist for more contemporary MitraClip generations, particularly the large MitraClip XT(R/W). We aimed to evaluate acute and 30-day outcomes in patients undergoing mitral valve transcatheter edge-to-edge repair (M-TEER) with one of the large devices, either PASCAL P10 or MitraClip XT(R/W) (3rd/4th generation). Methods: A total of 309 PASCAL-treated patients were matched by propensity score to 253 MitraClip-treated patients, resulting in 200 adequately balanced pairs. Procedural, clinical, and echocardiographic outcomes were collected for up to 30 days, including subgroup analysis for mitral regurgitation (MR) etiologies. Results: PASCAL and MitraClip patients were comparable regarding age (80 vs. 79 years), sex (female: 45.5% vs. 50.5%), and MR etiology (degenerative MR: n = 94, functional MR [FMR]: n = 96, mixed MR: n = 10 in each group). Technical success rates were comparable (96.5% vs. 96.0%; p > 0.999). At discharge, the mean gradient was higher (3.3 mmHg vs. 3.0 mmHg; p = 0.038), and the residual mitral valve orifice area was smaller in MitraClip patients (3.0 cm2 vs. 2.3 cm2; p < 0.001). At discharge, the reduction to MR ≤ 2+ was comparable (92.4% vs. 87.8%; p = 0.132). However, reduction to MR ≤ 1+ was more frequently observed in PASCAL patients (67.7% vs. 56.6%; p = 0.029), driven by the FMR subgroup (74.0% vs. 60.0%; p = 0.046). No difference was observed in 30-day mortality (p = 0.204) or reduction in NYHA-FC to ≤II (p > 0.999). Conclusions: Both M-TEER devices exhibited high and comparable rates of technical success and MR reduction to ≤2+. PASCAL may be advantageous in achieving MR reduction to ≤1+ in patients with FMR.

Tricuspid Regurgitation in Patients With Heart Failure and Preserved Ejection Fraction: JACC State-of-the-Art Review

Heart failure with preserved ejection fraction (HFpEF) is associated with high morbidity and mortality. Important risk factors for the development of HFpEF are similar to risk factors for the progression of tricuspid regurgitation (TR), and both conditions frequently coexist and thus is a distinct phenotype or a marker for advanced HF. Many patients with severe, symptomatic atrial secondary TR have been enrolled in current transcatheter device trials, and may represent patients at an advanced stage of HFpEF. Management of HFpEF thus may affect the pathophysiology of TR, and the physiologic changes that occur following transcatheter treatment of TR, may also impact symptoms and outcomes in patients with HFpEF. This review discusses these issues and suggests possible management strategies for these patients.