Secondary tricuspid valve regurgitation: a forgotten entity

Advanced Echocardiographic Guidance for Transcatheter Tricuspid Edge-To-Edge Repair

Echocardiography, in all its forms (transthoracic echocardiography [TTE], transesophageal echocardiography [TEE], and intracardiac echocardiography [ICE]), is pivotal for the evaluation, guidance, and follow-up of transcatheter tricuspid edge-to-edge repair (TV-TEER) therapies. Although two-dimensional (2D) echocardiography remains essential, three-dimensional (3D) echo with multiplanar reconstruction (MPR) has revolutionized the field of structural imaging. In addition, the advent of 3D ICE has added an important modality to the imaging toolbox, particularly helpful when intraprocedural TEE images are challenging. In this review, we provide a detailed, step-by-step approach for advanced echocardiographic guidance of TV-TEER using 3D MPR.

The impact of small movements with dual lumen cannulae during venovenous extracorporeal membrane oxygenation: A computational fluid dynamics analysis

BACKGROUND AND OBJECTIVES

Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) provides respiratory support to patients with severe lung disease failing conventional medical therapy. An essential component of the ECMO circuit are the cannulas, which drain and return blood into the body. Despite being anchored to the patient to prevent accidental removal, minor cannula movements are common during ECMO. The clinical and haemodynamic consequences of these small movements are currently unclear. This study investigated the risk of thrombosis and recirculation caused by small movements of a dual lumen cannula (DLC) in an adult using computational fluid dynamics.

METHODS

The 3D model of an AVALON Elite DLC (27 Fr) and a patient-specific vena cava and right atrium were generated for an adult patient on ECMO. The baseline cannula position was generated where the return jet enters the tricuspid valve. Alternative cannula positions were obtained by shifting the cannula 5 and 15 mm towards inferior (IVC) and superior (SVC) vena cava, respectively. ECMO settings of 4 L/min blood flow and pulsatile flow at SVC and IVC were applied. Recirculation was defined as a scalar value indicating the infused oxygenated blood inside the drainage lumen, while thrombosis risk was evaluated by shear stress, stagnation volume, washout, and turbulent kinetic energy.

RESULTS

Recirculation for all models was less than 3.1 %. DLC movements between -5 to 15 mm increased shear stress and turbulence kinetic energy up to 24.7 % and 11.8 %, respectively, compared to the baseline cannula position leading to a higher predicted thrombosis risk. All models obtained a complete washout after nine seconds except for when the cannula migrated 15 mm into the SVC, indicating persisting stasis and circulating zones.

CONCLUSION

In conclusion, small DLC movements were not associated with an increased risk of recirculation. However, they may increase the risk of thrombosis due to increased shear rate, turbulence, and slower washout of blood. Developing effective cannula securement devices may reduce this risk.

A tissue-silicone integrated simulator for right ventricular pulsatile circulation with severe functional tricuspid regurgitation

There is a great demand for development of a functional tricuspid regurgitation (FTR) model for accelerating development and preclinical study of tricuspid interventional repair devices. This study aimed to develop a severe FTR model by creating a tissue-silicone integrated right ventricular pulsatile circulatory simulator. The simulator incorporates the porcine tricuspid annulus, valve leaflets, chordae tendineae, papillary muscles, and right ventricular wall as one continuous piece of tissue, thereby preserving essential anatomical relationships of the tricuspid valve (TV) complex. We dilated the TV annulus with collagenolytic enzymes under applying stepwise dilation, and successfully achieved a severe FTR model with a regurgitant volume of 45 ± 9 mL/beat and a flow jet area of 15.8 ± 2.3 cm2 (n = 6). Compared to a normal model, the severe FTR model exhibited a larger annular circumference (133.1 ± 8.2 mm vs. 115.7 ± 5.5 mm; p = 0.009) and lower coaptation height (6.6 ± 1.0 mm vs. 17.7 ± 1.3 mm; p = 0.003). Following the De-Vega annular augmentation procedure to the severe FTR model, a significant reduction in regurgitant volume and flow jet area were observed. This severe FTR model may open new avenues for the development and evaluation of transcatheter TV devices.

The 4A classification for patients with tricuspid regurgitation

INTRODUCTION AND OBJECTIVES

Significant tricuspid regurgitation (TR) is associated with increased morbidity and mortality. Clinical evaluation of TR patients is challenging. Our aim was to establish a new clinical classification specific for patients with TR, the 4A classification, and evaluate its prognostic performance.

METHODS

We included patients with isolated TR that was at least severe and without previous episodes of heart failure (HF) who were assessed in the heart valve clinic. We registered signs and symptoms of asthenia, ankle swelling, abdominal pain or distention and/or anorexia and followed up the patients every 6 months. The 4A classification ranged from A0 (no A) to A3 (3 or 4 As present). We defined a combined endpoint consisting of hospital admission due to right HF or cardiovascular mortality.

RESULTS

We included 135 patients with significant TR between 2016 and 2021 (69% females, mean age 78±7 years). During a median follow-up of 26 [IQR, 10-41] months, 39% (n=53) patients had the combined endpoint: 34% (n=46) were admitted for HF and 5% (n=7) died. At baseline, 94% of the patients were in NYHA I or II, while 24% were in classes A2 or A3. The presence of A2 or A3 conferred a high incidence of events. The change in 4A class remained an independent marker of HF and cardiovascular mortality (adjusted HR per unit of change of 4A class, 1.95 [1.37-2.77]; P<.001).

CONCLUSIONS

This study reports a novel clinical classification specifically for patients with TR that is based on signs and symptoms of right HF and has prognostic value for events.

Reverse remodeling of the tricuspid valve complex by sinus rhythm restoration after catheter ablation

BACKGROUND

Atrial fibrillation (AF) can cause right atrium enlargement and structural changes of the tricuspid valve annulus (TVA). The features of the structural changes and benefits obtained from rhythm-control therapy is unknown.

OBJECTIVES

We investigated how the TVA changes and whether its size decreases after rhythm-control therapy.

METHODS

Multi-detector row computed tomography (MDCT) was performed before and after catheter ablation for AF. TVA morphology and right atrium (RA) volume was evaluated by MDCT. The features of TVA morphology in patients with AF after rhythm-control therapy were analyzed.

RESULTS

MDCT was performed in 89 patients with AF. The 3D perimeter was more correlated with diameter in the anteroseptal-posterolateral (AS-PL) direction than in the anterior-posterior direction. Seventy patients showed 3D perimeter reduction owing to rhythm-control therapy and the change was associated with the rate of change in the AS-PL diameter. Rate of change of the 3D perimeter was associated with that of the AS-PL diameter among TVA morphology and RA volume. We divided the subjects into three groups according to the tertiles of the TA perimeter. 3D perimeter in all groups was decreased after rhythm-control therapy. The AS-PL diameter in the 2nd and 3rd tertiles was decreased and increased TVA height in all groups.

CONCLUSION

TVA in patients with AF was enlarged and flattened in the early phase, and rhythm-control therapy resulted in reverse remodeling of the TVA and in the reduction of right atrial volume. These results suggest that early AF intervention can lead to the restoration of the TVA structure.

Surgical edge-to-edge repair for tricuspid regurgitation: Impact of the concomitant annuloplasty

BACKGROUND

Surgical edge-to-edge repair has been suggested for tricuspid regurgitation (TR) with complex tricuspid valve (TV) pathologies. Nevertheless, the impact of concomitant TAP has not been well established. This study aimed to compare the outcomes of tricuspid edge-to-edge repair according to the implementation of concomitant TAP.

METHODS

A total of 264 patients who underwent tricuspid edge-to-edge repair between January 2001 and December 2020 were enrolled in the study, and 23 patients who had undergone previous TV repair were excluded. The remaining 241 patients were categorized into two groups: TAP (n = 190) and non-TAP (n = 51). Inverse probability of treatment weighting (IPTW) was used to adjust the baseline differences between the two groups.

RESULTS

Early mortality and morbidity did not differ between the two groups. The mean follow-up duration was 111.5 ± 72.4 months. IPTW-adjusted survival analysis did not reveal a difference between the two groups in late significant tricuspid stenosis (trans-tricuspid pressure gradient ≥5 mmHg) and TV reoperations. However, freedom from overall mortality and late severe TR were significantly higher in the TAP group (p = 0.033 and 0.006, respectively). The sensitivity analysis, including propensity score matching, showed consistent results.

CONCLUSION

The long-term outcomes of surgical tricuspid edge-to-edge repair were better when performed with concomitant TAP.

Different Causes of Functional Tricuspid Valve Regurgitation Are Linked to Differences in Tricuspid Valve and Right-Sided Heart Geometry and Function: 3D Echocardiography Study

Background and Objectives: The aim of this study was to clarify the tricuspid valve (TV) and right ventricular (RV) geometry and function characteristics using 3D echocardiography-based analysis and to identify echocardiographic predictors for severe tricuspid regurgitation (TR) in different etiologies of functional TR (fTR). Methods and Results: The prospective study included 128 patients (median age 64 years, 57% females): 109 patients with moderate or severe fTR (69-caused by dominant left-sided valvular pathology (LSVP), 40 due to precapillary pulmonary hypertension (PH)), and 19 healthy controls. The 2D and 3D-transthoracic echocardiography analysis included TV, right atrium, RV geometry, and functional parameters. All the RV geometry parameters as well as 3D TV parameters were increased in both fTR groups when compared to controls. Higher RV diameters, length, areas, volumes, and more impaired RV function were in PH group compared to LSVP group. PH was associated with larger leaflet tenting height, volume, and more increased indices of septal-lateral and major axis tricuspid annulus (TA) diameters. LVSP etiology was associated with higher anterior-posterior TA diameter and sphericity index. Univariate and multivariate logistic regression and ROC analyses revealed that different fTR etiologies were associated with various 2D and 3D echocardiographic parameters to predict severe TR: major axis TA diameter and TA perimeter, the leaflet tenting volume had the highest predictive value in PH group, septal-lateral systolic TA diameter-in LSVP group. The 3D TA analysis provided more reliable prediction for severe fTR. Conclusions: TV and RV geometry vary in different etiologies of functional TR. Precapillary PH is related to more severe RV remodeling and dysfunction and changes of TV geometry, when compared to LSVP group. The 3D echocardiography helps to determine echocardiographic predictors of severe TR in different fTR etiologies.

Does concomitant tricuspid valve surgery increase the risks of minimally invasive mitral valve surgery? A multicentre comparison based on data from The Netherlands Heart Registration

OBJECTIVES

Mitral valve (MV) disease is often accompanied by tricuspid valve (TV) disease. The indication for concomitant TV surgery during primary MV surgery is expected to increase, especially through a minimally invasive surgical (MIS) approach. The aim of the current study is to investigate the safety of the addition of TV surgery to MV surgery in MIMVS in a nationwide registry.

METHODS

Patients undergoing atrioventricular valve surgery through sternotomy or MIS between 2013 and 2018 were included. Patients undergoing MV surgery only through sternotomy or MIS were used as comparison. Primary outcomes were short-term morbidity and mortality and long-term survival. Propensity score matching was used to correct for potential confounders.

RESULTS

The whole cohort consisted of 2698 patients. A total of 558 patients had atrioventricular double valve surgery through sternotomy and 86 through MIS. As a comparison, 1365 patients underwent MV surgery through sternotomy and 689 patients through MIS. No differences in 30- and 120-day mortality were observed between the groups, both unmatched and matched. 5-year survival did not differ for double atrioventricular valve surgery through either sternotomy or MIS in the matched population (90.1% vs. 95.3%, Log-Rank p = .12). A higher incidence of re-exploration for bleeding (n = 12 [15.2%] vs. n = 3 [3.8%], p = .02) and new onset arrhythmia (n = 35 [44.3%] vs. n = 13 [16.5%], p < .001) was observed in double valve surgery through MIS. Median length of hospital stay (LOHS) was longer in the minimally invasive double valve group (9 days [6-13]) compared with sternotomy (7 days [6-11]; p = .04).

CONCLUSION

No differences in short-term mortality and 5-year survival were observed when tricuspid valve was added to MV surgery in MIS or sternotomy. The addition of tricuspid valve surgery is associated with higher incidence of re-exploration for bleeding, new onset arrhythmia. A longer LOHS was observed for MIS compared to sternotomy.

Texas TriValve 1.0 : a reverse‑engineered, open model of the human tricuspid valve

Nearly 1.6 million Americans suffer from a leaking tricuspid heart valve. To make matters worse, current valve repair options are far from optimal leading to recurrence of leakage in up to 30% of patients. We submit that a critical step toward improving outcomes is to better understand the "forgotten" valve. High-fidelity computer models may help in this endeavour. However, the existing models are limited by averaged or idealized geometries, material properties, and boundary conditions. In our current work, we overcome the limitations of existing models by (reverse) engineering the tricuspid valve from a beating human heart in an organ preservation system. The resulting finite-element model faithfully captures the kinematics and kinetics of the native tricuspid valve as validated against echocardiographic data and others' previous work. To showcase the value of our model, we also use it to simulate disease-induced and repair-induced changes to valve geometry and mechanics. Specifically, we simulate and compare the effectiveness of tricuspid valve repair via surgical annuloplasty and via transcatheter edge-to-edge repair. Importantly, our model is openly available for others to use. Thus, our model will allow us and others to perform virtual experiments on the healthy, diseased, and repaired tricuspid valve to better understand the valve itself and to optimize tricuspid valve repair for better patient outcomes.

Transcatheter Tricuspid Valve Replacement: A Feasible Solution to a Real-world Problem

Background and Objective

As one of the most prevalent valvular pathologies affecting millions globally, moderate-to-severe tricuspid regurgitation (TR) predisposes to increased mortality. Despite the well-established risk of adverse outcomes, an overwhelming majority of TR patients are managed conservatively due to challenges associated with timely diagnosis, clinical course of the disease, competing comorbities that carry prohibitive surgical risk, and poor surgical outcomes. These challenges highlight the importance of transcatheter tricuspid valve replacement (TTVR) which has restructured TR management in promising and innovative ways.

Methods

We start with an overview of the pathophysiology of TR considering its implications in management. We then elaborate on the current state of TR management, including its limitations, thereby highlighting the unique role of TTVR. This is followed by a review of perioperative considerations such as careful patient selection, role of multimodality imaging, the various imaging techniques that are available and their contribution towards successful TTVR. We then review the valves that are currently available and under investigation, including the latest data available on device efficacy and safety, and highlight the ongoing clinical trials.

Results and Conclusions

TTVR is evolving at an exponential pace and has made its mark in the treatment of severe symptomatic tricuspid regurgitation. The promising results sustained by currently available devices and ongoing investigation of valves under development continue to pave the path for further innovation in transcatheter interventions. However, it is important to acknowledge and appreciate the novelty of this approach, the lack of long-term data on safety, efficacy, morbidity, and mortality, and use the lessons learned from real-world experiences to provide a definitive and reproducible solution for patients with symptomatic TR.

Interobserver Variation in Echocardiographic Measurements and Grading of Tricuspid Regurgitation Based on a Novel Web-Based Assessment Environment

OBJECTIVES

The primary aim of this study was to assess interobserver variability in grading tricuspid regurgitation (TR) severity. The authors' secondary goals were to delineate which transesophageal echocardiographic (TEE) parameters best correlate with severity and how consistent the participants were at grading severity.

DESIGN

This was a prospective cohort study of how clinicians evaluated previously acquired TEE images and videos.

SETTING

The 19 TEE studies of patients with TR were recorded by 4 senior echocardiographers across 4 US academic institutions. The participants evaluated these cases on a novel, web-based, assessment environment designed specifically for this study.

PARTICIPANTS

Twenty-nine fellowship-trained and board-certified cardiologists and cardiothoracic anesthesiologists volunteered to participate in the study as observers from 19 different institutions.

INTERVENTIONS

No interventions were performed on the participants.

MEASUREMENTS AND MAIN RESULTS

For each case, participants measured the vena contracta (VC), proximal isovelocity surface area (PISA), and jet area before giving a final classification on the severity of TR. Variation was highest for effective regurgitant orifice area and lowest for VC and PISA. The coefficient of variation, defined as the standard deviation from the mean divided by the mean, for all cases of trace, mild, moderate and severe TR were as follows: Jet Area-111%, 46%, 48%, 76%; VC-67%, 44%, 43%, 36%; PISA-52%, 48%, 31%, 35%; and effective regurgitant orifice area-127%, 95%, 66%, 58%.

CONCLUSIONS

The interobserver variation in quantifying TEE parameters for TR is high, suggesting these may be difficult to measure reliably in a busy perioperative setting. Of the parameters assessed, VC and PISA radius had the highest interobserver agreement and the highest correlation with severity.

Determination of Cross-Directional and Cross-Wall Variations of Passive Biaxial Mechanical Properties of Rat Myocardia

Heart myocardia are critical to the facilitation of heart pumping and blood circulating around the body. The biaxial mechanical testing of the left ventricle (LV) has been extensively utilised to build the computational model of the whole heart with little importance given to the unique mechanical properties of the right ventricle (RV) and cardiac septum (SPW). Most of those studies focussed on the LV of the heart and then applied the obtained characteristics with a few modifications to the right side of the heart. However, the assumption that the LV characteristics applies to the RV has been contested over time with the realisation that the right side of the heart possesses its own unique mechanical properties that are widely distinct from that of the left side of the heart. This paper evaluates the passive mechanical property differences in the three main walls of the rat heart based on biaxial tensile test data. Fifteen mature Wistar rats weighing 225 ± 25 g were euthanised by inhalation of 5% halothane. The hearts were excised after which all the top chambers comprising the two atria, pulmonary and vena cava trunks, aorta, and valves were all dissected out. Then, 5 × 5 mm sections from the middle of each wall were carefully dissected with a surgical knife to avoid overly pre-straining the specimens. The specimens were subjected to tensile testing. The elastic moduli, peak stresses in the toe region and stresses at 40% strain, anisotropy indices, as well as the stored strain energy in the toe and linear region of up to 40% strain were used for statistical significance tests. The main findings of this study are: (1) LV and SPW tissues have relatively shorter toe regions of 10–15% strain as compared to RV tissue, whose toe region extends up to twice as much as that; (2) LV tissues have a higher strain energy storage in the linear region despite being lower in stiffness than the RV; and (3) the SPW has the highest strain energy storage along both directions, which might be directly related to its high level of anisotropy. These findings, though for a specific animal species at similar age and around the same body mass, emphasise the importance of the application of wall-specific material parameters to obtain accurate ventricular hyperelastic models. The findings further enhance our understanding of the desired mechanical behaviour of the different ventricle walls.

Right ventricular volume and its relationship to functional tricuspid regurgitation

Background

Significant right ventricular (RV) dilatation has long been considered integral to the pathogenesis of functional tricuspid regurgitation (FTR).

Objectives

To explore the relationship of RV dilatation and FTR in patients with ‘pure’ RV volume overload.

Methods

Patients (>17yrs) with RV dilatation due to pre-tricuspid shunts (atrial septal defect; ASD and/or partial anomalous pulmonary venous drainage; PAPVD) referred to our service (2000–2019) were retrospectively identified. Those with pulmonary hypertension, primum ASD or left-heart disease were excluded. Using standard cardiac MRI protocols, RV, right atrial and TV parameters were measured and compared.

Results

Of 52 consecutively eligible patients (42 ± 15yrs, 25 males), 25 had ASDs, 13 had PAPVD and 14 had both conditions. All were in sinus rhythm and none had pulmonary regurgitation. Left and right ventricular ejection fractions were normal (LVEF 63 ± 8%, RVEF 56 ± 8%). Indexed RV end-diastolic volumes (RVEDVi) were moderately increased (males 148 ± 33 mL/m² and females 141 ± 42 mL/m², range 95–267 mL/m²). Despite substantial RV volume overload, no patients had severe tricuspid regurgitation (TR). Only two had > mild TR. There was a weak correlation between tricuspid annular diameter and both degree of RV dilatation (r = 0.37; p = 0.01) and degree of TR (r = 0.38; p = 0.006). There was a similarly poor correlation between right atrial dimensions and the degree of TR (r = 0.34; p = 0.02).

Conclusion

When RV dilatation is simply due to volume overload, we find that significant TR is extremely rare. This gives an important and novel insight; that RV dilatation per se does not result in FTR.

Transcatheter Annular Approaches for Tricuspid Regurgitation (Cardioband and Others)

The tricuspid valve often is referred to as "the forgotten valve" because it frequently is managed conservatively due to poor prognostic outcomes with conventional surgical intervention, in particular, in high-risk patients. Nevertheless, a paradigm shift has occurred in recent years, due to a growing evidence base supporting the independent prognostic influence of severe tricuspid regurgitation (TR) on patient outcomes. Both transcatheter valve replacement and valve repair have emerged as feasible and efficacious interventions for TR correction. Novel transcatheter repair techniques that replicate surgical annuloplasty are evolving as potentially lower-risk alternatives.

Anatomy of the Tricuspid Valve and Pathophysiology of Tricuspid Regurgitation

Transcatheter valve interventions have seen a significant increase in the past decade. The combination of improved techniques and available tools provides less invasive options supplementing surgical therapies. The tricuspid valve (TV) apparatus is a complex structure between the right atrium and the right ventricle; it generally consists of 3 leaflets (anterior, posterior, and septal) inserted in the fibrous tricuspid annulus and connected to the papillary muscle via the chordae tendinae. This article reviews TV anatomy, the pathophysiology of tricuspid regurgitation, and multimodality imaging to study TV, as well as provides an overview of transcatheter TV intervention.

Fusion imaging guided implantation of a Tricento transcatheter heart valve for severe tricuspid regurgitation

We report the case of a 64-year-old patient with history of chronic kidney disease on dialysis who was repeatedly hospitalized due to hydropic decompensation. Right heart failure with secondary severe tricuspid regurgitation was diagnosed. An interventional approach was recommended due to the heavy calcification of the sinus venosus and the perioperative risk (EuroScore II 3.2%) and taking into account the explicit request of the patient. After analysis of a full-cycle computed tomography, the patient was eligible for the implantation of the Tricento transcatheter heart valve. The custom-made prosthesis was implanted successfully using periprocedural transoesophageal guidance supported by fusion imaging that integrates live co-registration. After implantation of the valve prosthesis, the primary result was excellent. The patient was discharged without further complications shortly after the procedure and her status is being closely monitored.

Initial Experience With the PASCAL Ace Implant System for Treatment of Severe Tricuspid Regurgitation

[Figure: see text].

Clinical impact and 'natural' course of uncorrected tricuspid regurgitation after implantation of a left ventricular assist device: an analysis of the European Registry for Patients with Mechanical Circulatory Support (EUROMACS)

OBJECTIVES

Data on the impact and course of uncorrected tricuspid regurgitation (TR) during left ventricular assist device (LVAD) implantation are scarce and inconsistent. This study explores the clinical impact and natural course of uncorrected TR in patients after LVAD implantation.

METHODS

The European Registry for Patients with Mechanical Circulatory Support was used to identify adult patients with LVAD implants without concomitant tricuspid valve surgery. A mediation model was developed to assess the association of TR with 30-day mortality via other risk factors. Generalized mixed models were used to model the course of post-LVAD TR. Joint models were used to perform sensitivity analyses.

RESULTS

A total of 2496 procedures were included (median age: 56 years; men: 83%). TR was not directly associated with higher 30-day mortality, but mediation analyses suggested an indirect association via preoperative elevated right atrial pressure and creatinine (P = 0.035) and bilirubin (P = 0.027) levels. Post-LVAD TR was also associated with increased late mortality [hazard ratio 1.16 (1.06–1.3); P = 0.001]. On average, uncorrected TR diminished after LVAD implantation. The probability of having moderate-to-severe TR immediately after an implant in patients with none-to-mild TR pre-LVAD was 10%; in patients with moderate-to-severe TR pre-LVAD, it was 35% and continued to decrease in patients with moderate-to-severe TR pre-LVAD, regardless of pre-LVAD right ventricular failure or pulmonary hypertension.

CONCLUSIONS

Uncorrected TR pre-LVAD and post-LVAD is associated with increased early and late mortality. Nevertheless, on average, TR diminishes progressively without intervention after an LVAD implant. Therefore, these data suggest that patient selection for concomitant tricuspid valve surgery should not be based solely on TR grade.

Contemporary review in the multi-modality imaging evaluation and management of tricuspid regurgitation

The tricuspid valve has gained interest recently because of the poor outcomes with current treatments and advances in percutaneous valve interventions. A sound understanding of the anatomy and pathologies of the tricuspid valve is critical in its evaluation and management of tricuspid regurgitation (TR). A multi-modality imaging approach with transthoracic echocardiography, transesophageal echocardiography, computed tomography, magnetic resonance imaging all have their individual and collective roles in the evaluation of TR and guidance of surgical and percutaneous procedures. This combined with clinical factors will contribute to defining timing, indications, modality selection and risk stratification for tricuspid valve interventions, which currently remains controversial.

Changes of Right Ventricular Function After Transcatheter Aortic Valve Replacement and Association With Outcomes

BACKGROUND

Baseline right ventricular (RV) dysfunction represents a predictor for poor outcome in patients undergoing transcatheter aortic valve replacement (TAVR). However, RV function may improve after TAVR, which could have important implications on outcomes. The aim of the present study was to assess changes in RV function after TAVR and its prognostic value regarding clinical outcome.

METHODS AND RESULTS

Patients undergoing TAVR at our institution were consecutively enrolled and categorized into 4 groups according to changes in RV function during echocardiographic follow-up at 6 months. A total of 188 patients were included. Of those showing normal function at baseline, 87% (130/149) had preserved RV function at follow-up (group 1), whereas 13% (19/149) developed new RV dysfunction (group 2). Of those with RV dysfunction at baseline (39 patients), RV function normalized in 46% (18/39) (group 3) and remained impaired in 54% (21/39) (group 4). The Kaplan-Meier estimated survival at 3 years was highest in patients in group 1 (83%), intermediate in group 2 (65%) and 3 (69%), whereas group 4 had the worst survival (37%; P < .001). Furthermore, new or persistent RV dysfunction was identified to be independently associated with mortality during follow-up (hazard ratio 2.55; interquartile range 1.03-6.47, P = .004).

CONCLUSIONS

Patients with preserved RV function have a high 3-year survival. Normalization of RV function showed improved survival compared with patients with persistent RV dysfunction, who had a dismal prognosis despite TAVR.

Right ventricular myocardial mechanics: Multi-modal deformation, microstructure, modeling, and comparison to the left ventricle

The right ventricular myocardium, much like the rest of the right side of the heart, has been consistently understudied. Presently, little is known about its mechanics, its microstructure, and its constitutive behavior. In this work, we set out to provide the first data on the mechanics of the mature right ventricular myocardium in both simple shear and uniaxial loading and to compare these data to the mechanics of the left ventricular myocardium. To this end, we tested ovine tissue samples of the right and left ventricle under a comprehensive mechanical testing protocol that consisted of six simple shear modes and three tension/compression modes. After mechanical testing, we conducted a histology-based microstructural analysis on each right ventricular sample that yielded high resolution fiber distribution maps across the entire samples. Equipped with this detailed mechanical and histological data, we employed an inverse finite element framework to determine the optimal form and parameters for microstructure-based constitutive models. The results of our study show that right ventricular myocardium is less stiff then the left ventricular myocardium in the fiber direction, but similarly exhibits non-linear, anisotropic, and tension/compression asymmetric behavior with direction-dependent Poynting effect. In addition, we found that right ventricular myocardial fibers change angles transmurally and are dispersed within the sheet plane and normal to it. Through our inverse finite element analysis, we found that the Holzapfel model successfully fits these data, even when selectively informed by rudimentary microstructural information. And, we found that the inclusion of higher-fidelity microstructural data improved the Holzapfel model's predictive ability. Looking forward, this investigation is a critical step towards understanding the fundamental mechanical behavior of right ventricular myocardium and lays the groundwork for future whole-organ mechanical simulations.

Prognostic Implications of a Novel Algorithm to Grade Secondary Tricuspid Regurgitation

OBJECTIVES

A novel tricuspid regurgitation (TR) grading system, using vena contracta (VC) width and effective regurgitant orifice area (EROA), was proposed and validated based on its prognostic usefulness.

BACKGROUND

The clinical need of a new grading system for TR has recently been emphasized to depict the whole spectrum of TR severity, particularly beyond severe TR (massive or torrential).

METHODS

TR severity was characterized in 1,129 patients with moderate or severe secondary TR (STR). Recently proposed cutoff values of VC width were more effective in differentiating the prognosis of patients with moderate STR, whereas EROA cutoff values performed better in characterizing the risk of patients with more severe STR. Therefore, these 2 parameters were combined into a novel grading system to define moderate (VC <7 mm), severe (VC ≥7 mm and EROA <80 mm²), and torrential (VC ≥7 mm and EROA ≥80 mm²) STR.

RESULTS

A total of 143 patients (13%) showed moderate STR, whereas 536 patients (47%) had severe STR, and 450 (40%) had torrential STR. Patients with torrential STR had larger right ventricular (RV) dimensions, lower RV systolic function, and were more likely to receive diuretics. The cumulative 10-year survival rate was 53% for moderate, 45% for severe, and 35% for torrential STR (p = 0.007). After adjusting for potential confounders, torrential STR retained an association with worse prognosis compared with other STR grades (hazard ratio: 1.245; 95% confidence interval: 1.023 to 1.516; p = 0.029).

CONCLUSIONS

A novel STR grading system was able to capture the whole range of STR severity and identified patients with torrential STR who were characterized by a worse prognosis.

New Percutaneous Options for Tricuspid Intervention: How to Identify the Good Clinical Candidate

The tricuspid valve has been neglected for a long time and severe tricuspid regurgitation (TR) was largely undertreated in the past due to a high operative risk. In the last years we observed the development of different less invasive percutaneous options to treat TR. Currently, percutaneous treatments are reserved for high-risk patients presenting with advanced stage disease by which time they are likely to derive a partial benefit at best. There is a limited evidence base, including no randomized trials, to guide the management strategy for severe TR. In the interim we feel that choosing the best device for the most appropriate clinical candidate and with an adequate timing (most probably an “earlier” timing) will be the key combination to improve early and late outcomes of percutaneous treatments.

The use of cardiac valve procedures for rheumatic heart disease in Australia; a cross-sectional study 2002-2017

Background

Australia, although a high income economy, carries a significant burden of rheumatic heart disease (RHD). Acute rheumatic fever (ARF) and RHD are endemic in the Indigenous population. Immigrants from low/lower-income countries (‘non-Indigenous high-risk’) are also at increased risk compared with ‘non-Indigenous low-risk’ Australians. This study describes the utilisation of surgical and percutaneous procedures for RHD-related valve disease among patients aged less than 50 years, from 2002 to 2017.

Methods

A descriptive study using data from the ‘End RHD in Australia: Study of Epidemiology (ERASE) Project’ linking RHD Registers and hospital inpatient data from five states/territories, and two surgical databases. Trends across three-year periods were determined and post-procedural all-cause 30-day mortality calculated.

Results

A total of 3900 valves interventions were undertaken in 3028 procedural episodes among 2487 patients. Over 50% of patients were in the 35–49 years group, and 64% were female. Over 60% of procedures for 3-24 year-olds were for Indigenous patients. There were few significant changes across the study period other than downward trends in the number and proportion of procedures for young Indigenous patients (3–24 years) and ‘non-Indigenous/low risk’ patients aged ≥35 years. Mitral valve procedures predominated, and multi-valve interventions increased, including on the tricuspid valve. The majority of replacement prostheses were mechanical, although bioprosthetic valve use increased overall, being highest among females <35 years and Indigenous Australians. All-cause mortality (n = 42) at 30-days was 1.4% overall (range 1.1–1.7), but 2.0% for Indigenous patients.

Conclusions

The frequency of cardiac valve procedures, and 30-day mortality remained steady across 15 years. Some changes in the distribution of procedures in population groups were evident. Replacement procedures, the use of bioprosthetic valves, and multiple-valve interventions increased. The challenge for Australian public health officials is to reduce the incidence, and improve the early detection and management of ARF/RHD in high-risk populations within Australia.

•

Epidemic RHD in Indigenous Australians drives RHD-related cardiac valve procedures.

•

30-day mortality post-procedural is low in those under 50 years.

•

Bioprosthetic valve replacements higher in young women, and increasing in older patients.

Predictors of cardiovascular outcomes after surgery in severe tricuspid regurgitation: clinical, imaging and hemodynamic prospective study

INTRODUCTION AND OBJECTIVES

Severe tricuspid regurgitation (TR) is a prevalent valve disease with a high mortality rate. Current guidelines do not define specific thresholds at which patients should be considered for surgery or percutaneous procedures. Thus, patients are usually referred for intervention at a late stage of the disease. This study aimed to assess predictors of cardiovascular outcomes in a prospective cohort of patients with severe TR referred for surgery.

METHODS

This was an observational, prospective, nonrandomized study. All patients underwent surgery for severe TR based on current clinical guidelines. Complete anamnesis, blood test, echocardiogram, cardiovascular magnetic resonance and right and left catheterization were performed. Patients were followed up in the outpatient department and a combined endpoint (hospitalization for heart failure and cardiovascular mortality) was registered.

RESULTS

Forty-three consecutive patients were included (age: 66.9 ± 9.6 years, 67.4% female). Tricuspid annuloplasty was performed in all patients. After a median follow-up of 38 months, 12 patients (27.9%) showed the combined endpoint and 7 (16.3%) died. Above all clinical, blood and imaging data, the indexed right ventricular end-diastolic volume constituted the best predictor of the combined endpoint (HR, 1.1; P = .02) and cardiovascular mortality (HR, 1.1; P = .05). Furthermore, indexed right ventricular end-diastolic volume was associated with TR recurrence after surgery, with no impact on clinical outcomes.

CONCLUSIONS

In patients with severe TR referred for surgery, right ventricular remodeling assessed by cardiovascular magnetic resonance constituted the best independent predictor of cardiovascular outcomes at follow-up.

Strategies for tricuspid valve repair

Tricuspid valve repair is in many ways more challenging than mitral valve repair, especially since tricuspid valve anatomy is more complex with three leaflets, a saddle-shaped dynamic annulus and a complex subvalvular apparatus. The late referral of patients for tricuspid valve surgery adds to this challenge and contributes to poor prognosis. Nevertheless, studies have shown that the presence of moderate or greater tricuspid valve regurgitation leads to poor survival. Consequently, tricuspid valve surgery is now being performed more often, in order to improve the quality of life and survival. Tricuspid valve disease can be broadly classified into congenital and acquired tricuspid valve pathologies. Various repair techniques besides simple annular reduction maneuvers are used which are primarily aimed at restoring the complex interplay of various anatomical components. This review is a summary of the various operative techniques which provide successful reproducible results and achieve a competent and durable tricuspid valve repair with satisfactory late outcomes.

Catheter-based treatment of tricuspid regurgitation: state of the art

Tricuspid regurgitation is a highly prevalent condition, with detrimental effects on long-term survival. However, it has been historically neglected, and only surgically addressed when symptomatic diuretic agents proved insufficient to alleviate congestion. Besides, mortality rates of isolated tricuspid regurgitation surgery have been persistently high, even in contemporary series. This has led to the advent of a myriad of transcatheter tricuspid valve interventions mimicking current surgical technologies, for which a comprehensive imaging work-up holds the key for proper patient selection and intraprocedural monitoring. Although initially designed for compassionate use patients, growing experience and encouraging results of these less-invasive technologies are broadening the spectrum of beneficiaries. In this review, we will focus on the current picture of transcatheter tricuspid valve interventions, with special interest on the current understanding of pathoanatomic tricuspid regurgitation progression, preprocedural multimodality imaging and the latest experience on the different transcatheter devices.

Association of spectral Doppler cardiac activity in the lower limb veins and echocardiographic findings in patients with tricuspid regurgitation

Objective: To determine the association between spectral Doppler cardiac activity in the lower limb veins and echocardiographic findings in patients with tricuspid regurgitation. Material and methods: A cross-sectional analysis was performed in the Gilani Ultrasound Center over a period of 13 months. The total study sample comprised 400 subjects. All individuals referred for abdominal ultrasound having cardiac activities in external iliac vein, popliteal and posterior tibial vein, individuals having normal venous Doppler ultrasound, both genders and all ages, were included, and unwilling and non-cooperative patients were excluded from the study. Results: Out of 400 individuals, 200 showed cardiac activity in the lower limb veins on Doppler vascular ultrasound, while 200 did not show cardiac activity. On echocardiography, 204 individuals were diagnosed with tricuspid regurgitation, and 196 individuals had a competent tricuspid valve. According to the independent sample t-test the mean difference in the posterior tibial vein was 25.54 (95% CI: 24.09; 26.98), while the mean difference in the iliac vein was 2.34 (95% CI: 0.64; 4.03) among normal and tricuspid regurgitation. Conclusion: A correlation was found between the cardiac activities in the lower limb veins and tricuspid regurgitation.

Objective: To determine the association between spectral Doppler cardiac activity in the lower limb veins and echocardiographic findings in patients with tricuspid regurgitation. Material and methods: A cross-sectional analysis was performed in the Gilani Ultrasound Center over a period of 13 months. The total study sample comprised 400 subjects. All individuals referred for abdominal ultrasound having cardiac activities in external iliac vein, popliteal and posterior tibial vein, individuals having normal venous Doppler ultrasound, both genders and all ages, were included, and unwilling and non-cooperative patients were excluded from the study. Results: Out of 400 individuals, 200 showed cardiac activity in the lower limb veins on Doppler vascular ultrasound, while 200 did not show cardiac activity. On echocardiography, 204 individuals were diagnosed with tricuspid regurgitation, and 196 individuals had a competent tricuspid valve. According to the independent sample t-test the mean difference in the posterior tibial vein was 25.54 (95% CI: 24.09; 26.98), while the mean difference in the iliac vein was 2.34 (95% CI: 0.64; 4.03) among normal and tricuspid regurgitation. Conclusion: A correlation was found between the cardiac activities in the lower limb veins and tricuspid regurgitation.

Tricuspid valve geometry in patients with functional tricuspid regurgitation: A three-dimensional echocardiographic study

INTRODUCTION

Tricuspid valve (TV) has a complex anatomy causing some difficulties in echocardiographic evaluation. In this study, we sought to assess the geometry of TV in patients with functional tricuspid regurgitation (TR) by the implementation of 2- and 3-dimennsional (2D and 3D) echocardiography.

METHODS

In a case-control study, the geometrical features of TV were evaluated in forty patients with functional TR using echocardiographic examinations, and those data compared with twenty-five age- and sex-matched healthy individuals.

RESULTS

The mean age of patients was 50 ± 12 years, and 75% were female. All echocardiographic features of TV geometry were significantly greater in TR compared to control group. The 3D evaluation of TV annulus showed that the annulus shape was more circular in the TR compared to the control group. When compared patients with moderate and severe TR, there was a significant difference between groups regarding the size of the TV septolateral annulus diameter (3.5 ± 0.4 vs 3.9 ± 0.7 cm; P = .048), and the angle between mitral valve and TV annuluses (12.5 ± 4.3 vs 17 ± 9º; P = .048). Tenting areas measured by 2D echocardiography and obtained by TomTec software were significantly greater in severe TR compared to moderate TR group. The diameter of TV by 2D echocardiography was significantly higher in atrial fibrillation than that in sinus rhythm group among patients with TR.

CONCLUSIONS

The implementation of 3D echocardiography is useful in the determination of TV geometry in patients with functional TR. The accurate evaluation of anatomical features of TV might provide valuable tools in the evaluation of patients with functional TR.

Impact of tricuspid regurgitation on postoperative outcomes after non-cardiac surgeries

Objective

Tricuspid regurgitation (TR) severity has known adverse implications, its impact on patients undergoing non-cardiac surgery (NCS) remains unclear. We sought to determine the impact of TR on patient outcomes after NCS.

Methods

We performed a retrospective cohort study in patients undergoing NCS. Outcomes in patients with moderate or severe TR were compared with no/trivial TR after adjusting for baseline characteristics and revised cardiac risk index (RCRI). The primary outcome was defined as 30-day mortality and heart failure (HF), while the secondary outcome was long-term mortality.

Results

Of the 7064 patients included, 312 and 80 patients had moderate and severe TR, respectively. Thirty-day mortality was higher in moderate TR (adjusted OR 2.44, 95% CI 1.25 to 4.76) and severe TR (OR 2.85, 95% CI 1.04 to 7.79) compared with no/trivial TR. There was no difference in 30-day HF in patients with moderate TR (OR 1.48, 95% CI 0.90 to 2.44) or severe TR (OR 1.42, 95% CI 0.60 to 3.39). The adjusted HR for long-term mortality in moderate TR was 1.55 (95% CI 1.31 to 1.82) and 1.87 (95% CI 1.40 to 2.50) for severe TR compared with no/trivial TR.

Conclusion

Increasing TR severity has higher postoperative 30-day mortality in patients undergoing NCS, independent of RCRI risk factors, ejection fraction or mitral regurgitation. Severity of TR should be considered in risk stratification for patients undergoing NCS.

Prognostic role of moderate functional tricuspid regurgitation in length of hospitalization in patients undergoing isolated coronary artery bypass grafting

Functional tricuspid regurgitation (FTR) is defined as abnormal systolic tricuspid leakage with normal valve structures, and its prognostic role and management in patients with left-heart valve disease is well known. Due to paucity of data on FTR in patients with ischemic heart disease, the aim of our prospective study was to compare the prognostic effect of FTR between patients with moderate FTR and those with less-than-moderate FTR undergoing isolated coronary artery bypass graft (CABG) surgery. This prospective cohort study included all the patients who were candidate for isolated CABG and were referred for preoperative transthoracic echocardiography between April 2018 and November 2018. Patients were categorized into two groups: less-than-moderate FTR and moderate FTR. The endpoints of the study were the prognostic effect of FTR on short-term mortality and morbidities as a composite endpoint, as well as length of hospitalization, length of intensive care unit (ICU) stay, and ventilation time. Of a total of 410 patients, 363 patients (mean age = 62.4 years, 63.7% men) entered our final analysis. Logistic regression analysis demonstrated that composite endpoints of short-term mortality and morbidities was not significantly different between the two groups, but moderate FTR had a statistically significant effect on length of hospitalization (P = 0.002) and the ventilation time (P = 0.048). This effect, however, did not persist after adjustments for probable known confounders. Our study indicated no significant prognostic effect for preoperative FTR versus less-than-moderate FTR on short-term mortality and morbidities, as well as length of hospitalization, length of ICU stay, and the ventilation time.

Evolution of Tricuspid Regurgitation After Repair of Degenerative Mitral Regurgitation

BACKGROUND

The fate of unrepaired tricuspid regurgitation (TR) after mitral valve repair for degenerative mitral regurgitation remains highly debated. The objective of this study was to examine the progress of unrepaired TR after mitral valve repair for degenerative mitral regurgitation, with a particular focus on comparing patients with moderate preoperative TR with those having none or mild preoperative TR.

METHODS

Between 2008 and 2018, 183 consecutive patients (mean age, 61 years [SD, 14]) with severe degenerative mitral regurgitation and less-than-severe TR underwent mitral valve repair alone without concomitant TR repair. They were prospectively followed for a median duration of 3.1 years (interquartile range, 1.6-5.5; maximal duration of 9.4 years).

RESULTS

At baseline 146 patients (80%) had none or mild TR; 37 patients (20%) had moderate TR. At follow-up 51 patients (30%) had improved TR compared with 28 patients (17%) who had worse TR. At 3 years postoperatively echocardiographic data were available for 82 of 183 patients: 70 (85%) had none or mild TR, 11 (13%) had moderate TR, and 1 (1.2%) had moderate to severe TR. In an exploratory multivariable analysis with limited statistical power, patients with moderate preoperative TR (vs those with none or mild TR) had an association with higher mortality (hazard ratio, 2.8; 95% confidence interval, 0.81-9.4; P = .11).

CONCLUSIONS

After mitral valve repair but without concomitant tricuspid valve repair, a number of patients had progression in their TR. There was a signal of harm in patients having moderate preoperative TR in terms of mortality, but this finding is exploratory and requires investigation.

Mechanics of the Tricuspid Valve-From Clinical Diagnosis/Treatment, In-Vivo and In-Vitro Investigations, to Patient-Specific Biomechanical Modeling

Proper tricuspid valve (TV) function is essential to unidirectional blood flow through the right side of the heart. Alterations to the tricuspid valvular components, such as the TV annulus, may lead to functional tricuspid regurgitation (FTR), where the valve is unable to prevent undesired backflow of blood from the right ventricle into the right atrium during systole. Various treatment options are currently available for FTR; however, research for the tricuspid heart valve, functional tricuspid regurgitation, and the relevant treatment methodologies are limited due to the pervasive expectation among cardiac surgeons and cardiologists that FTR will naturally regress after repair of left-sided heart valve lesions. Recent studies have focused on (i) understanding the function of the TV and the initiation or progression of FTR using both in-vivo and in-vitro methods, (ii) quantifying the biomechanical properties of the tricuspid valve apparatus as well as its surrounding heart tissue, and (iii) performing computational modeling of the TV to provide new insight into its biomechanical and physiological function. This review paper focuses on these advances and summarizes recent research relevant to the TV within the scope of FTR. Moreover, this review also provides future perspectives and extensions critical to enhancing the current understanding of the functioning and remodeling tricuspid valve in both the healthy and pathophysiological states.

[Medicinal treatment of tricuspid valve regurgitation]

The vast majority of tricuspid valve regurgitations are of low degree without prognostic relevance in healthy individuals; however, morbidity and mortality increase with the degree of regurgitation, which can be secondary to either primary (structural) or secondary (functional) alterations of the valve. Due to the frequent lack of symptoms, echocardiographic examinations should be annually performed in patients with higher degree (at least moderate) tricuspid valve regurgitation, in particular in the presence of risk factors. Individual therapeutic management strategies should consider the etiology of the tricuspid valve regurgitation, the degree of regurgitation, the valve pathology and the risk-to-benefit ratio of the envisaged therapeutic procedure. Medicinal treatment options for tricuspid valve regurgitation are limited and generalized recommendations cannot be provided due to the lack of conclusive clinical trials. Symptomatic therapeutic measures encompass especially (loop) diuretics for the reduction of preload and afterload of the right ventricle. Pharmaceutical reduction of the heart rate should be avoided in patients with right heart insufficiency. While symptomatic therapeutic measures are often associated with only moderate effects, the most effective therapy of tricuspid valve regurgitation consists in the treatment of underlying illnesses, in most cases pulmonary hypertension due to pulmonary arterial hypertension (PAH), left heart disease or acute pulmonary embolism. Based on a number of published clinical studies and licensing of new drugs, treatment options for patients with PAH and heart failure with reduced ejection fraction (HFrEF) have substantially improved during the past years allowing for a differentiated, individualized management.

Comparative early outcomes of tricuspid Valve repair versus replacement for secondary tricuspid regurgitation

Background

Comparative outcome data on tricuspid valve repair (TVr) versus tricuspid valve replacement (TVR) for severe secondary tricuspid regurgitation (TR) are limited.

Methods

We used a national inpatient sample to assess in-hospital morbidity and mortality, length of stay and cost in patients with severe secondary TR undergoing isolated TVr versus TVR.

Results

A total of 1364 patients (national estimate=6757) underwent isolated tricuspid valve surgery during the study period, of whom 569 (41.7%) had TVr and 795 (58.3%) had TVR. There was no difference in the prevalence of major morbidities between the two groups, except for liver disease and hepatic cirrhosis, which were more common in the TVR group. Before propensity matching, in-hospital mortality was similar between patients who underwent isolated TVr and TVR (8.1% vs 10.8%, p=0.093), but the incidence of postoperative morbidities differed: TVR was associated with higher rates of permanent pacemaker implantation and blood transfusion, while TVr was associated with more acute kidney injury. After rigorous propensity score matching, TVR was associated with significantly higher rates of in-hospital death (12% vs 6.9%, p=0.009) and permanent pacemaker implantation (33.7% vs 11.2%, p<0.001). Postoperative morbidities and length of stay, however, were not different between the two groups. Nonetheless, cost of hospitalisation was 16% higher in the TVr group.

Conclusions

In patients undergoing isolated surgery for secondary TR, TVR is associated with higher in-hospital mortality and need for permanent pacemaker compared with TVr. Further studies are needed to understand the impact of the type of surgery on the short-term and long-term mortality in this complex undertreated population.