Determinants of Recurrent or Residual Functional Tricuspid Regurgitation After Tricuspid Annuloplasty

Current management of tricuspid regurgitation: a focus on the spiral suspension approach

The indication for surgery for tricuspid regurgitation (TR) has reached a major turning point. It has become clear that the presence of moderate or severe TR alone worsens the prognosis of life, and the previous guidelines of Japanese Circulation Society, in which the indication for surgery was recommended at the timing of "right heart failure difficult to treat medically," now recommends surgery with a trigger of "repeated right heart failure" in the 2020 edition. In addition, a new repair technique targeting at subvalvular structure has been developed for end-stage TR to overcome a high TR recurrence rate that is associated with severe right ventricular enlargement and leaflet tethering. This review focuses on the spiral suspension technique, in which the papillary muscles are spirally suspended towards the septal leaflet annulus to correct tethering and enhances the understanding of its application in the context of TR management.

A Novel Transcatheter Device for the Edge-to-Edge Treatment of Tricuspid Regurgitation: A Preliminary Evaluation

Tricuspid regurgitation (TR) is the most common pathology of the tricuspid valve (TV), with significant mortality in severe cases. A well-established strategy to treat TR is represented by the clover surgical technique, which consists of stitching together the free edges of TV leaflets, producing a clover-shaped valvular orifice. Transcatheter treatments for TR constitute a valuable alternative for high-risk patients. In this work we investigated haemodynamic performances and safety of a novel device (StarTric device (STD)) aiming to perform the clover technique via percutaneous access. To assess haemodynamic performances, STD and clover were applied on porcine pathological TVs and tested. Fluid dynamic indexes of both strategies were compared to the pathological model. To evaluate device safety, forces exchanged between device and leaflets were compared to the extraction force (EF) required to STD to completely pass through the leaflet. Clover technique and STD induced a comparable TV backflow reduction (48% and 47%, respectively), with associated increase of TV flow in all tested conditions. Diastolic transvalvular pressure similarly increased indicating a reduction, though not significant, of the valvular orifice. Forces ranged from 1N to 1.71N, compared to an EF of 22.16 ± 8.6N. Force varied significantly amongst different working conditions (normotensive, mild, and severe hypertensive) for each leaflet, whilst no significative variation was found on different leaflets in the same working condition. In the adopted experimental scenario, STD demonstrated comparable efficacy to the surgical strategy in restoring TV haemodynamic. The forces acting on the leaflets following STD implantation were far lower when compared to EFs.

Right ventricular remodeling and clinical outcomes following transcatheter tricuspid valve intervention

AIMS

Characterize the impact of residual tricuspid regurgitation (TR) on right ventricle (RV) remodeling and clinical outcomes after transcatheter tricuspid valve intervention.

METHODS

We performed a single-center retrospective analysis of transcatheter tricuspid valve repair (TTVr) or replacement (TTVR) patients. The primary outcomes were longitudinal tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), pulmonary artery systolic pressure (PASP), and RV dimensions (RVd). We used multivariable linear mixed models to evaluate association with replacement versus repair and degree of TR reduction with changes in these echo measures over time. Multivariable Cox regression was used to identify associations between changes in these echo measures and a composite clinical outcome of death, heart failure hospitalization, or re-do tricuspid valve intervention.

RESULTS

We included a total of 61 patients; mean age was 77.5 ± 11.7 and 62% were female. TTVR was performed in 25 (41%) and TTVr in 36 (59%). Initially, 72% (n = 44) had ≤ severe TR and 28% (n = 17) had massive or torrential TR. The median number of follow up echos was 2: time to 1st follow-up was 50 days (interquartile range [IQR]: 20, 91) and last follow-up was 147 (IQR: 90, 327). Median TR reduction was 1 (IQR: 0, 2) versus 4 (IQR: 3, 6) grades in TTVr versus TTVR (p < 0.0001). In linear mixed modeling, TTVR was associated with decline in TAPSE and PASP, and TR reduction was associated with decreased RVd. In multivariable Cox regression, greater RVd was associated with the clinical outcome (hazard ratio: 9.27, 95% confidence interval: 1.23-69.88, p = 0.03).

CONCLUSION

Greater TR reduction is achieved by TTVR versus TTVr, which is in turn associated with RV reverse remodeling. RV dimension in follow-up is associated with increased risk of a composite outcome of death, heart failure hospitalization, or re-do tricuspid valve intervention.

Morphometric Characterization of an Ex Vivo Porcine Model of Functional Tricuspid Regurgitation

Emerging treatments for tricuspid valve (TV) regurgitation require realistic TV pathological models for preclinical testing. The aim of this work was to investigate structural features of fresh and defrosted porcine right-heart samples as models of mild and severe functional tricuspid regurgitation (FTR) condition in ex-vivo pulsatile flow platform. Ten fresh hearts were tested ex-vivo under steady and pulsatile flow in typical right-heart loading conditions. Hemodynamics and 3D echocardiographic imaging of TV and right ventricle (RV) were acquired. Hearts were then kept frozen for 14 days, defrosted, and tested again with the same protocol. Morphometric parameters of TV and RV were derived from 3D reconstructions based on echo data. Fresh samples showed a slightly dilated TV morphology, with coaptation gaps among the leaflets. Sample freezing induced worsening of TV insufficiency, with significant (p < 0.05) increases in annulus size (annulus area and perimeter 7.7-3.1% respectively) and dilation of RV (9.5%), which led to an increase in tenting volume (123.7%). These morphologic alterations reflected into a significant increment of regurgitation fraction (27%). Together, such results suggest that fresh porcine heart samples may be a reliable ex-vivo model of mild FTR condition, which can be enhanced through freezing/thawing treatment to model a severe pathological condition.

Developing Insights Regarding Tricuspid Valve Regurgitation: Morphology, Assessment of Severity, and the Need for a Novel Grading Scheme

Current understanding that progressive tricuspid regurgitation (TR) is associated with worse outcomes has highlighted the clinical need for a more accurate assessment of TR morphology and severity. This need has been further emphasized owing to the development of a myriad of percutaneous right-sided interventions, which may offer successful treatment of TR in selected patients. Understanding the etiology and quantification of the severity of TR has important implications in the selection of novel therapeutic strategies, i.e., medical vs. percutaneous vs. surgical approaches. Newer grading schemas that better reflect the TR lesion severity have been recently proposed and may facilitate monitoring of the evolution of TR following percutaneous and/or surgical treatment. In this review, we summarize contemporary concepts regarding tricuspid valve morphology, TR etiology, and associated mechanisms and echocardiographic approaches to grade TR severity.

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

Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Imaging is pivotal in the evaluation of native valve regurgitation and echocardiography is the primary imaging modality for this purpose. The imaging assessment of valvular regurgitation should integrate quantification of the regurgitation, assessment of the valve anatomy and function, and the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation largely relies on the results of imaging. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing native valve regurgitation. The present document aims to present clinical guidance for the multi-modality imaging assessment of native valvular regurgitation.

Morphological diversity of the tricuspid posterior leaflet affects surgical complexity for control of tricuspid regurgitation

Objective

We investigated the effect of morphological diversity of the tricuspid valve with multiple posterior leaflets on the technical outcomes of tricuspid valve repair.

Methods

From April 2016 to November 2020, 141 patients were diagnosed with secondary tricuspid regurgitation associated with left heart disease and underwent tricuspid valve repair. We retrospectively analyzed the clinical and echocardiographic data of patients who underwent both preoperative and postoperative transthoracic echocardiography. We divided the patients into two groups according to the surgical technique used to treat tricuspid regurgitation: ring annuloplasty alone (Group 1, n = 109) or additional approximation of leaflet edges (edge-to-edge repair) with ring annuloplasty (Group 2, n = 32). We measured the morphological diversity of the tricuspid valve during the operation in all patients.

Results

The preoperative tricuspid regurgitation score was higher in Group 2 than in Group 1 (2.1 ± 0.78 vs. 1.6 ± 0.7, respectively; p = 0.0046), and Group 2 contained more patients with two posterior leaflets than Group 1 [20 (63%) vs. 36 (33%), respectively; p = 0.003]. The univariate and multivariate logistic regression analyses showed that the presence of two posterior leaflets was an independent risk factor for additional procedures during tricuspid valve repair (odds ratio, 2.6; 95% confidence interval, 1.1–6.1; p = 0.033).

Conclusions

Additional procedures to reduce tricuspid regurgitation were required more frequently in patients with two posterior leaflets of the tricuspid valve. The morphological diversity of two posterior leaflets is a potential risk factor for a more complicated tricuspid repair.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01762-5.

Long-term outcomes of pericardial strip versus prosthetic ring annuloplasty for secondary tricuspid regurgitation by a minimally invasive approach

Background

This study was conducted to compare the outcomes of prosthetic ring versus autologous pericardial strip for the treatment of functional tricuspid regurgitation during left-sided valve surgery by minimally invasive approach.

Methods

From January 2008 and July 2016, autologous pericardial strip (group P-TAP) was used in 109 patients, and prosthetic ring (group R-TAP) in 115 patients. The primary outcomes were long-term overall survival, development of patch degeneration, and significant tricuspid regurgitation recurrence. The second outcome was the assessment of right ventricular functional parameters.

Results

Operative mortality was 1 case (0.9%) in the R-TAP group. At the time of hospital discharge only one patient (0.9%) in the R-TAP group had grade III+ tricuspid regurgitation, and none had grade IV+. Mean follow-up was 94.1 ± 24.5 months. Mild and moderate tricuspid regurgitation recurrence was 3.7% and 4.5% (P-TAP vs. R-TAP groups, p = 0.99). Severe regurgitation was observed in 1.8% of cases only in the R-TAP group (p = 0.49). There were no reoperations. Late mortality was 3.7% and 5.4% (P-TAP vs. R-TAP groups, p = 0.75). Freedom from death, all causes, were comparable among groups (log-rank p = 0.45). There were no statistically significant differences between two groups in TAPSE, left ventricular end-diastolic diameter, left ventricular ejection fraction, and left atrial diameter.

Conclusions

Tricuspid annuloplasty using an autologous pericardial strip in patients undergoing minimally invasive surgery is associated to similar long results (survival, late tricuspid regurgitation, and functional echocardiographic parameters) than annuloplasty with a prosthetic ring. In particular, the pericardial strip over time does not develop any degeneration or retraction.

Diagnosis and Management of Failed Surgical Tricuspid Valve Annuloplasty

PURPOSE OF THE REVIEW

Annular-based strategies for treating tricuspid valve (TV) regurgitation do not always have satisfactory long-term outcomes. Management of failed TV annuloplasty can be challenging and requires a dedicated heart team approach. This review explores the treatment options available for failed TV annuloplasty.

RECENT FINDINGS

Recent developments and novel percutaneous treatment options have emerged as promising alternatives for patients with failed TV annuloplasty. Leaflet-based interventions, valve-in-valve procedures, transcatheter tricuspid valves and new-generation trans-caval valves are all feasible options, which can assure good results whilst minimizing risks for the patient. Failure of tricuspid annuloplasty is not uncommon amongst patients treated with either a tricuspid ring or suture-based device. The complex anatomy, physiology and clinical risk profile should be carefully evaluated on an individual patient-by-patient basis in order to select the most appropriate clinical and percutaneous treatment strategy. Different transcatheter tricuspid valve repair or replacement techniques may provide an attractive alternative treatment option for managing this challenging patient cohort.

Early Multinational Experience of Transcatheter Tricuspid Valve Replacement for Treating Severe Tricuspid Regurgitation

OBJECTIVES

The aim of this registry was to evaluate the feasibility and safety of transcatheter tricuspid valve implantation (TTVI) in patients with extreme surgical risk.

BACKGROUND

Isolated tricuspid regurgitation (TR) surgery is associated with high in-hospital mortality.

METHODS

Thirty consecutive patients (mean age 75 ± 10 years; 56% women) from 10 institutions, with symptomatic functional TR, had institutional and notified body approval for compassionate use of the GATE TTVI system. Baseline, discharge, and 30-day follow-up echocardiographic data and procedural, in-hospital, and follow-up clinical outcomes were collected.

RESULTS

At baseline, all patients had multiple comorbidities, severe or greater TR, and reduced baseline right ventricular function. Technical success was achieved in 26 of 30 patients (87%). Device malpositioning occurred in 4 patients, with conversion to open heart surgery in 2 (5%). Of those who received the device, 100% had reductions in TR of ≥1, and 75% experienced reductions of ≥2 grades, resulting in 18 of 24 of patients (76%) with mild or less TR at discharge. All patients had mild or less central TR. There was continued improvement in TR grade between discharge and 30 days in 15 of 19 patients (79%). In-hospital mortality was 10%. At mean follow-up of 127 ± 82 days, 4 patients (13%) had died. Of patients alive at follow-up, 62% were in New York Heart Association functional class I or II, with no late device-related adverse events.

CONCLUSIONS

Compassionate treatment of severe, symptomatic functional TR using a first-generation TTVI device is associated with significant reduction in TR and improvement in functional status with acceptable in-hospital mortality. Further studies are needed to determine the appropriate patient population and long-term outcomes with TTVI therapy.

Tricuspid Regurgitation in Left Ventricular Systolic Dysfunction: Marker or Target?

Far from being historically considered a primary healthcare problem, tricuspid regurgitation (TR) has recently gained much attention from the scientific community. In fact, in the last years, robust evidence has emerged regarding the epidemiological impact of TR, whose prevalence seems to be similar to that of other valvulopathies, such as aortic stenosis, with an estimated up to 4% of people >75 years affected by at least moderate TR in the United States, and up to 23% among patients suffering from heart failure with reduced ejection fraction. This recurrent coexistence of left ventricular systolic dysfunction (LVSD) and TR is not surprising, considered the multiple etiologies of tricuspid valve disease. TR can complicate heart failure mostly as a functional disease, because of pulmonary hypertension (PH), subsequent to elevated left ventricular end-diastolic pressure, leading to right ventricular dilatation, and valve tethering. Moreover, the so-called "functional isolated" TR can occur, in the absence of PH, as a result of right atrial dilatation associated with atrial fibrillation, a common finding in patients with LVSD. Finally, TR can result as a iatrogenic consequence of transvalvular lead insertion, another frequent scenario in this cohort of patients. Nonetheless, despite the significant coincidence of these two conditions, their mutual relation, and the independent prognostic role of TR is still a matter of debate. Whether significant TR is just a marker for advanced left-heart disease, or a crucial potential therapeutical target, remains unclear. Aim of the authors in this review is to present an update concerning the epidemiological features and the clinical burden of TR in the context of LVSD, its prognostic value, and the potential benefit for early tricuspid intervention in patients affected by contemporary TR and LVSD.

Complicated postoperative course in isolated tricuspid valve surgery: Looking for predictors

BACKGROUND

This study aims at better defining the profile of patients with a complicated versus noncomplicated postoperative course following isolated tricuspid valve (TV) surgery to identify predictors of a favorable/unfavorable hospital outcome.

METHODS

All patients treated with isolated tricuspid surgery from March 1997 to January 2020 at our institution were retrospectively reviewed. Considering the complexity of most of these patients, a regular postoperative course was arbitrarily defined as a length-of-stay in intensive care unit less than 4 days and/or postoperative length-of-stay less than 10days. Patients were therefore divided accordingly in two groups.

RESULTS

One hundred and seventy-two patients were considered, among whom 97 (56.3%) had a regular (REG) and 75 (43.6%) a non-regular (NEG) postoperative course. The latter had worse baseline clinical and echocardiographic characteristics, with higher rate of renal insufficiency, previous heart failure hospitalizations, cardiac operations, and right ventricular dysfunction. NEG patients more frequently needed tricuspid replacement and experienced a greater number of complications (p < .001) and higher in-hospital mortality (13% vs. 0%, p < .001). The majority of these complications were related to more advanced stage of the tricuspid disease. Among most important predictors of a negative outcome univariate analysis identified chronic kidney disease, ascites, previous right heart failure hospitalizations, right ventricular dysfunction, previous cardiac surgeries, TV replacement and higher MELD scores. At multivariate analysis, liver enzymes and diuretics' dose were predictors of complicated postoperative course.

CONCLUSION

In isolated TV surgery a complicated postoperative course is observed in patients with more advanced right heart failure and organ damage. Earlier surgical referral is associated to excellent outcomes and should be recommended.

Isolated tricuspid valve surgery: first outcomes report according to a novel clinical and functional staging of tricuspid regurgitation

OBJECTIVES

The goal of this study was to assess the applicability of a novel classification of patients with tricuspid regurgitation based on 5 stages and to evaluate outcomes following isolated surgical treatment.

METHODS

All patients treated with isolated tricuspid valve repair or tricuspid valve replacement (TVR) from March 1997 to January 2020 at a single institution were retrospectively reviewed. Patients were divided according to a novel clinical-functional classification, based on the degree of regurgitation together with symptoms, right ventricular size and function and medical therapy. A total of 195 patients were treated; however, 23/195 were excluded due to lack of sufficient preoperative data.

RESULTS

A total of 172 patients were considered; of these, 129 (75%) underwent TVR and 43 (25%) had tricuspid valve repair. The distribution of patients showed that 46.5% of patients who underwent tricuspid valve repair were in stage 2, whereas 51.9% who underwent TVR were in stage 3. TVR patients were in more advanced stages of the disease, with dilated right ventricles, more pronounced symptoms and development of organ damage. Hospital mortality was 5.8%, in particular 0% in stages 2 and 3 and 15.3% in stages 4 and 5 (P < 0.001). Both intensive care unit and hospital stays were significantly longer in more advanced stages (P < 0.001). Patients in stages 4 and 5 developed more postoperative complications, such as acute kidney injury (3.7-10% in stages 2 and 3 vs 44-100% in stages 4 and 5; P < 0.001) and low cardiac output syndrome (15-50% in stages 2 and 3 vs 71-100% in stages 4 and 5; P < 0.001).

CONCLUSIONS

Patients in more advanced stages had higher hospital mortality and longer hospitalizations. Timely referral is associated with lower mortality, short postoperative course and mostly valve repair.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Echocardiographic assessment of the tricuspid and pulmonary valves: a practical guideline from the British Society of Echocardiography

Transthoracic echocardiography is the first-line imaging modality in the assessment of right-sided valve disease. The principle objectives of the echocardiographic study are to determine the aetiology, mechanism and severity of valvular dysfunction, as well as consequences on right heart remodelling and estimations of pulmonary artery pressure. Echocardiographic data must be integrated with symptoms, to inform optimal timing and technique of interventions. The most common tricuspid valve abnormality is regurgitation secondary to annular dilatation in the context of atrial fibrillation or left-sided heart disease. Significant pulmonary valve disease is most commonly seen in congenital heart abnormalities. The aetiology and mechanism of tricuspid and pulmonary valve disease can usually be identified by 2D assessment of leaflet morphology and motion. Colour flow and spectral Doppler are required for assessment of severity, which must integrate data from multiple imaging planes and modalities. Transoesophageal echo is used when transthoracic data is incomplete, although the anterior position of the right heart means that transthoracic imaging is often superior. Three-dimensional echocardiography is a pivotal tool for accurate quantification of right ventricular volumes and regurgitant lesion severity, anatomical characterisation of valve morphology and remodelling pattern, and procedural guidance for catheter-based interventions. Exercise echocardiography may be used to elucidate symptom status and demonstrate functional reserve. Cardiac magnetic resonance and CT should be considered for complimentary data including right ventricular volume quantification, and precise cardiac and extracardiac anatomy. This British Society of Echocardiography guideline aims to give practical advice on the standardised acquisition and interpretation of echocardiographic data relating to the pulmonary and tricuspid valves.

Functional tricuspid regurgitation: indications, techniques, and outcomes

Functional tricuspid regurgitation (TR) results from asymmetric dilation of the tricuspid valve annulus. This often occurs due to right ventricular enlargement and dysfunction as a consequence of myocardial or valvular abnormalities of the left heart. Even mild TR at the time of left-sided valvular surgery may worsen postoperatively, which carries poor prognostic implications. In spite of data revealing poor outcomes associated with residual TR, surgery for functional TR remains underutilized. Surgical repair techniques for TR include placement of a rigid or semi-rigid tricuspid annular ring, which has been shown to provide superior longevity compared with suture and flexible band repair techniques. Additionally, emerging percutaneous annuloplasty techniques to correct functional TR can expand interventional treatment options to patients who would otherwise carry prohibitive operative risk.

Catheter ablation or surgical therapy in moderate-severe tricuspid regurgitation caused by long-standing persistent atrial fibrillation. Propensity score analysis

BACKGROUND

This study aimed to describe the mid-term outcomes of different treatments in patients with atrial fibrillation caused tricuspid regurgitation.

METHODS

A retrospective study of patients diagnosed as atrial fibrillation caused moderate-severe tricuspid regurgitation undergoing ablation (n = 411) were reviewed. The surgical cohort (n = 114) underwent surgical ablation and tricuspid valve repair; the catheter cohort (n = 279) was selected from those patients who had catheter ablation.

RESULTS

The estimated actuarial 5-year survival rates were 96.8% (95% CI: 92.95-97.78) and 92.0% (95% CI: 85.26-95.78) in the catheter and surgical cohort, respectively. Tethering height was showed as independent risk factors for recurrent atrial fibrillation and tricuspid regurgitation in both cohorts. A matched group analysis using propensity-matched was conducted after categorizing total patients by tethering height < 6 mm and ≥ 6 mm. Kaplan-Meier analysis showed in patients with tethering height < 6 mm, there were no differences in survival from mortality, stroke, recurrent atrial fibrillation and tricuspid regurgitation between two groups. In patients with tethering height ≥ 6 mm, there were significantly higher cumulative incidence of stroke (95% CI, 0.047-0.849; P = 0.029), recurrent atrial fibrillation (95% CI, 0.357-09738; P = 0.039) and tricuspid regurgitation (95% CI, 0.359-0.981; P = 0.042) in catheter group.

CONCLUSIONS

Atrial fibrillation caused tricuspid regurgitation resulted in less leaflets coaptation, which risk the recurrence of atrial fibrillation and tricuspid regurgitation. Patients whose tethering height was less than 6 mm showed satisfying improvement in tricuspid regurgitation with the restoration of sinus rhythm after catheter ablation. However, in patients with severe leaflets tethering, the results favored surgical over catheter.

Imaging for Tricuspid Valve Repair and Replacement

Primary or secondary tricuspid regurgitation (TR) represents an important health care burden and challenge which has often been neglected or undertreated in the past. The expansion and reinforcement of the indications for tricuspid valve (TV) intervention in the 2017 editions of the guidelines as well as the introduction of transcatheter tricuspid valve intervention (TTVI) has considerably increased the attention of the community on the TV and the volume of TV interventions in the past years. Depending on the anatomic target, TTVI can be categorized as the following: 1) direct or indirect tricuspid restrictive annuloplasty; 2) direct (edge-to-edge repair) or indirect (coaptation device) restoration of leaflet coaptation; 3) heterotopic tricuspid valve implantation; and 4) transcatheter tricuspid valve replacement. Multimodality imaging has crucial role for the following: 1) patient selection for TTVI and procedure planning; 2) guiding and monitoring the procedure; and 3) assessing and following over time the results of the procedure. The key points for pre-procedural imaging are: 1) accurate quantitation of TR severity; 2) proper identification of the mechanism(s) responsible for the TR; and 3) quantitation of RV dysfunction and pulmonary arterial hypertension. This imaging work-up is essential to select the right type of intervention for the right patient and TV. Transesophageal echocardiography and fluoroscopy imaging is also key for guiding the TTVI procedures and fusion between these 2 modalities may further enhance the quality of procedure guiding.

Imaging and Patient Selection for Transcatheter Tricuspid Valve Interventions

With the emergence of transcatheter solutions for the treatment of tricuspid regurgitation (TR) increased attention has been directed to the once neglected tricuspid valve (TV) complex. Recent studies have highlighted new aspects of valve anatomy and TR etiology. The assessment of valve morphology along with quantification of regurgitation severity and RV function pose several challenges to cardiac imagers guiding transcatheter valve procedures. This review article aims to give an overview over the role of modern imaging modalities during assessment and treatment of the TV.

Pacemaker lead as an iatrogenic cause of right heart failure: Case report

Technical advances in health care have improved patient survival and quality of life, but are not devoid of complications. We present the case of a 74-year-old woman with a history of hypertensive heart disease with preserved systolic function, atrial fibrillation and dyslipidemia. She had a DDDR pacemaker implanted in 2005 due to symptomatic complete atrioventricular block. The patient reported progressive fatigue, weakness, ascites with abdominal discomfort, and lower limb edema, accompanied by non-specific hepatic cholestasis on biochemical testing. Abdominal ultrasound revealed homogeneous hepatomegaly and dilatation of the inferior vena cava and upper hepatic veins, suggestive of congestive hepatopathy. Echocardiography revealed tricuspid regurgitation progressively worsening over the previous four years and dilatation and progressive dysfunction of the right ventricle, with preserved left ventricular function. The transesophageal echocardiogram revealed severe tricuspid regurgitation with flail septal leaflet and marked dilatation of the tricuspid annulus due to mechanical interference of the pacemaker lead, which was adhering to the septal leaflet. Minimally invasive surgical treatment was performed with partial resection of the leaflet, placement of a tricuspid annuloplasty ring and replacement of the pacemaker lead. Regression of the congestive symptoms was observed, and the postoperative echocardiogram showed the tricuspid annuloplasty ring with no evidence of stenosis and only slightly dilated right chambers with moderate pulmonary hypertension. Six months after the procedure, the patient suffered an acute neurological event and died.

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

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

Transcatheter innovations in tricuspid regurgitation: Cardioband

Functional tricuspid regurgitation (FTR) has been neglected for a long time, however its prevalence and clinical relevance is not negligible. In presence of FTR, a certain quote of annular dilatation is present thus contributing to the mechanism of regurgitation. Historically, surgical annuloplasty has been the main treatment to correct FTR; however surgical repair is limited by a high risk of mortality and morbidity. For this reason, percutaneous tricuspid annuloplasty is an attractive tool for the treatment of FTR in patients at high surgical risk. A number of both direct and indirect percutaneous annuloplasty systems are currently under pre-clinical and clinical development. This review will discuss the Cardioband system, a novel direct annuloplasty device with promising result in terms of clinical safety and efficacy.

Lack of Increased Cardiovascular Risk due to Functional Tricuspid Regurgitation in Patients with Left-Sided Heart Disease

BACKGROUND

Significant tricuspid regurgitation (TR) is associated with higher risk for adverse cardiovascular outcomes. Left-sided heart disease (LHD) is a potentially important confounder of this association because it is strongly linked to both TR and clinical outcome.

METHODS

We studied 5,886 patients who were followed for a period of 10 years after the index echocardiographic examination. The relationship between TR severity and the end point of admission for heart failure or cardiovascular mortality was analyzed using competing risk analysis, Cox model, and propensity score matching.

RESULTS

Higher TR grade was associated with markers of LHD including left ventricular systolic dysfunction, valvular heart disease ≥ moderate, left atrial enlargement, and pulmonary hypertension (all P < .001). There was a significant interaction between TR and the presence of LHD with regard to the end point of heart failure in the competing risks model (P = .01) and the combined end point of heart failure and cardiovascular mortality (P = .02). In both models, moderate/severe TR was associated with higher risk for heart failure (hazard ratio [HR] = 3.10; 95% CI, 1.41-6.84; P = .005) and the combined end point of heart failure or cardiovascular mortality (HR = 2.75; 95% CI, 1.33-5.63, P = .006) only in patients without LHD. Propensity score matching yielded 350 patient pairs, of which 88% had LHD. The HR for heart failure or cardiovascular mortality at 10 years was 0.78 (95% CI, 0.56-1.08; P = .14) in the moderate/severe TR group as compared with the trivial/mild TR.

CONCLUSIONS

Moderate or severe functional TR portends an increased risk for heart failure and cardiovascular mortality only when isolated, without concomitant LHD.

The Forgotten, Not Studied or Not Valorized Tricuspid Valve: The Transcatheter Revolution Is Coming

The tricuspid valve (TV) has been known as the forgotten valve. However, considering recent information from scientific studies, this nomenclature may need to be adjusted for the valve, which also needs to be better studied and understood. For decades, tricuspid regurgitation (TR) was not fully appreciated and was never the priority. However, studies have revealed that such pathology is related to a possible negative impact on prognosis of patients. Severe TR is a predictor of higher mortality. For the treatment of TR, repair or valve replacement can be performed. Repair techniques can be performed on the annulus (suture annuloplasty or ring implant), on the leaflets (e.g. triangular resection), on the cords (transfers or new cords) and on the papillary muscles (e.g. sliding technique). The anatomical characteristics of the TV determine the repair technique to be used. In some cases, valve repair is not possible and/or not indicated and valve replacement is selected based on the strategy. Nowadays transcatheter therapies have been used and studied. The main transcatheter strategies for the treatment of TR are based on reduction of the annulus (Cardioband, Trialign, TriCinch, Millipede and TRAIPTA), improvement of the leaflet coaptation (Mitraclip, FORMA device, PASCAL system, and TV occluder), reduction of the reflux for the vena cava system (Tric valve and Sapien valve implant), and valve implants (Navigate, Trisol, Sapien, Melody). In this context, there are still other devices (such as Tricentro, Pasta, etc.) being developed and tested throughout several phases of research. In the future, improved knowledge of the TV and the evolution of transcatheter treatments will alter the history of the TV. The transcatheter revolution is coming!

Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association

Background and Purpose:

The diverse causes of right-sided heart failure (RHF) include, among others, primary cardiomyopathies with right ventricular (RV) involvement, RV ischemia and infarction, volume loading caused by cardiac lesions associated with congenital heart disease and valvular pathologies, and pressure loading resulting from pulmonic stenosis or pulmonary hypertension from a variety of causes, including left-sided heart disease. Progressive RV dysfunction in these disease states is associated with increased morbidity and mortality. The purpose of this scientific statement is to provide guidance on the assessment and management of RHF.

Methods:

The writing group used systematic literature reviews, published translational and clinical studies, clinical practice guidelines, and expert opinion/statements to summarize existing evidence and to identify areas of inadequacy requiring future research. The panel reviewed the most relevant adult medical literature excluding routine laboratory tests using MEDLINE, EMBASE, and Web of Science through September 2017. The document is organized and classified according to the American Heart Association to provide specific suggestions, considerations, or reference to contemporary clinical practice recommendations.

Results:

Chronic RHF is associated with decreased exercise tolerance, poor functional capacity, decreased cardiac output and progressive end-organ damage (caused by a combination of end-organ venous congestion and underperfusion), and cachexia resulting from poor absorption of nutrients, as well as a systemic proinflammatory state. It is the principal cause of death in patients with pulmonary arterial hypertension. Similarly, acute RHF is associated with hemodynamic instability and is the primary cause of death in patients presenting with massive pulmonary embolism, RV myocardial infarction, and postcardiotomy shock associated with cardiac surgery. Functional assessment of the right side of the heart can be hindered by its complex geometry. Multiple hemodynamic and biochemical markers are associated with worsening RHF and can serve to guide clinical assessment and therapeutic decision making. Pharmacological and mechanical interventions targeting isolated acute and chronic RHF have not been well investigated. Specific therapies promoting stabilization and recovery of RV function are lacking.

Conclusions:

RHF is a complex syndrome including diverse causes, pathways, and pathological processes. In this scientific statement, we review the causes and epidemiology of RV dysfunction and the pathophysiology of acute and chronic RHF and provide guidance for the management of the associated conditions leading to and caused by RHF.

Early Clinical Outcomes of Tricuspid Valve Repair with a Tri-Ad Annuloplasty Ring in Comparison with the Outcomes Using an MC3 Ring

Background

We evaluated the early clinical outcomes of tricuspid valve annuloplasty (TAP) with the Tri-Ad annuloplasty ring for functional tricuspid regurgitation (TR).

Methods

From January 2015 to March 2017, 36 patients underwent TAP with a Tri-Ad ring for functional TR. To evaluate the early clinical outcomes of TAP with the Tri-Ad ring, we conducted a propensity score-matched analysis comparing the Tri-Ad and MC³ tricuspid annuloplasty rings (n=34 in each group). The follow-up duration was 11.0±7.07 months.

Results

There was 1 case of operative mortality (2.8%) and no cases of late mortality. Postoperative complications occurred in 15 patients (41%), including acute kidney injury in 6 patients (16%), bleeding requiring reoperation in 4 patients (11%), and low cardiac output syndrome in 4 patients (11%). There were no ring-related complications, such as atrioventricular block or ring dehiscence. The TR grade decreased significantly (from 2.03±1.06 to 1.18±0.92, p<0.01), as did the systolic pulmonary artery pressure (from 43.53±13.84 to 38.00±9.72 mm Hg, p=0.03). There were no cases of severe residual TR, but moderate TR was observed in 3 patients, all of whom had severe TR preoperatively. Severe preoperative TR was also associated with moderate in the univariate analysis (p<0.01). In the propensity score-matched analysis comparing the Tri-Ad and MC³ rings, there was no significant difference in early clinical outcomes.

Conclusion

TAP with the Tri-Ad ring corrected functional TR effectively and provided good early clinical and echocardiographic results without ring-related complications. However, severe preoperative TR was associated with moderate or severe residual TR in the immediate postoperative period. A follow-up study is necessary to confirm the stability of this procedure.

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

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

Flexible band versus rigid ring annuloplasty for functional tricuspid regurgitation: two different patterns of right heart reverse remodelling

OBJECTIVES

Annuloplasty bands and rings are widely used to treat functional tricuspid regurgitation (TR). However, the question as to which is the ideal annuloplasty device remains open. Early and late outcomes of tricuspid valve annuloplasty with flexible band (B-TVA) or rigid ring (R-TVA) are compared in the present study.

METHODS

Between 1999 and 2014, 462 consecutive patients (mean age, 69.2 ± 9.5 years) with grade ≥1+ functional TR (graded from 0 to 3+) underwent either B-TVA (n = 345; mean EuroSCORE II 9.2 ± 10.8%) or R-TVA (n = 117; mean EuroSCORE II 12 ± 13.4%) in addition to other cardiac procedures at the authors' institution.

RESULTS

One-to-one propensity score-matched analysis resulted in 98 pairs with similar baseline characteristics and operative risk. Hospital mortality was 7.5% after B-TVA and 12% after R-TVA (P = 0.14). R-TVA was associated with higher rates of low cardiac output (10.1 vs 17.9%, P = 0.025) and transient complete atrioventricular block (10.3 vs 17.2%, P = 0.046). Among the matched pairs, there were no significant differences in hospital mortality (5.1 vs 9.2%, P = 0.27) and perioperative complications. Both in overall series and matched pairs, between B-TVA and R-TVA patients, there were no significant differences in freedom from all-cause death (P = 0.29 and 0.91), cardiac and cerebrovascular deaths (P = 0.63 and 0.87) and grade ≥2+ TR (P = 0.68 and 0.77). Right atrial and tricuspid valve reverse remodelling combined with right ventricular reverse remodelling occurred after R-TVA but not after B-TVA.

CONCLUSIONS

B-TVA and R-TVA are equally effective in the treatment of functional TR. However, R-TVA causes over time a more complete right heart reverse remodelling.

Long-term echocardiographic follow-up of untreated 2+ functional tricuspid regurgitation in patients undergoing mitral valve surgery

OBJECTIVES

Concomitant tricuspid valve surgery with mitral valve surgery is recommended for patients with severe functional tricuspid regurgitation (TR). However, the treatment for 2+ TR (mild TR) remains controversial. Here, we evaluated the long-term results of untreated 2+ TR in patients undergoing mitral valve surgery.

METHODS

We retrospectively reviewed the records of 96 patients with untreated 2+ TR among 885 patients who underwent mitral valve surgery from 2003 to 2010. Exclusion criteria were tricuspid valve surgery (TVS), emergency surgery, primary TR and pacemaker lead through the tricuspid valve. We assessed survival and freedom from heart failure. The freedom from 3+ (moderate) or 4+ (severe) TR was investigated by echocardiographic data at pre- and postoperative week 1, then at 1, 3, 5, 7 and 10 postoperative years, which were compared with those in patients who had 2+ TR preoperatively and underwent concomitant TVS in the same period (n = 47).

RESULTS

The mean follow-up was 7.1 ± 2.7 years. There was no 30-day mortality. The survival rate was 97.5% at 5 years and 87.5% at 10 years. The independent risk factors for mortality were age (OR 1.2, P = 0.03) and left ventricular ejection fraction (OR 0.9, P = 0.03). Untreated 2+ TR improved transiently within the first postoperative year (P < 0.001), but progressed again in the mid- to long term. Freedom from ≥3+ TR was 64.2% at 5 years and 46.7% at 10 years, which was significantly lower than that from ≥3+ TR in patients who underwent concomitant TVS (P = 0.006). The independent risk factors for TR progression (≥3 + TR) were age (OR 1.1, P = 0.005), atrial fibrillation (OR 2.2, P = 0.04) and tricuspid annular diameter (TAD) index (mm/m(2); OR 1.1, P = 0.02). Receiver operating characteristic curves showed that the optimal TAD index cut-off value was 21.0 for long-term survival [area under the curve (AUC) = 0.72] and 21.2 for TR progression (AUC = 0.64).

CONCLUSIONS

Although untreated, 2+ TR significantly improved after mitral valve surgery, it then progressed again in the mid- to long term. Therefore, concomitant TVS should be considered in patients with 2+ TR who have dilated tricuspid annulus or atrial fibrillation, if feasible.

Reoperations after tricuspid valve repair: re-repair versus replacement

BACKGROUND

Data demonstrating results of reoperation after initial tricuspid valve repair are scarce. We evaluated outcomes of tricuspid reoperations after tricuspid valve repair and compared the results of tricuspid re-repair with those of tricuspid valve replacement (TVR).

METHODS

From 1994 to 2012, 53 patients (56±15 years, male:female =14:39) underwent tricuspid reoperations due to recurrent tricuspid regurgitation (TR) after initial repair. Twenty-two patients underwent tricuspid re-repair (TAP group) and 31 patients underwent TVR (TVR group).

RESULTS

Early mortality occurred in 6 patients (11%). Early mortality and incidence of postoperative complications were similar between the 2 groups. There were 14 cases of late mortality including 9 cardiac deaths. Five- and 10-year free from cardiac death rates were 82% and 67%, respectively, without any intergroup difference. Recurrent TR (> moderate) developed in 6 TAP group patients and structural valve deterioration occurred in 1 TVR group patient (P=0.002). Isolated tricuspid valve surgery (P=0.044) and presence of atrial fibrillation during the follow-up (P=0.051) were associated with recurrent TR after re-repair. However, the overall tricuspid valve-related event rates were similar between the 2 groups with 5- and 10-year rates of 61% and 41%, respectively.

CONCLUSIONS

Tricuspid valve reoperation after initial repair resulted in high rates of operative mortality and complications. Long-term event-free rate was similar regardless of the type of surgery. However, great care might be needed when performing re-repair in patients with atrial fibrillation and those who had isolated tricuspid valve disease due to high recurrence of TR after re-repair.

Functional and Biomechanical Performance of Stentless Extracellular Matrix Tricuspid Tube Graft: An Acute Experimental Porcine Evaluation

BACKGROUND

Stentless porcine extracellular matrix tricuspid tubular valves have been developed for tricuspid valve reconstruction. The purpose of this study was to compare biomechanical and functional performance of native and tube graft valves in an acute porcine model.

METHODS

Twenty-two 65-kg pigs were randomized to tube graft or control with native valve preservation. Anterior papillary muscle force was measured with a dedicated force transducer. Microtip pressure catheters were placed in the right atrium and ventricle. Leaflet motion and three-dimensional valve geometry were evaluated using 13 sonomicrometry crystals: six in the tricuspid annulus, one on each leaflet free edge, one on each papillary muscle tip, and one in the right ventricular apex.

RESULTS

No regurgitation and no significant differences in intracavitary pressures, annular motion, or leaflet excursion angles were observed after tube graft implantation (p > 0.05). Compared with the native valve, the tricuspid annulus, leaflet orifice area, annular diameters, and the septal segment of the annulus were significantly smaller in the tube graft group (p < 0.05). Maximum anterior papillary muscle force was significantly lower in the tube graft group (p < 0.005). The implantation technique led to an annular circumferential downsizing of 20% ± 17%.

CONCLUSIONS

An extracellular matrix tube graft implanted in the tricuspid position produces a competent valve with physiologic performance that, despite downsizing, makes the tube graft an attractive alternative to valve replacement. The downsizing of the implantation should be considered when planning tube graft size and may be potentially beneficial by relieving tension on the repaired tissue, thereby increasing durability.