Tricuspid Valve Geometrical Changes in Patients with Functional Tricuspid Regurgitation: Insights from a CT Scan Analysis Focusing on Commissures

BACKGROUND

Cardiac computed tomography (CT) provides important insights into the geometrical configuration of the tricuspid valve (TV). The purpose of the present study was to assess the geometrical changes of TV in patients with functional tricuspid regurgitation (TR) using novel CT scan parameters and to correlate these findings with echocardiography.

METHODS

This single-center study enrolled 86 patients undergoing cardiac CT and divided them into two groups according to the presence or not of severe TR (43 patients with TR ≥ 3+ and 43 controls). The measurements collected were as follows: TV annulus area and perimeter, septal-lateral and antero-posterior annulus diameters, eccentricity, distance between commissures, segment between the geometrical centroid and commissures, and the angles of commissures.

RESULTS

We found a significant correlation between all annulus measurements and the grade of TR, except in regard to angles. TR ≥ 3+ patients had significantly larger TV annulus area and perimeter, larger septal-lateral, and antero-posterior annulus dimensions, as well as larger commissural distance and centroid-commissural distance. In patients with TR ≥ 3+ and controls, the eccentricity index predicted a circular shape and an oval shape of the annulus, respectively.

CONCLUSIONS

These novel CT variables focusing on commissures increase the anatomical understanding of the TV apparatus and the TV geometrical changes in patients with severe functional TR.

604 PERCUTANEOUS TRANSCATHETER CLOSURE OF SYMPTOMATIC PATENT FORAMEN OVALE IN PATIENT WITH INFERIOR VENA CAVA INTERRUPTION

Percutaneous closure of a patent forame ovale (PFO) is indicated in selected patients with a confirmed cryptogenic stroke, transient ischemic attack (TIA), or systemic embolism and an estimated high probability of a casual role of the PFO as assessed by clinical, anatomical and imaging features. This procedure is usually undertaken from the femoral vein. In this case, the patient was affected by vena cava agenesis with a compensatory enlargement of azygos vein.

We performed the percutaneous closure of the PFO using a 9F jugular vein access. We advanced a straight guide trough the foramen with a Multipurpose 6F catheter supported by a Destino Oscor 8F. Then we changed the straight guide with an Amplatz Super-Stiff 0.035" guide in the left ventricle, on which a Mullins 9F trans-septal catheter was advanced. Finally we delivered an Amplatzer Multifenestrated Septal Occluder "Cribriform" 25/25 mm.

In our case, it was impossible to perform the PFO closure procedure using the classic femoral vein access due to the inferior vena cava agenesis. Performing PFO closure using the right internal jugular venous approach was technically challenging but safe and it is possible using standard equipment normally present in the Catheterization Laboratory.

In rare cases of an indication for PFO closure and lack of access through the femoral veins, alternative techniques using on the shelf materials help in overcoming the challenging anatomies. The use of steerable catheter is critical for engaging the foramen ovale with unfavourable angulation. The procedure with nitinol double disk devices is safe and effective.

683 TWO IS BETTER THAN ONE!

Patients suffering from atrial fibrillation (AF) and severe aortic stenosis thus undergoing transcatheter aortic valve implantation (TAVI) have a worse prognosis than those in sinus rhythm. One of the reasons of this is related to the augmented bleeding risk associated with oral anticoagulation (OAC). Left atrial appendage occlusion (LAAO) represents a therapeutic choice to avoid this drug intake and to reduce this kind of adverse outcome. So, a combined procedure of TAVI and LAAO could be an option for TAVI candidates with AF to omit the need for OAC.

The clinical case concerns an 85-year-old man with hypertension and dyslipidemia with a history of recent syncope and permanent atrial fibrillation in therapy with antithrombotic drug. Brain MRI performed during hospitalization showed numerous hemosiderin deposits with microhemorrhagic foci thus contraindicating oral anticoagulation. Severe aortic stenosis has also been found to the transthoracic echocardiogram with a mean gradient of 35 mmHg and confirmed by transesophageal echocardiogram with a planimetric area of 0.8 sq.cm.

Furthermore, given the finding of significative left circumflex artery disease, after Heart Team discussion and the execution of CT scan that demonstrated the feasibility of transcatheter approach, it was decided to perform in a single session percutaneous coronary intervention (PCI) plus TAVI plus left atrial appendage closure (LAAO).

This kind of approach allowed a quick recovery to the patient after a short period of hospitalization. After six months from interventional procedure his NYHA (New York Heart Association Functional Classification) status improved abutting on I/II class.

As described above, it can be deduced that combined approach (TAVI+LAAO) is feasible for certain kind of patients thus avoiding surgical approach and long hospitalization. Furthermore, multimodality imaging is of critical importance to plan a complex procedure and an accurate step-by-step pre-procedural strategical planning is the key for procedural success.

526 ALAGILLE SYNDROME, A CASE REPORT

Alagille syndrome (AGS) is a dominantly inherited multisystem disorder caused by heterozygous mutations of genes that are components of the Notch signaling pathway. The main clinical manifestations of AGS are intrahepatic bile duct paucity, congenital heart defects involving primarily the pulmonary arteries, butterfly vertebrae, anterior chamber defects of the eye and facial dysmorphism.

A male patient of 39 years old came to our observation due to the worsening of dyspnea, cyanosis, dizziness, heartbeat and asthenia for about two years. His cardiological history includes percutaneous pulmonary artery angioplasty in both left and right main pulmonary artery in 1994. In 2012, finding of pulmonary hypertension and diagnosis of Alagille syndrome confirmed by genetic analysis (JAG1 gene), and vasoreactivity testing of the pulmonary circulation was positive. Intrastent restenosis of the right lobar pulmonary artery treated with POBA in 2016. Patient therapy includes, diltiazem 60 mg OD, macitentan 10 mg OD, sildenafil 40 mg TID. Echocardiogram showed: preserved global and segmental systolic function. Minimal mitral valve insufficiency. Dilated right ventricle (RV / LV> 1), ipokinetic. Right atrium of increased size. Mild tricuspid valve insufficiency (VD-AD 20 mmHg). reduced systolic flow acceleration time (80 msec). Inferior vena cava of normal caliber with preserved inspiratory collapse. Indirect signs of pulmonary hypertension. The six minutes walking test showed severe desaturation after only one hundred meters.

Right catheterization showed severe pulmonary hypertension (PAPm 63 mmHg). blood gas analysis showed oxygen saturation of 83% in the pulmonary artery. Angiography of the pulmonary arteries showed intrastent restenosis on the left pulmonary artery and fracture of the stent on the right pulmonary artery. For which was performed angioplasty with stent intrastent implantation in the right pulmonary artery.

After the procedure there was immediate reduction in pulmonary mean arterial pressure (53 mmHg), a progressive improvement in 02 saturation (88% at discharge) while the echocardiogram after the procedure results unchanged except for the increasing of the systolic flow acceleration time (100 msec).

Right catheterization showed a gradient trans-stenosis of 96 mmHg. We performed angioplasty with stent intrastent implantation in the right pulmonary artery.

After that we saw a drop in the gradient trans-stenosis (63 mmHg) and a raise in the systolic pressure of the left pulmonary artery.

In Conclusion, in this particular population of patients with pulmonary hypertension even if on maximal therapy, the worsening of symptoms should in our opinion be an indication for right cardiac catheterization and angiography of the pulmonary arteries.

Edge-to-Edge Repair for Tricuspid Valve Regurgitation. Preliminary Echo-Data and Clinical Implications from the Tricuspid Regurgitation IMAging (TRIMA) Study

Background: The natural history of tricuspid valve regurgitation (TR) is characterized by poor prognosis and high in-hospital mortality when treated with isolated surgery. We report the preliminary echocardiographic and procedural results of a prospective cohort of symptomatic patients with high to prohibitive surgical risk and at least severe TR who underwent transcatheter edge-to-edge repair through the TriClipTM system. Methods: From June 2020 to March 2022, 27 consecutive patients were screened, and 13 underwent transcatheter TriClipTM repair. In-hospital, 30-day and six-month clinical and echocardiographic outcomes were collected. Results: Nine patients had severe, three massive and one baseline torrential TR. Sustained TR reduction of ≥1 grade was achieved in all patients, of which 90% reached a moderate TR or less. On transthoracic echocardiographic examination, there were significant reductions in vena contracta width (p < 0.001), effective regurgitant orifice area (p < 0.001) and regurgitant volume (p < 0.001) between baseline and hospital discharge. We also observed a significant reduction in tricuspid annulus diameter (p < 0.001), right ventricular basal diameter (p = 0.001) and right atrial area (p = 0.026). Conclusion: Treatment with the edge-to-edge TriClip device is safe and effective. The resulting echocardiographic improvements indicate tricuspid valve leaflet approximation does not just significantly reduce the grade of TR but also affects adjacent structures and improves right ventricular afterload adaptation.

Questions and answers on the use of aspirin for primary prevention of cardiovascular disease in diabetes

Patients with diabetes have a prothrombotic state and a 2 to 4 times higher risk of cardiovascular events than those without diabetes. Aspirin is the cornerstone of treatment in patients withcardiovascular disease, irrespective of diabetes status, being able to confer a 19% relative risk reduction per year in serious vascular events compared with placebo at long-term follow-up (6.7% vs 8.2% per year, p < 0.0001). Data regarding the benefit-risk ratio of aspirin prescribed to patients with diabetes without established cardiovascular disease are less convincing, especially when compared to other preventive strategies. Of note, in primary prevention trials, aspirin allocation yielded a significant 12% proportional reduction in serious vascular events, irrespective of diabetes status, corresponding to a small annual absolute risk reduction (0.06% per year). However, in everyday clinical practice aspirin is still largely prescribed by both diabetologists and cardiologists. In this article, we provide eight questions and answers corroborated by available evidence on the use of aspirin for primary prevention of cardiovascular disease in diabetes.

Novel Computed Tomography Variables for Assessing Tricuspid Valve Morphology: Results from the TRIMA (Tricuspid Regurgitation IMAging) Study

BACKGROUND

Computed tomography (CT) is the recommended imaging technique for defining the anatomical suitability for current transcatheter technologies and planning tricuspid valve (TV) intervention. The aim of the Tricuspid Regurgitation IMAging (TRIMA) study was to assess the geometrical characteristics of the TV complex using novel CT parameters.

METHODS

This prospective, single-center study enrolled 22 consecutive patients with severe tricuspid regurgitation, who underwent a cardiac CT study dedicated to the right chambers. The following variables were obtained: annulus area and perimeter, septal-lateral and antero-posterior diameters, tenting height, and anatomical regurgitant orifice area. Moreover, the following novel annular parameters were assessed: distance between commissures, distance between TV centroid and commissures, and angles between centroid and commissures.

RESULTS

A significant phasic variability during the cardiac cycle existed for all variables except for eccentricity, angles, and distance between the postero-septal and antero-posterior commissure and distance between the centroid and antero-posterior commissure. There was a significant relationship between the TV annulus area and novel annular parameters, except for annular angles. Additionally, novel annular variables were found to predict the annulus area.

CONCLUSIONS

These novel additional variables may provide an initial platform from which the complexity of the TV annular morphology can continue to be better understood for further improving transcatheter therapies.

In Stent Neo-Atherosclerosis: Pathophysiology, Clinical Implications, Prevention, and Therapeutic Approaches

Despite the dramatic improvements of revascularization therapies occurring in the past decades, a relevant percentage of patients treated with percutaneous coronary intervention (PCI) still develops stent failure due to neo-atherosclerosis (NA). This histopathological phenomenon following stent implantation represents the substrate for late in-stent restenosis (ISR) and late stent thrombosis (ST), with a significant impact on patient’s long-term clinical outcomes. This appears even more remarkable in the setting of drug-eluting stent implantation, where the substantial delay in vascular healing because of the released anti-proliferative agents might increase the occurrence of this complication. Since the underlying pathophysiological mechanisms of NA diverge from native atherosclerosis and early ISR, intra-coronary imaging techniques are crucial for its early detection, providing a proper in vivo assessment of both neo-intimal plaque composition and peri-strut structures. Furthermore, different strategies for NA prevention and treatment have been proposed, including tailored pharmacological therapies as well as specific invasive tools. Considering the increasing population undergoing PCI with drug-eluting stents (DES), this review aims to provide an updated overview of the most recent evidence regarding NA, discussing pathophysiology, contemporary intravascular imaging techniques, and well-established and experimental invasive and pharmacological treatment strategies.

732 TEE role in patients selection for transcatheter edge to edge tricuspid repair

Aims

The natural history of tricuspid valve (TV) regurgitation is characterized by dismal prognosis and high in-hospital mortality when treated with isolated TV surgery. Although the anatomy and the imaging of the TV are very challenging, the edge-to-edge repair with the TriClip (Abbott Vascular, Santa Clara, CA) showed promising results. We report preliminary results of our experience with the TriClip System in a cohort of ‘real life’ patients with functional tricuspid regurgitation (TR).

Methods and results

From January to September 2021, 30 consecutive patients with severe TR has been screened, 8 underwent transcatheter TriClip repair. The anatomical feasibility was established according to a complete transesophageal echocardiogram (TEE) and a dedicated CT scan for the right cardiac chambers. All the echocardiographic projections focused on right ventricle were used during the procedure, with the aim of optimizing the visualization of the catheters and device with respect to the anatomical structures of the tricuspid valve complex. The procedure was conducted under general anesthesia, guided by TEE and fluoroscopy. In-hospital and 30-day clinical and echocardiographic outcomes were recorded. The annulus septo-lateral diameter was enlarged in all cases, and functional TR was present in all patients. In two patients, the pacemaker lead interfered with leaflets coaptation. TR jet was predominantly central. The implant and procedural success were achieved in all cases, implanting one device in five patients and two in three patients. The final TR grade was 2+ in four patients and and 1+ in the others. All patients were extubated in the catheterization laboratory. There were no procedural or in-hospital adverse events. At 30-day follow-up, we observed significant improvement in clinical and echocardiographic outcomes.

Conclusions

In our experience, 26% of screened patients were selected for the procedure. Favourable anatomical findings for the TV edge-to-edge repair were the following: moderate leaflet tethering (coaptation depth &lt;10 mm); large annulus but with small coaptation gap (&lt;7 mm); antero-septal or postero-septal jet location; commissural jet; small right ventricular dimensions; pacemaker lead with no leaflet tethering. The best transcatheter approach consists of obliterating the antero-septal coaptation rim for a more favourable angle between the inferior vena cava and valvular plane. High-quality TEE imaging during the procedure is required for obtaining procedural success. Patient selection and tricuspid valve anatomy characterization with TEE and cardiac CT scan is critical for procedural success and clinical improvements.

731 Single centre experience tricuspid valve transcatheter edge to edge repair

Aims

Severe tricuspid valve regurgitation (TVR) is critically associated with an increased risk of morbidity and mortality, surgical treatment is limited by high perioperative risk. In these patients, transcatheter edge to edge valve repair (TEER) is progressively recognized as an effective treatment strategy. The aim of this work is to report the single centre experience procedural results and clinical outcomes in ‘real-world’ patients suffering TVR treated with the TriClip™ device (Abbott Vascular, Santa Clara, California).

Methods

From January up to July 2021, we screened 30 patients with severe TR, among which 8 were treated with TEER. All patients underwent cardiac computerized tomography and both transesophageal and transthoracic echocardiography, with the purpose to identify a dedicated grasping strategy. TEER was performed through right common femoral vein access, advancing a 24 F steerable guiding catheter (SGC) in the right atrium. Following, the TriClip delivery system was advanced and positioned over the valve centroid and, once oriented, the clip was opened. Under fluoroscopic and transesophageal monitoring, the clip was advanced in the right ventricle and pulled back to grasp the target leaflets. Following echocardiographic control, the clip was released.

Results

Procedural success, defined as a significative reduction of the regurgitation’s severity, was achieved in all patients. No procedural or in-hospital adverse events were reported. At 30 days follow-up, all patients were alive and no further hospitalizations occurred.

Conclusions

In our single centre experience, TEER appeared to be a valid and feasible therapeutic option in patients with severe TVR. Multicentre prospective studies are mostly needed to assess the long terms outcomes of TEER in these patients, with the purpose to introduce in the clinical practice a valid alternative to the highly risk surgical option.

757 Cardio-TC role in patients selection for transcatheter edge to edge tricuspid repair

Aims

Anatomic knowledge of the tricuspid valve (TV) is the first step in the management of patients with tricuspid regurgitation (TR) who are candidates for transcatheter tricuspid valve intervention (TTVI). Echocardiography is undoubtedly the first approach in assessing the aetiology and severity of TR and the size and function of the right chambers. Computed tomography (CT) provides a detailed morphological visualization of the cardiac structures owing to acquisition of 3D data with high spatial resolution. These findings may undoubtedly help in decision-making progress for novel transcatheter therapies. The purpose of the present study was to assess the geometrical changes of the TV complex using CT images, in patients suffering from functional TR and lead-induced TR.

Methods

The study population consisted of 21 consecutive patients with symptomatic severe TR referred to Policlinico Universitario Campus Biomedico between November 2020 and October 2021. Patients were prospectively included in the study only if they presented severe TR, diagnosed by echocardiography and underwent cardiac CT study dedicated to the right-chambers. The reconstructions were transferred to an external workstation for off-line image analysis. The following measurements were reported: tricuspid annulus area, perimeter, septal–lateral and antero-posterior diameters. Commissures were identified as antero-septal (AS), postero-septal (PS) and anteroposterior (AP). Were measured the inferior vena cava ostium to tricuspid valve centroid distance, anatomic regurgitant orifice area (AROA) and its position respect to the centroid, and the right chambers.

Results

All 21 patients underwent CT scan using Siemens SOMATOM Definition AS 128 Slice CT Machine. The measurements were calculated off-line using the 3mensio workstation. In our study population, the annulus resulted enlarged in the annulus area, perimeter, septal-lateral and anterior-posterior dimensions. Measurements did not differ significantly, except for the septal-lateral diameter that was smaller in systole (52.80 ± 7.28 mm vs. 47.83 ± 6.83 mm (P=0.027). Also, distances between the commissures were similar except for the AP-AS distance that was shorter in systole (45.26 ± 3.48 mm vs. 42.13 ± 3.73, P=0.007). The AROA resulted to be central in 7 patients, the IVC ostium to TV centroid distance was 23±3 mm. Right chambers and IVC resulted very enlarged in all patients.

Conclusions

CT provides a complete morphologic imaging of the heart structures, thanks to a high spatial resolution with excellent capacity to define the endocardial border and allows acquisition of three-dimensional data with high spatial resolution of the TV and provides valuable information about the geometric variations of the tricuspid complex in patients with TR. Image quality for analysis should be optimized with specific CT acquisition protocols that focus on the right ventricles.