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Galloo X, Meucci MC, Stassen J, Dietz MF, Prihadi EA, Van Der Bijl P, Ajmone Marsan N, Braun J, Bax JJ, Delgado V. Right ventricular remodelling in patients with significant tricuspid regurgitation undergoing tricuspid valve surgery. Eur Heart J Cardiovasc Imaging 2022. [DOI: 10.1093/ehjci/jeab289.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Inconsistent changes in right ventricular (RV) dimensions and function have been observed after tricuspid valve (TV) surgery and their associations with long-term outcomes have not been explored.
Purpose
To evaluate RV remodelling and RV function in patients with significant (moderate or severe) tricuspid regurgitation (TR) undergoing TV surgery and their association with outcome.
Methods
A total of 121 patients (mean age 63 ± 12 years, 47% male) with significant TR treated with TV surgery and who had an echocardiogram between 3 months and 1 year of follow-up, were included for this analysis. Remodelling was assessed by comparing dimensions and function at follow-up to baseline values. The population was stratified by tertiles of percentage reduction of RV end-systolic area (RVESA) and absolute change of RV fractional area change (RVFAC). Five-year mortality rates were compared across the tertiles of RV remodelling and the independent associates of mortality were investigated.
Results
Reduction in RVESA and improvement in RVFAC were significantly associated with better survival after TV surgery, whereas reduction in RV end-diastolic area was not (Figure 1). One third of the patients presented with a reduction in RVESA of at least 17.2% and improvement in RVFAC of at least 2.3%, constituting the third tertiles for comparison. Kaplan-Meier curves for overall survival according to RVESA- and RVFAC-tertiles are shown in Figure 2. Cumulative survival rates were significantly better in patients in the third tertile of RVESA reduction: 49%, 69%, and 90% for tertile 1, tertile 2, and tertile 3, respectively (log-rank chi-square: 12.526; p = 0.002); as well as according to RVFAC improvement: 57%, 65%, and 87% for tertile 1, tertile 2, and tertile 3, respectively (log-rank chi-square: 7.784; p = 0.02). Tertile 3 of RVESA-reduction as well as tertile 3 of RVFAC-change were both independently associated with better survival after TV surgery compared to tertile 1 (hazard ratio: 0.221 [95% CI: 0.074 to 0.658] and 0.327 [95% CI: 0.118 to 0.907], respectively).
Conclusion
The magnitude of RV reverse remodelling (based on reduction in RVESA) and improvement in RVFAC were associated with better survival at 5 years’ follow-up after TV surgery for significant TR. Abstract Figure 1: Spline curves Abstract Figure 2: KM curves for overal survival
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Affiliation(s)
- X Galloo
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - MC Meucci
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - J Stassen
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - MF Dietz
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - EA Prihadi
- ZNA Middelheim Hospital, Cardiology, Antwerp, Belgium
| | - P Van Der Bijl
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - N Ajmone Marsan
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - J Braun
- Leiden University Medical Center, Cardio-Thoracic Surgery, Leiden, Netherlands (The)
| | - JJ Bax
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - V Delgado
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
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Galloo X, Stassen J, Butcher SC, Meucci MC, Dietz MF, Mertens BJA, Prihadi EA, Van Der Bijl P, Ajmone Marsan N, Bax JJ, Delgado V. Prognostic implications of staging right heart failure in patients with significant tricuspid regurgitation undergoing tricuspid valve surgery. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Mortality of tricuspid valve (TV) surgery for severe secondary tricuspid regurgitation (TR) remains relatively high. Current guidelines advise surgery in patients with symptomatic severe TR as a concomitant procedure to left-sided valve surgery. Right ventricular (RV) dysfunction is an important prognostic marker and may appear late in the natural history of TR. How a staging algorithm of right heart failure (RHF) may impact on TV surgery outcomes has not been evaluated.
Purpose
To evaluate the impact of staging RHF on survival of patients with significant TR undergoing TV surgery.
Methods
Patients diagnosed with significant (moderate and severe) TR who subsequently underwent TV surgery, were staged into 4 groups of progressive disease according to the diagnosis of RV dysfunction and the presence of RHF: stage 1, at risk for RHF; stage 2, RV dysfunction without clinical symptoms of RHF; stage 3, RV dysfunction with symptoms of RHF, and stage 4, RV dysfunction with refractory symptoms of RHF (Figure 1). The study endpoint was all-cause mortality.
Results
A total of 279 patients (mean age 64±12 years, 49% male), were included in the analysis, of which 20 patients (7%) were in stage 1, 14 patients (5%) were in stage 2, 141 patients (51%) were in stage 3 and 104 patients (37%) were in stage 4.
The majority of the patients (266 patients, 95%) underwent TV annuloplasty. Most patients had TV surgery concomitant to left-sided valve surgery or coronary artery bypass grafting (254 patients, 91%). In per-group analysis, patients in stage 4 had significantly larger left ventricular (LV) and RV dimensions, lower LV ejection fraction and more severe diastolic dysfunction than patients in other RHF stages.
During a median follow-up of 65 [15 - 106] months after TV surgery, 145 deaths (52%) occurred. The cumulative survival rates were 88%, 77% and 60% at 1 month, 1 year and 5 years, respectively. The Kaplan-Meier curves for overall survival according to RHF stage are shown in Figure 2. Survival rates at 5 years were significantly worse in more advanced stages of RHF: 71% (stage 1 and 2), 66% (stage 3) and 49% (stage 4); log-rank chi-square: 11.302; p=0.004. Right heart failure stage was independently associated with all-cause mortality following adjustment for age, gender, LV ejection fraction, kidney function, TV annulus diameter, concomitant mitral valve surgery and time delay from diagnosis until surgery (p=0.021).
Conclusion
Patients diagnosed with significant TR may benefit from earlier referral for surgical intervention, before presenting with RV dysfunction and before the onset of symptoms of RHF.
Funding Acknowledgement
Type of funding sources: None. Figure 1. Stages of right heart failureFigure 2. Kaplan-Meier curves for overall survival
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Affiliation(s)
- X Galloo
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - J Stassen
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - S C Butcher
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - M C Meucci
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - M F Dietz
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - B J A Mertens
- Leiden University Medical Center, Bioinformatics Center of Expertise, Leiden, Netherlands (The)
| | - E A Prihadi
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - P Van Der Bijl
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - N Ajmone Marsan
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - J J Bax
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - V Delgado
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
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Singh GK, Vollema EM, Prihadi EA, Regeer MV, Ewe SH, Ng ACT, Mertens BJA, De Weger A, Ajmone-Marsan N, Bax JJ, Delgado V. Sex-differences in left ventricular remodeling and mechanics after aortic valve surgery in patients with severe aortic valve disease. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Sex-differences in left ventricular (LV) remodeling in patients with aortic valve disease have been reported. However, sex-differences in LV remodeling and mechanics in response to aortic valve replacement (AVR) remained largely unexplored.
Purpose
The present study aimed to evaluate the sex-differences during the time course of LV remodeling and LV mechanics (by LV global longitudinal strain (GLS)) after aortic valve replacement.
Methods
Patients with severe aortic valve disease (aortic stenosis (AS) or aortic regurgitation (AR)) undergoing AVR with echocardiographic follow-up at 1,2, and/or 5 years were evaluated. LV mass index, LV ejection fraction, LV GLS and stroke volume (SV) were measured. Linear mixed models analyses were used to assess changes in LV mass index, LVEF, LV GLS and SV between time points. The models were corrected for age, LV end-diastolic diameter at baseline and time between echocardiograms.
Results
A total of 211 patients (61±14 years, 61% male) with severe aortic valve disease (AS 63% or AR 39%) were included. Before AVR, men had larger LV mass index and higher SV compared to women. Both men and women had a preserved LV ejection fraction (54±12 and 56±9, P=0.102, respectively), but moderately impaired LV GLS (14.6±4.1 and 16.1±4.1, P=0.009, respectively). After AVR, both groups showed LV mass regression, improvement in LV ejection fraction and LV GLS. LV mass index and SV remained higher in men. During follow-up women showed significantly better LV GLS compared to men (P=0.030, figure 1).
Conclusion
In men and women with severe aortic valve disease undergoing AVR, the time course of changes in LV mass regression, LV ejection fraction, LV GLS and SV are similar. During follow-up LV mass index remained larger in men and women showed significantly better LV GLS.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The department of Cardiology received unrestricted research grants from Abbott Vascular, Bayer, Bioventrix, Biotronik, Boston Scientific, Edwards Lifesciences, GE Healthcare and Medtronic. Victoria Delgado received speaker fees from Abbott Vascular, Edwards Lifesciences, GE Healthcare, MSD and Medtronic. Nina Ajmone Marsan received speakers fees from Abbott Vascular and GE healthcare. Jeroen J Bax received speaker fees from Abbott Vascular. The remaining authors have nothing to disclose.
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Affiliation(s)
- G K Singh
- Leiden University Medical Centre, Leiden, Netherlands (The)
| | - E M Vollema
- Leiden University Medical Centre, Leiden, Netherlands (The)
| | | | - M V Regeer
- Leiden University Medical Centre, Leiden, Netherlands (The)
| | - S H Ewe
- National Heart Centre Singapore, Singapore, Singapore
| | - A C T Ng
- Princess Alexandra Hospital, University of Queensland, Ipswich, Australia
| | - B J A Mertens
- Leiden University Medical Centre, Leiden, Netherlands (The)
| | - A De Weger
- Leiden University Medical Centre, Leiden, Netherlands (The)
| | | | - J J Bax
- Leiden University Medical Centre, Leiden, Netherlands (The)
| | - V Delgado
- Leiden University Medical Centre, Leiden, Netherlands (The)
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Butcher SC, Fortuni F, Dietz MF, Prihadi EA, van der Bijl P, Ajmone Marsan N, Bax JJ, Delgado V. Renal function in patients with significant tricuspid regurgitation: pathophysiological mechanisms and prognostic implications. J Intern Med 2021; 290:715-727. [PMID: 34114700 PMCID: PMC8453518 DOI: 10.1111/joim.13312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/17/2021] [Accepted: 05/05/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The pathophysiological mechanisms linking tricuspid regurgitation (TR) and chronic kidney disease (CKD) remain unknown. This study aimed to determine which pathophysiological mechanisms related to TR are independently associated with renal dysfunction and to evaluate the impact of renal impairment on long-term prognosis in patients with significant (≥ moderate) secondary TR. METHODS A total of 1234 individuals (72 [IQR 63-78] years, 50% male) with significant secondary TR were followed up for the occurrence of all-cause mortality and the presence of significant renal impairment (eGFR of <60 mL min-1 1.73 m-2 ) at the time of baseline echocardiography. RESULTS Multivariable analysis demonstrated that severe right ventricular (RV) dysfunction (TAPSE < 14 mm) was independently associated with the presence of significant renal impairment (OR 1.49, 95% CI 1.11 to 1.99, P = 0.008). Worse renal function was associated with a significant reduction in survival at 1 and 5 years (85% vs. 87% vs. 68% vs. 58% at 1 year, and 72% vs. 64% vs. 39% vs. 19% at 5 years, for stage 1, 2, 3 and 4-5 CKD groups, respectively, P < 0.001). The presence of severe RV dysfunction was associated with reduced overall survival in stage 1-3 CKD groups, but not in stage 4-5 CKD groups. CONCLUSIONS Of the pathophysiological mechanisms identified by echocardiography that are associated with significant secondary TR, only severe RV dysfunction was independently associated with the presence of significant renal impairment. In addition, worse renal function according to CKD group was associated with a significant reduction in survival.
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Affiliation(s)
- S. C. Butcher
- From theDepartment of CardiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of CardiologyRoyal Perth HospitalPerthWAAustralia
| | - F. Fortuni
- From theDepartment of CardiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Molecular MedicineUniversity of PaviaPaviaItaly
| | - M. F. Dietz
- From theDepartment of CardiologyLeiden University Medical CenterLeidenThe Netherlands
| | - E. A. Prihadi
- From theDepartment of CardiologyLeiden University Medical CenterLeidenThe Netherlands
- Antwerp Cardiovascular CenterZNA MiddelheimAntwerpBelgium
| | - P. van der Bijl
- From theDepartment of CardiologyLeiden University Medical CenterLeidenThe Netherlands
| | - N. Ajmone Marsan
- From theDepartment of CardiologyLeiden University Medical CenterLeidenThe Netherlands
| | - J. J. Bax
- From theDepartment of CardiologyLeiden University Medical CenterLeidenThe Netherlands
| | - V. Delgado
- From theDepartment of CardiologyLeiden University Medical CenterLeidenThe Netherlands
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Dietz MF, Prihadi EA, Van Der Bijl P, Ajmone Marsan N, Delgado V, Bax JJ. P1783Prognostic implications of significant tricuspid regurgitation in patients with atrial fibrillation in the absence of left-sided heart disease or pulmonary hypertension. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Tricuspid regurgitation (TR) can be caused by atrial fibrillation (AF) in the absence of left-sided heart disease or pulmonary hypertension. The prognostic impact of AF-TR has not been investigated.
Purpose
The aim of this study was to investigate the prognostic significance of TR in AF patients who do not show left-sided heart disease, pulmonary hypertension or primary structural abnormalities.
Methods
A total of 63 AF patients with moderate and severe TR were identified and matched by age and gender to 116 patients with AF without significant TR, resulting in a total study population of 179 patients (mean age 71±7 years, 59% male). As per design of the study, patients with primary TR, significant (moderate or severe) aortic and/or mitral valve disease, previous valvular surgery, congenital heart disease, left ventricular ejection fraction <50%, systolic pulmonary artery pressure >40mmHg, pacemaker or implantable cardioverter defibrillator leads in situ were excluded as well as patients with AF de novo. Patients were followed for the combined endpoint of all-cause mortality, hospitalization for heart failure and stroke.
Results
Patients with AF-TR had more often paroxysmal AF as compared to patients without TR (60% vs. 43%, p=0.028). In addition, right atrial volumes and the tricuspid annulus diameter (TAD) were significantly larger in patients with AF-TR compared to their counterparts (p<0.001 for all). Furthermore, tricuspid annular plane systolic excursion was significantly lower in patients with AF-TR (17±5 mm vs. 21±6 mm, p<0.001). During follow-up (median 62 [32–95] months) 55 events for the combined endpoint occurred. One- and 5-year event-free survival rates for patients with TR were 71% and 53%, compared to 92% and 85% for patients without TR, respectively (Log rank Chi-Square p<0.001; Figure). In the multivariable Cox proportional hazard model adjusted for age, gender, NYHA functional class >2, renal function, right ventricular (RV) function and TAD, the presence of significant TR was independently associated with the combined endpoint (HR, 2.495; 95% CI, 1.167–5.335; p=0.018), while RV function was not (HR, 1.026; 95% CI, 0.971–1.085; p=0.364).
Figure 1. Kaplan-Meier curves
Conclusion
In the absence of left-sided heart disease and pulmonary hypertension, significant TR is independently associated with worse event-free survival in patients with AF.
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Affiliation(s)
- M F Dietz
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - E A Prihadi
- ZNA Middelheim Hospital, Cardiology, Antwerp, Belgium
| | - P Van Der Bijl
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - N Ajmone Marsan
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - V Delgado
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
| | - J J Bax
- Leiden University Medical Center, Cardiology, Leiden, Netherlands (The)
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Dietz MF, Prihadi EA, Van Der Bijl P, Goedemans L, Gursoy E, Van Genderen OS, Ajmone Marsan N, Delgado V, Bax JJ. 5320Prognostic implications of staging significant tricuspid regurgitation: new paradigm for risk stratification. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.5320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M F Dietz
- Leiden University Medical Center, Cardiology, Leiden, Netherlands
| | - E A Prihadi
- Leiden University Medical Center, Cardiology, Leiden, Netherlands
| | - P Van Der Bijl
- Leiden University Medical Center, Cardiology, Leiden, Netherlands
| | - L Goedemans
- Leiden University Medical Center, Cardiology, Leiden, Netherlands
| | - E Gursoy
- Leiden University Medical Center, Cardiology, Leiden, Netherlands
| | - O S Van Genderen
- Leiden University Medical Center, Cardiology, Leiden, Netherlands
| | - N Ajmone Marsan
- Leiden University Medical Center, Cardiology, Leiden, Netherlands
| | - V Delgado
- Leiden University Medical Center, Cardiology, Leiden, Netherlands
| | - J J Bax
- Leiden University Medical Center, Cardiology, Leiden, Netherlands
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Prihadi EA, Van Der Bijl P, Dietz M, Abou R, Vollema EM, Marsan NA, Delgado V, Bax JJ. 5322Prognostic value of right ventricular systolic dysfunction by speckle tracking echocardiography beyond conventional echocardiography in significant functional tricuspid regurgitation. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.5322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- E A Prihadi
- Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands
| | - P Van Der Bijl
- Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands
| | - M Dietz
- Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands
| | - R Abou
- Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands
| | - E M Vollema
- Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands
| | - N A Marsan
- Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands
| | - V Delgado
- Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands
| | - J J Bax
- Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands
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