Impact of changes in tricuspid regurgitation on clinical outcomes following mitral valve teer compared to guideline-directed medical therapy: a sub-analysis of the COAPT trial

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT)

Background

Prior studies suggest tricuspid regurgitation (TR) diminishes/resolves following mitral valve surgery and thus do not require treatment and may not influence outcomes.

Purpose

  We sought to evaluate the change in TR (ΔTR) and its association with outcomes after transcatheter edge-to-edge repair (TEER) compared with guideline-directed medical therapy (GDMT) in the COAPT trial.

Methods

Patients from the COAPT trial with echo core lab TR assessment at baseline and 30-day follow-up (n = 504) were included and divided into 2 groups: those whose TR worsened (ΔTR-INC) and those with no change or improvement in TR (ΔTR-SAME/DEC).  Two-year composite endpoints of death or heart failure hospitalization (HFH) and the individual components were analyzed, after excluding events occurring within the first 30 days.

Results

ΔTR-SAME/DEC occurred in 430 pts (228 TEER, 202 GDMT) while ΔTR-INC was noted in 74 pts (38 TEER, 36 GDMT) (Figure 1A). From 30 days to 2 years, ΔTR-INC pts had a higher rate of the composite outcome of death or HFH compared with ΔTR-SAME/DEC (p = 0.006, Figure 1B). Both 2-year death (HR 1.52, 95% CI 1.01-2.27; p = 0.04) and HFH (HR 1.52, 95% CI 1.04-2.22; p = 0.03) were associated with ΔTR-INC. Assessed by treatment group (Figure 1C and 1D), the relationship between ΔTR-INC and composite death or HFH was significant in GDMT alone pts (HR 1.86, 95% CI 1.21-2.86) but not in TEER pts (HR 1.33, 95% CI 0.79-2.23), although interaction testing demonstrated consistency between the two treatments  (Pint = 0.31). 

Conclusions

Worsening TR at 30 days occurred in ∼15% of pts in the COAPT trial whether they were treated with TEER or GDMT alone. DTRINC was associated with increased death and HFH during 2-year follow-up. Abstract Figure 1

P1766 Comparison of left ventricular stroke volume in healthy adults among regions around the world: results from the World Alliance of Societies of Echocardiography (WASE) Normal Values Study

Funding Acknowledgements

WASE Normal Values Study is sponsored by American Society Echocardiography Foundation.

OnBehalf

the WASE Investigators

Background

The American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI) chamber quantification guidelines provide normal reference values for a variety of size and function parameters. While used worldwide, these were predominantly obtained from American and European Caucasian populations and may not represent individuals from other regions around the world. Accordingly, ASE in collaboration with its International Alliance Partners conducted the World Alliance of Societies of Echocardiography (WASE) Normal Values Study to establish and compare normal echocardiographic values across races, ethnicities and countries worldwide. While most previous studies focused on left ventricular (LV) size and ejection fraction, LV stroke volume (SV) in healthy normal subjects has not been well defined. In this report, we aim to examine similarities and differences in normal LV SV indexed by body surface area (SVI) among regions around the world.

Methods

WASE Normal Values Study is a multinational, observational, cross-sectional study. Individuals free from known cardiac, lung and renal disease were prospectively enrolled with even distribution among age groups and gender. Echocardiographic images were acquired following a standardized protocol. LV SV was assessed by Doppler-derived (LVOT diameter and VTI) and two-dimensional (2D) biplane Simpson’s methods. LV SVI was calculated to account for differences in body size. These measurements were analyzed (TOMTEC) in a single core laboratory following ASE/EACVI Guidelines.

Results

As of May 2019, LV SV has been analyzed in 1164 cases from 13 countries, representing 8 distinct regions worldwide. In this population, age, body surface area and 2D LV ejection fraction were 47 ± 17 years old (range 18-87 years old), 1.76 ± 0.22 m² (range 0.95-2.44 m²) and 63.2 ± 2.9 % (range 52.7-73.7 %), respectively. LV SV and SVI by Doppler were larger than those obtained by 2D method in all regions. LV SV and SVI in both methods had significant differences among regions (p< 0.0001, Kruskal-Wallis test). LV SV and SVI in South Asia (India) were smallest in both methods and were also significantly smaller than other Asian regions (Figure). North America and Europe had largest LV SV and SVI by Doppler method, while Oceania had largest values by 2D.

Conclusions

The WASE Normal Values Study shows geographical variability in LV SVI across continents and countries. This information should be considered when determining normative values for SV and SVI.

Abstract P1766 Figure.

104 Left ventricular stroke volume differences among echocardiographic methods in healthy adults from the World Alliance of Societies of Echocardiography (WASE) Normal Values Study

Funding Acknowledgements

WASE Normal Values Study is sponsored by American Society Echocardiography Foundation.

OnBehalf

the WASE Investigators

Background

Left ventricular (LV) stroke volume (SV) can be determined by multiple ultrasound methods, including Doppler, two- (2D) and three-dimensional (3D) echocardiography. However, how methods compare to each other is not well understood. In this report from the WASE study, we aim to examine and compare normal reference ranges for SV and SV index (SVI) obtained from healthy adults by Doppler, 2D Simpson’s and 3D methods.

Methods

WASE Normal Values Study is a multinational, observational, cross-sectional study. Individuals free from known cardiac, lung and renal disease were prospectively enrolled with even distribution among age groups and gender. Doppler, 2D and 3D datasets were acquired at the enrolling centers, following a standardized protocol. LV SV was measured by three methods: Doppler (LV outflow tract diameter and velocity time integral), 2D biplane Simpson’s rule and 3D volume method. SV was indexed by body surface area (SVI). All measurements were analyzed (TOMTEC) in two core laboratories (for 2D and 3D) following ASE Guidelines. Methods were compared by Friedman test and Bland-Altman analysis.

Results

As of May 2019, 646 cases have been analyzed in both 2D and 3D datasets. In this population, age was 45 ± 16 years old (range 18-85) and body surface area was 1.76 ± 0.22 m² (range 0.95-2.44). LV EF by 2D Simpson’s rule and 3D method were 63.2 ± 2.9 and 62.3 ± 5.0 %, respectively (p < 0.0001, Wilcoxon test). SVI by Doppler, 2D and 3D were 39.6 ± 7.6, 33.8 ± 6.5 and 41.0 ± 9.4 ml/m², respectively. There were significant differences between the three methods (p < 0.0001, Friedman test). 2D underestimated SVI compared to Doppler by 14.6% (mean of differences 5.8 ml/m², p < 0.0001) and 3D by 17.6% (7.2 ml/m², p < 0.001). The difference between Doppler and 3D was smaller (3.4% lower by Doppler) but still statistically significant (1.4 ml/m², p = 0.0008). The results are shown in the figure.

Conclusions

Comparing 3 modalities in a large population of healthy individuals, SV and SVI are underestimated by 2D Simpson’s method. Given the large differences, combining 2D and Doppler or 3D measurements for hemodynamic calculations (such as regurgitant volumes and fraction) should be done with caution.

Abstract 104 Figure.