Artificial intelligence-enabled assessment of right ventricular to pulmonary artery coupling in patients undergoing transcatheter tricuspid valve intervention

AIMS

Right ventricular to pulmonary artery (RV-PA) coupling has been established as a prognostic marker in patients with severe tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve interventions (TTVI). RV-PA coupling assesses right ventricular systolic function related to pulmonary artery pressure levels, which are ideally measured by right heart catheterization. This study aimed to improve the RV-PA coupling concept by relating tricuspid annular plane systolic excursion (TAPSE) to mean pulmonary artery pressure (mPAP) levels. Moreover, instead of right heart catheterization, this study sought to employ an extreme gradient boosting (XGB) algorithm to predict mPAP levels based on standard echocardiographic parameters.

METHODS AND RESULTS

This multicentre study included 737 patients undergoing TTVI for severe TR; among them, 55 patients from one institution served for external validation. Complete echocardiography and right heart catheterization data were available from all patients. The XGB algorithm trained on 10 echocardiographic parameters could reliably predict mPAP levels as evaluated on right heart catheterization data from external validation (Pearson correlation coefficient R: 0.68; P value: 1.3 × 10-8). Moreover, predicted mPAP (mPAPpredicted) levels were superior to echocardiographic systolic pulmonary artery pressure (sPAPechocardiography) levels in predicting 2-year mortality after TTVI [area under the curve (AUC): 0.607 vs. 0.520; P value: 1.9 × 10-6]. Furthermore, TAPSE/mPAPpredicted was superior to TAPSE/sPAPechocardiography in predicting 2-year mortality after TTVI (AUC: 0.633 vs. 0.586; P value: 0.008). Finally, patients with preserved RV-PA coupling (defined as TAPSE/mPAPpredicted > 0.617 mm/mmHg) showed significantly higher 2-year survival rates after TTVI than patients with reduced RV-PA coupling (81.5% vs. 58.8%, P < 0.001). Moreover, independent association between TAPSE/mPAPpredicted levels and 2-year mortality after TTVI was confirmed by multivariate regression analysis (P value: 6.3 × 10-4).

CONCLUSION

Artificial intelligence-enabled RV-PA coupling assessment can refine risk stratification prior to TTVI without necessitating invasive right heart catheterization. A comparison with conservatively treated patients is mandatory to quantify the benefit of TTVI in accordance with RV-PA coupling.

A Comparative Study of 1-Year Postprocedural Outcomes in Transcatheter Mitral Valve Repair in Advanced Primary Mitral Regurgitation: PASCAL vs. MitraClip

Both the MitraClip and PASCAL systems offer transcatheter edge-to-edge repair (TEER) solutions for mitral regurgitation. Evidence indicates a lower technical success rate for TEER in complex degenerative mitral regurgitation (DMR) cases. We conducted a retrospective analysis of patients who underwent transcatheter edge-to-edge therapy for primary mitral regurgitation with advanced anatomy, defined as mitral regurgitation effective regurgitant orifice area (MR-EROA) ≥0.40 cm2 or large flail gap (≥5 mm) or width (≥7 mm) or Barlow's disease, that completed follow-up after 1 year. Our criteria were met by 27 patients treated with PASCAL and 18 with MitraClip. All patients exhibited a significant, equivalent short-term reduction in MR-EROA, mitral regurgitation vena contracta diameter (MR-VCD), regurgitant volume, and clinical status. At 1 year follow-up, reductions in MR-VCD, regurgitant volume, and MR-EROA remained significant for both groups without significant differences between groups. MR-Grade ≤ 1+ was achieved in 18 (66.7%) and 10 (55.6%) patients, respectively. At follow-up, no difference in hospitalization for cardiac decompensation was observed. Overall death was similar in both groups. Our study suggests that both the PASCAL and MitraClip systems significantly reduce mitral regurgitation even in advanced degenerative diseases. Within our limited data, we found no evidence of inferior performance of the PASCAL system.

Leaflet Morphology and its Implications for Direct Transcatheter Annuloplasty of Tricuspid Regurgitation

BACKGROUND

Leaflet morphology has been associated with treatment success in edge-to-edge repair of tricuspid regurgitation (TR), but the impact on annuloplasty is unclear.

OBJECTIVES

The authors sought to examine the association of leaflet morphology with efficacy and safety of direct annuloplasty in TR.

METHODS

The authors analyzed patients who underwent catheter-based direct annuloplasty with the Cardioband at 3 centers. Leaflet morphology was assessed according to number and location of leaflets by echocardiography. Patients with simple morphology (2 or 3 leaflets) were compared with complex morphology (>3 leaflets).

RESULTS

The study included 120 patients (median age 80 years) with ≥severe TR. A total of 48.3% of patients had a 3-leaflet morphology, 5% a 2-leaflet morphology, and 46.7% had >3 tricuspid leaflets. Baseline characteristics did not differ relevantly between groups except for a higher incidence of torrential TR grade (50 vs 26.6%) in complex morphologies. Postprocedural improvement of 1 (90.6% vs 92.9%) and 2 (71.9% vs 67.9%) TR grades was not significantly different between groups, but patients with complex morphology had more often residual TR ≥3 at discharge (48.2 vs 26.6%; P = 0.014). This difference did not remain significant (P = 0.112) after adjusting for baseline TR severity, coaptation gap, and nonanterior jet localization. Safety endpoints including complications of the right coronary artery, and technical success did not show significant differences.

CONCLUSIONS

Efficacy and safety of transcatheter direct annuloplasty using Cardioband are not affected by leaflet morphology. Assessment of leaflet morphology should be part of procedural planning in patients with TR and might help to individually tailor repair techniques to patient anatomy.

Epiphenomenon or Prognostically Relevant Interventional Target? A Novel Proportionality Framework for Severe Tricuspid Regurgitation

Background Tricuspid regurgitation (TR) frequently develops in patients with long-standing pulmonary hypertension, and both pathologies are associated with increased morbidity and mortality. This study aimed to improve prognostic assessment in patients with severe TR undergoing transcatheter tricuspid valve intervention (TTVI) by relating the extent of TR to pulmonary artery pressures. Methods and Results In this multicenter study, we included 533 patients undergoing TTVI for moderate-to-severe or severe TR. The proportionality framework was based on the ratio of tricuspid valve effective regurgitant orifice area to mean pulmonary artery pressure. An optimal threshold for tricuspid valve effective regurgitant orifice area/mean pulmonary artery pressure ratio was derived on 353 patients with regard to 2-year all-cause mortality and externally validated on 180 patients. Patients with a tricuspid valve effective regurgitant orifice area/mean pulmonary artery pressure ratio ≤1.25 mm²/mm Hg (defining proportionate TR) featured significantly lower 2-year survival rates after TTVI than patients with disproportionate TR (56.6% versus 69.6%; P=0.005). In contrast with patients with disproportionate TR (n=398), patients with proportionate TR (n=135) showed more pronounced mPAP levels (37.9±9.06 mm Hg versus 27.9±8.17 mm Hg; P<2.2×10^-16) and more severely impaired right ventricular function (tricuspid annular plane systolic excursion: 16.0±4.11 versus 17.0±4.64 mm; P=0.012). Moreover, tricuspid valve effective regurgitant orifice area was smaller in patients with proportionate TR when compared with disproportionate TR (0.350±0.105 cm² versus 0.770±0.432 cm²; P<2.2×10^-16). Importantly, proportionate TR remained a significant predictor for 2-year mortality after adjusting for demographic and clinical variables (hazard ratio, 1.7; P=0.006). Conclusions The proposed proportionality framework promises to improve future risk stratification and clinical decision-making by identifying patients who benefit the most from TTVI (disproportionate TR). As a next step, randomized controlled studies with a conservative treatment arm are needed to quantify the net benefit of TTVI in patients with proportionate TR.

Clinically atypical abdominal manifestation of the lipoma localized in the right atrium: "Invagination hypothesis" revisited

Cardiac lipomas are the second most common cardiac tumors. They are usually asymptomatic and diagnosed as incidental findings. We describe a 71-year-old patient with a tumor in the right atrium. In echocardiography and MRI scan, the diagnosis of a cardiac lipoma was suspected. Moreover, MRI demonstrated continuity of pericardial fat and the tumor in the right atrium by infolding of the atrial wall and epicardial adipose tissue in the space between the atrial walls, which might be a hint for the Waterstone groove hypothesis. An operative resection was performed which confirmed the suspected diagnosis.

Female patients with coronary artery disease and aortic stenosis undergoing a surgical or interventional treatment in terms of revascularization and valve replacement

Background

Coronary artery disease (CAD) in female patients undergoing a Transcatheter Aortic Valve Implantation (TAVI) is accompanied with a worse outcome compared to those without CAD. Nevertheless, it is still unclear whether a complete revascularization and outcome are achieved similarly in women treated with an interventional (PCI plus TAVI) or surgical (CABG plus SAVR) treatment strategy.

Purpose

This study aims to compare the completeness of revascularization in terms of residual SyntaxScore and to evaluate the differences in 30-days (short-term), one-year and three-years (intermediate term) mortality in women with CAD and AS undergoing a surgical or catheter-based treatment.

Methods

Patients were recruited at one tertiary center in Germany between 2016 and 2019. Initially the surgical group contained 932 patients and the interventional cohort 360 patients as a result of setting a maximum time interval of 3 months between PCI and TAVI.

The surgical group (CABG+SAVR) and the interventional group (PCI+TAVI) were compared by using a propensity score analysis. Age, left ventricular function, EuroSCORE II and degree of CAD served as matching parameters so that the matched female cohort finally consisted of 114 patients (57 patients treated interventionally, 57 treated surgically). Syntax Score was measured before and after revascularization. As a primary endpoint all-cause mortality was analyzed at 30 days, one and three years after the procedure.

Results

Median age was 80 years both in the interventional and surgical cohort (p=0.298). Both groups represented a moderate to high-risk population (EuroScore II in PCI+TAVI: 4.39 [2.83–8.82] vs 6.18 [3.43–8.6] in CABG+SAVR (p=0.279) and showed no significant difference in median pre-interventional/preoperative SyntaxScore I (PCI+TAVI: 16.00 [9–26.5] vs CABG+SAVR: 18 [9.5–25.5]; p=0.719). In the interventional group coronary physiology was measured more frequently (6.8% vs 1.8%, p=0.024). There was no significant difference in the presence of an aortoostial lesion, heavy calcification and a length of the lesion &gt;20mm between PCI+TAVI and CABG+SAVR before therapy (PCI+TAVI vs CABG+SAVR: 11.1% vs 13.0%, p=0.581; 60.5% vs 55.1%, p=0.289; 20.4% vs 25.1%, p=0.316). The main stem as target lesion was present in both groups with no significant difference (PCI+TAVI vs CABG+SAVR: 8.8% vs 19.3%, p=0.106).

Median residual SyntaxScore I was significantly higher in PCI+TAVI than in CABG+SAVR (5.0 [0.0–13.0] vs 0.0 [0.0–8.5], p=0.03).

No significant difference in 30-days, 1-year and 3-years mortality was observed between the interventional and surgical group (PCI+TAVI vs CABG+SAVR: 3.5% vs 8.8%, p=0.242; 10.5% vs 14%, p=0.568; 22.8% vs 15.8%, p=0.342).

Conclusion

Female patients with AS and CAD with low SyntaxScore undergoing CABG+SAVR reach a more complete revascularization than those treated interventionally. Nevertheless, this fact seems to have no influence on short and intermediate term mortality.

Funding Acknowledgement

Type of funding sources: None.

Solving the Pulmonary Hypertension Paradox in Patients With Severe Tricuspid Regurgitation by Employing Artificial Intelligence

OBJECTIVES

This study aimed to improve echocardiographic assessment of pulmonary hypertension (PH) in patients presenting with severe tricuspid regurgitation (TR).

BACKGROUND

Echocardiographic assessment of PH in patients with severe TR carries several pitfalls for underestimation, hence concealing the true severity of PH in very sick patients in particular, and ultimately obscuring the impact of PH on survival after transcatheter tricuspid valve intervention (TTVI).

METHODS

All patients in this study underwent TTVI for severe TR between 2016 and 2020. To predict the mean pulmonary artery pressure (mPAP) solely based on echocardiographic parameters, we trained an extreme gradient boosting (XGB) algorithm. The derivation cohort was constituted by 116 out of 162 patients with both echocardiography and right heart catheterization data, preprocedurally obtained, from a bicentric registry. Moreover, 142 patients from an independent institution served for external validation.

RESULTS

Systolic pulmonary artery pressure was consistently underestimated by echocardiography in comparison to right heart catheterization (40.3 ± 15.9 mm Hg vs 44.1 ± 12.9 mm Hg; P = 0.0066), and the assessment was most discrepant among patients with severe defects of the tricuspid valve and impaired right ventricular systolic function. Using 9 echocardiographic parameters as input variables, an XGB algorithm could reliably predict mPAP levels (R = 0.96, P < 2.2 × 10^-16). Moreover, patients with elevations in predicted mPAP levels ≥29.9 mm Hg showed significantly reduced 2-year survival after TTVI (58.3% [95% CI: 41.7%-81.6%] vs 78.8% [95% CI: 68.7%-90.5%]; P = 0.026). Importantly, the poor prognosis associated with elevation in predicted mPAP levels was externally confirmed (HR for 2-year mortality: 2.9 [95% CI: 1.5-5.7]; P = 0.002).

CONCLUSIONS

PH in patients with severe TR can be reliably assessed based on echocardiographic parameters in conjunction with an XGB algorithm, and elevations in predicted mPAP levels translate into increased mortality after TTVI.

Predicting procedural success in patients treated with Cardioband system for severe tricuspid regurgitation by employing a random forest algorithm

Background

Severe tricuspid regurgitation (TR) is associated with high morbidity and mortality despite optimal medical treatment. Transcatheter tricuspid valve intervention (TTVI) is therefore emerging as a novel treatment option, fueling the hope to prolong survival and reduce rehospitalization for heart failure. Obviously, procedural success of TTVI is an important determinant of survival, but predictors for procedural success in patients treated with Cardioband system, which mimics the surgical approach by implanting an annular reduction system and hence targets tricuspid annulus dilatation as the central pathology in most patients, are largely elusive.

Purpose

This study aims to refine prediction of procedural success in patients with severe TR undergoing TTVI with Cardioband system by employing a random forest algorithm.

Methods

Procedural success was evaluated in 72 patients enrolled at two tertiary centers in Germany between 2018 and 2020. Key inclusion criterion was TR ≥ III/V° with high symptomatic burden despite optimal medical treatment. Procedural success war defined as patient alive at the end of the procedure, successful Cardioband implantation, and TR reduction ≥ II/V° as assessed on transthoracic echocardiography before discharge. Since 66.7% of patients were classified as “success”, a synthetic minority over-sampling technique was applied in order to train the random forest algorithm on a balanced data set.

Results

A random forest algorithm reached 85.4% accuracy (AUC: 0.923) in predicting procedural success in a balanced data set using eight parameters from pre-procedural echocardiography as input variables. Partial dependence analysis revealed that enlargement of the tricuspid valve (TV) anteroseptal diameter was most important for model accuracy. Applied to the real-world data set (24 patients classified as “failure” and 48 patients classified as “success”), the now trained random forest algorithm predicted procedural success with high sensitivity (70.8%) and specificity (100.0%), significantly outperforming the no information rate (p-value: 0.0069). Patients with low probability for success were characterized by impaired right ventricular function (TAPSE: 15.5±3.63 mm) and enlarged right sided cardiac diameters (basal right ventricular diameter: 51.6±3.79 mm; TV anteroseptal diameter: 45.0±5.10 mm). Notably, systolic pulmonary artery pressure (sPAP) and TV effective regurgitant orifice area were negatively correlated (R: −0.3004, p-value: 0.0322), and elevation in sPAP was attenuated in patients with low probability for procedural success (sPAP: 34.0±11.7 mmHg).

Conclusion

A random forest algorithm enables precise prediction of procedural success in patients treated with Cardioband system. TR reduction ≥ II/V° appears less achievable in patients with advanced stages of right heart failure, emphasizing the importance of adequate patient selection and timing of intervention.

Funding Acknowledgement

Type of funding sources: None.

Short- and intermediate-term mortality in women and men after surgical versus interventional revascularization and aortic valve replacement

Background

Patients with isolated aortic valve stenosis (AS) at intermediate and even low-risk benefit from an interventional treatment with TAVI as compared to surgical aortic valve replacement. Whether patients with concomitant coronary artery disease have a better outcome with an interventional (PCI plus TAVI) or surgical (CABG plus SAVR) treatment strategy is still unclear.

Purpose

To evaluate the differences in 30-days (short-term) and one-year (intermediate term) mortality in women and men with CAD and AS undergoing a surgical or catheter-based treatment.

Methods

All patients were treated in Heart and Diabetes Center Bad Oeynhausen during 2016–2019. The surgical group contained 932 patients, the interventional cohort 360 patients as a result of setting a maximum time interval of 3 months between PCI and TAVR.

CABG+SAVR and PCI+TAVR cohorts were compared by using a propensity score analysis including age, left ventricular function, EuroSCORE II and degree of CAD as matching parameters. After matching the total cohort, 406 patients could be obtained. The matched female cohort consisted of 114 patients, the matched male cohort of 284 patients. As a primary endpoint all-cause mortality was analyzed at 30 days and one year after the procedure. Furthermore, procedural and post-procedural outcome were analyzed.

Results

The studied TAVI cohort was a low to intermediate risk population (EuroScore II of the total cohort: 3.82 [2.49–6.64] in CABG+SAVR vs 4.36 [2.59–7.12] in PCI+TAVR, p=0.38; women: 6.18 [3.43–8.6], p=0.279; men: 4.39 [2.83–8.82], p=0.279). There was no significant difference in 30-days mortality between the surgical and interventional group, regarding the total cohort (3.9% vs 2.5%; p=0.398). Whereas in the male cohort 30-days mortality was comparable between interventional and surgical treatment (2.1% vs 2.1%; p=1), in the female group the surgical treatment showed a trend towards higher mortality without reaching statistical significance (8.8% vs 3.5%; p=0.242). Additionally, one-year mortality did not differ in the three cohorts between CABG+SAVR and PCI+TAVR (total cohort: 11.3% vs 12.8%; p=0.648 women: 14% vs 10.5%; p=0.568; men: 11.3% vs 14.8%; p=0.378). The number of postprocedural permanent pacemaker implantations was statistically higher after TAVR plus PCI (total cohort: 7.4% vs 15.3%; p=0.012; women: 7% vs 19.3%; p=0.052; men: 8.5% vs 19%; p=0.01). Furthermore, a significantly longer length of hospital stay was reported for the surgical cohort (total cohort: 13 [11–17] vs 11 [9–15]; p=0; women: 14 [12–18] vs 12 [10.5–15.5]; p=0.019; men: 13 [11–15] vs 11 [9–15]; p=0).

Conclusion

In patients with AS and CAD there is no significant difference in short and intermediate term mortality when comparing surgical or interventional treatment.

Subsequently, an interventional approach might be a legitimate alternative to CABG+SAVR in these patients.

Funding Acknowledgement

Type of funding sources: None.

Impact of cleft-like indentations on procedural outcome of percutaneous edge-to-edge mitral valve repair

OBJECTIVES AND BACKGROUND

Percutaneous edge-to-edge mitral valve (MV) repair (PMVR) is broadly applied in high-risk patients with relevant mitral regurgitation (MR). We investigated the incidence of cleft-like indentations (CLI) and their impact on PMVR.

METHODS AND RESULTS

In a retrospective single center analysis including 263 patients undergoing PMVR with the MitraClip®-system between 11/2012 and 7/2016, MV anatomy was assessed by 3-dimensional transesophageal echocardiography. CLI were present in 37/263 patients (14.1%). Of these, 62.2% had 1 CLI, 27% had 2 CLI, and 10.8% had 3 CLI, mostly concerning segment P2 or P2/3 of the MV. Baseline characteristics were similarly distributed. Interestingly, most patients with CLI suffered from secondary MR (n = 29, 78%). The number of deployed MitraClips was higher in patients with CLI (2 [1.25-2] vs. 2 [1, 2], p = .035), whereas procedural as well as clinical success was similar: MR grade (1.2 vs. 1.5, p = .061), vena contracta width (4.2 vs. 4.5 mm, p = .293), dPmean (4.2 vs. 4.0 mmHg, p = .618) at discharge and NYHA class at 30 days did not differ between groups. Periprocedural complications were rare and equally distributed between groups. At 30 days, MR reduction persisted in patients with CLI (95.8% of these selected patients had a MR grade ≤ 2).

CONCLUSIONS

CLI of the MV are common in patients undergoing PMVR, also when presenting mainly with secondary MR. While the number of clips needed to address MR is slightly higher in patients with CLI, procedural success rates appear not to be affected. PMVR seems to be a safe treatment option for patients with CLI.

Interatrial Thrombus in Left-Atrial Septal Pouch Prohibiting Transseptal Puncture for Percutaneous Mitral Valve Therapy

An 82-year-old female patient with severe mitral regurgitation was referred for evaluation of percutaneous mitral valve repair. Transoesophageal echocardiography revealed a left-atrial septal pouch (LASP) with an echogenic structure. Following the heart-team decision, interventional therapy was therefore discarded. During surgery, a thrombus in the LASP was found and carefully resected. Afterward, conventional valve replacement with a biological 31-mm SJM-EPIC prosthesis (Abbott Structural Heart Devices, Santa Clara, CA) was performed. In the fast-evolving field of interventional mitral valve therapy, a trans-septal approach is the common strategy. Therefore, careful evaluation of the interatrial septum—which may contain thrombi with transoesophageal echocardiography before intervention—is of crucial importance.