Tricuspid annular area and leaflets stretch are associated with functional tricuspid regurgitation - insights from three-dimensional transesophageal echocardiography

BACKGROUND

The presence of functional tricuspid regurgitation (TR) is associated with mortality and morbidity. Although uniform management with a tricuspid annuloplasty ring is currently considered as a standard surgical procedure, high rates of residual TR despite annuloplasty are reported. Therefore, the identification of the TR mechanisms would be necessary to provide personalized treatment for each TR patient.

METHODS

This study population consisted of 106 patients with mitral regurgitation (MR) who were scheduled for procedure. Transthoracic and transesophageal echocardiography were performed prior to mitral valve intervention. We performed three-dimensional quantitative assessment including tricuspid annular (TA) area and the distance between the three commissures of tricuspid valve.

RESULTS

Significant TR, which is defined as moderate or greater TR, was detected in 23 (22%). TA area (P < 0.01), the distance of septal-leaflet length (SL) (P = 0.03) and posterior-leaflet length (PL) (p = 0.02) were significantly associated with significant TR, while TA diameter assessed by transthoracic echocardiography was not. When patients were divided into four groups according to SL and PL, the group with longer SL and PL had a significantly higher incidence of significant TR (P < 0.01).

CONCLUSIONS

Greater stretch of the septal and posterior leaflet between commissures and larger TA area are associated with significant TR in patients with severe MR. In order to prevent TR recurrence, the intervention of the septal leaflet in tricuspid annuloplasty may be beneficial. The precise implement of three-dimensional transesophageal echocardiography of tricuspid valve is valuable for a personalized strategy of tricuspid annuloplasty.

Valvular complex and tissue remodelling in ovine functional tricuspid regurgitation

OBJECTIVES

Pathophysiology of function tricuspid regurgitation (FTR) is incompletely understood. We set out to comprehensively evaluate geometric and tissue remodelling of the tricuspid valve complex in ovine FTR.

METHODS

Twenty adult sheep underwent left thoracotomy and pulmonary artery banding (PAB) to induce right heart pressure overload and FTR. After 8 weeks, 17 surviving animals and 10 healthy controls (CTL) underwent sternotomy, echocardiography and implantation of sonomicrometry crystals on right ventricle and tricuspid valvular apparatus. Haemodynamic and sonomicrometry data were acquired in all animals after weaning from cardiopulmonary bypass. Leaflet tissue was harvested for pentachrome histologic analysis and biomechanical testing.

RESULTS

Animal weight was 62 ± 5 and 63 ± 3 kg for CTL and PAB, respectively (P = 0.6). At terminal procedure, systolic pulmonary artery pressure was 22 ± 3 and 40 ± 7 mmHg for CTL and PAB, respectively (P = 0.0001). The mean TR grade (+0-4) was 0.8 ± 0.4 and 3.2 ± 1.2 (P = 0.0001) for control and banded animals, respectively. Right ventricle volume (126 ± 13 vs 172 ± 34 ml, P = 0.0019), tricuspid annular area (651 ± 109 vs 865 ± 247 mm2, P = 0.037) and area between papillary muscle tips (162 ± 51 vs 302 ± 75 mm2, P = 0.001) increased substantially while systolic excursion of anterior leaflet decreased significantly (23.8 ± 6.1° vs 7.4 ± 4.5°, P = 0.001) with banding. Total leaflet surface area increased from 806 ± 94 to 953 ± 148 mm2 (P = 0.009), and leaflets became thicker and stiffer.

CONCLUSIONS

Detailed analysis of the tricuspid valve complex revealed significant ventricular, annular, subvalvular and leaflet remodelling to be associated with ovine functional tricuspid regurgitation. Durable surgical repair of severe FTR may require a multi-level approach to the valvular apparatus.

Isolated functional tricuspid regurgitation: how to define patients at risk for event?

AIMS

Functional tricuspid regurgitation (TR) is a turning point in cardiac diseases. Symptoms typically appear late. The optimal timing for proposing a valve repair remains a challenge. We sought to analyse the characteristics of right heart remodelling in patients with significant functional TR to identify the parameters that could be used in a simple prognostic model predicting clinical events.

METHODS AND RESULTS

We designed a prospective observational French multicentre study including 160 patients with significant functional TR (effective regurgitant orifice area > 30 mm² ) and left ventricular ejection fraction > 40%. Clinical, echocardiographic, and electrocardiogram data were collected at baseline and at the 1 and 2 year follow-up. The primary outcome was all-cause death or hospitalization for heart failure. At 2 years, 56 patients (35%) achieved the primary outcome. The subset with events showed more advanced right heart remodelling at baseline, but similar TR severity. Right atrial volume index (RAVI) and the tricuspid annular plane systolic excursion to systolic pulmonary arterial pressure (TAPSE/sPAP) ratio, reflecting right ventricular-pulmonary arterial coupling, were 73 mL/m² and 0.40 vs. 64.7 mL/m² and 0.50 in the event vs. event-free groups, respectively (both P < 0.05). None among all the clinical and imaging parameters tested had a significant group × time interaction. The multivariable analysis leads to a model including TAPSE/sPAP ratio > 0.4 (odds ratio = 0.41, 95% confidence limit 0.2 to 0.82) and RAVI > 60 mL/m² (odds ratio = 2.13, 95% confidence limit 0.96 to 4.75), providing a clinically valid prognostic evaluation.

CONCLUSIONS

RAVI and TAPSE/sPAP are relevant for predicting the risk for event at 2 year follow-up in patients with an isolated functional TR.

Prevalence and determinants of tricuspid regurgitation after repair of tetralogy of Fallot

BACKGROUND

The prevalence and determinants of tricuspid regurgitation (TR) in patients with repaired Tetralogy of Fallot (rTOF) remain incompletely understood.

OBJECTIVES

To explore the prevalence of and factors associated with TR in patients with rTOF, specifically, the relationship of right ventricular (RV) dilatation with TR severity.

METHODS

Patients (≥17 yrs) with rTOF referred to our service (2000-2019) were identified. Those with severe pulmonary stenosis, significant shunt, or previous tricuspid valve surgery were excluded. Using standard cardiac MRI protocols, RV, right atrial (RA) and tricuspid valve (TV) parameters were measured and compared.

RESULTS

68 consecutively eligible patients with rTOF were included in the study (27 ± 9 yrs., 35% female). Despite substantial RV volume overload (mean RVEDVi 153 mL/m²), the majority of the cohort (78%) had no or only mild TR. RA volumes, tenting height/area and annular diameter were normal (4.9 ± 2.0 mm, 1.1 ± 1.0 cm² and 32.4 ± 6.2 mm, respectively). There was no significant correlation of TR fraction with RVEDVi (r = 0.13; p = 0.30), RVEF (r = 0.09; p = 0.44) or tricuspid annular diameter (r = 0.07; p = 0.62). Only RAVi showed a weak but significant correlation with TR fraction (0.29; p = 0.03). In a pooled cohort analysis, including both rTOF patients and adults with a dilated RV from pre-tricuspid shunt lesions, only rTOF was independently associated with higher TR fraction (p = 0.017).

CONCLUSION

Despite substantial RV dilatation in a cohort with rTOF, there was surprisingly little TR. We found poor correlation between RVEDVi, RA volumes, tricuspid annular dilatation and the presence of significant TR. These findings question commonly held notions regarding the pathophysiology of functional TR in these patients.

Suture map for endoscopic tricuspid valve repair

Minimally invasive tricuspid surgery using a complete endoscopic approach has a steep learning curve. The purpose of creating the suture map is to allow placement of sutures with minimal tissue handling and to improve operating efficiency. This process is useful for surgeons who are just beginning to learn minimally invasive surgery and are at an early stage of their endoscopic surgical career.

Association of longitudinal left atrial strain with mortality after tricuspid valve surgery

AIMS

Tricuspid valve (TV) surgery for functional tricuspid regurgitation (TR) is becoming more common, but the associated mortality remains high. Therefore, we evaluated the clinical and echocardiographic parameters associated with all-cause mortality in patients with severe functional TR who underwent TV surgery.

METHODS AND RESULTS

A total of 286 patients with severe functional TR who underwent TV replacement or repair was analysed between January 2006 and December 2017. We assessed changes in conventional echocardiographic parameters and strain, such as peak atrial longitudinal strain (PALS). During a median follow-up period of 5.3 years, 71 (24.8%) patients died due to any cause. When comparing groups with and without all-cause deaths, there were no significant differences in terms of sex, co-morbidities, medication use, and surgery type. However, patients who died were older and more likely to have refractory atrial fibrillation (AF). With multivariate Cox modelling, age >65 years (adjusted hazard ratio [HR], 2.81, 95% confidence interval [CI], 1.59-4.96; P < 0.001), refractory AF (adjusted HR, 2.84, 95% CI, 1.36-5.94; P = 0.006), lower albumin level (adjusted HR, 0.50, 95% CI, 0.31-0.82), and reduced PALS (adjusted HR, 1.87, 95% CI, 1.06-3.33; P = 0.032) were significant determinants of all-cause mortality. PALS decline was associated with refractory AF (adjusted HR, 5.74, 95% CI, 2.81-11.7; P < 0.001) and the absence of a Maze procedure (adjusted HR, 2.95, 95% CI, 1.51-5.78; P = 0.002).

CONCLUSIONS

A reduction in PALS was significantly associated with all-cause mortality in our cohort of patients with severe functional TR who underwent TV surgery. This phenomenon is related to refractory AF and more aggressive intervention for AF is necessary concomitant with TV surgery.

Right ventricular volume and its relationship to functional tricuspid regurgitation

Background

Significant right ventricular (RV) dilatation has long been considered integral to the pathogenesis of functional tricuspid regurgitation (FTR).

Objectives

To explore the relationship of RV dilatation and FTR in patients with ‘pure’ RV volume overload.

Methods

Patients (>17yrs) with RV dilatation due to pre-tricuspid shunts (atrial septal defect; ASD and/or partial anomalous pulmonary venous drainage; PAPVD) referred to our service (2000–2019) were retrospectively identified. Those with pulmonary hypertension, primum ASD or left-heart disease were excluded. Using standard cardiac MRI protocols, RV, right atrial and TV parameters were measured and compared.

Results

Of 52 consecutively eligible patients (42 ± 15yrs, 25 males), 25 had ASDs, 13 had PAPVD and 14 had both conditions. All were in sinus rhythm and none had pulmonary regurgitation. Left and right ventricular ejection fractions were normal (LVEF 63 ± 8%, RVEF 56 ± 8%). Indexed RV end-diastolic volumes (RVEDVi) were moderately increased (males 148 ± 33 mL/m² and females 141 ± 42 mL/m², range 95–267 mL/m²). Despite substantial RV volume overload, no patients had severe tricuspid regurgitation (TR). Only two had > mild TR. There was a weak correlation between tricuspid annular diameter and both degree of RV dilatation (r = 0.37; p = 0.01) and degree of TR (r = 0.38; p = 0.006). There was a similarly poor correlation between right atrial dimensions and the degree of TR (r = 0.34; p = 0.02).

Conclusion

When RV dilatation is simply due to volume overload, we find that significant TR is extremely rare. This gives an important and novel insight; that RV dilatation per se does not result in FTR.

Caval Valve Implantation

Transcathetertherapy has expanded the treatment options for patients with heart valve disease. Interventional therapy for aortic, mitral, and pulmonic valve disease is well established; however, catheter-based approaches to tricuspid regurgitation (TR) are still in early stages of development. For some of the interventional concepts to TR, including the edge-to-edge-repair, transcatheter annuloplasty, the tricuspid spacer, and caval valves, procedural feasibility and favorable early clinical outcome have been demonstrated in small compassionate case series. This article reviews the pathophysiological background and current evidence for caval valve implantation and examines the potential role of this approach for the treatment of severe TR.

The role of left atrial strain in patients with functional tricuspid regurgitation before and after annuloplasty: a long-term follow-up study

Background

Functional tricuspid regurgitation (TR) is common among patients with left heart disease and may recur during the follow-up period after selective tricuspid valve annuloplasty (TVA). This study aims to analyse the relationship between left atrial (LA) strain and the degree of preoperative functional TR and to explore the role of LA strain in predicting TR recurrence.

Methods

This study included 63 patients with rheumatic mitral stenosis who underwent mitral valve replacement and concomitant TVA. Additionally, 20 healthy controls were enrolled. Preoperative conventional LA echocardiographic parameters and LA strain were measured. The association between LA strain and preoperative functional TR severity was analysed by Pearson correlation. Predictors of recurrent TR were determined by multivariate logistic regression analyses.

Results

Compared with the control group, the mitral stenosis group developed a significant impairment in terms of LA strain. The degree of preoperative functional TR exhibited moderate correlations with LA reservoir strain (r = − 0.57) and LA conduit strain (r = 0.48). During a median follow-up period of 66.4 ± 36.4 months, TR recurred in 18 patients. Preoperative LA reservoir strain and the mean transmitral gradient were predictors of postoperative TR recurrence. When the two indexes were combined to establish a prediction, the sensitivity and specificity of prediction increased. The area under the receiver operating characteristic curve of the combined indicator was higher than those of the single indicators (0.90 vs. 0.70 and 0.72).

Conclusions

LA strain correlates with preoperative functional TR severity in patients with rheumatic mitral stenosis. The LA reservoir strain and preoperative mean transmitral gradient are independent predictive factors for recurrent TR after TVA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-021-00264-z.

Functional tricuspid regurgitation, related right heart remodeling, and available treatment options: good news for patients with heart failure?

Significant functional tricuspid regurgitation (FTR) represents a poor prognostic factor independent of right ventricular (RV) function. It is usually the consequence of left-sided cardiac diseases that induce RV dilatation and dysfunction, but it can also resulted from right atrial (RA) enlargement and consequent tricuspid annular dilatation. FTR is very frequent among patients with heart failure, particularly in those with reduced LVEF and concomitant functional mitral regurgitation. The development of three-dimensional echocardiography enabled detailed assessment of tricuspid valve anatomy, subvavlular apparatus, and RA and RV changes, as well as accurate evaluation of FTR etiology. Due to high in-hospital mortality risk in patients who were operatively treated for isolated FTR, it has been treated only medically for a long time. Percutaneous approach considers mainly transcatheter tricuspid valve repair (edge-to-edge and annuloplasty) and represents a very attractive option for the high-risk patients. Studies that investigated the effects of different devices showed excellent feasibility and safety, followed by significant reduction in FTR grade, improvement in functional capacity and NYHA class, quality of life, and reduction in hospitalization due to heart failure. Some investigations also reported a decreased mortality in FTR patients. Nevertheless, the results of these investigations should be interpreted with cautious due to the small number of participants and relatively short follow-up. The aim of this review was to summarize the existing data about the clinical importance of FTR and FTR-induced right heart remodeling and currently existing therapeutic approaches for treatment of FTR.

Prognostic Implication of Right Ventricle Parameters Measured on Preoperative Cardiac MRI in Patients with Functional Tricuspid Regurgitation

OBJECTIVE

To investigate the prognostic value of preoperative cardiac magnetic resonance imaging (MRI) for long-term major adverse cardiac and cerebrovascular events (MACCEs) in patients undergoing tricuspid valve (TV) surgery for functional tricuspid regurgitation (TR).

MATERIALS AND METHODS

The preoperative cardiac MR images, New York Heart Association functional class, comorbidities, and clinical events of 78 patients (median [interquartile range], 59 [51-66.3] years, 28.2% male) who underwent TV surgery for functional TR were comprehensively reviewed. Cox proportional hazards analyses were performed to assess the associations of clinical and imaging parameters with MACCEs and all-cause mortality.

RESULTS

For the median follow-up duration of 5.4 years (interquartile range, 1.2-6.6), MACCEs and all-cause mortality were 51.3% and 23.1%, respectively. The right ventricular (RV) end-systolic volume index (ESVI) and the systolic RV mass index (RVMI) were higher in patients with MACCEs than those without them (77 vs. 68 mL/m², p = 0.048; 23.5 vs. 18.0%, p = 0.011, respectively). A high RV ESVI was associated with all-cause mortality (hazard ratio [HR] per value of 10 higher ESVI = 1.10, p = 0.03). A high RVMI was also associated with all-cause mortality (HR per increase of 5 mL/m² RVMI = 1.75, p < 0.001). After adjusting for age and sex, only RVMI remained a significant predictor of MACCEs and all-cause mortality (p < 0.05 for both). After adjusting for multiple clinical variables, RVMI remained significantly associated with all-cause mortality (p = 0.005).

CONCLUSION

RVMI measured on preoperative cardiac MRI was an independent predictor of long-term outcomes in patients who underwent TV surgery for functional TR.

Impact of concomitant tricuspid annuloplasty on right ventricular remodeling in patients with rheumatic mitral valve disease

Background

Studies on the management of functional tricuspid regurgitation (TR) during mitral valve operations have drawn inconsistent conclusions. This study was designed to compare the treatment strategy of concomitant tricuspid annuloplasty (TAP) against isolated mitral valve replacement (MVR) in rheumatic mitral valve disease patients, and to assess the effect of concomitant TAP on postoperative right ventricular (RV) remodeling and function.

Methods

One hundred-seventy patients with rheumatic mitral valve disease receiving MVR were categorized into TAP group (n = 124) and non-TAP group (n = 46). Clinical and echocardiographic data were collected preoperatively and at 1-year follow-up. Three-dimensional echocardiographic indices of RV geometry and function were analyzed.

Results

At baseline, concomitant TAP group had larger RV end-diastolic volume, more decreased RV ejection fraction and RV longitudinal strain than non-TAP group (all P <  0.001). At 1-year follow-up, TAP group had improved RV geometry and function. While adverse changes were observed in non-TAP group. In analysis of variance, the above indices demonstrated significant interaction with different treatment group (all P <  0.001). In multivariate regression analysis, independent of age and Maze procedure, concomitant TAP was associated with postoperative RV volume reduction (P <  0.001), improvement of RV ejection fraction (P <  0.001), and relieved postoperative functional TR severity (P = 0.025).

Conclusions

Our results suggest that concomitant TAP could improve RV remodeling and function for rheumatic mitral valve disease patients, while those with mild preoperative functional TR who had isolated MVR might experience RV dilation and deterioration of RV function at follow-up. Concomitant surgery for functional TR could be considered for patients undergoing MVR with rheumatic mitral valve disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-021-00245-2.

The Pathophysiological Link between Right Atrial Remodeling and Functional Tricuspid Regurgitation in Patients with Atrial Fibrillation: A Three-Dimensional Echocardiography Study

BACKGROUND

Atrial fibrillation (AF) itself may lead to functional tricuspid regurgitation (FTR) through tricuspid annulus (TA) dilation. However, the pathophysiological determinants of TA enlargement in AF patients remain to be clarified. The objectives of this study were (1) to compare the TA size and function in AF patients versus healthy subjects; (2) to identify the determinants of TA remodeling in patients with AF and FTR; and (3) to assess the relationships among right heart structures and severity of FTR in AF patients.

METHODS

Eighty-three consecutive patients with long-term persistent AF and FTR (61 ± 9.9 years, 67% women) were prospectively enrolled and compared with 83 sex and body surface area-matched healthy subjects. Heart chamber size and function and TA geometry were analyzed using three-dimensional echocardiography.

RESULTS

Among AF patients, 33%, 34%, and 33% had mild, moderate, and severe FTR, respectively. Right atrial (RA) dilation was detected in 93% of AF patients, while only 27% and 12% of them showed dilated or dysfunctional right ventricle (RV), respectively. End-diastolic TA area had the strongest correlation with the minimum volume of the RA (RAVmin r = 0.6981, P < .0001) but only mild correlation with RV end-diastolic volume and sex (r = 0.3405, P = .0019; r = 0.2914, P = .0075). At multivariable analysis, only RAVmin was independently associated with TA area in AF patients (r = 0.665, P < .0001). The RAVmin and TA area were the only predictors of FTR severity.

CONCLUSIONS

In patients with AF, RA dilation seems to be more important than RV dilation to determine TA enlargement and subsequent FTR development. The RAVmin and TA area were directly correlated to FTR severity.

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.

Significant functional tricuspid regurgitation portends poor outcomes in patients with atrial fibrillation and preserved left ventricular ejection fraction

Background

Significant tricuspid regurgitation (TR) can be found in patients with atrial fibrillation (AF). The results of previous studies are controversial about whether significant functional TR (FTR) in patients with AF leads to worse clinical outcomes. The aims of the study were to investigate the prevalence, predictors and prognosis of significant FTR in patients with AF with preserved left ventricular ejection fraction (LVEF).

Methods

The present study was a retrospective cohort study in patients with AF and preserved LVEF from May 2013 through January 2018. Significant FTR was defined as moderate to severe TR without structural abnormality of the tricuspid valve. Pulmonary hypertension (PH) was defined as pulmonary artery systolic pressure ≥ 50 mmHg or mean pulmonary artery pressure ≥ 25 mmHg determined by echocardiography. The adverse outcomes were defined as heart failure and death from any cause within 2 years of follow up.

Results

A total of 300 patients with AF (mean age 68.8 ± 10.8 years, 50% male) were included in the study. Paroxysmal and non-paroxysmal AF were reported in 34.7 and 65.3% of patients, respectively. Mean LVEF was 65.3 ± 6.3%. PH and significant FTR were observed in 31.3 and 21.7% of patients, respectively. Patients with significant FTR were significantly older, more female gender and non-paroxysmal AF, and had higher left atrial volume index and pulmonary artery pressure than those without. A total of 26 (8.7%) patients died and heart failure occurred in 39 (13.0%) patients. There was a statistically significant difference in the adverse outcomes between patients with significant and insignificant FTR (44.6% vs. 11.9%, p <  0.010). Multivariable analysis showed that factors associated with significant FTR were female gender, presence of PH and left atrial volume index (OR = 2.61, 1.87, and 1.04, respectively). The predictors of the adverse outcomes in patients with AF were significant FTR, presence of PH and high CHA₂DS₂-VASc score (OR = 5.23, 2.23 and 1.60, respectively).

Conclusions

Significant FTR was common in patients with AF, and independently associated with adverse outcomes. Thus, comprehensive echocardiographic assessment of FTR in patients with AF and preserved LVEF is fundamental in determining the optimal management.

Tricuspid Valve Anterior Leaflet Strains in Ovine Functional Tricuspid Regurgitation

Functional tricuspid regurgitation (FTR) is thought to arise due to annular dilation and alteration of right ventricular (RV) geometry in the presence of normal leaflets, yet mitral leaflets have been shown to remodel significantly in functional mitral regurgitation. We set out to evaluate tricuspid valve anterior leaflet deformations in ovine FTR. Eleven animals (FTR group) underwent implantation of a pacemaker with high rate pacing to induce biventricular dysfunction and at least moderate TR. Subsequently, both FTR (n = 11) and Control (n = 12) animals underwent implantation of 6 sonomicrometry crystals around the tricuspid annulus, 4 on the anterior leaflet, and 14 on RV epicardium. Tricuspid valve geometry and anterior leaflet strains were calculated from crystal coordinates. Left ventricular ejection fraction and RV fractional area change were significantly lower in FTR animals versus Control. Tricuspid annular area, septo-lateral diameter, RV pressures were all significantly greater in the FTR group. Mean TR grade (+0-3) was 0.7 ± 0.5 in Control and 2.4 ± 0.5 in FTR (P = < 0.001). The anterior leaflet area and length increased significantly. Global radial leaflet strain was significantly lower in FTR mostly driven by decreased free edge leaflet strain. Global circumferential anterior leaflet strain was also significantly lower in FTR with more remarkable reduction in the belly region. Rapid ventricular pacing in sheep resulted in a clinically pertinent model of RV and annular dilation with FTR and leaflet enlargement. Both circumferential and radial anterior leaflet strains were significantly reduced with FTR. Functional TR may be associated with alteration of leaflet mechanical properties.

Unsolved questions in prophylactic tricuspid valve repair and the possible role of transcatheter tricuspid intervention

Tricuspid regurgitation progression after left-sided surgery and its correlation with worse postoperative and long-term outcomes is a highly debated topic. Some studies support prophylactic tricuspid repair based on annulus dimension rather than on tricuspid regurgitation severity only, while others are in favor of a more conservative management. Furthermore, the advent of percutaneous tricuspid valve intervention and its promising short-term outcomes has introduced a new factor to be taken into account on the tricuspid intervention decision-making process. We present a review on prophylactic tricuspid valve intervention, covering currently available data, as well as the role of transcatheter tricuspid valve intervention in this equation.

Sex-Related Differences in the Mechanism of Functional Tricuspid Regurgitation

BACKGROUND

Predictive factors of significant functional tricuspid regurgitation (FTR) are not completely understood. We investigated sex-related differences in predictors of FTR progression.

METHOD

Clinical and echocardiographic variables were recorded in a prospective single-centre observational cohort of 251 consecutive stable patients with FTR. Multivariable logistic regression analyses stratified by sex were performed to identify predictors of significant FTR.

RESULTS

The mean age of the whole cohort was 72.2±11.4 years, and 133 (53%) patients were women. Females tended to have a higher prevalence of significant FTR (22.6% vs 13.6%; p=0.066). Women were also older than men (mean age 74.4 vs 69.6 years; p<0.001), with more frequent history of arterial hypertension, worse New York Heart Association functional class, higher E/e' quotient, and higher left ventricular ejection fraction. The independent predictors of significant FTR in women were atrial fibrillation (AF) (odds ratio [OR] 10.8, 95% confidence interval [CI] 2.9-40.7; p<0.001), indexed tricuspid diameter annulus (OR 1.24, 95% CI 1.04-1.47; p=0.017), and pulmonary artery systolic pressure (PASP) (OR 1.09, 95% CI 1.04-1.15; p=0.001). The independent predictors of outcome in men were indexed tricuspid tenting height (OR 2.71, 95% CI 1.20-6.11; p=0.016), indexed tricuspid diameter annulus (OR 1.98, 95% CI 1.26-3.09; p=0.003), and PASP (OR 1.08, 95% CI 1.01-1.16; p=0.021).

CONCLUSIONS

The presence of AF and longer indexed tenting height convey a greater risk of significant FTR in females and males, respectively. These findings suggest the existence of different physiopathological mechanisms involved in the progression of FTR in both sexes.

Right-sided double valve replacement in an adult patient who underwent surgery for pulmonary stenosis in childhood: a case report

BACKGROUND

Pulmonary regurgitation and the subsequent functional tricuspid regurgitation are frequently observed in adult patients who previously underwent pulmonary valvular operations. Pulmonary valve replacement, in combination with tricuspid annuloplasty, is frequently performed in adult patients. However, postoperative worsening or recurrence of tricuspid regurgitation is a major concern after pulmonary valve replacement with tricuspid annuloplasty.

CASE PRESENTATION

Herein, we describe the case of a 56-year-old woman with severe pulmonary regurgitation and functional tricuspid regurgitation after congenital pulmonary stenosis surgery in childhood. Functional tricuspid regurgitation was due to tricuspid annular dilatation, marked right ventricle enlargement, and significant tethering. We performed a bioprosthetic double valve replacement, and the postoperative course was uneventful. The patient is doing well one year after the surgery without prosthetic valve dysfunction.

CONCLUSIONS

When functional tricuspid regurgitation is severe and is associated with right ventricular dilatation and subsequent tethering, tricuspid valve replacement rather than annuloplasty should be considered.

Functional Tricuspid Regurgitation and Atrial Fibrillation: Which Comes First, the Chicken or the Egg?

•

3D echo is key to understand the pathophysiology of FTR.

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AF may be the primary cause of FTR through right atrial (RA) and TA remodeling.

•

In some patients, restoring the sinus rhythm is associated with improvement of FTR.

•

Our findings reinforce the concept of the atriogenic FTR.

•

Aggressive rhythm control in patients with AF seems to prevent RA and TA remodelling.

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.

Transcatheter Tricuspid Valve Interventions: An Emerging Field

PURPOSE OF REVIEW

This review aims to provide an updated overview and a clinical perspective on novel transcatheter tricuspid valve interventions (TTVI), highlighting potential challenges and future directions.

RECENT FINDINGS

Severe tricuspid regurgitation (TR) is a predictor of mortality. However, a sizeable number of patients remain untreated until the end-stage when cardiac surgery presents a prohibitive risk. The emergent need in finding a treatment for patients with TR, deemed for surgery options, has encouraged the development of TTVI. These procedures mimic classical surgery techniques and are mainly divided in four categories: annuloplasty and coaptation devices, edge-to-edge techniques and transcatheter tricuspid valve replacement. Early studies showed promising results, but long-term follow-up data are not available. For patients with severe TR and high surgical risk, several percutaneous options are available. However, these therapies are in a growing phase and bigger studies and long term follow-up are needed to prove their efficacy.

Functional tricuspid regurgitation and recurrent admissions in patients with acute heart failure

BACKGROUND

Functional tricuspid regurgitation (TR) is a common echocardiographic finding in patients with heart failure (HF), and its role in disease progression and prognosis stratification is becoming increasingly relevant in recent years. However, data regarding its association with the burden of HF-readmission is scarce. In this work, we sought to evaluate the association between TR severity and HF-related readmissions following a hospitalization for acute heart failure (AHF).

METHODS

We prospectively included a cohort of 2101 patients admitted with the diagnosis of AHF. TR severity was assessed using a multiparametric integrative approach, and classified as none, mild, moderate, and severe. We used negative binomial regression to identify the association between TR grade and HF-related recurrent admissions. The risk associated to severity of TR was expressed as incidence rate ratio (IRR).

RESULTS

At a median follow-up of 2.53 years (IQR: 1.03-4.36), 978 (46.5%) patients died, and 1657 HF-readmissions occurred in 842 patients (40.0%). The proportion of patients with two or more admissions was 18.4%. The proportion of patients with moderate to severe TR was 17.2%. There was a stepwise increase in the incidence of readmissions from none to severe TR. After multivariable adjustment, only patients with severe TR were independently associated with higher risk of recurrent HF admissions (IRR = 1.34, CI 95%: 1.05-1.71; p = .019).

CONCLUSIONS

In patients with AHF, severe functional TR is independently associated with an increased risk of long-term recurrent HF hospitalizations.

Suture dehiscence and collagen content in the human mitral and tricuspid annuli

Postoperative suture dehiscence is an important mode of short-term mitral and tricuspid valve (MV, TV) repair failure. We sought to evaluate suture pullout forces and collagen density in human atrioventricular valves for a better understanding of the comparative physiology between the valves and the underlying mechanobiological basis for suture retention. Mitral and tricuspid annuli were each excised from hearts from human donors age 60-79 with no history of heart disease (n = 6). Anchor sutures were vertically pulled until tearing through the tissue. Suture pullout force (F_P) was measured as the maximum force at dehiscence. Subsequently, tissue samples from each tested suture position were evaluated for collagen content using a standard hydroxyproline assay. Among all mitral positions, no significant differences were detected among positions or regions with mean F_P values falling between 6.9 ± 2.6 N (posterior region) and 10.3 ± 4.7 N (anterior region). Among all tricuspid positions, the maximum F_P and minimum F_P were 24.0 ± 9.2 N (trigonal region) and 4.5 ± 2.6 N (anterior region). Although for the MV, a given sample's collagen content had no correlation to its corresponding F_P, the same relationship was significant for the TV. Further, the TV exhibited comparable F_P to the MV overall, despite a nearly 40% reduction in collagen content. These findings suggest that sutures placed in the trigonal region of the TV have higher pullout force than those placed along other segments of the annuli. Furthermore, there are likely differences in collagen orientation between the mitral and tricuspid annuli, such that collagen content strongly impacts F_P in one, but not the other.

Longitudinal echocardiographic and clinical follow-up of patients undergoing mitral valve surgery without concomitant tricuspid valve repair

Background

In patients with mild to moderate functional tricuspid regurgitation (TR) and absence of right ventricular dysfunction or tricuspid annulus (TA) dilatation, there is currently no indication for concomitant tricuspid valve (TV) repair during elective mitral valve (MV) surgery. However, long-term results are conflicting. Here, we sought to determine the clinical outcome of this cohort, the rate of TR progression after MV surgery and the role of MV aetiology.

Methods

Patients for elective MV surgery without concomitant TV repair were retrospectively analysed with longitudinal echocardiographic and clinical follow-up, focusing on TR progression and MV aetiology. Linear regression analysis was performed for change in TR at follow-up, using pre-determined variables and confounders.

Results

In total 204 patients without TV repair were analysed. Development of more than moderate TR after a median of 3.1 [1.6–4.6] years was rarely seen: only in 2 out of 161 patients (1.2%) with known TR grade at follow-up. Overall, median preoperative and late postoperative TR grade were equal (p = 0.116). Subanalysis showed no significant difference in MV aetiology subgroups. Preoperative TR grade and male gender were inversely correlated to change in TR. Mortality was not influenced by the 1‑year postoperative TR severity.

Conclusion

Our data showed that in a study population of patients with mild to moderate TR undergoing MV surgery without concomitant TV repair, significant late TR was rarely seen. Based on our study, it is safe to waive concomitant TV repair in this specific patient cohort.

Electronic supplementary material

The online version of this article (10.1007/s12471-018-1159-4) contains supplementary material, which is available to authorized users.

Long-Term Results of Tricuspid Annuloplasty Using MC3 Ring for Functional Tricuspid Regurgitation

BACKGROUND

This study aimed to evaluate the long-term results of tricuspid annuloplasty using the MC3 ring for functional tricuspid regurgitation (TR). Methods and Results: Between 2004 and 2014, 249 patients underwent tricuspid ring annuloplasty using the MC3 ring for functional TR (FTR). Main etiologies of FTR were left-sided valvular disease (n=211) and left-to-right shunt (n=34). Based on the interval between the operation and last echocardiographic scan, patients were divided into short-term and long-term follow-up groups. Mean follow-up duration was 84.4±37.1 months. Operative death occurred in 8 patients (3.2%). Predischarge echocardiography showed that both TR grade and systolic pulmonary artery pressure were significantly decreased compared with preoperative values, and these values were sustained during follow-up in both the short-term and long-term follow-up groups. There were no ring-related complications in either the postoperative or follow-up period, except for permanent pacemaker implantation in 2 patients. The freedom from TR ≥moderate and tricuspid valve (TV)-related events at 10 years were 92.1% and 92.8%, respectively. TV annular size was a risk factor for the recurrence of TR ≥moderate (P=0.001), and 42 mm was the cutoff value for predicting the recurrence of TR ≥moderate.

CONCLUSIONS

Tricuspid annuloplasty using the MC3 ring for FTR provides satisfactory early results that are sustained during long-term follow-up. Preoperative TV annular size was associated with the recurrence of TR ≥moderate.

Percutaneous tricuspid valve therapies: the new frontier

Moderate-to-severe tricuspid regurgitation (TR) affects ∼1.6 million patients in the USA, of whom only 8000 undergo tricuspid surgery annually; this results in an extremely large number of untreated patients with significant TR. Therefore, there is a large unmet clinical need for patients with severe TR who are not referred for conventional surgery, mainly due to expected high surgical risk. Percutaneous procedures are an attractive alternative to surgery for patients deemed to be high-risk surgical candidates. Whereas over the past few years, the development and clinical use of percutaneous approaches to the aortic valve and mitral valve have been widespread, few data are available about the feasibility and the efficacy of the percutaneous tricuspid valve treatment. This review will explore the available technologies, which are today under evaluation and the preliminary clinical results.

Engineering Analysis of Tricuspid Annular Dynamics in the Beating Ovine Heart

Functional tricuspid regurgitation is a significant source of morbidity and mortality in the US. Furthermore, treatment of functional tricuspid regurgitation is suboptimal with significant recurrence rates, which may, at least in part, be due to our limited knowledge of the relationship between valvular shape and function. Here we study the dynamics of the healthy in vivo ovine tricuspid annulus to improve our understanding of normal annular deformations throughout the cardiac cycle. To this end, we determine both clinical as well as engineering metrics of in vivo annular dynamics based on sonomicrometry crystals surgically attached to the annulus. We confirm that the tricuspid annulus undergoes large dynamic changes in area, perimeter, height, and eccentricity throughout the cardiac cycle. This deformation may be described as asymmetric in-plane motion of the annulus with minor out-of-plane motion. In addition, we employ strain and curvature to provide mechanistic insight into the origin of this deformation. Specifically, we find that strain and curvature vary considerable across the annulus with highly localized minima and maxima resulting in aforementioned configurational changes throughout the cardiac cycle. It is our hope that these data provide valuable information for clinicians and engineers alike and ultimately help us improve treatment of functional tricuspid regurgitation.

Caval Valve Implantation

Recently, transcatheter therapy has expanded the treatment options for patients with heart valve disease. With the growing understanding of tricuspid regurgitation and its natural history, it becomes increasingly obvious that this patient population is a heterogeneous cohort presenting for treatment in different stages of a continuous disease process. It is still unclear which interventional approach will result in functional and clinical success and in which subtype of patient population. This article reviews the pathophysiologic background and current evidence for caval valve implantation and examines the potential role of this approach for the treatment of severe tricuspid regurgitation.

Revisit of Functional Tricuspid Regurgitation; Current Trends in the Diagnosis and Management

Current knowledge of functional tricuspid regurgitation (FTR) as a progressive entity, worsening the prognosis of patients irrespective of its aetiology, has led to renewed interest in the pathophysiology and assessment of FTR. For the proper management of FTR, not only its severity, but also the mechanisms, the mode of leaflet coaptation, the degree of tricuspid annulus enlargement and leaflet tenting, and the haemodynamic consequences for right atrial and right ventricular morphology and function have to be taken into account. A better assessment of the anatomy and function of tricuspid apparatus and tricuspid regurgitation severity should help with the appropriate selection of patients who will benefit from either surgical tricuspid valve repair/replacement or a percutaneous procedure, especially among patients who are to undergo or have undergone primary left-sided valvular surgery. In this article, we review the anatomy, pathophysiology and the use of imaging techniques to assess patients with FTR, as well as the various treatment options for FTR, including emerging transcatheter procedures. The limitations affecting the current approach to FTR patients and the unmet clinical needs for their management have also been discussed.

Clinical and echocardiographic results of the Kalangos biodegradable tricuspid ring for moderate and severe functional tricuspid regurgitation treatment

INTRODUCTION

The Kalangos Biodegradable Tricuspid Ring (Kalangos Biodegradable Tricuspid Ring®, Bioring SA, Lonay, Switzerland) is a biodegradable prothesis in the treatment of functional tricuspid regurgitation (FTR). In this study, we aimed to determine the clinical and echocardiographic results of this prosthesis for moderate and severe FTR treatment and compare this technique with the results of semicircular DeVega annuloplasty.

MATERIALS AND METHODS

From January 2005 through January 2010 we retrospectively studied the data on 64 consecutive patients underwent annuloplasty procedures for FTR treatment. The patients were assigned to 2 groups: (1) Kalangos BTR annuloplasty was performed in 32 patients, and (2) Semicircular DeVega annuloplasty was performed in the 32 patients. All patients were evaluated clinically and by echocardiography preoperatively, at the end of the 1st week, 3rd and 6th month following surgery.

RESULTS

No complications related to the prosthesis or the procedures within the follow-up period were recorded. At the follow-up period, systolic pulmonary arterial pressure and tricuspid valve area diameter were found to be significantly lower than the preoperative values in both groups (p < 0.0001). At the follow-up period residual tricuspid regurgitation and the Tei index (Myocardial performance index) was significantly lower in group 1 compared to group 2 (p < 0.05). Three-quarters of the annuloplasty ring had degraded in the postoperative 6-months period.

DISCUSSION

We conclude that Kalangos BTR is an efficient and safe prosthesis with easy implantation technique for FTR treatment, with encouraging midterm results.

Efficiency of different annuloplasty in treating functional tricuspid regurgitation and risk factors for recurrence

Background

Functional tricuspid regurgitation (FTR) is frequent in patients with mitral valve disease. Untreated tricuspid regurgitation (TR) may cause poor clinical outcomes. The surgical factors involved in annuloplasty for FTR remain controversial. Our objective was to compare effectiveness of different tricuspid annuloplasty (TVP), and reveal the risk factors of recurrence.

Methods

We analyzed the clinical details of 399 consecutive patients who underwent mitral surgery with concomitant TVP, from 2006 to 2011, in two Chinese single-centers. Three methods were used for TVP: De Vega surgery was completed in 242 patients; annuloplasty using a flexible band was completed in 98 patients; and surgery with a rigid ring was performed in 59 patients.

Results

The operative mortality rate was 2.3%. After surgery, the TR grade of all patients decreased significantly. At three years postoperatively, 13.7% of patients were diagnosed with recurrent FTR. At the three year time point, severe TR in the De Vega group was 18%, which was higher than those in the flexible (8.4%) and rigid planner ring groups (5.2%). During follow-up, the recurrent rates in the rigid group were significantly lower than in the flexible group. Multivariate analysis revealed that pre-operative atrial fibrillation, severe TR, large left atrial, ejection fraction (EF) < 40%, De Vega annuloplasty, and postoperative permanent pacemaker installation were independent risk factors for severe recurrent TR.

Conclusions

Rigid ring annuloplasty efficaciously improved post-operative tricuspid valve function in patients with FTR. Atrial fibrillation, a large left atrium, low EF and postoperative permanent pacemaker installation were independent risk factors for severe recurrent TR.

The tricuspid valve in adult congenital heart disease

The tricuspid valve is frequently affected in adults with congenital heart disease but is also frequently overlooked. Disease of this valve can occur primarily or develop secondary to changes in the right ventricle caused by other disease states. The embryology and anatomy of the tricuspid valve are important to understanding pathogenesis of valve dysfunction in congenital heart disease. Clinical findings can be subtle. Multimodality imaging may be necessary to fully assess the cause and impact of tricuspid valve lesions. More research is needed in pathophysiology, imaging, and treatment in this area.

Adjustable tricuspid annuloplasty

The methods for repairing functional tricuspid regurgitation (TR) are still controversial. A novel concept of tricuspid annuloplasty for functional TR was developed. A flexible annuloplasty band, through which an expanded polytetrafluoroethylene (ePTFE) thread (CV3) was passed inside the cover cloth, was secured to the tricuspid annulus. Both ends of the ePTFE thread were passed through the right atrial wall. The thread was snared from outside the ejecting heart under observation by a transoesophageal echocardiogram after weaning off the cardiopulmonary bypass. We used this technique in 11 patients with functional TR (mean TR grade: 3.4 ± 0.8). The mean circumference of the annulus after snaring was 86.5 ± 4.6 mm (diameter 27.6 ± 1.5 mm). The postoperative TR at discharge was trivial or 0 in 9 patients and Grade 1 in 2. We concluded that this method has the potential to minimize residual regurgitation.

Functional tricuspid regurgitation: an underestimated issue

This review article focuses on functional tricuspid regurgitation (FTR) that has long been a neglected and underestimated entity. FTR is defined as leakage of the tricuspid valve during systole in the presence of structurally normal leaflets and chordae. FTR may be secondary to several heart diseases, more commonly mitral valve disease, pulmonary hypertension, atrial fibrillation, cardiomyopathies, right ventricular dysplasia, and idiopathic annular dilatation. The reported prevalence of moderate or greater FTR is roughly 16%, but it rises up to 89% when considering FTR of any grade. According to the recommendations of the European Association of Echocardiography, two-dimensional transthoracic echocardiography (TTE) is the first-line imaging modality for the assessment of valvular regurgitation, whereas three-dimensional TTE may provide additional information in patients with complex valve lesions. Transesophageal echocardiography may be used when TTE results are inconclusive. The natural history of FTR is unfavorable, even in less than severe tricuspid regurgitation. Data from the literature suggest that moderate or greater FTR is a risk factor for worse survival. In addition, FTR of any grade may worsen over time, which makes it reasonable to consider the correction of FTR at an early stage, preferably at the time of mitral valve surgery. Tricuspid valve annuloplasty is the gold standard surgical treatment for FTR and is associated with a recurrence rate, defined as postoperative moderate or severe FTR, ranging from 2.5 to 5.5% at 1-year follow-up.