Prognostic Value of a New Right Ventricular-to-Pulmonary Artery Coupling Parameter Using Right Ventricular Longitudinal Shortening Fraction in Patients Undergoing Transcatheter Aortic Valve Replacement: A Prospective Echocardiography Study

Introduction: Right-ventricular-to-pulmonary artery (RV-PA) coupling, measured as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP), has emerged as a predictor factor in patients undergoing transcatheter aortic valvular replacement (TAVR). Right ventricular longitudinal shortening fraction (RV-LSF) outperformed TAPSE as a prognostic parameter in several diseases. We aimed to compare the prognostic ability of two RV-PA coupling parameters (TAPSE/PASP and the RV-LSF/PASP ratio) in identifying MACE occurrences. Method: A prospective and single-center study involving 197 patients who underwent TAVR was conducted. MACE (heart failure, myocardial infarction, stroke, and death within six months) constituted the primary outcome. ROC curve analysis determined cutoff values for RV-PA ratios. Multivariable Cox regression analysis explored the association between RV-PA ratios and MACE. Results: Forty-six patients (23%) experienced the primary outcome. No significant difference in ROC curve analysis was found (RV-LSF/PASP with AUC = 0.67, 95%CI = [0.58-0.77] vs. TAPSE/PASP with AUC = 0.62, 95%CI = [0.49-0.69]; p = 0.16). RV-LSF/PASP < 0.30%.mmHg-1 was independently associated with the primary outcome. The 6-month cumulative risk of MACE was 59% (95%CI = [38-74]) for patients with RV-LSF/PASP < 0.30%.mmHg-1 and 17% (95%CI = [12-23]) for those with RV-LSF/PASP ≥ 0.30%.mmHg-1; (p < 0.0001). Conclusions: In a contemporary cohort of patients undergoing TAVR, RV-PA uncoupling defined by an RV-LSF/PASP < 0.30%.mmHg-1 was associated with MACE at 6 months.

Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery

Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.

The causality between obstructive sleep apnea and ventricular structure and function: a bidirectional Mendelian randomization study

Background: Multiple observational studies have discovered a substantial link between obstructive sleep apnea (OSA) and ventricular dysfunction. However, conventional observational studies are vulnerable to causal reversal and confounding, making it challenging to infer the causes of effects and their direction. Methods: With the help of a bidirectional, two-sample Mendelian randomization (MR) study, we assessed the potential causality between OSA and left and right ventricular (LV, RV) structure and function. We conducted our analysis utilizing summary data from genome-wide association studies of OSA (16,761 cases and 201,194 controls) in the FinnGen Study, as well as LV (36,041 participants) and RV (29,506 participants) in the UK Biobank cardiovascular magnetic resonance research. The inverse variance weighted (IVW) was selected as the main strategy, with the MR-Egger and weighted median methods serving as supplements. Other methods were employed as sensitivity analysis tools to look at heterogeneity and pleiotropy, including MR-Egger intercept, Cochran Q statistic, MR-PRESSO, and leave-one-out analysis. Results: In the primary IVW analysis, genetically predicted OSA was strongly causative on LV end-diastolic volume (β = 0.114, 95% CI = 0.034-0.194, p = 0.006) and LV stroke volume (β = 0.111, 95% CI = 0.031-0.191, p = 0.007), and genetically predicted LV ejection fraction was linked to an increased risk of OSA (OR = 1.161, 95% CI = 1.029-1.309, p = 0.015). However, there was no connection found between OSA and any RV parameters. Conclusion: Our genetic analysis raises a potential causative link between OSA and ventricular structure and function, which may improve the knowledge of OSA as a risk factor for cardiovascular disease by demonstrating a direct impact on cardiac structure and function.

An inflammatory granuloma in right ventricular: Preliminarily diagnosed by echocardiography

Inflammatory granuloma is a rare non neoplastic benign disease that rarely reported in the heart tissue, and surgical resection is the final treatment with satisfactory results. Hereinafter, we report a case of inflammatory granuloma in the right ventricle of a 25-year-old man who underwent multimodality imaging and successful resection of the mass. Results of the case suggested that when evaluating patients with cardiac mass in unusual locations, it was necessary to comprehensively consider multiple imaging features and combine laboratory examination to make clinical suspicion.

Right Ventricular Function and Pulmonary Coupling in Patients With Heart Failure and Preserved Ejection Fraction

BACKGROUND

Limited data exist to characterize novel measures of right ventricular (RV) function and the coupling to pulmonary circulation in patients with heart failure and preserved left ventricular ejection fraction (HFpEF).

OBJECTIVES

This study sought to assess the clinical implications of RV function, the association with N-terminal pro-B-type natriuretic peptide, and the risk for adverse events among patients with HFpEF.

METHODS

This study analyzed measures of RV function by assessing absolute RV free wall longitudinal strain (RVFWLS) and its ratio to estimated pulmonary artery systolic pressure (PASP) (RVFWLS/PASP ratio) in 528 patients (mean age 74 ± 8 years, 56% female) with adequate echocardiographic images quality enrolled in the PARAGON-HF trial. Associations with baseline N-terminal pro-B-type natriuretic peptide and with total HF hospitalizations and cardiovascular death were assessed, after accounting for confounders.

RESULTS

Overall, 311 patients (58%) had evidence of RV dysfunction, defined as absolute RVFWLS <20%, and among the 388 patients (73%) with normal tricuspid annular planar systolic excursion and RV fractional area change, more than one-half showed impaired RV function. Lower values of RVFWLS and RVFWLS/PASP ratios were significantly associated with higher circulating N-terminal pro-B-type natriuretic peptide. With a median follow-up of 2.8 years, there were 277 total HF hospitalizations and cardiovascular deaths. Both absolute RVFWLS (HR: 1.39; 95% CI: 1.05-1.83; P = 0.018) and RVFWLS/PASP ratio (HR: 1.43; 95% CI: 1.13-1.80; P = 0.002) were significantly associated with the composite outcome. Treatment effect of sacubitril/valsartan was not modified by measures of RV function.

CONCLUSIONS

Worsening RV function and its ratio to pulmonary pressure is common and significantly associated with an increased risk of HF hospitalizations and cardiovascular death in patients with HFpEF. (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).

The Role of Strain by Cardiac Magnetic Resonance Imaging in Predicting the Prognosis of Patients with Chronic Thromboembolic Pulmonary Hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by thrombotic obstruction of the pulmonary arteries, and right ventricular (RV) dysfunction is a major cause of death. Cardiac magnetic resonance (CMR) is the gold standard for assessing heart wall deformation; therefore, we aimed to determine the prognostic value of CMR strain in patients with CTEPH. Strain derived by CMR was measured at the time of diagnosis in 45 patients with CTEPH, and the relationship between RV strain and prognosis was determined through follow-up. The value of RV strain in the prognostic model was compared with that of pulmonary arterial hypertension (PAH) risk stratification. The RV global peak longitudinal strain (GLS) and global peak circumferential strain (GCS) in CTEPH patients were lower than the normal references of RV strain in the control group. GLS and longitudinal strain in the basal segment were independent risk factors for adverse events (P < .050). Adding CMR parameters to PAH risk stratification improved its predictive power in patients with CTEPH. GLS and GCS scores were impaired in patients with chronic RV overload. RV strain derived by CMR imaging is a promising noninvasive tool for the follow-up of patients with CTEPH.

Maternal Right Ventricular and Left Atrial Function in Uncomplicated Twin Pregnancies: A Longitudinal Study

Objective: The knowledge regarding maternal cardiovascular hemodynamic adaptation in twin pregnancies is incomplete. We performed a longitudinal investigation of maternal right ventricular (RV) and left atrial (LA) function in a cohort of uncomplicated twin pregnancies compared to singleton pregnancies. Study design: Healthy women with uncomplicated twin pregnancies were prospectively enrolled and assessed by transthoracic echocardiography at 10−15 weeks’ (w) gestation (T1), 19-26 w gestation (T2), and 30−38 w gestation (T3). Subjects with uneventful singleton pregnancies were selected as controls at the same gestational ages. Cardiac findings were compared to those of women with uneventful singleton gestations. RV systolic and diastolic functions were assessed by conventional echocardiography (FAC, TAPSE, sPAP, E, A, DT) and tissue Doppler imaging (TDI) (E’, A’, S’, IVA, IVCT, IVRT, ET, MPI), and LA dimensions were calculated. Speckle-tracking imaging was also applied to evaluate RV global longitudinal strain and LA 2D strains (at LV end-systole (LAS) and at atrial contraction (LAA)). Results: Overall, 30 uncomplicated twin and 30 uncomplicated singleton pregnancies were included. Regarding maternal RV function in twins, all the parameters (FAC, TAPSE, sPAP, E, A, E/A, DT, E/E’, IVA, IVCT, MPI and 2D longitudinal strain) were almost stable throughout gestation, with the exception of the TDI findings (E’ decreased from T1 to T3 (p = 0.03), while E’/A’ increased from T1 to T2 and then decreased (p = 0.01); A’ and basal S’ increased (p = 0.04 and p = 0.03, respectively), while IVRT and ET significantly decreased (p = 0.009 and p = 0.007, respectively)). These findings were similar to those found for singleton pregnancies. LA dimensions significantly increased throughout gestation in both twins and singletons (p < 0.001), without intergroup difference. LA strains did not vary during either twin or singleton pregnancies, except for LAA in T1, which was higher among twins than among singletons. Conclusion: Maternal RV and LA function in uncomplicated twin pregnancies does not seem to undergo more significant changes than in singletons, being characterized by similar findings in RV systolic and diastolic functions, as well as LA dimensions and strains.

Epicardial adipose tissue and right ventricular function in type 2 diabetes mellitus using two-dimensional speckle tracking echocardiography

BACKGROUND

Epicardial adipose tissue is an emerging cardiovascular risk factor. The aim of this study was to evaluate right ventricular function and investigate its association with EAT in T2DM patients.

METHODS

154 T2DM patients were divided into two groups according to EAT thickness: T2DM with EAT <5 mm and T2DM with EAT ≥5 mm. Seventy non-T2DM patients were enrolled as control group. RV function was evaluated using both conventional echocardiography as well as two-dimensional speckle tracking echocardiography. EAT thickness was measured as the echo-free space between the free wall of the right ventricle and the visceral layer of pericardium at end-systole.

RESULTS

Compared to control group, EAT thickness was significantly higher and RV systolic function and early diastolic function are all impaired in all T2DM patients. In T2DM with EAT ≥5 mm group, RV systolic function and early diastolic function suffered more severe impairment when compared with T2DM with EAT <5 mm group. Multivariate linear regression analysis revealed that EAT was associated with RV systolic and early diastolic dysfunction independent of traditional cardiovascular risk factors.

CONCLUSIONS

Our research suggest that in T2DM patients RV systolic function and early diastolic function are all impaired which are associated with the thickened EAT.

Arrhythmogenic Right Ventricular Cardiomyopathy and Differential Diagnosis with Diseases Mimicking Its Phenotypes

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart muscle disease, which is characterized by fibro-fatty replacement of predominantly the right ventricle (RV). The disease can result in ventricular tachyarrhythmias and sudden cardiac death. Our understanding of the pathophysiology and clinical expressivity of ARVC has been continuously evolving. The diagnosis can be challenging due to its variable expressivity, incomplete penetrance and the lack of specific diagnostic criteria. Idiopathic RV outflow tract tachycardia, Brugada Syndrome, athlete’s heart, dilated cardiomyopathy, myocarditis, cardiac sarcoidosis, congenital aneurysms and diverticula may mimic clinical phenotypes of ARVC. This review aims to provide an update on the differential diagnosis of ARVC.

Celastrol attenuates the remodeling of pulmonary vascular and right ventricular in monocrotaline-induced pulmonary arterial hypertension in rats

BACKGROUND

Pulmonary arterial hypertension is a progressive angio-proliferative disease associated with high morbidity and mortality rates. Although the histopathology of pulmonary arterial hypertension is well described, its therapeutic option remains unsatisfactory. This study investigated the effect of celastrol treatment on right ventricular dysfunction, remodeling, and pulmonary vascular remodeling in pulmonary arterial hypertension rats as well as its possible mechanisms.

METHODS

Pulmonary arterial hypertension was induced in male Sprague-Dawley rats by a single subcutaneously injection of monocrotaline. After daily delivery of celastrol (1 mg/kg) or vehicle via intraperitoneal injection for 4 weeks, the effects of celastrol on right ventricular function, fibrosis, and pulmonary vascular remodeling were assessed. The infiltration of macrophages, the expression of inflammatory cytokines, including MCP-1, IL-1β, IL-6, and IL-10, and the expression of NF-κB signaling pathway-associated proteins, IκBα, p-IKKα/β and p65 were further detected. Finally, the effect of celastrol on human pulmonary artery smooth cells proliferation under hypoxia was studied in vitro.

RESULTS

Rats with pulmonary arterial hypertension had decreased right ventricular function, increased right ventricular fibrosis and pulmonary arteries with interstitial thickening and prominent media hypertrophy. Treatment with celastrol improved right ventricular function, attenuated right ventricular fibrosis and pulmonary vascular remodeling. Significantly decreased macrophage infiltration, reduced levels of pro-inflammatory cytokines, increased level of anti-inflammatory cytokine and inhibited NF-κB signaling pathway were observed in the lung tissues of rats treated with celastrol. Moreover, celastrol significantly suppressed the proliferation of human pulmonary artery smooth cells under hypoxia.

CONCLUSIONS

We showed that in rats with pulmonary arterial hypertension, celastrol could improve right ventricular function, attenuate right ventricular and pulmonary vascular remodeling, and inhibit human pulmonary artery smooth cells proliferation under hypoxia. Suppression of the nuclear factor-κB (NF-κB) signaling pathway may be a part of the protective mechanism.

Congestive Hepatopathy Secondary to Right Ventricular Hypertrophy Related to Monocrotaline-Induced Pulmonary Arterial Hypertension

Heart dysfunction and liver disease often coexist. Among the types of cardiohepatic syndrome, Type 2 is characterized by the chronic impairment of cardiac function, leading to chronic liver injury, referred to as congestive hepatopathy (CH). In this study, we aimed to establish a rat model of CH secondary to right ventricular hypertrophy (RVH) related to monocrotaline (MCT)-induced pulmonary arterial hypertension (PAH). Fifty male Wistar rats were divided into four groups and randomly assigned to control and experimental groups. Three experimental groups were submitted to intraperitoneal MCT inoculation (60 mg/kg) and were under its effect for 15, 30 and 37 days. The animals were then sacrificed, obtaining cardiac and hepatic tissues for anatomopathological and morphometric analysis. At macroscopic examination, the livers in the MCT groups presented a nutmeg-like appearance. PAH produced marked RVH and dilatation in the MCT groups, characterized by a significant increase in right ventricular free wall thickness (RVFWT) and chamber area. At histological evaluation, centrilobular congestion was the earliest manifestation, with preservation of the hepatocytes. Centrilobular hemorrhagic necrosis was observed in the groups exposed to prolonged MCT. Sinusoidal dilatation was markedly increased in the MCT groups, quantified by the Sinusoidal Lumen Ratio (SLR). The Congestive Hepatic Fibrosis Score and the Centrilobular Fibrosis Ratio (CFR) were also significantly increased in the MCT₃₀ group. Hepatic atrophy, steatosis, apoptotic bodies and, rarely, hydropic swelling were also observed. SLR correlated strongly with CFR and RVFWT, and CFR correlated moderately with RVFWT. Our rat model was able to cause CH, related to monocrotaline-induced PAH and RVH; it was feasible, reproducible, and safe.

First-in-Human Percutaneous Transcatheter Tricuspid Valve Replacement With a Novel Valve

The surgical intervention to treat isolated severe tricuspid regurgitation (TR) is challenging due to the severe TR patients' high-risk profile, hence associated with a high complication rate. Herein, we describe a first-in-human percutaneous deployment of a novel transcatheter prosthetic xenograft valve to treat severe TR. (Level of Difficulty: Advanced.).

Prognostic Value of Right Ventricular 3D Speckle-Tracking Strain and Ejection Fraction in Patients With HFpEF

Background: Right ventricular longitudinal strain of free wall (RV FWLS) assessed by two-dimensional speckle-tracking echocardiography (2D-STE) is recognized as an independent predictor of poor prognosis in patients with heart failure with preserved ejection fraction (HFpEF). However, the prognostic implications of three-dimensional STE (3D-STE) parameters in patients with HFpEF have not been well-established. The purpose of our study was to determine whether 3D-STE parameters were the more powerful predictors of poor outcomes in HFpEF patients compared with 2D-STE indices.

Methods: Eighty-one consecutive patients with HFpEF were studied by 2D-STE and 3D-STE. RV volumes, ejection fraction (EF) and 3D-RVFWLS were measured by 3D-STE. 2D-RVFWLS was determined by 2D-STE. Patients were followed for the primary end point of heart failure (HF)-related hospitalization and death for HF.

Results: After a median follow-up period of 17 months, 39 (48%) patients reached the end point of cardiovascular events. Compared with HFpEF patients without end-point events, those with end-point events had lower RVEF and 3D-RVFWLS (P < 0.05). Separate multivariate Cox regression analyses revealed that 3D-RVFWLS (HR 5.73; 95% CI 2.77–11.85; P < 0.001), RVEF (HR 3.47; 95% CI 1.47–8.21; P = 0.005), and 2D-RVFWLS (HR 3.17; 95% CI 1.54–6.53; P = 0.002) were independent predictors of adverse outcomes. The models with 3D-RVFWLS (AIC = 246, C-index = 0.75) and RVEF (AIC = 247, C-index = 0.76) had similar predictive performance for future clinical events as with 2D-RVFWLS (AIC = 248, C-index = 0.74).

Conclusions: 3D-STE parameters are powerful predictors of poor outcomes, providing a similar predictive value as 2D-STE indices in patients with HFpEF. These findings support the potential of RV 3D-STE to identify HFpEF patients at higher risk for adverse cardiac events.

QRS dispersion detected in ARVC patients and healthy gene carriers using 252-leads body surface mapping: an explorative study of a potential diagnostic tool for arrhythmogenic right ventricular cardiomyopathy

BACKGROUND

The diagnosis of ARVC remains complex requiring both imaging and electrocardiographic (ECG) techniques. The purpose was therefore to investigate whether QRS dispersion assessed by body surface mapping (BSM) could be used to detect early signs of ARVC, particularly in gene carriers.

METHODS

ARVC patients, gene carriers without a history of arrhythmias or structural cardiac changes and healthy controls underwent 12-lead resting ECG, signal-averaged ECG, echocardiographic examination, 24-hours Holter monitoring, and BSM with electrocardiographic imaging. All 252-leads BSM recordings and 12-leads ECG recordings were manually analyzed for QRS durations and QRS dispersion.

RESULTS

Eight controls, 12 ARVC patients with definite ARVC and 20 healthy gene carriers were included. The ECG-QRS dispersion was significantly greater in ARVC patients (42 vs. 25 ms, p < .05), but failed to fully differentiate them from controls. The BSM-derived QRS dispersion was also significantly greater in ARVC patients versus controls (65 vs. 29 ms, p < .05) and distinguished 11/12 cases from controls using the cut-off 40msec. The BSM derived QRS dispersion was abnormal (> 40 ms) in 4/20 healthy gene carriers without signs of ARVC, which may indicate early depolarization changes.

CONCLUSIONS

QRS dispersion, when assessed by BSM versus 12-lead ECG, seem to better distinguish ARVC patients from controls, and could potentially be used to detect early ARVC in gene carriers. Further studies are required to confirm the value of BSM-QRS dispersion in this respect.

Prognostic value of right ventricular dilatation in patients with COVID-19: a multicentre study

Aims

Although cardiac involvement has prognostic significance in coronavirus disease 2019 (COVID-19) and is associated with severe forms, few studies have explored the prognostic role of transthoracic echocardiography (TTE). We investigated the link between TTE parameters and prognosis in COVID-19.

Methods and results

Consecutive patients with COVID-19 admitted to 24 French hospitals were retrospectively included. Comprehensive data, including clinical and biological parameters, were recorded at admission. Focused TTE was performed during hospitalization, according to clinical indication. Patients were followed for a primary composite outcome of death or transfer to intensive care unit (ICU) during hospitalization. Among 2878 patients, 445 (15%) underwent TTE. Most of these had cardiovascular risk factors, a history of cardiovascular disease, and were on cardiovascular treatments. Dilatation and dysfunction were observed in, respectively, 12% (48/412) and 23% (102/442) of patients for the left ventricle, and in 12% (47/407) and 16% (65/402) for the right ventricle (RV). Primary composite outcome occurred in 44% (n = 196) of patients [9% (n = 42) for death without ICU transfer and 35% (n = 154) for admission to ICU]. RV dilatation was the only TTE parameter associated with the primary outcome. After adjustment, male sex [hazard ratio (HR) 1.56, 95% confidence interval (CI) 1.09 − 2.25; P = 0.02], higher body mass index (HR 1.10, 95% CI 1.02 − 1.18; P = 0.01), anticoagulation (HR 0.53, 95% CI 0.33 − 0.86; P = 0.01), and RV dilatation (HR 1.66, 95% CI 1.05 − 2.64; P = 0.03) remained independently associated with the primary outcome.

Conclusion

Echocardiographic evaluation of RV dilatation could be useful for assessing risk of severe COVID-19 developing in hospitalized patients.

Stent in left renal vein stuck at the opening of tricuspid valve

A 41-year-old male patient attended the hospital suffering from chest tightness and intermittent chest pain. Through cardiac ultrasonography, a metallic foreign body was found in the right ventricle, accompanied by tricuspid insufficiency. Chest computed tomography scan further confirmed a foreign body stuck at the opening of the tricuspid valve. The 14 × 40mm stent was removed from the right ventricular through thoracotomy. One month ago, the patient received left renal venous stenting for treatment of Nutcracker Syndrome. Thus, for patients who have received left renal venous stenting for treatment of Nutcracker Syndrome, clinicians should pay due attention to stent-graft migration.

Umbilical Artery Doppler Patterns and Right Ventricular Outflow Abnormalities in Twin-Twin Transfusion Syndrome

OBJECTIVES

To evaluate the association of abnormal Doppler velocimetric patterns in the umbilical arteries (UAs) and right ventricular outflow tract abnormalities (RVOTAs) in twin- twin transfusion syndrome (TTTS) cases.

METHODS

This retrospective study involved women who had laser surgery for TTTS between January 2012 and May 2018 at a single institution. The prevalence of an RVOTA in either twin was compared among TTTS cases in which both twins had positive end-diastolic flow (EDF) in the UA and those in which either twin had intermittent or persistent absent/reversed UA EDF. Nonparametric tests were used for comparisons. Logistic regression was performed to identify variables associated with an RVOTA in either twin, adjusted for moderate or severe tricuspid regurgitation, right ventricular hypertrophy, right ventricular systolic or diastolic dysfunction, the Quintero stage, and other confounders. P < .05 was considered significant.

RESULTS

A total of 126 consecutive TTTS cases were included. Right ventricular outflow tract abnormalities were seen in 8.7% (11of 126) of cases, all in recipient twins. Significant differences in the rate of RVOTAs in the recipient twin were seen between TTTS cases with intermittent absent/reversed UA EDF and those with positive UA EDF (26.9% [7 of 26] versus 3.7% [3 of 82]; P = .002]. However, no significant differences were noted among the other study groups. Intermittent absent/reversed UA EDF was associated with a significantly increased risk for an RVOTA (adjusted odds ratio, 20.6 [95% confidence interval, 3.1-138]; P = .002) after adjusting for confounders.

CONCLUSIONS

Intermittent changes in vascular impedance to UA flow may contribute to the pathogenesis of acquired right-sided cardiac lesions in the recipient twin affected with TTTS.

Preexisting Right Ventricular Diastolic Dysfunction and Postoperative Cardiac Complications in Patients Undergoing Nonemergency Coronary Artery Bypass Surgery

OBJECTIVES

To evaluate whether the presence of preexisting right ventricular diastolic dysfunction (RVDD) in patients undergoing coronary artery bypass grafting (CABG) is associated with a greater incidence of postoperative cardiac complications.

DESIGN

Single-center, observational, retrospective, cohort study.

SETTING

Research institute hospital.

PARTICIPANTS

Patients undergoing CABG from February 2017 to November 2018 (n = 200).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Transthoracic echocardiography was performed to obtain the following values of right ventricular (RV) diastolic function: peak velocity of early (Et) and late (At) transtricuspid flow, e't, a't, s't, tricuspid annular plane systolic excursion, and the RV Tei index. All patients were divided into the following 2 groups: with RVDD (n = 92) or without RVDD (n = 108). Compared with control patients, the patients with RVDD developed postoperative heart failure (PHF) (primary outcome) more frequently (p = 0.026). RVDD, low left ventricular ejection fraction, were female, underwent cardiopulmonary bypass, increased left ventricular mass index, and an Et/At ratio that increased the risk of the development of PHF. However, only RVDD (odds ratio 4.82; p = 0.015), cardiopulmonary bypass (odds ratio 4.04; p = 0.028), and female sex were associated independently with the development of PHF in the multivariate analyses.

CONCLUSIONS

Preoperative RVDD, cardiopulmonary bypass, and female sex are independent risk factors for the development of PHF after CABG in coronary artery disease patients. The decreased Et/At ratio was the best echocardiographic marker predicting PHF development after CABG. Nevertheless, the possibility of assessing preoperative diastolic RV function to predict the development of PHF after CABG requires confirmation in additional studies.

Drag-reducing polymers attenuates pulmonary vascular remodeling and right ventricular dysfunction in a rat model of chronic hypoxia-induced pulmonary hypertension

Drag-reducing polymers (DRPs) was previously demonstrated to increase blood flow, tissue perfusion, and reduce vascular resistance. The purpose of this study was to investigate the effect of DRPs on pulmonary vascular remodeling and right ventricular dysfunction in a rat model of chronic hypoxia-induced pulmonary hypertension (HPH). A total of forty male Wistar rats were randomly and equally assigned into four experimental groups (Group I: normoxia + saline, Group II: normoxia + PEO, Group III: hypoxia + saline, Group IV: hypoxia + PEO) and maintained in normoxia (21% O2) or hypobaric hypoxia (10% O2). After four weeks, comparisons were made of the following aspects: the mean pulmonary arterial pressure (mPAP), right ventricular systolic pressure (RVSP), right ventricular hypertrophy, wall thickness of pulmonary trunk and arteries, internal diameter of pulmonary arteries, cardiomyocyte cross-sectional area (CM CSA), and ultrastructure of right ventricular. Treatment with PEO in Group IV attenuated the increases in RVSP and mPAP (40.5±7.2 and 34.7±7.0 mmHg, respectively, both P < 0.05), compared with Group III. Distal vascular remodeling was visible as a significant increase in medial wall thickness (64.2±12.3% vs. 43.95±7.0%, P < 0.01) and a remarkable decrease in internal diameter of small pulmonary arteries (35.2±9.7μ m vs. 50.4±14.7μ m, P < 0.01) in Group III, to a greater extent than that detected in Group IV. Nevertheless, no significant histopathological differences in medial wall thickness was observed in pulmonary trunk between Group III and Group IV (P > 0.05), denoting that PEO chiefly attenuated the remodeling of small pulmonary arteries rather than main arteries in hypoxic environment. Infusion of DRPs (intravenous injection twice weekly) also attenuated the index of right ventricular hypertrophy, protected against the increase of cardiomyocyte cross-sectional area, and provided protection for cardiac ultrastructure. DRP treatment with intravenous injection elicited a protective effect against pulmonary vascular remodeling and right ventricular dysfunction in the rat model of HPH. DRPs may offer a new potential approach for the treatment of HPH, which may have theoretical significance and application value to society.

Right Ventricular Dysfunction Staging System for Mortality Risk Stratification in Heart Failure With Preserved Ejection Fraction

Right ventricular dysfunction (RVD) parameters are increasingly important features in heart failure with preserved ejection fraction (HFpEF). We sought to evaluate the prognostic impact of a progressive RVD staging system by combining the tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (TAPSE/PASP) ratio with functional tricuspid regurgitation (TR) severity. We prospectively included 1355 consecutive HFpEF patients discharged for acute heart failure (HF). Of them, in 471 (34.7%) patients, PASP could not be accurately measured, leaving the final sample size to be 884 patients. Patients were categorized as Stage 1: TAPSE/PASP ≥ 0.36 without significant TR; stage 2: TAPSE/PASP ≥ 0.36 with significant TR; stage 3: TAPSE/PASP < 0.36 without significant TR; and stage 4: TAPSE/PASP < 0.36 with significant TR. By the 1 year follow-up, 207 (23.4%) patients had died. We found a significant and graded association between RVD stages and mortality rates (15.8%, 25%, 31.2%, and 45.4% from stage 1 to stage 4, respectively; log-rank test, p < 0.001). After multivariable adjustment, and compared to stage 1, stages 3 and 4 were independently associated with mortality risk (HR: 1.8219; 95% CI 1.308–2.538; p < 0.001 and HR = 2.2632; 95% CI 1.540–3.325; p < 0.001, respectively). A RVD staging system, integrating TAPSE/PASP and TR, provides a comprehensive and widely available tool for risk stratification in HFpEF.

The Right Ventricle-You May Forget it, but It Will Not Forget You

Right ventricular (RV) dysfunction and failure are common and often overlooked causes of perioperative deterioration and adverse outcomes. Due to its unique pathophysiologic underpinnings, RV failure often does not respond to typical therapeutic measures such as volume resuscitation and often worsens when therapy is escalated and mechanical ventilation is begun, with a danger of irreversible cardiovascular collapse and death. The single most important factor in improving outcomes in the context of RV failure is anticipating and recognizing it. Once established, a vicious circle of systemic hypotension, and RV ischemia and dilation is set in motion, rapidly spiraling down into a state of shock culminating in multi-organ failure and ultimately death. Therapy of RV failure must focus on rapidly reestablishing RV coronary perfusion, lowering pulmonary vascular resistance and optimizing volemia. In parallel, underlying reversible causes should be sought and if possible treated. In all stages of diagnostics and therapy, echocardiography plays a central role. In severe cases of RV dysfunction there remains a role for the use of the pulmonary artery catheter. When these mostly simple measures are undertaken in a timely fashion, the spiral of death of RV failure can often be broken or even prevented altogether.

Graded balloon atrial septostomy for palliation of congenital pulmonary hypertension in a dog: A case report

CASE DESCRIPTION

A 6-month-old intact female Maltese dog was presented for acute onset of syncope.

CLINICAL FINDINGS

The dog was presented for collapse upon excitement and exercise. It collapsed at discharge and suffered cardiopulmonary arrest. Echocardiography after resuscitation indicated severe pulmonary hypertension without evidence of intracardiac or extracardiac shunting. A presumptive diagnosis of congenital pulmonary hypertension was made.

TREATMENT AND OUTCOME

Initial treatment with sildenafil was effective at relieving syncope, but the extent of pulmonary hypertension as determined by serial echocardiography was unchanged. Graded balloon atrial septostomy was performed as a palliative procedure. Follow-up echocardiography identified a patent interatrial communication with bidirectional shunting. The dog remained asymptomatic 18 months after treatment.

CLINICAL RELEVANCE

To the best of our knowledge, this study is the first report in the veterinary literature of graded balloon atrial septostomy performed for therapeutic purposes. Further studies are required to determine if this palliative procedure is a beneficial treatment option for dogs with congenital or severe refractory pulmonary hypertension.

Cardiac Magnetic Resonance Imaging (MRI) Findings in Arrhythmogenic Right Ventricular Dysplasia (ARVD) Compared with Echocardiography

Arrhythmogenic right ventricular dysplasia (ARVD) is an abnormality in the right side of the heart that may lead to sudden death. The study aims to compare cardiac MRI (magnetic resonance imaging findings) with echocardiography in patients with ARVD. For the cross-sectional study, patients with ARVD that were diagnosed using Task Force criteria were included, and their cardiac MRI findings were evaluated. Additionally, the right ventricle was divided into three levels-basal, middle, and apical-and each of them was also subdivided into three secondary segments. Gadolinium enhancement was evaluated in each segment. Overall, 39 patients were studied. Thirty-one patients (81%) were men. The average age of female and male patients was 37.8 ± 4.6 and 32.48 ± 5.8, respectively. The average ejection fraction found was 43 ± 9.4 and 42.8 ± 8.5% by MRI and echocardiography, respectively. Additionally, 46 and 35.8% of the patients had hypokinesia in the right ventricle, found based on MRI and echocardiography, respectively. The right ventricular aneurysm was found in 20.5 and 5.1% of patients based on MRI and echocardiography, respectively. The cardiac MRI managed to diagnose some cases which echocardiography was not able to detect. Thus, MRI plays an important role in presenting diagnostic data for the management of patients with ARVD and also making the diagnosis in suspicious patients definitive.

Right Ventricle Perforation Post Pacemaker Insertion Complicated with Cardiac Tamponade

Pacemaker-lead-associated right ventricular perforation is a life-threatening complication. Acute perforation usually presents within 24 hours. Patients with lead perforation are often asymptomatic but fatal complications like hemopericardium, leading to cardiac tamponade and death, are reported. Diagnosis is based on chest x-ray, computed tomography (CT) scan, and echocardiography. The management of the lead perforation is based on clinical presentation. Extraction is avoided in cases of chronic asymptomatic lead perforations because of the associated complications. Urgent intervention is needed in hemodynamically unstable patients with pericardial effusion or cardiac tamponade physiology.

Assessing right ventricular function in pulmonary hypertension patients and the correlation with the New York Heart Association (NYHA) classification

This investigation aimed to compare the pressure-volume loop (PV loop) measurements in three less symptomatic categories (New York Heart Association classes , NYHA I, II, and III) of pulmonary hypertension (PH) patients since NYHA classification system performance is limited by the shortcomings discussed above.

Thirty-six patients were enrolled in this study with PV loop measurement acquisition via micro-conductance catheters. Functional classification according to NYHA was determined with comprehensive assessing function and activity. Catheterization and MRI was applied to obtain variables on right ventricle (RV) functions. Correlation test was applied to test the relationship between measured PV loop measurements and NYHA classification.

A group of PV loop measurements, including end-systolic pressure (RVESP) RV end-diastolic pressure (RVEDP), and RV arterial elastance (RVEa), are well correlated with three NYHA classes (I, II, and III). Moreover, RVESP and RVEa significantly correlated with two groups of NYHA classes (I and II/III) while RVEDP, RV end-diastolic volume (RVEDV), and RV end-systolic volume (RVESV) significantly moderately correlated with two groups of NYHA classes (I/II and III). This study suggests the promising role of PV loop analysis in assessing functional capacity in progressive but less symptomatic PH patients.

A neonatal rat model of increased right ventricular afterload by pulmonary artery banding

OBJECTIVE

To construct a neonatal rat model of increased right ventricular (RV) afterload for studying the pathophysiological remodeling of the right ventricle in patients with congenital heart disease with increased RV afterload.

METHODS

Surgery was performed within 6 hours after birth. Horizontal thoracotomy was performed by dissecting the intercostal muscles and splitting the sternum. The PA was then banded with 11-0 nylon thread. At postnatal day 7 (P7), constriction of PA was confirmed by echocardiography. The RV systolic and diastolic pressures were measured by cardiac catheterization. The RV end-systolic volume, end-diastolic volume, end-diastolic diameter, and free wall thickness were assessed by magnetic resonance imaging. The histological changes in sham-operated and PA-banding (PAB) hearts were evaluated by hematoxylin and eosin staining.

RESULTS

Increased RV afterload was established by constriction of the PA in neonatal rats within 6 hours after birth. The survival rate was 75% at P7. Relative to the sham group, the peak pressure gradient across the PA constriction and RV systolic and diastolic pressures, end-systolic volume, end-diastolic volume, end-diastolic diameter, and free wall thickness were significantly increased in the PAB group at P7 (P < .01). Consistently, histological examination showed that the RV free wall was significantly hypertrophic in the PAB group.

CONCLUSIONS

We successfully established a neonatal RV afterload increase model through PAB within 6 hours after birth, which can be used to study the pathophysiological changes in congenital heart diseases with increased RV afterload.

A novel method for sensitive determination of subclinical right ventricular systolic dysfunction in patients with obstructive sleep apnea

OBJECTIVE

The aim of this study was to evaluate right ventricular (RV) regional systolic function and dyssynchrony in patients with newly diagnosed obstructive sleep apnea using real-time three-dimensional (3D) echocardiography.

METHODS

Eighty-two subjects without hypertension, diabetes mellitus or any cardiac or pulmonary disease referred for evaluation of obstructive sleep apnea (OSA) had overnight polysomnography and complete echocardiographic assessment. According to the apnea hypopnea index (AHI), subjects were divided into four groups: group 1: control subjects (AHI < 5, n = 19), group 2: patients with mild OSA (AHI: 5-14, n = 21), group 3: moderate OSA (AHI: 15-30, n = 18), group 4: severe OSA (AHI > 30, n = 24). Real-time three-dimensional echocardiographic images were acquired to obtain RV regional (inflow, body and outflow) ejection fraction (EF) and time to minimum systolic volume in all subjects.

RESULTS

Body weight and body mass index were greater in the severe and moderate OSA group than those of mild and controls group (P < 0.05). There was a significant decrease in mean SaO2 and the lowest SaO2 in severe OSA when compared to other groups (P < 0.001). Inflow EF and global EF were significantly lower in moderate and severe OSA patients than in controls (P < 0.05). Inflow EF and global EF were negatively correlated with AHI (r = -0.534 and r = -0.479, respectively, P < 0.001).

CONCLUSIONS

In patients with OSA, RV inflow and global systolic function were impaired and were in inverse relationship with AHI. Evaluation of RV regional systolic function using real-time three-dimensional echocardiography may play a potential role in the noninvasive assessment of the severity of OSA.

Inhibition of kinin B1 receptors attenuates pulmonary hypertension and vascular remodeling

This study examined whether the kinin B1 receptor is involved in the pathogenesis of pulmonary hypertension, and whether its inhibition could reduce inflammation, pulmonary hypertension, vascular remodeling, and right heart dysfunction. Male Wistar rats underwent left pneumonectomy. Seven days later, the rats were injected subcutaneously with monocrotaline (60 mg/kg). The rats were then randomly assigned to receive treatment with vehicle or with BI113823 (a selective B1 receptor antagonist, 30 mg/kg, twice per day) via oral gavage from the day of monocrotaline injection to day 28. By day 28, BI113823-treated rats had significantly lower mean pulmonary artery pressure, less right ventricular hypertrophy, and pulmonary arterial neointimal formation than that of the vehicle-treated rats. Real-time polymerase chain reaction revealed that there was a significant increase in mRNA expression of B1 receptors in the lungs of monocrotaline-challenged pneumonectomized rats. Treatment with BI113823 significantly reduced macrophage recruitment, as measured via bronchoalveolar lavage. It also markedly reduced CD-68 positive macrophages and proliferating cell nuclear antigen positive cells in the perivascular areas, reduced expression of inducible nitric oxide synthase, matrix metalloproteinase 2 and 9, and B1 receptors compared with measurements in vehicle-treated rats. These findings demonstrate that kinin B1 receptors represent a novel therapeutic target for pulmonary arterial hypertension.

Treatment goals of pulmonary hypertension. J Am Coll Cardiol. 2013;62:D73-D81. [PMID: 24355644 DOI: 10.1016/j.jacc.2013.10.034]

With significant therapeutic advances in the field of pulmonary arterial hypertension, the need to identify clinically relevant treatment goals that correlate with long-term outcome has emerged as 1 of the most critical tasks. Current goals include achieving modified New York Heart Association functional class I or II, 6-min walk distance >380 m, normalization of right ventricular size and function on echocardiograph, a decreasing or normalization of B-type natriuretic peptide (BNP), and hemodynamics with right atrial pressure <8 mm Hg and cardiac index >2.5 mg/kg/min(2). However, to more effectively prognosticate in the current era of complex treatments, it is becoming clear that the "bar" needs to be set higher, with more robust and clearer delineations aimed at parameters that correlate with long-term outcome; namely, exercise capacity and right heart function. Specifically, tests that accurately and noninvasively determine right ventricular function, such as cardiac magnetic resonance imaging and BNP/N-terminal pro-B-type natriuretic peptide, are emerging as promising indicators to serve as baseline predictors and treatment targets. Furthermore, studies focusing on outcomes have shown that no single test can reliably serve as a long-term prognostic marker and that composite treatment goals are more predictive of long-term outcome. It has been proposed that treatment goals be revised to include the following: modified New York Heart Association functional class I or II, 6-min walk distance ≥ 380 to 440 m, cardiopulmonary exercise test-measured peak oxygen consumption >15 ml/min/kg and ventilatory equivalent for carbon dioxide <45 l/min/l/min, BNP level toward "normal," echocardiograph and/or cardiac magnetic resonance imaging demonstrating normal/near-normal right ventricular size and function, and hemodynamics showing normalization of right ventricular function with right atrial pressure <8 mm Hg and cardiac index >2.5 to 3.0 l/min/m(2).

Right heart adaptation to pulmonary arterial hypertension: physiology and pathobiology

Survival in patients with pulmonary arterial hypertension (PAH) is closely related to right ventricular (RV) function. Although pulmonary load is an important determinant of RV systolic function in PAH, there remains a significant variability in RV adaptation to pulmonary hypertension. In this report, the authors discuss the emerging concepts of right heart pathobiology in PAH. More specifically, the discussion focuses on the following questions. 1) How is right heart failure syndrome best defined? 2) What are the underlying molecular mechanisms of the failing right ventricle in PAH? 3) How are RV contractility and function and their prognostic implications best assessed? 4) What is the role of targeted RV therapy? Throughout the report, the authors highlight differences between right and left heart failure and outline key areas of future investigation.

Cardiac positron emission tomography enhances prognostic assessments of patients with suspected cardiac sarcoidosis

OBJECTIVES

This study sought to relate imaging findings on positron emission tomography (PET) to adverse cardiac events in patients referred for evaluation of known or suspected cardiac sarcoidosis.

BACKGROUND

Although cardiac PET is commonly used to evaluate patients with suspected cardiac sarcoidosis, the relationship between PET findings and clinical outcomes has not been reported.

METHODS

We studied 118 consecutive patients with no history of coronary artery disease, who were referred for PET, using [(18)F]fluorodeoxyglucose (FDG) to assess for inflammation and rubidium-82 to evaluate for perfusion defects (PD), following a high-fat/low-carbohydrate diet to suppress normal myocardial glucose uptake. Blind readings of PET data categorized cardiac findings as normal, positive PD or FDG, positive PD and FDG. Images were also used to identify whether findings of extra-cardiac sarcoidosis were present. Adverse events (AE)-death or sustained ventricular tachycardia (VT)-were ascertained by electronic medical records, defibrillator interrogation, patient questionnaires, and telephone interviews.

RESULTS

Among the 118 patients (age 52 ± 11 years; 57% males; mean ejection fraction: 47 ± 16%), 47 (40%) had normal and 71 (60%) had abnormal cardiac PET findings. Over a median follow-up of 1.5 years, there were 31 (26%) adverse events (27 VT and 8 deaths). Cardiac PET findings were predictive of AE, and the presence of both a PD and abnormal FDG (29% of patients) was associated with hazard ratio of 3.9 (p < 0.01) and remained significant after adjusting for left ventricular ejection fraction (LVEF) and clinical criteria. Extra-cardiac FDG uptake (26% of patients) was not associated with AE.

CONCLUSIONS

The presence of focal PD and FDG uptake on cardiac PET identifies patients at higher risk of death or VT. These findings offer prognostic value beyond Japanese Ministry of Health and Welfare clinical criteria, the presence of extra-cardiac sarcoidosis and LVEF.

Acute electrical and hemodynamic effects of multisite left ventricular pacing for cardiac resynchronization therapy in the dyssynchronous canine heart

BACKGROUND

Multisite left ventricular (multi-LV) epicardial pacing has been proposed as an alternative to conventional single-site LV (single-LV) pacing to increase the efficacy of cardiac resynchronization therapy.

OBJECTIVE

To compare the effects of multi-LV versus single-LV pacing in dogs with left bundle branch block (LBBB).

METHODS

Studies were performed in 9 anaesthetized dogs with chronic LBBB using 7 LV epicardial electrodes. Each electrode was tested alone and in combination with 1, 2, 3, and 6 other electrodes, the sequence of which was chosen on the basis of practical real-time electrical mapping to determine the site of the latest activation. LV total activation time (LVTAT) and dispersion of repolarization (DRep) were measured by using approximately 100 electrodes around the ventricles. LV contractility was assessed as the maximum derivative of left ventricular pressure (LVdP/dtmax ).

RESULTS

Single-LV pacing provided, on average, a -4.0% ± 9.3% change in LVTAT and 0.2% ± 13.7% change in DRep. Multi-LV pacing markedly decreased both LVTAT and DRep in a stepwise fashion to reach -41.3% ± 5% (P < .001 for overall comparison) and -14.2% ± 19.5% (P < .02 for overall comparison) in the septuple-LV pacing configuration, respectively. Single-LV pacing provided a mean increase of 10.7% ± 7.7% in LVdP/dtmax. LVdP/dtmax incrementally increased by the addition of pacing electrodes to 16.4% ± 8.7% (P < .001 for overall comparison). High response to single-LV pacing could not be improved further during multi-LV pacing.

CONCLUSIONS

Compared with single-LV pacing, multi-LV pacing can considerably reduce both LVTAT and DRep in dogs with LBBB, but the improvement in contractility is limited to conditions where single-LV pacing provides suboptimal improvement. Further studies are warranted to determine whether these acute effects translate in antiarrhythmic properties and better long-term outcomes.

The predictive value of heart-type fatty acid-binding protein is independent from symptom duration in normotensive patients with pulmonary embolism

BACKGROUND

Heart-type fatty acid-binding protein (H-FABP) is a useful biomarker for risk stratification of patients with pulmonary embolism (PE). In patients with acute myocardial infarction, H-FABP plasma concentrations rise after 30 minutes and return to normal within 20-24 hours. We tested whether the predictive value of H-FABP is affected by the duration of symptoms prior to diagnosis in patients with PE.

MATERIAL AND METHODS

We prospectively studied 257 consecutive normotensive patients with confirmed symptomatic PE.

RESULTS

Patients with acute (<24 hours; n=150) symptom onset presented more often with syncope (28.7% vs. 6.5%; p<0.001) compared to patients with symptoms ≥ 24 hours (n=107); other baseline characteristics, comorbidities, and risk factors were distributed equally. Patients with an adverse 30-day outcome (6.6%) had higher H-FABP levels (11.84 [3.57-19.62] ng/ml) compared to patients with a favorable course (3.42 [1.92-5.42] ng/ml; p<0.001). However, the proportion of patients with H-FABP levels ≥ 6 ng/ml did not differ among patients with acute symptom onset and late presentation (p=0.104). Only tachycardia and elevation of H-FABP were associated with an increased risk of an adverse 30-day outcome both in patients with acute symptom onset (H-FABP: OR, 5.8; 95% CI, 1.4-24.5; p=0.016; tachycardia: 7.0 [1.4-36.0]; p=0.018) and late presentation (H-FABP: 9.3 [2.0-43.2]; p=0.004 and tachycardia: 12.3 [1.5-103.6]; p=0.021). The prognostic value could further be improved by the use of a simple H-FABP-based clinical prediction score.

CONCLUSIONS

Our findings indicate that H-FABP is a useful biomarker for risk stratification of normotensive patients with PE regardless of symptom duration prior to diagnosis.

High-density substrate-guided ventricular tachycardia ablation: role of activation mapping in an attempt to improve procedural effectiveness

BACKGROUND

Advanced techniques of electroanatomical mapping efficiently guide ventricular tachycardia (VT) ablation strategies; in this context, the adjunctive value of combining activation mapping (AMap) to improve accuracy has not been elucidated.

OBJECTIVE

To investigate whether conventional AMap further contributes to the identification of critical sites of VT reentry and whether this translates into a more effective ablation outcome in a cohort of patients undergoing VT ablation.

METHODS

We prospectively enrolled 126 patients (mean age 65.3 ± 10.5 years; left ventricular ejection fraction 33.3% ± 7.2%) with ischemic (n = 89) or idiopathic (n = 37) dilated cardiomyopathy undergoing endocardial (n = 105) or endo-epicardial (n = 21) electroanatomical mapping and ablation. A substrate-guided strategy targeting surrogate markers of reentry was accomplished in all patients, but the feasibility and efficacy of AMap was preliminarily assessed for all induced VTs focusing on early VT suppression obtained during radiofrequency delivery. VT-free survival was assessed by ICD interrogation.

RESULTS

AMap successfully guided ablation in 62 of 104 (59.6%) patients with inducible VT(s). At 1 year, 6 of 126 (4.8%) patients died; VT recurred in 28 of 126 (22.2%) patients. No significant difference in VT recurrence rate was observed between patients in whom AMap proved effective versus those in whom substrate-guided ablation was not corroborated by AMap (16 of 62 [25.8%] vs 12 of 64 [18.8%]; log-rank test, P = .3).

CONCLUSIONS

Our findings support the efficacy of a substrate-guided strategy targeting specific markers of arrhythmogenicity identified during sinus rhythm. AMap proves highly efficient acutely but does not improve overall VT-free survival, suggesting that in patients with advanced cardiac disease, life-threatening arrhythmias can be successfully treated by ablation in sinus rhythm, thus limiting procedural risks.

Prevalence of externalized conductors in Riata and Riata ST silicone leads: results from the prospective, multicenter Riata Lead Evaluation Study

BACKGROUND/OBJECTIVE

Following a class I recall of St. Jude Medical Riata/Riata ST silicone implantable cardioverter-defibrillator leads, we report on the phase I results of the Riata Lead Evaluation Study, a prospective, multicenter investigation to assess the prevalence of externalized conductors (ECs) and the electrical dysfunction in these leads.

METHODS

We enrolled patients previously implanted with Riata/Riata ST leads and performed cinefluoroscopy using multiple views. A physician panel adjudicated the images for the presence of EC. The prevalence of EC was stratified and compared by lead model and patient characteristics. Upon occurrence of a lead revision, another physician panel determined whether electrical dysfunction had occurred based on predefined criteria.

RESULTS

Seven hundred seventy six patients with Riata/Riata ST silicone leads (8Fr/7Fr = 66.6%/33.4%; single-/dual-coil = 12.9%/87.1%) across 23 centers were analyzed. Implant duration was 4.8 ± 0.9 years for 7Fr and 6.5 ± 1.6 years for 8Fr leads (P <.001). The prevalence of EC was significantly lower in 7Fr compared with 8Fr leads for the entire study population (9.3% vs 24.2%, P < .001) and for leads implanted ≤6 years (9.4% vs 18.8%, P = .006). Other than lead size, there were no significant differences in lead, patient, or electrical characteristics between leads with and without EC. Over a period of 9.8 ± 2.0 months, the overall prevalence of electrical dysfunction was 1.3% (confidence interval 0.49%-2.1%), with only 3 of 10 cases occurring in leads with EC.

CONCLUSION

Larger-diameter Riata leads were more prone to EC than smaller-diameter Riata ST leads. The prevalence of electrical dysfunction was not associated with EC.

Atypical complications encountered with epicardial electrophysiological procedures

BACKGROUND

With the increasing use, complexity, anatomical approaches, and tools related to epicardial procedures, complications previously not seen during endovascular ablation are now well recognized with epicardial ablation. Whether newer approaches and the regional anatomy of the pericardial space contribute to unexpected complications after epicardial access (EpiAcc) is presently unknown.

OBJECTIVE

To characterize underreported, or novel, complications associated with percutaneous EpiAcc as part of an electrophysiology procedure.

METHODS

We retrospectively reviewed percutaneous EpiAcc as part of an ablation procedure from January 1, 2004, to December 31, 2011.

RESULTS

Of 116 attempts in 107 patients, 8 atypical ablation complications (no procedural deaths) were noted; complications included delayed pericarditis (2 weeks), chronic refractory pericarditis, requirement for snaring of broken intrapericardial wire, pleural perforation, phrenic nerve injury despite protective strategies, hemoperitoneum, and abdominal-pericardial fistula.

CONCLUSION

Vigilance both during and after EpiAcc is needed to recognize these complications, some of which may be life-threatening.

Noninvasive monitoring of serial changes in pulmonary vascular resistance and acute vasodilator testing using cardiac magnetic resonance

OBJECTIVES

The study sought to evaluate the ability of cardiac magnetic resonance (CMR) to monitor acute and long-term changes in pulmonary vascular resistance (PVR) noninvasively.

BACKGROUND

PVR monitoring during the follow-up of patients with pulmonary hypertension (PH) and the response to vasodilator testing require invasive right heart catheterization.

METHODS

An experimental study in pigs was designed to evaluate the ability of CMR to monitor: 1) an acute increase in PVR generated by acute pulmonary embolization (n = 10); 2) serial changes in PVR in chronic PH (n = 22); and 3) changes in PVR during vasodilator testing in chronic PH (n = 10). CMR studies were performed with simultaneous hemodynamic assessment using a CMR-compatible Swan-Ganz catheter. Average flow velocity in the main pulmonary artery (PA) was quantified with phase contrast imaging. Pearson correlation and mixed model analysis were used to correlate changes in PVR with changes in CMR-quantified PA velocity. Additionally, PVR was estimated from CMR data (PA velocity and right ventricular ejection fraction) using a formula previously validated.

RESULTS

Changes in PA velocity strongly and inversely correlated with acute increases in PVR induced by pulmonary embolization (r = -0.92), serial PVR fluctuations in chronic PH (r = -0.89), and acute reductions during vasodilator testing (r = -0.89, p ≤ 0.01 for all). CMR-estimated PVR showed adequate agreement with invasive PVR (mean bias -1.1 Wood units,; 95% confidence interval: -5.9 to 3.7) and changes in both indices correlated strongly (r = 0.86, p < 0.01).

CONCLUSIONS

CMR allows for noninvasive monitoring of acute and chronic changes in PVR in PH. This capability may be valuable in the evaluation and follow-up of patients with PH.

Relationships between right ventricular function, body composition, and prognosis in advanced heart failure

OBJECTIVES

This study sought to examine the relationships between right ventricular (RV) function, body composition, and prognosis in patients with advanced heart failure (HF).

BACKGROUND

Previous studies investigating HF-related cachexia have not examined the impact of RV function on body composition. We hypothesized that RV dysfunction is linked to weight loss, abnormal body composition, and worsened prognosis in advanced HF.

METHODS

Subjects with advanced HF (n = 408) underwent prospective assessment of body composition (skinfold thickness, dual-energy X-ray absorptiometry), comprehensive echocardiography, and blood testing. Subjects were followed up for adverse events (defined as death, transplantation, or circulatory assist device).

RESULTS

Subjects with RV dysfunction (51%) had lower body mass index, lower fat mass index, and were more likely to display cachexia (19%). The extent of RV dysfunction correlated with greater antecedent weight loss and a lower fat/lean body mass ratio. Over a median follow-up of 541 days, there were 150 events (37%). Risk of event was greater in subjects with RV dysfunction (hazard ratio: 3.09 [95% confidence interval (CI): 2.18 to 4.45]) and cachexia (hazard ratio: 2.90 [95% CI: 2.00 to 4.12]) in univariate and multivariate analyses. Increased body mass index was associated with a lower event rate (HR per kg/m(2): 0.92 [95% CI: 0.88 to 0.96]), and this protection was mediated by a higher fat mass (0.91 [95% CI: 0.87 to 0.96]) but not a fat-free mass index (0.97 [95% CI: 0.92 to 1.03]).

CONCLUSIONS

RV dysfunction and cardiac cachexia often coexist, have additive adverse impact, and might be mechanistically interrelated. Wasting of fat but not of lean mass was predictive of adverse outcome, suggesting that fat loss is either a surrogate of enhanced catabolism or adipose tissue is cardioprotective in the context of HF.

Exercise increases age-related penetrance and arrhythmic risk in arrhythmogenic right ventricular dysplasia/cardiomyopathy-associated desmosomal mutation carriers

OBJECTIVES

This study sought to determine how exercise influences penetrance of arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) among patients with desmosomal mutations.

BACKGROUND

Although animal models and anecdotal evidence suggest that exercise is a risk factor for ARVD/C, there have been no systematic human studies.

METHODS

Eighty-seven carriers (46 male; mean age, 44 ± 18 years) were interviewed about regular physical activity from 10 years of age. The relationship of exercise with sustained ventricular arrhythmia (ventricular tachycardia/ventricular fibrillation [VT/VF]), stage C heart failure (HF), and meeting diagnostic criteria for ARVD/C (2010 Revised Task Force Criteria [TFC]) was studied.

RESULTS

Symptoms developed in endurance athletes (N = 56) at a younger age (30.1 ± 13.0 years vs. 40.6 ± 21.1 years, p = 0.05); they were more likely to meet TFC at last follow-up (82% vs. 35%, p < 0.001) and have a lower lifetime survival free of VT/VF (p = 0.013) and HF (p = 0.004). Compared with those who did the least exercise per year (lowest quartile) before presentation, those in the second (odds ratio [OR]: 6.64, p = 0.013), third (OR: 16.7, p = 0.001), and top (OR: 25.3, p < 0.0001) quartiles were increasingly likely to meet TFC. Among 61 individuals who did not present with VT/VF, the 13 subjects experiencing a first VT/VF event over a mean follow-up of 8.4 ± 6.7 years were all endurance athletes (p = 0.002). Survival from a first VT/VF event was lowest among those who exercised most (top quartile) both before (p = 0.036) and after (p = 0.005) clinical presentation. Among individuals in the top quartile, a reduction in exercise decreased VT/VF risk (p = 0.04).

CONCLUSIONS

Endurance exercise and frequent exercise increase the risk of VT/VF, HF, and ARVD/C in desmosomal mutation carriers. These findings support exercise restriction for these patients.

Clinical outcomes with synchronized left ventricular pacing: analysis of the adaptive CRT trial

BACKGROUND

Acute studies have suggested that left ventricular pacing (LVP) may have benefits over biventricular pacing (BVP). The adaptive cardiac resynchronization therapy (aCRT) algorithm provides LVP synchronized to produce fusion with the intrinsic activation when the intrinsic atrioventricular (AV) interval is normal. The randomized double-blind adaptive cardiac resynchronization therapy trial demonstrated noninferiority of the aCRT algorithm compared to echocardiography-optimized BVP (control).

OBJECTIVE

To examine whether synchronized LVP (sLVP) resulted in better clinical outcomes.

METHODS

First, stratification by percent sLVP (%sLVP) and multivariate Cox proportional hazards model was used to assess the relationship between %sLVP and clinical outcomes. Second, outcomes were compared between patients in the aCRT arm (n = 318) and control patients (n = 160) stratified by intrinsic AV interval at randomization.

RESULTS

In the aCRT arm, %sLVP ≥50% (n = 142) was independently associated with a decreased risk of death or heart failure hospitalization (hazard ratio 0.49; 95% confidence interval 0.28-0.85; P = .012) compared with %sLVP <50% (n = 172). A greater proportion of patients with %sLVP ≥50% improved in Packer's clinical composite score at 6-month (82% vs. 68%; P = .002) and 12-month (80% vs. 62%; P = .0006) follow-ups compared to controls. In the subgroup with normal AV (n = 241), there was a lower risk of death or heart failure hospitalization (hazard ratio 0.52; 95% confidence interval 0.27-0.98; P = .044) with the aCRT algorithm. A greater proportion of patients in the aCRT arm improved in the clinical composite score at 6-month (81% vs. 69%; P = .041) and 12-month (77% vs. 66%; P = .076) follow-ups compared to controls.

CONCLUSIONS

Higher %sLVP was independently associated with superior clinical outcomes. In patients with normal AV conduction, the aCRT algorithm provided mostly sLVP and demonstrated better clinical outcomes compared to echocardiography-optimized BVP.

An exploratory study on coronary sinus lead tip three-dimensional trajectory changes in cardiac resynchronization therapy

BACKGROUND

Prediction of response to cardiac resynchronization therapy (CRT) is still an unsolved major issue. The interface between left ventricular mechanics, coronary sinus (CS) lead, and pacing delivery has been little investigated.

OBJECTIVE

To investigate CS lead tip movements at baseline and during biventricular pacing (BiV) in the hypothesis that they could provide some insights into left ventricular mechanical behavior in CRT.

METHODS

Three-dimensional reconstruction of CS lead tip trajectory throughout the cardiac cycle using a novel fluoroscopy-based method was performed in 22 patients with chronic heart failure (19 men; mean age 70 ± 10 years). Three trajectories were computed: before (T-1) and immediately after (T0) BiV start-up and after 6 months (T1). CRT response was the echocardiographic end-systolic volume reduction ≥15% at T1. Metrics describing trajectory at T0, T-1, and T1 were compared between 9 responders (R) and 13 nonresponders (NR).

RESULTS

At T-1 trajectories demonstrated heterogeneous shapes and metrics, but at T0 the variations in the ratio between the two main axes (S1/S2) and in the eccentricity were statistically different between R and NR, pointing out a trajectory's change toward a significantly more circular shape at BiV start-up in R. Remarkably, R and NR could be completely separated by means of the percent variation in S1/S2 from T-1 to T0 (R: 47.5% [31.5% to 54.1%] vs. NR: -25.6% [-67% to -6.5%]). This single marker computed at T0 would have predicted CRT response at T1.

CONCLUSIONS

Preliminary data showed that CS lead tip trajectory changes induced by BiV were related to mechanical resynchronization.

Malignant arrhythmogenic right ventricular dysplasia/cardiomyopathy with a normal 12-lead electrocardiogram: a rare but underrecognized clinical entity. Heart Rhythm. 2013;10:1484-1491. [PMID: 23816439 DOI: 10.1016/j.hrthm.2013.06.022]

BACKGROUND

In Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C), a normal electrocardiogram (ECG) is considered reassuring. However, some patients with ARVD/C experiencing ventricular arrhythmias have a normal ECG.

OBJECTIVES

To estimate how often patients with ARVD/C experiencing ventricular arrhythmias have a normal ECG during sinus rhythm, and to provide a clinical profile of these patients.

METHODS

We included 145 patients with ARVD/C experiencing a documented sustained ventricular arrhythmia. Conventional 12-lead sinus rhythm ECGs within 6 months of the event were reviewed for diagnostic Task Force Criteria (TFC). ECGs were classified as abnormal (≥1 TFC), nonspecific (abnormal, no TFC), or normal. Cardiologic investigations within 6 months of the event were evaluated as per TFC in those with a nonspecific or normal ECG.

RESULTS

The ECG was nonspecific or normal in 17 of 145 (12%) subjects. Mean age of these patients was 41.3 ± 12.4 years and 14 (82%) were men, comparable to those with an abnormal ECG. Most patients with a nonspecific or normal ECG showed ≥1 TFC on Holter monitoring (n = 9 of 10) and signal-averaged ECG (n = 4 of 5), and all had nonsustained ventricular tachycardia recorded. Among 15 patients who underwent structural evaluation, 11 (73%) showed structural TFC (9 major and 2 minor).

CONCLUSIONS

Although most patients with ARVD/C experiencing arrhythmias have an abnormal ECG, a nonspecific or normal ECG does not preclude ARVD/C diagnosis. All patients with a nonspecific or normal ECG had alternative evidence of disease expression. These results alert the physician not to rely exclusively on ECG in ARVD/C, but to assess arrhythmic risk by comprehensive clinical evaluation.

Incremental value of cardiac magnetic resonance imaging in arrhythmic risk stratification of arrhythmogenic right ventricular dysplasia/cardiomyopathy-associated desmosomal mutation carriers. J Am Coll Cardiol. 2013;62:1761-1769. [PMID: 23810894 DOI: 10.1016/j.jacc.2012.11.087]

OBJECTIVES

The aim of this study was to identify the incremental value and optimal role of cardiac magnetic resonance (CMR) imaging in arrhythmic risk stratification of arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C)-associated desmosomal mutation carriers without histories of sustained ventricular arrhythmia.

BACKGROUND

Risk stratification of ARVD/C mutation carriers is challenging.

METHODS

Sixty-nine patients (mean age 27.0 ± 15.3 years, 42% men) harboring ARVD/C-associated pathogenic mutations (83% plakophilin 2) without prior sustained ventricular arrhythmias were included. Electrocardiographic and 24-h Holter monitoring findings closest to presentation were analyzed for electrical abnormalities per revised task force criteria. CMR studies were done to identify abnormal cardiac structure and function according to the revised task force criteria.

RESULTS

Overall, 42 patients (61%) presented with electrical abnormalities on the basis of electrocardiography and Holter monitoring, of whom 20 (48%) had abnormal results on CMR. Only 1 of 27 patients (4%) without electrical abnormalities at initial evaluation had abnormal CMR results. Over a mean follow-up period of 5.8 ± 4.4 years, 11 patients (16%) experienced sustained ventricular arrhythmias, exclusively in patients with both electrical abnormalities (electrocardiography and/or Holter monitoring) and abnormal CMR results.

CONCLUSIONS

These results suggest that electrical abnormalities on electrocardiography and Holter monitoring precede detectable structural abnormalities in ARVD/C mutation carriers. Therefore, evaluation of cardiac structure and function using CMR is probably not necessary in the absence of baseline electrical abnormalities. Among ARVD/C mutation carriers, the presence of both electrical and CMR abnormalities identifies patients at high risk for events and thus patients who might benefit from prophylactic implantable cardioverter-defibrillator placement.

The reverse mode switch algorithm: how well does it work?

BACKGROUND

The performance of the Reverse Mode Switch (RMS) algorithm, aimed at minimizing right ventricular pacing by operating in the AAI(R) mode with switch to the DDD(R) mode if atrioventricular (AV) conduction loss is detected, is not well known.

OBJECTIVE

To determine the appropriateness of the RMS episodes available from patient follow-up data at our center.

METHODS

Patients with the TELIGEN dual-chamber implantable cardioverter-defibrillator and the RMS algorithm activated were identified. The RMS episodes with available electrograms were analyzed and classified as appropriate (AV conduction loss) or inappropriate (non-AV conduction loss) events. Cumulative percentage of ventricular pacing and amount of premature ventricular complexes (PVCs) were recorded.

RESULTS

Of 21 patients, RMS episodes had occurred in 19 of them, with a mean of 527 episodes per month. Of the 172 RMS episodes available for analysis, 27 (16%) were classified as appropriate and 145 (84%) as inappropriate. Almost all (91%) inappropriate RMS episodes were due to PVC, and there was a positive correlation between the number of total RMS episodes per month and the number of PVCs per month (P < .0005). Considering patients with only inappropriate RMS episodes (n = 11), there was a positive correlation between the percentage of ventricular pacing and the number of RMS episodes per month (P < .05).

CONCLUSIONS

A large majority of the RMS episodes available for analysis inappropriately triggered switch from the AAI(R) mode to the DDD(R) mode owing to PVCs. Patients with the RMS algorithm and elevated PVC burden are probably at risk of a high percentage of unnecessary right ventricular pacing.

22q11.2 Deletion syndrome is associated with perioperative outcome in tetralogy of Fallot

OBJECTIVE

We sought to investigate the impact of 22q11.2 deletion on perioperative outcome in tetralogy of Fallot.

METHODS

We conducted a retrospective review of patients with tetralogy of Fallot who underwent complete surgical reconstruction at The Children's Hospital of Philadelphia between 1995 and 2006. Inclusion criteria included diagnosis of tetralogy of Fallot and known genotype. Fisher exact and Mann-Whitney tests were used for categoric and continuous variables, respectively. Regression analysis was used to determine whether deletion status predicts outcome.

RESULTS

We studied 208 subjects with tetralogy of Fallot, 164 (79%) without and 44 (20%) with 22q11.2 deletion syndrome. There were no differences in sex, race, gestational age, age at diagnosis, admission weight, and duration of mechanical ventilation. Presenting anatomy, survival, complications and reoperations were also comparable between patients with and without 22q11.2 deletion syndrome. Those with 22q11.2 deletion syndrome had more aortopulmonary shunts preceding complete surgical repair (21% vs 7%, P = .02). This association was present after adjustment for presenting anatomy (stenosis, atresia, or absence of pulmonary valve and common atrioventricular canal) and surgical era. In addition, those with 22q11.2 deletion syndrome had longer cardiopulmonary bypass time (84 vs 72 minutes, P = .02) and duration of intensive care (6 vs 4 days, P = .007).

CONCLUSIONS

Genotype affects early operative outcomes in tetralogy of Fallot resulting, in particular, in longer duration of intensive care. Future studies are required to determine factors contributing to such differences in this susceptible population.

Bioprosthetic pulmonary valve replacement: contemporary analysis of a large, single-center series of 170 cases

OBJECTIVE

The present study was designed to compare stented porcine and bovine pericardial valves used for pulmonary valve replacement to better define valve performance and postoperative quality of life.

METHODS

A retrospective review of all patients who underwent pulmonary valve replacement with a stented bioprosthesis from 1992 to 2008 was conducted. The medical records, imaging results, and quality of life questionnaires were analyzed. Differences in reintervention by valve type were determined using Cox proportional hazards models, controlling for subject age.

RESULTS

A total of 170 consecutive pulmonary valve replacements (73 stented porcine, group 1; 97 bovine pericardial, group 2) were reviewed. No significant differences were seen in patient age or implanted valve size between the groups. Surgical mortality was 1.2%. The median follow-up was 48.2 months and was longer for group 2. No significant difference was seen in the risk of reintervention by valve type (hazard ratio, 0.64; 95% confidence interval, 0.18-2.34; P = .51). After 39 months of follow-up, pulmonary stenosis and pulmonary insufficiency that was moderate or worse were more common in patients who had undergone pulmonary valve replacement at younger than 15 years (pulmonary stenosis, 30.9% vs 10.0%, P = .003; pulmonary insufficiency, 46.2% vs 3.8%, P < .001), regardless of valve type. All patients performed well mentally and physically on the quality of life surveys.

CONCLUSIONS

The present large series of stented bioprosthetic pulmonary valve replacements has demonstrated good results, particularly in adults, at intermediate follow-up. Freedom from reintervention was similar for the porcine and pericardial valves, and our finding did not clearly demonstrate the superiority of 1 type of valve. However, the stented bioprosthetic valves were less durable in younger patients.

Tricuspid regurgitation and right ventricular function after mitral valve surgery with or without concomitant tricuspid valve procedure

OBJECTIVES

To study the effect of mitral valve repair with or without concomitant tricuspid valve repair on functional tricuspid regurgitation and right ventricular function.

METHODS

From 2001 to 2007, 1833 patients with degenerative mitral valve disease, a structurally normal tricuspid valve, and no coronary artery disease underwent mitral valve repair, and 67 underwent concomitant tricuspid valve repair. Right ventricular function (myocardial performance index and tricuspid annular plane systolic excursion) was measured before and after surgery using transthoracic echocardiography for randomly selected patients with tricuspid regurgitation grade 0, 1+, and 2+ (100 patients for each grade) and 93 with grade 3+/4+, 393 patients in total.

RESULTS

In patients with mild (<3+) preoperative tricuspid regurgitation, mitral valve repair alone was associated with reduced tricuspid regurgitation and mild worsening of right ventricular function. Tricuspid regurgitation of 2+ or greater developed in fewer than 20%, and right ventricular function had improved, but not to preoperative levels, at 3 years. In patients with severe (3+/4+) preoperative tricuspid regurgitation, mitral valve repair alone reduced tricuspid regurgitation and improved right ventricular function; however, tricuspid regurgitation of 2+ or greater returned and right ventricular function worsened toward preoperative levels within 3 years. Concomitant tricuspid valve repair effectively eliminated severe tricuspid regurgitation and improved right ventricular function. Also, over time, tricuspid regurgitation did not return and right ventricular function continued to improve to levels comparable to that of patients with lower grades of preoperative tricuspid regurgitation.

CONCLUSIONS

In patients with mitral valve disease and severe tricuspid regurgitation, mitral valve repair alone was associated with improved tricuspid regurgitation and right ventricular function. However, the improvements were incomplete and temporary. In contrast, concomitant tricuspid valve repair effectively and durably eliminated severe tricuspid regurgitation and improved right ventricular function toward normal, supporting an aggressive approach to important functional tricuspid regurgitation.