Effect of interventional edge-to-edge repair in tricuspid regurgitation on dimensions of the annulus

Funding Acknowledgements

Type of funding sources: None.

Background

The technique of percutaneous tricuspid valve edge-to-edge repair (pTVR) depends upon the connection of leaflets in the area of regurgitation using a coaptation device. By closing the coaptation device a considerable tractive force is applied on the leaflets, which might have an effect on the valve annulus. The aim of this study was to examine the impact of device implantation on tricuspid annular dimensions.

Methods

During pTVR, 3D zoom loops of the tricuspid valve (TV) were acquired before and after clip placement using transesophageal echocardiography. Measurements of TV annular dimensions included the following parameters: annulus area (TV area), maximal diameter, minimal diameter, and eccentricity index (Figure 1). Tenting area was derived from a four-chamber view of the valve. Tricuspid regurgitation (TR) severity was graded from 1+ to 5+ by measuring vena contracta area (VCA3D) in 3D full volume color Doppler loop using multiplanar reconstruction.  Right atrial (RA) and ventricular volumes (RVVd3D, RVVs3D) and function (RVEF3D) were assessed in a 3D full volume loop.

Results

The study population consisted of 97 patients (age 78 ± 6 years, 47 male), undergoing pTVR at our hospital. As expected, cavity dimension correlated with TV area size (for RVVd3D r = 0.51, p < 0.001 and for RA volume r = 0.71, p < 0.001). The mean TV annular area was significantly reduced (Annular area 8.53 ± 2.23 cm²/m²BSA vs. 7.55 ± 2.18 cm²/m²BSA, p < 0.001) and the shape of the annulus became more oval (Eccentricity index 1.2 ± 0.15 vs. 1.29 ± 0.17, p < 0.001) after pTVR. The reduction in annular area (12 ± 7%, range 0.7-28%) was only modestly correlated with the number of implanted coaptation devices (r = 0.30, p < 0.001) and the percentage reduction of VCA3D (r =0.36, p < 0.001). In the patient group with an annular area change ≥12%, a decrease in TR grade to ≤2+ by pTVR was achieved in 83% of cases, whereas only 62% of patients achieved moderate TR when the change in area was below 12%.

Conclusion

  pTVR using coaptation devices reduces the area of the TV annulus. This effect may be modestly correlated to the number of devices implanted. Abstract Figure.

Impact of endocardial leads on the effectiveness of interventional edge-to-edge repair of tricuspid regurgitation

Funding Acknowledgements

Type of funding sources: None.

Background

A considerable proportion of patients who are considered for percutaneous tricuspid valve edge-to-edge repair (pTVR) interventions have endocardial lead induced tricuspid regurgitation (TR). The aim of this study was to examine the impact of lead-leaflet interaction on the effectiveness of pTVR.

Methods

For each patient, the lead position within the tricuspid valve (central, commissural, or towards one of the three leaflets) and the type of lead-leaflet interaction (leaflet impingement or adhesion) were identified during thorough 2D/3D transthoracic and transesophageal echocardiography examinations. Before and after pTVR, echocardiographic data, including 3D full-volume datasets, were obtained and quantified. TR severity was graded from 1+ to 5+, based upon the effective regurgitant orifice area by the PISA method (EROAPISA) and the vena contracta area (VCA3D) as measured by multiplanar reconstruction from a 3D color Doppler loop. Maximal diastolic tricuspid annulus area from a 3D zoom image, tricuspid tenting area, and right atrial volume were quantified. Right ventricular assessments included ejection fraction (RVEF3D) and diastolic (RVVd3D) and systolic (RVVs3D) volumes. 

Results

Out of 99 patients who underwent pTVR at our hospital, 38 patients had implanted cardiac devices of the following types: pacemakers (n = 25, 66%), cardiac defibrillators (n = 7, 18%), and biventricular pacemakers (n = 6, 16%). In 24 (63%) of these device patients, TR grade was ≤2+ after pTVR. In 14 of the device patients, TR grade remained severe after intervention (Grade 3+ in 15%, grade 4+ in 11%, and Grade 5+ in 11% of the device group). In comparison, in 78% of patients without endocardial leads, moderate TR was achieved after pTVR. Figure 1 shows the distribution of lead positions within the tricuspid valve. A relevant lead-leaflet interference (rLLI) for pTVR interventions was defined as impingement or adhesion in the target area of the coaptation device (anteroseptal or posteroseptal). Binary logistic regression analysis showed an increase risk (Odds ratio 11, R2 0.34, 95% CI 0.019-0.44, p = 0.003) for a suboptimal pTVR result (TR grade > 2+ after intervention) in patients with rLLI. Although patients with rLLI (n = 17) had significantly higher VCA3D values as compared to patients without rLLI (n = 21), it was not predictive for pTVR results. Echocardiographic parameters of right ventricular and tricuspid valve dimensions showed only a trend to higher values in the group with rLLI (Table 1).

Conclusion

  Endocardial lead induced TR negatively impacts the effectiveness of pTVR irrespective of the initial degree of TR. Abstract Figure.  Abstract Table 1 Echocardiographic parameters

Effect of interventional edge-to-edge repair in tricuspid regurgitation on ring dimensions

Background

The concept of percutaneous tricuspid valve edge-to-edge repair (pTVR) is based on the connection of leaflets in the area of insufficiency using a coaptation device. By closing the coaptation device a considerable tractive force is applied on the leaflets, which might have an effect on the valve ring. Aim of the study was to examine the impact of device implantation on tricuspid ring dimensions.

Methods

During pTVR 3D zoom loops of tricuspid valve were acquired before and after clip placement using transoesophageal echocardiography. Measurements of TV ring dimensions included the following parameters: ring area (TV area), maximal diameter, minimal diameter, eccentricity index (Figure 1). Tenting area was derived from a four-chamber view of the valve. In addition, regurgitation severity was graded from 1+ to 5+ by measuring vena contracta area (VCA3D) in 3D full volume colour Doppler loop using multiplanar reconstruction. Right atrial (RA) and ventricular volumes (RVVd3D, RVVs3D) and function (RVEF3D) were assessed in a 3D full volume loop.

Results

The study population comprised 97 patients (age 78±6 years, 47 male), who underwent pTVR at our hospital. As expected cavity dimension correlated with TV area size (for RVVd3D r=0.51, p<0.001 and for RA volume r=0.71, p<0.001). The mean TV ring area was significantly reduced (ring area 8.53±2.23 cm2/m2BSA vs. 7.55±2.18 cm2/m2BSA, p<0.001) and the ring shape became more oval (Eccentricity index 1.2±0.15 vs. 1.29±0.17, p<0.001) after pTVR. The reduction of ring area (12±7%, range 0.7–28%) showed an only modest correlation to the number of implanted coaptation devices (r=0.30, p<0.001) and percentage reduction of VCA3D (r=0.36, p<0.001). In the patient group with a ring area change ≥12% a reduction to TR grade ≤2+ by pTVR was achieved in 83% of cases, whereas only 62% of patients reached moderate TR when area change was below 12%.

Conclusion

pTVR using coaptation devices reduces the ring area. This effect is related to the number of devices implanted.

Funding Acknowledgement

Type of funding sources: None.

Echocardiographic predictors of the effectiveness of interventional edge-to-edge repair in tricuspid valve regurgitation

Background

Percutaneous tricuspid valve edge-to-edge repair (pTVR) is a promising interventional technique for patients with tricuspid regurgitation (TR), but guidance regarding patient selection and echocardiographic screening is lacking. The aim of this study was to identify echocardiographic parameters which may predict pTVR success.

Methods

Before and after pTVR, echocardiographic data, including 3D full-volume datasets, were obtained and quantified. Right ventricular assessments included ejection fraction (RVEF3D) and diastolic (RVVd3D) and systolic (RVVs3D) volumes. Also evaluated were: right atrial (RA) volume, effective regurgitant orifice area by PISA method (EROAPISA), vena contracta area (VCA3D) by multiplanar reconstruction from a 3D colour Doppler loop (Figure 1a), maximal diastolic tricuspid annulus area from a 3D zoom image (Figure 1b), and tricuspid tenting area. TR severity was graded according to EROAPISA and VCA3D as grade 1+ to 5+.

Results

Patients (n=99, age 79±6 years, 48 male) with at least moderate to severe TR undergoing pTVR were consecutively included. The patients were divided into groups according to their post-pTVR TR grade. Group 1 had TR grade ≤2+, and group 2 had TR grade ≥3+.Echocardiographic parameters before pTVR for both groups are presented in Table 1. As expected, patients with TVR ≥3+ after pTVR had significantly worse pre-intervention echocardiographic measurements of TR severity, valve dimensions, and chamber volumes. ROC curves for the prediction of TR ≤2+ (mild to moderate) after pTVR (defined as VCA3D <0.75 cm2 and EROAPISA <0.4 cm2) were drawn for different echocardiographic features (Figure 2). VCA3D by 3D colour Doppler yielded the highest area under the ROC curve followed by TV anatomy measurements (Annulus area3D, Tenting area) and right atrial volume.

Conclusion

A thorough evaluation of TR and valve dimensions by 3D echocardiography, particularly the evaluation of VCA3D by 3D colour Doppler, aids in the prediction of the probability of pTVR success.

Funding Acknowledgement

Type of funding sources: None.

Transcatheter mitral valve repair (TMVR) using MitraClip in patients younger than 65 years: a multicenter analysis of 2-years outcomes

Background

TMVR using MitraClip became a well-established interventional therapy for severe MR. However, TMVR has been almost only applied to old aged patients rejected from surgical therapy.

Objective

To present 2-years outcomes of 36 patients younger than 65 years with no surgical options treated by TMVR.

Methods

A retrospective clinical and TEE study was conducted to evaluate 36 patients younger than 65 years treated by TMVR in 3 heart centers.

Results

Mean age of the 36 study patients was 56.3±6.6 years, male gender was 72.2%. High operative risk was estimated by STS score (mean = 8.73±2.97) and EuroSCORE (mean = 24.71±12.79). All patients were refused for surgery by heart team decision, therefore admitted to TMVR. Baseline severity of MR was assessed by 3D-TEE based biplane vena contracta width (mean = 8.35±1.87 mm). Baseline transmitral mean pressure gradient was 1.81±0.78 mmHg. 21 patients showed mitral annular dilatation as the main cause of MR, 8 patients had leaflet prolapse, 4 patients exhibited papillary muscle displacement leading to leaflet tethering and 3 patients showed mitral leaflet thickening and/or retraction due to fibrosis. Procedural success was achieved in all patients with 1/2/3 clips implanted in 52.8%/44.4%/2.8% of cases with a mean of 1.5 clip per case. Two grades or more reduction in severity of MR (MR grade ≤ II/IV) was accomplished in 88.9% of patients. Mean postprocedural MPG was 3.78±1.96 mmHg. Average follow-up (FU) period was 25,8 months and the median was 20 months (25th–75th percentile: 12–36 months). During 2-years FU, statistically significant difference (p value <0.002) was detected for NT-proBNP levels compared to baseline (mean = 9870±10819, median = 7748, 25th–75th percentile: 2702–14237 pg/ml) and at follow up visits (mean = 7645±11292, median = 3263, 25th-75th percentile: 883–8078 pg/ml). Furthermore, persistent symptomatic improvement during FU, defined as NYHA functional class improvement by 2 or more Grades, was achieved in 69% of patient in parallel with efficient reduction of MR in 34 patients so that a second intervention by reclipping was required in 2 patients to correct recurrent significant MR. Only two patients experienced procedure-related complications by large puncture site hematoma. No procedure-related mortality during the first 30 days was detected. However, mortality was recorded in 2 patients during the first month and was attributed to severe advanced heart failure in one case and septicemia after exclusion of infective endocarditis in another case. Over 2 years FU, other 5 patients passed away, 3 cases owing to advanced heart failure, one case due to multi-organ failure and one because of tumor disease.

Conclusion

TMVR in patients younger than 65 years refused from surgical repair provides satisfactory clinical and echocardiography outcomes at 2 years. Future studies should evaluate the outcomes of MitraClip in this population in a larger cohort.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Hassan M.H. Mohammed received a scholarship grant from the Egyptian ministry of higher education and Minia University, Egypt.

The validation of four published algorithms to predict the need for pacemaker implantation after TAVR

Background

The identification of patients with high risk for PPMI after TAVR might change our decision as regard the type of the prosthesis and allow more patients' acceptance for this complication. Objective: we investigated the predictors of PPMI after TF-TAVR and validated the accuracy of four published algorithms in this group of patients.

Methods and results

We retrospectively examined all patients who were in need for pacemaker implantation during the index hospitalisation after TAVR between 2016 and 2019. We searched for the predictors of the new PPMI after TAVR in this group of patient and compared it with a matched group of patients. Moreover, we tested the accuracy of four published algorithms. The first tested algorithm from Kaneko et al had positive predictive value (PPV), negative predictive value (NPV) and accuracy from 50%, 65% and 60% consecutively. The second tested algorithm from Jilaihawi et al had PPV, NPV and accuracy from 13.6%, 100% and 26.9% consecutively. The third tested algorithm from Maeno et al had PPV, NPV and accuracy from 37%, 56% and 45% consecutively. The forth tested algorithm from Fujiti et al had PPV, NPV and accuracy from 42%, 65% and 50% consecutively. In this study, 3 ECG-predictors (RBBB, the presence of AF and LAHB) and 3 CT-predictors (Aortic valve calcification Volume >500mm3, eccentricity index >0.25, deep valve implantation in relation to the length of membranous septum) were independent predictors of PPMI. Moreover, the rate of preimplantation ballon valivuloplasty was higher in the group with new PPMI. Using these independent predictors, the new 7 points score was developed by assigning 1 point for each one. AUC of the new score in the derivation cohort was 0.809 (95% CI 0.758–0.86), with an optimal cut-off threshold of 4 points. All other scores had AUC from 0.6 or lower. In a validation cohort of 100 patients, the predictive value of the score was confirmed (AUC, 0.72; 95% CI, 0.70–0.87; P<0.001).

Conclusion

The four studied score systems had low accuracy to predict new PPMI after TAVR in our cohort of patients. The new score is more complex but might be more accurate.

Funding Acknowledgement

Type of funding sources: None.

Impact of endocardial leads on the effectiveness of interventional edge-to-edge repair of tricuspid regurgitation

Background

A considerable proportion of patients who are considered for percutaneous tricuspid valve edge-to-edge repair (pTVR) interventions have endocardial lead induced tricuspid regurgitation (TR). The aim of this study was to examine the impact of lead-leaflet interaction on the effectiveness of pTVR.

Methods

For each patient, the lead position within the tricuspid valve (central, commissural, or towards one of the three leaflets) and the type of lead-leaflet interaction (leaflet impingement or adhesion) were identified during thorough 2D/3D transthoracic and transesophageal echocardiography examinations. Before and after pTVR, echocardiographic data, including 3D full-volume datasets, were obtained and quantified. TR severity was graded from 1+ to 5+, based upon the effective regurgitant orifice area by the PISA method (EROAPISA) and the vena contracta area (VCA3D) as measured by multiplanar reconstruction from a 3D color Doppler loop. Maximal diastolic tricuspid annulus area from a 3D zoom image, tricuspid tenting area, and right atrial volume were quantified. Right ventricular assessments included ejection fraction (RVEF3D) and diastolic (RVVd3D) and systolic (RVVs3D) volumes.

Results

Out of 99 patients who underwent pTVR at our hospital, 38 patients had implanted cardiac devices of the following types: pacemakers (n=25, 66%), cardiac defibrillators (n=7, 18%), and biventricular pacemakers (n=6, 16%). In 24 (63%) of these device patients, TR grade was ≤2+ after pTVR. In 14 of the device patients, TR grade remained severe after intervention (Grade 3+ in 15%, grade 4+ in 11%, and Grade 5+ in 11% of the device group). In comparison, in 78% of patients without endocardial leads, only moderate TR was achieved after pTVR. Figure 1 shows the distribution of lead positions within the tricuspid valve. A relevant lead-leaflet interference (rLLI) for pTVR interventions was defined as impingement or adhesion in the target area of the coaptation device (anteroseptal or posteroseptal). Binary logistic regression analysis showed an increase risk (Odds ratio 11, R2 0.34, 95% CI 0.019–0.44, p=0.003) for a suboptimal pTVR result (TR grade >2+ after intervention) in patients with rLLI. Although patients with rLLI (n=17) had significantly higher VCA3D values as compared to patients without rLLI (n=21), it was not predictive for pTVR results. Echocardiographic parameters of right ventricular and tricuspid valve dimensions showed only a trend to higher values in the group with rLLI (Table 1).

Conclusion

Endocardial lead induced TR negatively impacts the effectiveness of pTVR irrespective of the initial degree of TR.

Funding Acknowledgement

Type of funding sources: None.

Hypertrophic cardiomyopathy mimicking acute anterior myocardial infarction associated with sudden cardiac death

Hypertrophic cardiomyopathy is the most common genetic disease of the heart. We report a rare case of hypertrophic obstructive cardiomyopathy mimicking an acute anterior myocardial infarction associated with sudden cardiac death. The patient presented with acute ST elevation myocardial infarction and significant elevation of cardiac enzymes. Cardiac catheterization showed some atherosclerotic coronary artery disease, without significant stenosis. Echocardiography showed left ventricular hypertrophy with a left ventricular outflow tract obstruction; the pressure gradient at rest was 20 mmHg and became severe with the Valsalva maneuver (100 mmHg). There was no family history of sudden cardiac death. Six days later, the patient suffered a syncope on his way to magnetic resonance imaging. He was successfully resuscitated by ventricular fibrillation.