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Hagemeyer D, Merdad A, Sierra LV, Ruberti A, Kargoli F, Bouchat M, Boiago M, Moschovitis A, Deva DP, Stolz L, Ong G, Peterson MD, Piazza N, Taramasso M, Dumonteil N, Modine T, Latib A, Praz F, Hausleiter J, Fam NP. Clinical Characteristics and Outcomes of Patients Screened for Transcatheter Tricuspid Valve Replacement: The TriACT Registry. JACC Cardiovasc Interv 2024; 17:552-560. [PMID: 38418058 DOI: 10.1016/j.jcin.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND Transcatheter tricuspid valve replacement (TTVR) abolishes tricuspid regurgitation (TR) and has emerged as a definitive treatment for TR. OBJECTIVES The purpose of this multicenter, observational study was to determine the clinical characteristics and short-term outcomes of patients with TR screened for TTVR. METHODS Patients underwent TTVR screening at 7 centers on a compassionate-use basis. The primary endpoints were NYHA functional class and TR grade at 30-day follow-up. Secondary endpoints included all-cause mortality, heart failure hospitalization, technical success, and reasons for TTVR screening failure. RESULTS A total of 149 patients (median age 79 years [Q1-Q3: 72-84 years], 54% women) underwent TTVR screening. The TTVR screening failure rate was 74%, mainly related to large tricuspid annular diameter. Patients undergoing TTVR (n = 38) had significant functional improvements (NYHA functional class I or II from 21% to 68%; P < 0.001), with TR ≤1+ in 97% at 30-day follow-up (P < 0.001 from baseline). Technical success was achieved in 91%, with no intraprocedural mortality or conversion to surgery. At 30-day follow-up, mortality was 8%, heart failure hospitalization 5%, major bleeding 18%, and reintervention 9%. Patients who failed screening for TTVR and subsequently underwent "bailout" transcatheter edge-to-edge repair (n = 26) had favorable outcomes (NYHA functional class I or II from 27% to 58%; P < 0.001), with TR ≤1+ in 43% at 30-day follow-up (P < 0.001 from baseline). CONCLUSIONS This first real-world report of TTVR screening demonstrated a high screening failure rate, mainly related to large tricuspid annular diameter. Patients undergoing TTVR had superior TR reduction and symptom alleviation compared with bailout tricuspid transcatheter edge-to-edge repair, at the cost of greater procedural complications.
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Affiliation(s)
- Daniel Hagemeyer
- Structural Heart Program, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anas Merdad
- Structural Heart Program, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Laura Villegas Sierra
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Andrea Ruberti
- Division of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Faraj Kargoli
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Marine Bouchat
- Medico-Surgical Department (Valvulopathies, Cardiac Surgery, Adult Interventional Cardiology), Hôpital Cardiologique de Haut-Lévèque, Bordeaux University Hospital, Bordeaux, France
| | - Mauro Boiago
- Groupe Cardio-Vasculaire lnterventionnel, Cinique Pasteur, Toulouse, France
| | | | - Djeven P Deva
- Structural Heart Program, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Lukas Stolz
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Geraldine Ong
- Structural Heart Program, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mark D Peterson
- Structural Heart Program, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nicolo Piazza
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Nicolas Dumonteil
- Groupe Cardio-Vasculaire lnterventionnel, Cinique Pasteur, Toulouse, France
| | - Thomas Modine
- Medico-Surgical Department (Valvulopathies, Cardiac Surgery, Adult Interventional Cardiology), Hôpital Cardiologique de Haut-Lévèque, Bordeaux University Hospital, Bordeaux, France
| | - Azeem Latib
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Fabien Praz
- Division of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Neil P Fam
- Structural Heart Program, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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Bombace S, Fortuni F, Viggiani G, Meucci MC, Condorelli G, Carluccio E, von Roeder M, Jobs A, Thiele H, Esposito G, Lurz P, Grayburn PA, Sannino A. Right Heart Remodeling and Outcomes in Patients With Tricuspid Regurgitation: A Literature Review and Meta-Analysis. JACC Cardiovasc Imaging 2024:S1936-878X(24)00032-9. [PMID: 38430099 DOI: 10.1016/j.jcmg.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 11/13/2023] [Accepted: 12/22/2023] [Indexed: 03/03/2024]
Abstract
BACKGROUND Functional tricuspid regurgitation (TR) can develop either because of right ventricular (RV) remodeling (ventricular functional TR) and/or right atrial dilation (atrial functional TR). OBJECTIVES This meta-analysis aimed to investigate the association between right heart remodeling and long-term (>1 year) all-cause mortality in patients with significant TR (at least moderate, ≥2+). METHODS MEDLINE, ISI Web of Science, and SCOPUS databases were searched. Studies reporting data on at least 1 RV functional parameter and long-term all-cause mortality in patients with significant TR were included. This study was designed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) requirements. RESULTS Out of 8,902 studies, a total of 14 were included, enrolling 4,394 subjects. The duration of follow-up across the studies varied, ranging from a minimum of 15.5 months to a maximum of 73.2 months. Overall, long-term all-cause mortality was 31% (95% CI: 20%-41%; P ≤ 0.001). By means of meta-regression analyses, an inverse relation was found between tricuspid annular plane systolic excursion (11 studies enrolling 3,551 subjects, -6.3% [95% CI: -11.1% to -1.4%]; P = 0.011), RV fractional area change (9 studies, 2,975 subjects, -4.4% [95% CI: -5.9% to -2.9%]; P < 0.001), tricuspid annular dimension (7 studies, 2,986 subjects, -4.1% [95% CI: -7.6% to -0.5%]; P = 0.026), right atrial area (6 studies, 1,920 subjects, -1.9% [95% CI: -2.5% to -1.3%]; P < 0.001) and mortality. CONCLUSIONS RV dysfunction parameters are associated to worse clinical outcomes in patients with TR, whereas right atrial dilatation is linked to a better prognostic outcome. Further studies are needed to unravel the pathophysiological differences within the functional TR spectrum. (Right heart remodeling and outcomes in patients with tricuspid regurgitation; CRD42023418667).
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Affiliation(s)
- Sara Bombace
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany. https://twitter.com/sarabombace
| | - Federico Fortuni
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, San Giovanni Battista Hospital, Foligno, Italy. https://twitter.com/FedeFortuni9
| | - Giacomo Viggiani
- Department of Internal Medicine I, School of Medicine, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maria Chiara Meucci
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Cardio Center, Humanitas Research Hospital IRCCS, Rozzano, Italy
| | - Erberto Carluccio
- Cardiology and Cardiovascular Pathophysiology, University of Perugia, Perugia, Italy
| | - Maximilian von Roeder
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at Leipzig University, Leipzig, Germany
| | - Alexander Jobs
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at Leipzig University, Leipzig, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at Leipzig University, Leipzig, Germany; Leipzig Heart Science, Leipzig, Germany
| | - Giovanni Esposito
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Philipp Lurz
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Paul A Grayburn
- Baylor Scott and White Research Institute, Plano, Texas, USA
| | - Anna Sannino
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy; Baylor Scott and White Research Institute, Plano, Texas, USA; Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany.
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Vogelhuber J, Tenaka T, Sudo M, Sugiura A, Öztürk C, Kavsur R, Donner A, Nickenig G, Zimmer S, Weber M, Wilde N. Impact of body mass index in patients with tricuspid regurgitation after transcatheter edge-to-edge repair. Clin Res Cardiol 2024; 113:156-167. [PMID: 37792020 PMCID: PMC10808352 DOI: 10.1007/s00392-023-02312-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/14/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Obesity and underweight represent classical risk factors for outcome in patients treated for cardiovascular disease. This study describes the impact of different body mass index (BMI) categories on 1-year clinical outcome in patients with tricuspid regurgitation (TR) undergoing transcatheter-edge-to-edge repair (TEER). METHODS We analyzed 211 consecutive patients (age 78.3 ± 7.2 years, 55.5% female, median EuroSCORE II 9.6 ± 6.7) with tricuspid regurgitation undergoing TEER from June 2015 until May 2021. Patients were prospectively enrolled in our single center registry and were retrospectively analyzed. Patients were stratified according to body mass index (BMI) into 4 groups: BMI < 20 kg/m2 (underweight), BMI 20.0 to < 25.0 kg/m2 (normal weight), BMI 25.0 to > 30.0 kg/m2 (overweight) and BMI ≥ 30 kg/m2 (obese). RESULTS Kaplan-Meier survival curves demonstrated inferior survival for underweight and obese patients, but comparable outcomes for normal and overweight patients (global log rank test, p < 0.01). Cardiovascular death was significantly higher in underweight patients compared to the other groups (24.1% vs. 7.0% vs. 6.3% vs. 6.4%; p < 0.01). Over all, there were comparable rates of bleeding, stroke and myocardial infarction. Multivariable Cox regression analysis (adjusted for age, gender, coronary artery disease, chronic obstructive pulmonary disease, tricuspid annular plane systolic excursion, left-ventricular ejection fraction) confirmed underweight (HR 3.88; 95% CI 1.64-7.66; p < 0.01) and obesity (HR 3.24; 95% CI 1.37-9.16; p < 0.01) as independent risk factors for 1-year all-cause mortality. CONCLUSIONS Compared to normal weight and overweight patients, obesity and underweight patients undergoing TEER display significant higher 1-year all-cause mortality.
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Affiliation(s)
- Johanna Vogelhuber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Tetsu Tenaka
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Mitsumasa Sudo
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Atsushi Sugiura
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Can Öztürk
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Refik Kavsur
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Anika Donner
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Nihal Wilde
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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Siddiqui HF, Khan AB, Nasir MM, Latif F, Siddiqui AF, Akhtar P, Hamza M, Barmanwalla A. Therapeutic Outcomes Following Isolated Transcatheter Tricuspid Valve Repair: A Systematic Review and Meta-analysis. Curr Probl Cardiol 2023; 48:101985. [PMID: 37479006 DOI: 10.1016/j.cpcardiol.2023.101985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/16/2023] [Indexed: 07/23/2023]
Abstract
Tricuspid regurgitation (TR) is traditionally treated surgically, but isolated transcatheter tricuspid valve repair (ITTVR) offers a less invasive option. This study conducts a meta-analysis and systematic review to evaluate ITTVR outcomes in patients with TR. Database searches until March 2023 identified studies assessing ITTVR safety and efficacy in moderate/severe TR patients. Primary outcomes analyzed were severe TR, NYHA functional class improvement, and 6-minute walking distance. Meta-analyses used Risk ratio (RR) or mean difference with a random effects model. The review included 25 studies with 2421 patients. ITTVR improved NYHA functional class (RR: 3.262), reduced TR severity (RR: 0.303), and enhanced 6-minute walking distance (MD: +47.077 m). Echocardiographic parameters improved, including reductions in TR vena contracta, TR EROA, septolateral tricuspid annular diameter, RVEDD, RV FAC, and TAPSE. LVEF and PASP showed no significant changes. ITTVR improves functional outcomes and echocardiographic parameters in TR patients.
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Affiliation(s)
- Hasan Fareed Siddiqui
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Adam Bilal Khan
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Sindh, Pakistan.
| | - Muhammad Moiz Nasir
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Fakhar Latif
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Aisha Fareed Siddiqui
- Department of Internal Medicine, Aga Khan University Hospital, Karachi, Sindh, Pakistan
| | - Parveen Akhtar
- Department of Cardiology, National Institute of Cardiovascular Diseases, Karachi, Sindh, Pakistan
| | - Mohammad Hamza
- Department of Internal Medicine, Albany Medical Center, Albany, NY
| | - Alina Barmanwalla
- Department of Internal Medicine, MD Brigham and Women's Hospital and Cape Cod Hospital, Boston, MA
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Venkataramani R, Hershberger A, Choi CH, Ng V, Bhardwaj A, Ramakrishna H. Tricuspid Regurgitation: A Focus on Updated Interventional Anatomy and Pathophysiology. J Cardiothorac Vasc Anesth 2023; 37:2327-2334. [PMID: 37573214 DOI: 10.1053/j.jvca.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 08/14/2023]
Affiliation(s)
- Ranjani Venkataramani
- Department of Anesthesiology and Critical Care, University of California, San Francisco, San Francisco, CA
| | - Amy Hershberger
- Department of Anesthesiology and Critical Care, University of California, San Francisco, San Francisco, CA
| | - Christine Heejae Choi
- Department of Anesthesiology and Critical Care, University of California, San Francisco, San Francisco, CA
| | - Victor Ng
- Department of Anesthesiology and Critical Care, University of California, San Francisco, San Francisco, CA
| | - Adarsh Bhardwaj
- Department of Cardiology, University of California, San Francisco, San Francisco, CA
| | - Harish Ramakrishna
- Department of Cardiology, University of California, San Francisco, San Francisco, CA.
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Badwan O, Mirzai S, Skoza W, Hawk F, Braghieri L, Persits I, Krishnaswamy A, Puri R, Kapadia SR. Clinical outcomes following tricuspid transcatheter edge-to-edge repair with PASCAL: A meta-analysis. Int J Cardiol 2023; 389:131194. [PMID: 37473817 DOI: 10.1016/j.ijcard.2023.131194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/11/2023] [Accepted: 07/14/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Patients with severe tricuspid regurgitation (TR) exhibit high morbidity and mortality. Tricuspid transcatheter edge-to-edge repair (T-TEER) is a rapidly evolving strategy to address the unmet clinical need of severe TR therapies. OBJECTIVE Organize the current body of evidence on outcomes following use of the PASCAL (Edwards Lifesciences) system for T-TEER. METHODS For this meta-analysis, we searched the MEDLINE/PubMed, Embase, and Cochrane databases for keywords ["tricuspid"] and ["transcatheter" or "edge-to-edge"] and ["PASCAL" or "leaflet repair" or "valve repair"] from the database inception until January 11, 2023. Primary outcomes of interest were procedural success, mortality, New York Heart Association (NYHA) functional class, 6-min walking distance (6MWD), and TR severity. RESULTS A total of 549 patients undergoing PASCAL or PASCAL Ace T-TEER were included. The mean age ranged from 71.0 to 80.3 years, with 25.0 to 63.6% females. The follow-up duration ranged from 30 days to 1 year. The success rate was 83.5% (409/490). There was improvement in symptoms based on NYHA classification (at 1- to 6-months; NYHA ≥3 RR 0.27 [95% CI 0.19-0.39]; p < 0.001) and 6MWD (at 1-month; 50.96 [95% CI 32.34-69.59]; p < 0.001) post-procedure. On imaging, there was improvement in TR severity post-procedure (at 1- to 12-months; ≥ severe TR 0.21 [95% CI 0.14-0.31]; p < 0.001), which remained significant with each study removed. CONCLUSION PASCAL for T-TEER is associated with high procedural success rates along with improvements in NYHA functional class, TR severity, 6MWD, and patient-reported outcomes.
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Affiliation(s)
- Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, United States of America
| | - Saeid Mirzai
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, United States of America
| | - Warren Skoza
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, United States of America
| | - Fahad Hawk
- Division of Cardiovascular Medicine, University of South Florida College of Medicine, Tampa, FL, United States of America
| | - Lorenzo Braghieri
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, United States of America
| | - Ian Persits
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, United States of America
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States of America.
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Mattig I, Barbieri F, Kasner M, Romero Dorta E, Heinrich-Schüler AL, Zhu M, Stangl K, Landmesser U, Reinthaler M, Dreger H. Comparison of procedural characteristics of percutaneous annuloplasty and edge-to-edge repair for the treatment of severe tricuspid regurgitation. Front Cardiovasc Med 2023; 10:1232327. [PMID: 37745102 PMCID: PMC10515198 DOI: 10.3389/fcvm.2023.1232327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023] Open
Abstract
Background In recent years, new interventional therapies for tricuspid regurgitation (TR) demonstrated their effectiveness in reducing TR severity and improving symptoms. Currently, tricuspid transcatheter edge-to-edge repair (T-TEER) and percutaneous annuloplasty are the most widely used techniques in Europe. In this retrospective study, we compared procedural characteristics and learning curves of both TR devices in a real-world cohort. Material and methods Eligible patients with severe to torrential TR underwent either percutaneous annuloplasty or T-TEER as recommended by the local heart team. Patients with combined mitral and tricuspid interventions were excluded from the analysis. The study focused on procedural characteristics, TR reduction and learning curves. Results A total of 122 patients underwent either percutaneous annuloplasty (n = 64) or T-TEER (n = 58) with a technical and device success rate of 98% and 97%, respectively. Reasons for technical failure included right coronary artery (RCA) dissection prior to percutaneous annuloplasty, and two single leaflet device attachments (SLDA) during T-TEER implantation. The mean improvement of TR severity was 2.4 ± 0.8 degrees after T-TEER and 2.5 ± 0.8 after percutaneous annuloplasty. T-TEER procedures were shorter in terms of both procedure time and radiation exposure, while percutaneous annuloplasty, although taking longer, showed a significant reduction in procedure time over the course of the analysed period. Conclusion In summary, both interventional therapies reduce TR severity by approximately two degrees when used in the appropriate anatomy. The learning curve for annuloplasty group showed a significant decrease of procedure times.
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Affiliation(s)
- Isabel Mattig
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Charité Mitte, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
| | - Fabian Barbieri
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
| | - Mario Kasner
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
| | - Elena Romero Dorta
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Charité Mitte, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anna Lisa Heinrich-Schüler
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Charité Mitte, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Miry Zhu
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
| | - Karl Stangl
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Charité Mitte, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Ulf Landmesser
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
| | - Markus Reinthaler
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
- Institute of Active Polymers and Berlin-Brandenburg Center for Regenerative Therapies, Helmholtz-Zentrum Hereon, Teltow, Germany
| | - Henryk Dreger
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Virchow Klinikum, Berlin, Germany
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Xu R, Cai Z, Ding J, Ma G. Insight into tricuspid transcatheter edge-to-edge repair: no longer the forgotten valve. Expert Rev Cardiovasc Ther 2023; 21:877-885. [PMID: 37983042 DOI: 10.1080/14779072.2023.2286010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/16/2023] [Indexed: 11/21/2023]
Abstract
INTRODUCTION Tricuspid regurgitation (TR) is one of the most prevalent types of valvular heart disease linked to poor prognosis in patients with heart failure and is usually ignored. TR has received considerable attention due to the progressive advancements in transcatheter therapies in recent years. AREAS COVERED With relatively solid data and rapid technological advancements, tricuspid transcatheter edge-to-edge repair (T-TEER) is the most frequently employed in a series of tricuspid transcatheter interventional treatments for TR. However, the efficacy and technical benefits of T-TEER are limited because of the unique anatomical characteristics and pathological mechanisms of the tricuspid valve. The aim of this review is to summarize reported data on current status of T-TEER and to provide an expert opinion regarding the challenges it is now experiencing and future development direction and approach. EXPERT OPINION T-TEER is a significant treatment for TR, but its effectiveness and technical promotion are limited due to the tricuspid valve unique anatomical characteristics and pathological mechanisms. The selection criteria for suitable patients, the choice of when to intervene, device innovation, the advancement of ultrasound technology, and the volume of evidence in evidence-based medicine all indicate that the disorder of TR will eventually be better treated and understood.
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Affiliation(s)
- Rongfeng Xu
- Department of Cardiology, Zhongda Hospital, Southeast University, Nanjing, P.R.China
| | - Zhenyu Cai
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen, P.R. China
| | - Jiandong Ding
- Department of Cardiology, Zhongda Hospital, Southeast University, Nanjing, P.R.China
| | - Genshan Ma
- Department of Cardiology, Zhongda Hospital, Southeast University, Nanjing, P.R.China
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Dimitriadis K, Pyrpyris N, Aznaouridis K, Iliakis P, Valatsou A, Tsioufis P, Beneki E, Mantzouranis E, Aggeli K, Tsiamis E, Tsioufis K. Transcatheter Tricuspid Valve Interventions: A Triumph for Transcatheter Procedures? Life (Basel) 2023; 13:1417. [PMID: 37374199 DOI: 10.3390/life13061417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/30/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023] Open
Abstract
Tricuspid regurgitation (TR) is a common valvular pathology, estimated to affect 1.6 million people in the United States alone. Even though guidelines recommend either medical therapy or surgical treatment for TR, the misconception of TR as a benign disease along with the high mortality rates of surgical intervention led to undertreating this disease and commonly describing it as a "forgotten" valve. Recently, the development of transcatheter interventions for TR show promising potential for use in the clinical setting. There are currently few approved and numerous tested percutaneously delivered devices, which can be categorized, based on their mechanism of action, to either valve repair or valve replacement procedures. Both procedures were tested in clinical trials and show an echocardiographic reduction in TR sustained for at least 1 year after the procedure, as well as symptom relief and functional improvement of the patients. Device selection should be personalized, taking into consideration the anatomy of each valve and the available options at each heart center. Moreover, appropriate patient selection and timing of the procedure are also crucial for the success of the procedure. In this review, we analyze the clinical trials available for all devices currently approved or tested, aiming to provide a comprehensive summary of the most recent evidence in the field of transcatheter TR interventions.
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Affiliation(s)
- Kyriakos Dimitriadis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece
| | - Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece
| | - Konstantinos Aznaouridis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece
| | - Panagiotis Iliakis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece
| | - Aggeliki Valatsou
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece
| | - Panagiotis Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece
| | - Eirini Beneki
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece
| | - Emmanouil Mantzouranis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece
| | - Konstantina Aggeli
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece
| | - Eleftherios Tsiamis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece
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Wu Z, Zhu W, Kaisaier W, Kadier M, Li R, Tursun G, Dong Y, Liu C, Chen Y. Periprocedural, short-term, and long-term outcomes following transcatheter tricuspid valve repair: a systemic review and meta-analysis. Ther Adv Chronic Dis 2023; 14:20406223231158607. [PMID: 36895329 PMCID: PMC9989399 DOI: 10.1177/20406223231158607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/03/2023] [Indexed: 03/06/2023] Open
Abstract
Background There has been an increasing use of transcatheter tricuspid valve repair (TTVR) recently. However, the periprocedural, short-term, and long-term outcomes of TTVR remain unclear. Objectives To determine the clinical outcomes in patients with significant tricuspid regurgitation undergoing TTVR. Design Systematic review and meta-analysis. Data Source and Methods The systematic review and meta-analysis is reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed and EMBASE were searched for clinical trials and observational studies until March 2022. Studies reporting the incidence of clinical outcomes after TTVR were included. The clinical outcomes included periprocedural, short-term (in-hospital or within 30 days), and long-term (>6-month follow-up) outcomes. The primary outcome was all-cause mortality whereas the secondary outcomes included technical success, procedural success, cardiovascular mortality, rehospitalization for heart failure (HHF), major bleeding, and single leaflet device attachment. The incidence of these outcomes across studies was pooled by a random-effects model. Results A total of 21 studies with 896 patients were included. A total of 729 (81.4%) patients underwent isolated TTVR while only 167 (18.6%) patients underwent combined mitral and tricuspid valve repair. Over 80% of the patients used coaptation devices while approximately 20% used annuloplasty devices. The median follow-up duration was 365 days. Technical and procedural success was high at 93.9% and 82.1%, respectively. The pooled perioperative, short-term, and long-term all-cause mortality for patients undergoing TTVR was 1.0%, 3.3%, and 14.1%, respectively. The long-term cardiovascular mortality rate was 5.3% while the HHF rate was 21.5%. Major bleeding and single leaflet device attachment were two major complications, accounting for 14.3% and 6.4%, respectively, during long-term follow-up. Conclusion TTVR is associated with high procedural success and low procedural and short-term mortality. However, all-cause mortality, cardiovascular mortality, and HHF rates remain high during long-term follow-up. Registration PROSPERO (CRD42022310020).
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Affiliation(s)
- Zexuan Wu
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, P.R. China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, P.R. China
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, P.R. China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, P.R. China
| | - Wulamiding Kaisaier
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, P.R. China
| | - Miriding Kadier
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, P.R. China
| | - Runkai Li
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, P.R. China
| | - Gulpari Tursun
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, P.R. China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, P.R. China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, P.R. China
| | - Chen Liu
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, P.R. China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, P.R. China
| | - Yili Chen
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, P.R. China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, P.R. China
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11
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Alperi A, Avanzas P, Almendárez M, León V, Hernández-Vaquero D, Silva I, Fernández del Valle D, Fernández F, Díaz R, Rodes-Cabau J, Morís C, Pascual I. Resultados a corto y medio plazo de la reparación transcatéter de la válvula tricúspide: revisión sistemática y metanálisis de estudios observacionales. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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12
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Chadderdon SM, Eleid MF, Thaden JJ, Makkar R, Nakamura M, Babaliaros V, Greenbaum A, Gleason P, Kodali S, Hahn RT, Koulogiannis KP, Marcoff L, Grayburn P, Smith RL, Song HK, Lim DS, Gray WA, Hawthorne K, Deuschl F, Narang A, Davidson C, Zahr FE. Three-Dimensional Intracardiac Echocardiography for Tricuspid Transcatheter Edge-to-Edge Repair. Struct Heart 2022; 6:100071. [PMID: 37288338 PMCID: PMC10242583 DOI: 10.1016/j.shj.2022.100071] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 06/08/2022] [Accepted: 06/17/2022] [Indexed: 06/09/2023]
Abstract
Patients with severe symptomatic tricuspid regurgitation face a significant dilemma in treatment options, as the yearly mortality with medical therapy and the surgical mortality for tricuspid repair or replacement are high. Transcatheter edge-to-edge repair (TEER) for the tricuspid valve is becoming a viable option in patients, although procedural success is dependent on high-quality imaging. While transesophageal echocardiography remains the standard for tricuspid TEER procedures, intracardiac echocardiography (ICE) with three-dimensional (3D) multiplanar reconstruction (MPR) has many theoretical and practical advantages. The aim of this article was to describe the in vitro wet lab-based imaging work done to facilitate the best approach to 3D MPR ICE imaging and the procedural experience gained with 3D MPR ICE in tricuspid TEER procedures with the PASCAL device.
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Affiliation(s)
- Scott M. Chadderdon
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Mackram F. Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy J. Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Raj Makkar
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Mamoo Nakamura
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Vasilis Babaliaros
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Georgia, USA
| | - Adam Greenbaum
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Georgia, USA
| | - Patrick Gleason
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Georgia, USA
| | - Susheel Kodali
- Structural Heart & Vascular Center, New York Presbyterian Hospital-Columbia University Irving Medical Center, New York, New York, USA
| | - Rebecca T. Hahn
- Structural Heart & Vascular Center, New York Presbyterian Hospital-Columbia University Irving Medical Center, New York, New York, USA
| | - Konstantinos P. Koulogiannis
- Department of Cardiovascular Medicine, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | - Leo Marcoff
- Department of Cardiovascular Medicine, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | - Paul Grayburn
- Baylor Scott & White The Heart Hospital, Plano, Texas, USA
| | | | - Howard K. Song
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - D. Scott Lim
- Division of Cardiology, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - William A. Gray
- Department of Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Katie Hawthorne
- Department of Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | | | - Akhil Narang
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Charles Davidson
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Firas E. Zahr
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
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13
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Sannino A, Ilardi F, Hahn RT, Lancellotti P, Lurz P, Smith RL, Esposito G, Grayburn PA. Clinical and Echocardiographic Outcomes of Transcatheter Tricuspid Valve Interventions: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:919395. [PMID: 35898276 PMCID: PMC9309386 DOI: 10.3389/fcvm.2022.919395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background Medically managed tricuspid regurgitation (TR) has detrimental outcomes. Transcatheter tricuspid valve interventions (TTVIs) represent an alternative to surgery in high-risk patients; however, only early experiences exist. Aim The aim of this study was to analyze the clinical and echocardiographic outcomes of TTVI. Methods MEDLINE, ISI Web of Science, and SCOPUS databases were searched for studies published up to June 2021. Studies reporting data on outcome post-TTVIs were included. This study was designed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) requirements. The primary endpoint was all-cause mortality at 30-day and 1-year post-TTVI. Results Out of 2,718 studies, 27 were included. Notably, 30-day and 1-year all-cause mortalities were 5% (95% confidence interval [CI]: 4–8%, p < 0.001) and 25% (95% CI: 12–45%, p = 0.016). Procedural success was associated with a 58% risk reduction in 1-year mortality vs. lack thereof (odds ratio 0.42, 95% CI: 0.27–0.66, p < 0.001). TTVI is associated with a significant reduction in TR severity (TR EROA, mean difference [MD] 0.31 cm2; 95% CI: 0.23–0.39 cm2, p < 0.001; regurgitant volume, MD 23.54 ml; 95% CI: 17.4–29.68 ml, p = 0.03) and increase in forward stroke volume (FSV, MD 3.98 ml; 95% CI: 0.11–7.86 ml, p = 0.04). Conclusion TTVI significantly reduces TR severity and increases FSV and is associated with improved survival at 1 year compared with patients without procedural success. Long-term outcomes compared with medical therapy await the results of ongoing pivotal trials; nonetheless, TTVIs appear to be a promising alternative to surgery for TR.
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Affiliation(s)
- Anna Sannino
- The Heart Hospital Baylor Plano, Plano, TX, United States
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
- *Correspondence: Anna Sannino
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Rebecca T. Hahn
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, United States
| | - Patrizio Lancellotti
- Department of Cardiology and Radiology, GIGA Cardiovascular Sciences, CHU SartTilman, University of Liège Hospital, Liège, Belgium
- Gruppo Villa Maria Care and Research, Lugo, Italy
| | - Philipp Lurz
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | | | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
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Wild MG, Löw K, Rosch S, Gerçek M, Higuchi S, Massberg S, Näbauer M, Rudolph V, Markovic S, Boekstegers P, Rassaf T, Luedike P, Geisler T, Braun D, Stolz L, Praz F, Lurz P, Hausleiter J. Multicenter Experience With the Transcatheter Leaflet Repair System for Symptomatic Tricuspid Regurgitation. JACC Cardiovasc Interv 2022; 15:1352-63. [DOI: 10.1016/j.jcin.2022.05.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 05/24/2022] [Accepted: 05/31/2022] [Indexed: 12/26/2022]
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15
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Wu IY, Gu Y, Pospishil L, Neuburger PJ. Transcatheter Tricuspid Valve Repair with the PASCAL Repair System: A Review of Emerging Technology. J Cardiothorac Vasc Anesth 2022; 36:3719-3721. [DOI: 10.1053/j.jvca.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 11/11/2022]
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16
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Alperi A, Avanzas P, Almendárez M, León V, Hernández-Vaquero D, Silva I, Fernández Del Valle D, Fernández F, Díaz R, Rodes-Cabau J, Morís C, Pascual I. Early and mid-term outcomes of transcatheter tricuspid valve repair: systematic review and meta-analysis of observational studies. Revista Española de Cardiología (English Edition) 2022; 76:322-332. [PMID: 35662675 DOI: 10.1016/j.rec.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/23/2022] [Indexed: 12/21/2022]
Abstract
INTRODUCTION AND OBJECTIVES Severe tricuspid regurgitation (TR) is associated with poor prognosis when left untreated, and a growing number of studies on transcatheter tricuspid valve repair (TTVr) have been published over the last few months. METHODS We performed a comprehensive systematic review of published literature providing clinical data on TTVr for patients with significant TR. Early and mid-term clinical and echocardiographic outcomes were evaluated. Risk ratios (RR) or mean differences (MD) were obtained when comparing pre- and postprocedural data. A sensitivity analysis was also performed according to the main approach for repair (edge-to-edge vs annuloplasty). RESULTS A total of 19 studies (all observational or single-arm trials) and 991 patients who underwent isolated TTVr were included. Thirty-day mortality and stroke rates were 2.8% and 0.2%, respectively. Pooled random-effects resulted in a significant reduction of ≥ severe TR (RR, 0.33; 95%CI, 0.26-0.42; P < .001), vena contracta width (MD, 5.9mm; 95%CI, 4-7.9; P <.001), right ventricular end-diastolic diameter (MD, 3.5mm; 95%CI, 2.5-4.5; P <.001), and New York Heart Association (NYHA) class III or IV at last follow-up (RR, 0.32; 95%CI, 0.27-0.37; P <.001). Bleeding complications and residual ≥ severe TR were numerically higher in the annuloplasty-like group compared with edge-to-edge repair (13.3% vs 3.8% for bleeding and 40.4% vs 27.9% for residual severe TR). CONCLUSIONS Among 991 patients comprising the early experience for several TTVr devices, there was a statistically significant reduction in ≥ severe TR, NYHA class III-IV, vena contracta width and right ventricular end-diastolic diameter after TTVr. Thus far, the edge-to-edge approach seems to be associated with a better safety profile.
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Affiliation(s)
- Alberto Alperi
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Pablo Avanzas
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Universidad de Oviedo, Oviedo, Spain.
| | - Marcel Almendárez
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Víctor León
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Daniel Hernández-Vaquero
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Universidad de Oviedo, Oviedo, Spain
| | - Iria Silva
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | | | - Félix Fernández
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Rocío Díaz
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | | | - César Morís
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Universidad de Oviedo, Oviedo, Spain
| | - Isaac Pascual
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Universidad de Oviedo, Oviedo, Spain
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17
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Estévez-Loureiro R, Sánchez-Recalde A, Amat-Santos IJ, Cruz-González I, Baz JA, Pascual I, Mascherbauer J, Abdul-Jawad Altisent O, Nombela-Franco L, Pan M, Trillo R, Moreno R, Delle Karth G, Salido-Tahoces L, Santos-Martinez S, Núñez JC, Moris C, Goliasch G, Jimenez-Quevedo P, Ojeda S, Cid-Álvarez B, Santiago-Vacas E, Jimenez-Valero S, Serrador A, Martín-Moreiras J, Strouhal A, Hengstenberg C, Zamorano JL, Puri R, Íñiguez-Romo A. Six-Month Outcomes of the TricValve® System in Patients with Tricuspid Regurgitation: TRICUS EURO Study. JACC Cardiovasc Interv 2022; 15:1366-1377. [PMID: 35583363 DOI: 10.1016/j.jcin.2022.05.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/10/2022] [Accepted: 05/10/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Severe tricuspid regurgitation (TR) is frequently associated with significant morbidity and mortality; such patients often deemed to be at high surgical risk. Heterotopic bi-caval stenting is an emerging, attractive transcatheter solution for these patients. OBJECTIVES To evaluate the 30-day safety and 6-month efficacy outcomes of specifically designed bioprosthetic valves for the superior and inferior vena cava. METHODS TRICUS EURO is a non-blinded, non-randomized, single-arm, multicenter, prospective trial that enrolled patients from 12 European centers between December 2019 to February 2021. High risk individuals with severe symptomatic TR despite optimal medical therapy were included. Primary end point was quality of life (QOL) improvement measured by Kansas City Cardiomyopathy Questionnaire (KCCQ12) and New York Heart Association functional class (NYHA) improvement at 6-month follow-up. RESULTS 35 patients (mean age 76±6.8 years; 83% women) were treated with TricValve® system. All patients at baseline were at NYHA ≥ 3 status. At 30-days, procedural success was 94% with no procedural deaths or conversions to surgery. A significant increase in QOL at 6-months follow-up was observed (baseline and 6-month KCCQ: 42.01±22.3 vs. 59.7±23.6 respectively; p=0.004), correlating with a significant improvement in NYHA functional class with 79.4% of patients noted to be in class I or II at 6 months (p=0.0006). The 6-month all-cause mortality and heart failure hospitalization rates were 8.5% and 20%, respectively. CONCLUSIONS The dedicated bi-caval system for treating severe, symptomatic TR was associated with high procedural success rate and significant increase in both, QOL and functional improvements at 6-months follow-up.
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Affiliation(s)
| | | | | | | | - Jose A Baz
- Complejo Hospitalario Universitario Alvaro Cunqueiro, Vigo, Spain
| | - Isaac Pascual
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Julia Mascherbauer
- Division of Cardiology, Department for Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | | | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Manuel Pan
- Hospital Universitario Reina Sofia, Córdoba, Spain
| | - Ramiro Trillo
- Hospital Clinico Universitario de Santiago de Compostela, CIBERCV, Santiago, Spain
| | - Raul Moreno
- Hospital Universitario La Paz, Madrid, Spain
| | | | | | | | - Jean C Núñez
- Hospital Clinico Universitario de Salamanca, CIBERCV. IBSAL. Salamanca, Spain
| | - Cesar Moris
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Georg Goliasch
- Division of Cardiology, Department for Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | | | | | - Belén Cid-Álvarez
- Hospital Clinico Universitario de Santiago de Compostela, CIBERCV, Santiago, Spain
| | | | | | - Ana Serrador
- CIBERCV. Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | | | - Christian Hengstenberg
- Division of Cardiology, Department for Internal Medicine II, Medical University of Vienna, Vienna, Austria
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Kitamura M, Kresoja KP, Balata M, Besler C, Rommel KP, Unterhuber M, Lurz J, Rosch S, Gunold H, Noack T, Thiele H, Lurz P. Health Status After Transcatheter Tricuspid Valve Repair in Patients With Functional Tricuspid Regurgitation. JACC Cardiovasc Interv 2021; 14:2545-2556. [PMID: 34887048 DOI: 10.1016/j.jcin.2021.09.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/15/2021] [Accepted: 09/21/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The aim of this study was to investigate changes in quality of life (QoL) after transcatheter tricuspid valve repair (TTVR) for tricuspid regurgitation (TR). BACKGROUND TTVR provides feasible and durable efficacy in reducing TR, but its clinical benefits on QoL still remain unclear. METHODS In 115 subjects undergoing TTVR for severe functional TR, QoL was evaluated using the 36-Item Short Form Health Survey (SF-36) and the Minnesota Living With Heart Failure Questionnaire (MLHFQ). All-cause mortality, heart failure (HF) rehospitalization, and a composite endpoint of all-cause mortality, HF rehospitalization, and repeat TTVR were recorded as clinical events. RESULTS Successful device implantation was achieved in 110 patients (96%). Moderate or less TR at discharge was achieved in 95 patients (83%). Mean SF-36 physical component summary (PCS) score improved from 34 ± 9 to 37 ± 9 points (+3 points; 95% CI: 1-5 points; P = 0.001), mean SF-36 mental component summary score improved from 49 ± 9 to 51 ± 10 points (+2 points; 95% CI: 0-4 points; P = 0.017), and mean MLHFQ score decreased from 29 ± 14 to 20 ± 15 points (-8 points; 95% CI: -11 to -5 points; P < 0.001). Baseline PCS, moderate or less TR at discharge, and baseline massive or torrential TR were associated with 1-month change in PCS score (P < 0.05). Change in PCS score after 1 month predicted HF rehospitalization after TTVR (adjusted HR: 0.74 [95% CI: 0.60-0.92] per 5-point increase in PCS score; P = 0.008). CONCLUSIONS This study demonstrates that TTVR provides improvement in QoL in patients with relevant TR. TR reduction to a moderate or less grade was associated with improvement of SF-36 and MLHFQ scores. Further, global QoL was associated with clinical outcomes and might serve as a future outcome surrogate following TTVR.
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Affiliation(s)
- Mitsunobu Kitamura
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Karl-Patrik Kresoja
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Mahmoud Balata
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Christian Besler
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Karl-Philipp Rommel
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Matthias Unterhuber
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Julia Lurz
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Sebastian Rosch
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Hilka Gunold
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Thilo Noack
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Philipp Lurz
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.
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da Rocha E Silva JG, Ruf TF, Hell MM, Tamm A, Geyer M, Munzel T, von Bardeleben RS, Kreidel F. Transgastric imaging-The key to successful periprocedural TEE guiding for edge-to-edge repair of the tricuspid valve. Echocardiography 2021; 38:1948-1958. [PMID: 34729813 DOI: 10.1111/echo.15196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/11/2021] [Accepted: 08/22/2021] [Indexed: 11/28/2022] Open
Abstract
Intraprocedural transesophageal echocardiography (TEE) guidance plays an essential role in transcatheter repair therapy of the tricuspid valve (TV). So far, several different imaging concepts are in use. We propose an imaging protocol that fully addresses the morphological complexity of the TV and further offers efficacious workarounds for the frequently occurring restrictions of TV imaging in edge-to-edge repair of the TV. As a tertiary referral center with a large experience of more than 250 cases of transcatheter edge-to-edge repair (TEER) of the TV performed at the Heart Valve Center in Mainz/Germany, we have constantly adapted our peri-interventional echocardiographic approach to accomplish both. As a key measure for success, we intensely rely on the transgastric acoustic windows that not only deliver high-resolution information on the morphology of the TV and all relevant procedural steps but also help to avoid the frequent shadowing artifacts experienced in transesophageal imaging.
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Affiliation(s)
| | - Tobias F Ruf
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Michaela M Hell
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Alexander Tamm
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Martin Geyer
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Thomas Munzel
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | | | - Felix Kreidel
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
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20
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Sugiura A, Tanaka T, Kavsur R, Öztürk C, Vogelhuber J, Wilde N, Becher MU, Zimmer S, Nickenig G, Weber M. Leaflet Configuration and Residual Tricuspid Regurgitation After Transcatheter Edge-to-Edge Tricuspid Repair. JACC Cardiovasc Interv 2021; 14:2260-2270. [PMID: 34424200 DOI: 10.1016/j.jcin.2021.07.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES This study aimed to assess the anatomical leaflet variation and investigate its impact on the procedural outcome in patients undergoing transcatheter edge-to-edge tricuspid repair. BACKGROUND Tricuspid regurgitation (TR) is associated with a poor prognosis. METHODS The study participants were consecutive patients who underwent transcatheter edge-to-edge tricuspid repair with the MitraClip, TriClip, or PASCAL systems from June 2015 to July 2020 at the Bonn Heart Center. The tricuspid leaflet morphologies were imaged using 2-dimensional and 3-dimensional transesophageal echocardiography. The severity of TR was assessed according to the 5-grade scheme. The primary endpoint was residual TR ≥3+ within 30 days. RESULTS Of the 145 study participants, 103 (71.1%) participants were categorized as the 3-leaflet configuration, while 42 (28.9%) were categorized as the 4-leaflet configuration. Successful device implantation was achieved in 136 (93.8%) patients, with no statistical difference between the 3-leaflet and 4-leaflet configuration groups. However, compared with patients with a 3-leaflet configuration, patients with 4-leaflet configuration more frequently had residual TR ≥3+ (18.4% vs 38.1%; P = 0.018). In the multivariable model, the 4-leaflet configuration was associated with an increased risk of residual TR ≥3+ (odds ratio: 2.65; 95% CI 1.15-6.10; P = 0.022), independent of baseline TR grade, coaptation gap width, and TR jet location. After 1-year follow-up, compared with patients with residual TR <3+, patients with residual TR ≥3+ had a significantly higher incidence of the composite of all-cause mortality or heart failure hospitalization (27.7% vs 56.1%; P = 0.016). CONCLUSIONS A 4-leaflet configuration of the tricuspid valve is observed in approximately one-third of patients undergoing transcatheter edge-to-edge tricuspid repair, which is associated with an increased risk of residual TR after the procedure.
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Affiliation(s)
- Atsushi Sugiura
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Tetsu Tanaka
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Refik Kavsur
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Can Öztürk
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Johanna Vogelhuber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Nihal Wilde
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marc Ulrich Becher
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany.
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21
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Rosch S, Lurz P. [Current technologies in interventional treatment of tricuspid valve regurgitation]. Herz 2021; 46:437-444. [PMID: 34374789 DOI: 10.1007/s00059-021-05056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
For a long time, severe tricuspid valve regurgitation (TR) was an underestimated disease, especially in the older population and was associated with high morbidity and mortality. Due to the high perioperative mortality of tricuspid valve surgery, historically only pharmaceutical treatment was a practical treatment option. In the first studies interventional approaches could achieve promising results with an effective reduction of TR with simultaneous proof of a convincing safety profile. Conceptually, the currently available interventional treatment options can be divided into three concepts: coaptation systems (edge-to-edge repair), annuloplasty and interventional valve replacement. The largest clinical experience and best scientific body of evidence could so far be generated in the field of coaptation systems. Very promising preliminary results with effective reduction of TR and improvement of the clinical symptoms are, however, also available for interventional valve replacement. Meticulous preprocedural diagnostics with selection of the most suitable treatment option for each individual patient is paramount for successful treatment in this critically ill patient cohort. Future prospective randomized studies will investigate the net benefit of an interventional treatment of TR in comparison to a purely conservative treatment concept.
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Affiliation(s)
- Sebastian Rosch
- Klinik für Innere Medizin/Kardiologie, Universität Leipzig - Herzzentrum, Strümpellstraße 39, 04289, Leipzig, Deutschland
| | - Philipp Lurz
- Klinik für Innere Medizin/Kardiologie, Universität Leipzig - Herzzentrum, Strümpellstraße 39, 04289, Leipzig, Deutschland.
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22
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Tadic M, Cuspidi C, Morris DA, Rottbauer W. Functional tricuspid regurgitation, related right heart remodeling, and available treatment options: good news for patients with heart failure? Heart Fail Rev 2021; 27:1301-1312. [PMID: 34264478 PMCID: PMC9197807 DOI: 10.1007/s10741-021-10141-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 11/28/2022]
Abstract
Significant functional tricuspid regurgitation (FTR) represents a poor prognostic factor independent of right ventricular (RV) function. It is usually the consequence of left-sided cardiac diseases that induce RV dilatation and dysfunction, but it can also resulted from right atrial (RA) enlargement and consequent tricuspid annular dilatation. FTR is very frequent among patients with heart failure, particularly in those with reduced LVEF and concomitant functional mitral regurgitation. The development of three-dimensional echocardiography enabled detailed assessment of tricuspid valve anatomy, subvavlular apparatus, and RA and RV changes, as well as accurate evaluation of FTR etiology. Due to high in-hospital mortality risk in patients who were operatively treated for isolated FTR, it has been treated only medically for a long time. Percutaneous approach considers mainly transcatheter tricuspid valve repair (edge-to-edge and annuloplasty) and represents a very attractive option for the high-risk patients. Studies that investigated the effects of different devices showed excellent feasibility and safety, followed by significant reduction in FTR grade, improvement in functional capacity and NYHA class, quality of life, and reduction in hospitalization due to heart failure. Some investigations also reported a decreased mortality in FTR patients. Nevertheless, the results of these investigations should be interpreted with cautious due to the small number of participants and relatively short follow-up. The aim of this review was to summarize the existing data about the clinical importance of FTR and FTR-induced right heart remodeling and currently existing therapeutic approaches for treatment of FTR.
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Affiliation(s)
- Marijana Tadic
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081, Ulm, Germany.
| | | | - Daniel Armando Morris
- Department of Cardiology, Charité - Universitätsmedizin Berlin (Campus Virchow-Klinikum), Berlin, Germany
| | - Wolfang Rottbauer
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081, Ulm, Germany
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