Prevalence, clinical characteristics and outcomes of heart failure patients with or without isolated or combined mitral and tricuspid regurgitation: An analysis from the ESC-HFA Heart Failure Long-Term Registry

Tricuspid regurgitation and outcomes in mitral valve transcatheter edge-to-edge repair

BACKGROUND AND AIMS

The association between periprocedural change in tricuspid regurgitation (TR) and outcomes in patients undergoing mitral transcatheter edge-to-edge repair (M-TEER) is unclear. This study aimed to examine the prognostic value of TR before and after M-TEER.

METHODS

Patients in the OCEAN-Mitral registry were divided into four groups according to baseline and post-procedure echocardiographic assessments: no TR/no TR (no TR), no TR/significant TR (new-onset TR), significant TR/no TR (normalized TR), and significant TR/significant TR (residual TR) (all represents before/after M-TEER). Tricuspid regurgitation ≥ moderate was defined as significant. The primary outcome was cardiovascular death or heart failure hospitalization. Tricuspid regurgitation pressure gradient was also evaluated.

RESULTS

The numbers of patients in each group were 2103 (no TR), 201 (new-onset TR), 504 (normalized TR), and 858 (residual TR). Baseline assessment for TR and TR pressure gradient was not associated with outcomes after M-TEER. In contrast, patients with new-onset TR had the highest adjusted risk for the primary outcome, followed by those with residual TR [compared with no TR as a reference, hazard ratio 1.83 (95% confidence interval: 1.39-2.40) for new-onset TR, 1.45 (1.23-1.72) for residual TR, and 0.82 (0.65-1.04) for normalized TR]. Similarly, from baseline to post-procedure, TR pressure gradient changes were associated with subsequent outcomes after M-TEER. New-onset and residual TR incidence was commonly associated with dilated tricuspid annulus diameter and atrial fibrillation.

CONCLUSIONS

Post-procedural TR, but not baseline TR, was associated with outcomes after M-TEER. Careful TR assessment after the procedure would provide an optimal management for concomitant significant TR in patients undergoing M-TEER.

Clinical management and therapeutic optimization of patients with heart failure with reduced ejection fraction and low blood pressure. A clinical consensus statement of the Heart Failure Association (HFA) of the ESC

Despite major advancements in heart failure (HF) management and guideline recommendations over the past two decades, real-world evidence highlights suboptimal implementation of guideline-directed medical therapy (GDMT) for HF with reduced ejection fraction (HFrEF). Low blood pressure (BP) is common in HFrEF patients and represents a major perceived barrier to implementing life-saving treatments in clinical practice, as physicians are often concerned about symptomatic hypotension and its consequences. Although low BP can be seen in those hospitalized with signs of shock, the most common scenario involves non-severe, asymptomatic hypotension in patients receiving foundational therapy for HFrEF, where premature down-titration or discontinuation of GDMT should be avoided. This clinical consensus statement provides a comprehensive overview of low BP in HFrEF, including its definition, risk factors, and effects of HF therapies on BP. We propose management pathways to optimize HFrEF treatment in the context of low BP, ultimately aiming to improve patient outcomes.

Edge-to-edge tricuspid valve repair and heart failure hospitalizations: the TRI-SPA registry

INTRODUCTION AND OBJECTIVES

The prognostic impact of a history of heart failure hospitalizations (HFH) in patients undergoing transcatheter tricuspid edge-to-edge repair (T-TEER) has been scarcely studied. This study presents the results of the TRI-SPA registry, which includes data from 15 Spanish centers.

METHODS

A multicenter, retrospective registry was conducted, including patients who underwent T-TEER between June 2020 and May 2023. Patients were classified into the 3 groups, based on the number of HFH in the 12 months prior to the procedure: no HFH, 1 HFH, and >1 HFH (recurrent). The primary endpoint was all-cause mortality and HFH.

RESULTS

Of the 262 patients included, 167 (63.7%) had no history of HFH, 60 (22.9%) had 1 HFH, and 35 (13.4%) had >1 HFH. Patients with >1 hospitalization had more comorbidities, higher surgical risk, and worse functional class; however, no significant differences were observed in the severity of tricuspid regurgitation either at baseline or after T-TEER. After a median follow-up of 365 [160-643] days, patients with recurrent HFH had higher rates of the composite outcome (9.9%, 16.7%, and 43.1%, respectively; P<.001), as well as higher mortality rates (P=.036) and HFH (P<.001). The number of HFH significantly decreased in the 12 months following T-TEER compared with the 12 months prior (P=.001).

CONCLUSIONS

Recurrent HFH within the 12 months prior to the procedure was associated with a higher risk of adverse clinical events during follow-up. T-TEER significantly reduced the number of hospitalizations during the follow-up period.

Clinical Characteristics, Outcomes, and Risk Stratification of Combined Mitral and Tricuspid Regurgitation: The China-VHD Study

BACKGROUND

Combined mitral regurgitation (MR) and tricuspid regurgitation (TR) is related to more complicated hemodynamic burdens than isolated atrioventricular valve regurgitation.

OBJECTIVES

This study aimed to investigate clinical characteristics and outcomes of combined MR and TR, as well as developing dedicated prognostic instruments.

METHODS

A total of 6,704 patients with ≥ moderate MR or TR from the China Valvular Heart Disease study were included in this analysis. The study outcomes included all-cause mortality, death or hospitalization for heart failure, and worsening functional status or death within 2 years.

RESULTS

Compared with those with isolated valvular regurgitation, patients with combined MR and TR more often experienced atrial fibrillation or flutter and pulmonary hypertension. During a median follow-up of 733 days (Q1, Q3: 706, 749 days), 624 (9.3%) deaths occurred. Combined MR and TR was related to poorer 2-year outcomes than isolated MR, and was independently associated with worse prognosis in symptomatic patients (all-cause mortality: MR vs MR+TR, HR: 0.776 [95% CI: 0.616-0.978]; P = 0.031) and those with normal left ventricular systolic function (composite endpoint: HR: 0.629 [95% CI: 0.400-0.990]; P = 0.045). Based on carefully evaluated predictors of mortality, a prognostic nomogram and a risk score were developed and externally validated for patients with combined MR and TR, with superior predictive performance than the MitraScore and comparable discrimination compared with artificial intelligence-derived models.

CONCLUSIONS

Patients with combined MR and TR displayed worse clinical profiles and poorer outcomes compared with those with isolated MR. The novel prognostic tools may improve personalized risk assessment of combined MR and TR.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Mechanical Adaptation of the Right Ventricle to Secondary Tricuspid Regurgitation and Its Association With Patient Outcomes

BACKGROUND

Data regarding right ventricular (RV) mechanical adaptation to secondary tricuspid regurgitation (STR) are scarce.

OBJECTIVES

The aim of this study was to investigate changes in RV contraction pattern in patients with different degrees of STR severity and etiologies and their association with outcomes.

METHODS

A total of 205 patients with STR (60% women; mean age, 77 ± 12 years) were enrolled in a single-center prospective observational study. Three-dimensional echocardiography was used to measure RV ejection fraction (RVEF); the absolute contributions of the longitudinal component of RVEF (LEF), the radial component of RVEF (REF), and the anteroposterior component of RVEF (AEF); and their relative contributions by indexing to global RVEF (LEF/RVEF, REF/RVEF, and AEF/RVEF, respectively). Patients were followed for a median of 9 months. The primary outcome was heart failure hospitalization or all-cause death.

RESULTS

Patients with different degrees of STR severity did not differ in terms of RVEF (mild vs moderate vs severe: 50 ± 11% vs 49 ± 9% vs 50 ± 10%, respectively, P = .085). However, LEF/RVEF was significantly lower in patients with severe STR (0.39 ± 0.08 vs 0.39 ± 0.09 vs 0.35 ± 0.10, respectively, P = .049). Patients with ventricular STR had lower global RVEF (48 ± 10% vs 53 ± 8%, P = .001), LEF (18 ± 6% vs 20 ± 5%, P = .043), REF (23 ± 9% vs 28 ± 8%, P = .002), and REF/RVEF (0.48 ± 0.012 vs 0.52 ± 0.09, P = .040) than patients with atrial STR. In a multivariable Cox regression model, REF/RVEF was a significant and independent predictor of outcomes in the entire cohort (hazard ratio, 0.980 [95% CI, 0.961-1.000] per 0.01-unit change, P = .047), whereas global RVEF was not.

CONCLUSIONS

Patients with STR demonstrate significant functional RV remodeling. Patients with severe STR show a significant decrease in RV longitudinal shortening. Apart from STR severity, STR etiology also influences the RV contraction pattern, which was associated with outcomes in our cohort.

Malnutrition and outcomes in patients with tricuspid regurgitation undergoing transcatheter tricuspid valve repair

AIMS

The impact of malnutrition in patients with tricuspid regurgitation (TR) undergoing tricuspid transcatheter edge-to-edge repair (T-TEER) is not well established. We evaluated the impact of malnutrition among patients with symptomatic TR undergoing T-TEER.

METHODS AND RESULTS

Baseline nutritional status was evaluated using the geriatric nutritional risk index (GNRI), based on serum albumin concentrations and body weight to ideal body weight ratio, among patients with symptomatic TR undergoing T-TEER, enrolled in the multicentre EuroTR registry between March 2016 and February 2024. Malnutrition was defined as GNRI ≤98. The primary outcome of interest was all-cause mortality. A total of 1034 patients were included (mean age 78.4 ± 7.3 years, 47.7% male). Among them, GNRI ≤98 (i.e. malnutrition) was observed in 211 patients (20.4%). Estimated rates of all-cause death at 2 years were 45.9% and 28.2% in patients with and without malnutrition, respectively (log-rank p < 0.001). After multivariable adjustment, malnutrition was independently associated with an increased risk of mortality (adjusted hazard ratio 1.53, 95% confidence interval 1.11-2.10, p = 0.009), also confirmed at inverse probability of treatment weighting-adjusted analysis. As compared to post-procedural residual TR ≥3+, residual TR ≤2+ was associated with a similar lower risk of mortality in patients with and without malnutrition (interaction p = 0.947).

CONCLUSION

In the large, real-world, multicentre EuroTR registry, malnutrition was present in one out of five patients with symptomatic TR undergoing T-TEER and was independently associated with increased mortality. The prognostic benefit of successful T-TEER in reducing mortality was consistently observed in patients with and without malnutrition.

Characteristics, determinants, and prognostic impact of severe tricuspid regurgitation in patients with atrial functional mitral regurgitation: Insights from the REVEAL-AFMR registry

AIMS

Tricuspid regurgitation (TR) is often seen in patients with atrial functional mitral regurgitation (AFMR). The aim of this study was to investigate the characteristics, determinants, and prognostic impact of severe TR coexisting with AFMR.

METHODS AND RESULTS

In 26 facilities in Japan, patients with significant AFMR defined with moderate or severe functional mitral regurgitation with dilated left atrium and preserved left ventricular function were enrolled. The primary endpoint was a composite of heart failure hospitalization and all-cause mortality. The secondary endpoint was all-cause mortality. In 792 patients with AFMR (mean age 77 ± 9 years, 55% female), the prevalence of severe TR was 14.9% (n = 118) overall, and 34.6% in severe AFMR. Patients with severe TR were older, mostly with atrial fibrillation, and had more severe heart failure symptoms and more advanced left atrial and right heart remodelling than those with non-severe TR. Age >75 years, permanent atrial fibrillation, chronic obstructive pulmonary disease, and higher right atrial pressure appeared as independent determinants of severe TR. Severe TR was associated with both the primary and secondary endpoints after adjusted for covariates including the severity of AFMR (adjusted hazard ratio 1.65 [95% confidence interval 1.09-2.47], p = 0.017 and 1.80 [1.06-3.06], p = 0.029 for the primary and secondary endpoints, respectively). Atrial and ventricular functional TR accounted for 41% and 59% of significant TR. Despite more advanced right heart remodelling in ventricular TR, these groups showed similar prognosis.

CONCLUSIONS

Severe TR coexisting with AFMR was common and was associated with increased event rates. Further study is warranted to establish therapeutic strategies.

2024 update in heart failure

In the last years, major progress has occurred in heart failure (HF) management. The 2023 ESC focused update of the 2021 HF guidelines introduced new key recommendations based on the results of the last years of science. First, two drugs, sodium-glucose co-transporter-2 (SGLT2) inhibitors and finerenone, a novel nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), are recommended for the prevention of HF in patients with diabetic chronic kidney disease (CKD). Second, SGLT2 inhibitors are now recommended for the treatment of HF across the entire left ventricular ejection fraction spectrum. The benefits of quadruple therapy in patients with HF with reduced ejection fraction (HFrEF) are well established. Its rapid and early up-titration along with a close follow-up with frequent clinical and laboratory re-assessment after an episode of acute HF (the so-called 'high-intensity care' strategy) was associated with better outcomes in the STRONG-HF trial. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. In the STEP-HFpEF-DM and STEP-HFpEF trials, semaglutide 2.4 mg once weekly administered for 1 year decreased body weight and significantly improved quality of life and the 6 min walk distance in obese patients with HF with preserved ejection fraction (HFpEF) with or without a history of diabetes. Further data on safety and efficacy, including also hard endpoints, are needed to support the addition of acetazolamide or hydrochlorothiazide to a standard diuretic regimen in patients hospitalized due to acute HF. In the meantime, PUSH-AHF supported the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e., mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, with the recent finding from the TRILUMINATE Pivotal trial, are also reviewed in this article.

Transcatheter Tricuspid Valve Replacement

Transcatheter tricuspid valve replacement (TTVR) has emerged as a promising intervention for the treatment of severe tricuspid regurgitation with complex valve morphology. This consensus document provides a comprehensive overview of the current state of orthotopic TTVR, focusing on patient selection, procedural details, and follow-up care. Clinical outcomes from initial studies and compassionate use cases are discussed, highlighting the effectiveness of TTVR in reducing tricuspid regurgitation, inducing reverse right ventricular remodeling, and enhancing patients' quality of life. This review paper also addresses potential complications and challenges associated with TTVR, such as new-onset conduction disturbances, bleeding complications, and afterload mismatch, and provides expert recommendations for the periprocedural management, anticoagulation strategies, and long-term follow-up. With the commercial approval of the first TTVR system in the United States and Europe, it intends to serve as a reference for clinicians and researchers involved in the evolving field of transcatheter tricuspid valve interventions.

Chronic mitral regurgitation predicts acute heart failure and worse outcomes after endovascular treatment for large vessel occlusion stroke

BACKGROUND

Valvular diseases are widely recognized as important etiologies for large vessel occlusion stroke (LVO) but their impact on outcomes among patients with LVO receiving endovascular treatment (EVT) are less well delineated.

METHODS

This study was a post hoc exploratory analysis of the RESCUE-BT trial, DEVT trial and BASILAR prospective registry. Outcome measures included the modified Rankin Scale (mRS) score at 90 days, symptomatic intracranial hemorrhage, and post-stroke early acute heart failure (EAHF). Chronic significant mitral regurgitation (csMR) was defined as a long-existing mitral regurgitation (MR) with moderate-to-severe MR grade examined by the transthoracic echocardiography. Adjusted odds ratio (aOR) and 95% confidence interval (CI) were obtained by logistic regression models.

RESULTS

Among 2011 patients in these three studies, 837 individuals receiving EVT with available information for valvular status were included in this study. In all categories of chronic valvular disorders, only csMR was related to very poor outcomes (mRS 5-6, aOR 2.76 (95% CI 1.59 to 4.78), P<0.001). CsMR (aOR 7.65 (95% CI 4.33 to 13.49), P<0.001) was an independent predictor of post-stroke EAHF. Mediation analysis showed that csMR increased EAHF instead of reocclusion events or venous thrombosis mediated its effects on functional outcome (49.50% (95% CI 24.83% to 90.00%)). Identical results of csMR on clinical outcomes and post-stroke EAHF were detected in novel cohorts constructed by propensity score matching and sensitivity analysis.

CONCLUSION

Our study demonstrated that csMR was a mediator of heart-brain interaction associated with poor outcomes of LVO after EVT by increasing the frequency of post-stroke EAHF. Replication of these findings in a larger cohort is warranted.

Atrial Functional Mitral Regurgitation: Definition, Mechanisms, and Treatment Perspectives

PURPOSE OF REVIEW

This review aims to explore the complex interplay between atrial functional mitral regurgitation (AFMR), atrial fibrillation (AF), and heart failure with preserved ejection fraction (HFpEF). The goal is to define these conditions, examine their underlying mechanisms, and discuss treatment perspectives, particularly addressing diagnostic challenges.

RECENT FINDINGS

Recent research highlights the rising prevalence of AFMR, now accounting for nearly one-third of significant mitral regurgitation cases. Advances in percutaneous treatment options have improved management for vulnerable HFpEF patients, but long-term outcomes remain unclear, and symptom relief is inconsistent. AF and HFpEF share the left atrium as a common pathological substrate, with progressive LA remodeling contributing to AFMR. Diagnostic limitations hinder effective symptom management with current mitral valve interventions. Future research should focus on better diagnostic tools to determine the contributions of valvular disease, arrhythmia, or myocardial dysfunction to clinical outcomes, as we currently lack definitive tests to establish this connection.

Hospitalization of Symptomatic Patients With Heart Failure and Moderate to Severe Functional Mitral Regurgitation Treated With MitraClip: Insights From RESHAPE-HF2

BACKGROUND

For patients with functional mitral regurgitation (FMR) and symptomatic heart failure (HF), randomized trials of mitral transcatheter edge-to-edge repair (M-TEER) have produced conflicting results.

OBJECTIVES

This study sought to assess the impact of M-TEER on hospitalization rates, and explore the effects of M-TEER on patients who did or did not have a history of recent HF hospitalizations before undergoing M-TEER.

METHODS

RESHAPE-HF2 (Randomized Investigation of the MitraClip Device in Heart Failure: 2nd Trial in Patients with Clinically Significant Functional Mitral Regurgitation) included patients with symptomatic HF and moderate to severe FMR (mean effective regurgitant orifice area 0.25 cm2; 14% >0.40 cm2, 23% <0.20 cm2) and showed that M-TEER reduced recurrent HF hospitalizations with and without the addition of cardiovascular (CV) death and improved quality of life. We now report the results of prespecified analyses on hospitalization rates and for the subgroup of patients (n = 333) with a HF hospitalization in the 12 months before randomization.

RESULTS

At 24 months, the time to first event of CV death or HF hospitalization (HR: 0.65; 95% CI: 0.49-0.85; P = 0.002), the rate of recurrent CV hospitalizations (rate ratio [RR]: 0.75; 95% CI: 0.57-0.99; P = 0.046), the composite rate of recurrent CV hospitalizations and all-cause mortality (RR: 0.74; 95% CI: 0.57-0.95; P = 0.017), and of recurrent CV death and CV hospitalizations (RR: 0.76; 95% CI: 0.58-0.99; P = 0.040), were all lower in the M-TEER group. The RR of recurrent hospitalizations for any cause was 0.82 (95% CI: 0.63-1.07; P = 0.15) for patients in the M-TEER group vs control group patients. Patients randomized to M-TEER lost fewer days due to death or HF hospitalization (13.9% [95% CI: 13.0%-14.8%] vs 17.4% [95% CI: 16.4%-18.4%] of follow-up time; P < 0.0001, and 1,067 vs 1,776 total days lost; P < 0.0001). Patients randomized to M-TEER also had better NYHA functional class at 30 days and at 6, 12, and 24 months of follow-up (P < 0.0001). A history of HF hospitalizations before randomization was associated with worse outcomes and greater benefit with M-TEER on the rate of the composite of recurrent HF hospitalizations and CV death (Pinteraction = 0.03) and of recurrent HF hospitalizations within 24 months (Pinteraction = 0.06).

CONCLUSIONS

These results indicate that a broader application of M-TEER in addition to optimal guideline-directed medical therapy should be considered among patients with symptomatic HF and moderate to severe FMR, particularly in those with a history of a recent hospitalization for HF.

Multimodality Imaging for Transcatheter Tricuspid Regurgitation Interventions: Novel Approaches to the Forgotten Valve

Tricuspid regurgitation (TR) poses a significant healthcare burden and is a major concern for patients who experience debilitating symptoms and face a poorer prognosis. Cardiologists are showing renewed interest in TR, as the previous belief that it was merely a bystander of left-sided heart disease has evolved. As a result, more transcatheter techniques addressing TR are emerging. Although a clear impact on mortality from these transcatheter tricuspid valve interventions (TTVI) has not yet been demonstrated, the improvement in symptoms and quality of life for patients is substantial, leading to increased use of these procedures in clinical practice. In this review, we focus on multimodality imaging as an essential tool for quantifying TR severity, assessing right ventricular (RV) function, understanding the underlying mechanisms, selecting the appropriate intervention, and ensuring thorough and accurate preprocedural planning to minimize complications.

Heart failure in Europe: Guideline-directed medical therapy use and decision making in chronic and acute, pre-existing and de novo, heart failure with reduced, mildly reduced, and preserved ejection fraction - the ESC EORP Heart Failure III Registry

AIMS

We analysed baseline characteristics and guideline-directed medical therapy (GDMT) use and decisions in the European Society of Cardiology (ESC) Heart Failure (HF) III Registry.

METHODS AND RESULTS

Between 1 November 2018 and 31 December 2020, 10 162 patients with acute HF (AHF, 39%, age 70 [62-79], 36% women) or outpatient visit for HF (61%, age 66 [58-75], 33% women), with HF with reduced (HFrEF, 57%), mildly reduced (HFmrEF, 17%) or preserved (HFpEF, 26%) ejection fraction were enrolled from 220 centres in 41 European or ESC-affiliated countries. With AHF, 97% were hospitalized, 2.2% received intravenous treatment in the emergency department, and 0.9% received intravenous treatment in an outpatient clinic. AHF was seen by most by a general cardiologist (51%) and outpatient HF most by a HF specialist (48%). A majority had been hospitalized for HF before, but 26% of AHF and 6.1% of outpatient HF had de novo HF. Baseline use, initiation and discontinuation of GDMT varied according to AHF versus outpatient HF, de novo versus pre-existing HF, and by ejection fraction. After the AHF event or outpatient HF visit, use of any renin-angiotensin system inhibitor, angiotensin receptor-neprilysin inhibitor, beta-blocker, mineralocorticoid receptor antagonist and loop diuretics was 89%, 29%, 92%, 78%, and 85% in HFrEF; 89%, 9.7%, 90%, 64%, and 81% in HFmrEF; and 77%, 3.1%, 80%, 48%, and 80% in HFpEF.

CONCLUSION

Use and initiation of GDMT was high in cardiology centres in Europe, compared to previous reports from cohorts and registries including more primary care and general medicine and regions more local or outside of Europe and ESC-affiliated countries.

Transcatheter Valve Repair in Heart Failure with Moderate to Severe Mitral Regurgitation

BACKGROUND

Whether transcatheter mitral-valve repair improves outcomes in patients with heart failure and functional mitral regurgitation is uncertain.

METHODS

We conducted a randomized, controlled trial involving patients with heart failure and moderate to severe functional mitral regurgitation from 30 sites in nine countries. The patients were assigned in a 1:1 ratio to either transcatheter mitral-valve repair and guideline-recommended medical therapy (device group) or medical therapy alone (control group). The three primary end points were the rate of the composite of first or recurrent hospitalization for heart failure or cardiovascular death during 24 months; the rate of first or recurrent hospitalization for heart failure during 24 months; and the change from baseline to 12 months in the score on the Kansas City Cardiomyopathy Questionnaire-Overall Summary (KCCQ-OS; scores range from 0 to 100, with higher scores indicating better health status).

RESULTS

A total of 505 patients underwent randomization: 250 were assigned to the device group and 255 to the control group. At 24 months, the rate of first or recurrent hospitalization for heart failure or cardiovascular death was 37.0 events per 100 patient-years in the device group and 58.9 events per 100 patient-years in the control group (rate ratio, 0.64; 95% confidence interval [CI], 0.48 to 0.85; P = 0.002). The rate of first or recurrent hospitalization for heart failure was 26.9 events per 100 patient-years in the device group and 46.6 events per 100 patient-years in the control group (rate ratio, 0.59; 95% CI, 0.42 to 0.82; P = 0.002). The KCCQ-OS score increased by a mean (±SD) of 21.6±26.9 points in the device group and 8.0±24.5 points in the control group (mean difference, 10.9 points; 95% CI, 6.8 to 15.0; P<0.001). Device-specific safety events occurred in 4 patients (1.6%).

CONCLUSIONS

Among patients with heart failure with moderate to severe functional mitral regurgitation who received medical therapy, the addition of transcatheter mitral-valve repair led to a lower rate of first or recurrent hospitalization for heart failure or cardiovascular death and a lower rate of first or recurrent hospitalization for heart failure at 24 months and better health status at 12 months than medical therapy alone. (Funded by Abbott Laboratories; RESHAPE-HF2 ClinicalTrials.gov number, NCT02444338.).

Sex-Specific Insights into Etiology, Diagnosis, Treatment, and Prognosis in Significant Tricuspid Regurgitation: A Narrative Review

In recent decades, a burgeoning interest in tricuspid regurgitation (TR) has been prompted by a heightened awareness of its prevalence and the advent of dedicated percutaneous treatment approaches. Despite considerable understanding of its intricate anatomy and response to varying pressure and loading conditions, the impact of biological sex remains a subject of investigation. While TR typically afflicts more women, significant differences in TR etiology and post-treatment outcomes have not been conclusively established. This narrative review seeks to consolidate the latest evidence concerning sex-related nuances in anatomy, pathophysiology, diagnosis, treatment, and prognosis of significant tricuspid regurgitation. Through synthesizing this information, we aim to provide a comprehensive understanding of how sex may influence the management and prognosis of this condition.

Heart failure with preserved ejection fraction epidemiology, pathophysiology, diagnosis and treatment strategies

The prevalence of HF with preserved ejection raction (HFpEF, with EF ≥50%) is increasing across all populations with high rates of hospitalization and mortality, reaching up to 80% and 50%, respectively, within a 5-year timeframe. Comorbidity-driven systemic inflammation is thought to cause coronary microvascular dysfunction and increased epicardial adipose tissue, leading to downstream friborsis and molecular changes in the cardiomyocyte, leading to increased stiffness and diastolic dynsfunction. HFpEF poses unique challenges in terms of diagnosis due to its complex and diverse nature. The diagnosis of HFpEF relies on a combination of clinical assessment, imaging studies, and biomarkers. An additional important step in diagnosing HFpEF involves excluding certain cardiac diagnoses that may be specific underlying causes of HFpEF or may be masquerading as HFpEF and require specific alternative treatment approaches. In addition to administering sodium-glucose cotransporter 2 inhibitors to all patients, the most effective approach to enhance clinical outcomes may involve tailored therapy based on each patient's unique clinical profile. Exercise should be recommended for all patients to improve the quality of life. Glucagon-like peptide-1 1 agonists are a promising treatment option in obese HFpEF patients. Novel approaches targeting inflammation are also in early phase trials.

Prevalence and Prognostic Implications of Changes in Tricuspid Regurgitation Severity in Acute Heart Failure

BACKGROUND

Tricuspid regurgitation (TR), prevalent in acute heart failure (AHF), has a poor prognosis; however, the dynamics of TR severity during hospitalization and its prognostic implications remain unclear. We investigated TR dynamism during hospitalization and its prognostic impact in AHF.

METHODS AND RESULTS

This is a post hoc analysis of a prospective multicenter study of patients with AHF who underwent echocardiographic TR severity evaluation at admission and before discharge. The primary end point was a combined of 1-year all-cause mortality and HF rehospitalization after discharge. Among 1079 participants, TR severity changed dynamically, with 60.3% of those with moderate TR and 29.6% of those with severe TR at admission being diagnosed as no or mild TR at discharge. In 3 groups stratified by changes in TR severity, the persistent TR groups had a higher incidence of the primary end point than the resolution and absence groups. In adjusted analyses, the persistent group (hazard ratio, 1.37; 95% confidence interval, 1.04-1.80), but not the resolution group (hazard ratio, 1.07; 95% confidence interval, 0.79-1.44), had a higher primary end point incidence than the absence group.

CONCLUSIONS

TR severity at admission in patients with AHF can change dynamically and is associated with subsequent prognosis. Significant TR that remains even after decongestive therapy might be a target for further treatment in hospitalized patients with AHF.

Heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) accounts for nearly half of all heart failure cases and has a prevalence that is expected to rise with the growing ageing population. HFpEF is associated with significant morbidity and mortality. Specific HFpEF risk factors include age, diabetes, hypertension, obesity and atrial fibrillation. Haemodynamic contributions to HFpEF include changes in left ventricular structure, diastolic and systolic dysfunction, left atrial myopathy, pulmonary hypertension, right ventricular dysfunction, chronotropic incompetence, and vascular dysfunction. Inflammation, fibrosis, impaired nitric oxide signalling, sarcomere dysfunction, and mitochondrial and metabolic defects contribute to the cellular and molecular changes observed in HFpEF. HFpEF impacts multiple organ systems beyond the heart, including the skeletal muscle, peripheral vasculature, lungs, kidneys and brain. The diagnosis of HFpEF can be made in individuals with signs and symptoms of heart failure with abnormality in natriuretic peptide levels or evidence of cardiopulmonary congestion, facilitated by the use of HFpEF risk scores and additional imaging and testing with the exclusion of HFpEF mimics. Management includes initiation of guideline-directed medical therapy and management of comorbidities. Given the significant impact of HFpEF on quality of life, future research efforts should include a particular focus on how patients can live better with this disease.

Tricuspid Regurgitation in Patients With Heart Failure and Preserved Ejection Fraction: JACC State-of-the-Art Review

Heart failure with preserved ejection fraction (HFpEF) is associated with high morbidity and mortality. Important risk factors for the development of HFpEF are similar to risk factors for the progression of tricuspid regurgitation (TR), and both conditions frequently coexist and thus is a distinct phenotype or a marker for advanced HF. Many patients with severe, symptomatic atrial secondary TR have been enrolled in current transcatheter device trials, and may represent patients at an advanced stage of HFpEF. Management of HFpEF thus may affect the pathophysiology of TR, and the physiologic changes that occur following transcatheter treatment of TR, may also impact symptoms and outcomes in patients with HFpEF. This review discusses these issues and suggests possible management strategies for these patients.

Functional Mitral Regurgitation and Heart Failure With Preserved Ejection Fraction: Clinical Implications and Management

Heart failure with preserved ejection fraction (HFpEF) is highly prevalent and associated with worse cardiovascular outcomes. The pathophysiology of HFpEF mostly relies on the development of elevated left ventricle filling pressure, diastolic dysfunction, and atrial dilatation and impairment. This dynamic process may eventually lead to the development of functional mitral regurgitation (MR), characterized by mitral annular dilatation and consequent leaflet remodeling, in the context of preserved left ventricular ejection fraction. These observations highlight the possible common pathophysiology of MR and HFpEF. However, less is known about the prevalence and the clinical value of MR in the context of HFpEF. This review aims to provide an overview of the association and interplay between functional MR and HFpEF, discuss the underlying mechanisms that are common to these diseases, and summarize potential targeted pharmacological treatments.

Prevalence and clinical outcomes of isolated or combined moderate to severe mitral and tricuspid regurgitation in patients with cardiac amyloidosis

AIMS

Evidence on the epidemiology and prognostic significance of mitral regurgitation (MR) and tricuspid regurgitation (TR) in patients with cardiac amyloidosis (CA) is scarce.

METHODS AND RESULTS

Overall, 538 patients with either transthyretin (ATTR, n = 359) or immunoglobulin light-chain (AL, n = 179) CA were included at three Italian referral centres. Patients were stratified according to isolated or combined moderate/severe MR and TR. Overall, 240 patients (44.6%) had no significant MR/TR, 112 (20.8%) isolated MR, 66 (12.3%) isolated TR, and 120 (22.3%) combined MR/TR. The most common aetiologies were atrial functional MR, followed by primary infiltrative MR, and secondary TR due to right ventricular (RV) overload followed by atrial functional TR. Patients with isolated or combined MR/TR had a more frequent history of heart failure (HF) hospitalization and atrial fibrillation, worse symptoms, and higher levels of NT-proBNP as compared to those without MR/TR. They also presented more severe atrial enlargement, atrial peak longitudinal strain impairment, left ventricular (LV) and RV systolic dysfunction, and higher pulmonary artery systolic pressures. TR carried the most advanced features. After adjustment for age, sex, CA subtypes, laboratory, and echocardiographic markers of CA severity, isolated TR and combined MR/TR were independently associated with an increased risk of all-cause death or worsening HF events, compared to no significant MR/TR [adjusted HR 2.75 (1.78-4.24) and 2.31 (1.44-3.70), respectively].

CONCLUSION

In a large cohort of patients with CA, MR, and TR were common. Isolated TR and combined MR/TR were associated with worse prognosis regardless of CA aetiology, LV, and RV function, with TR carrying the highest risk.

Prediction of Mortality and Heart Failure Hospitalization After Transcatheter Tricuspid Valve Interventions: Validation of TRISCORE

BACKGROUND

Data on the prognostic role of the TRI-SCORE in patients undergoing transcatheter tricuspid valve intervention (TTVI) are limited.

OBJECTIVES

The aim of this study was to evaluate the performance of the TRI-SCORE in predicting outcomes of patients undergoing TTVI.

METHODS

TriValve (Transcatheter Tricuspid Valve Therapies) is a large multicenter multinational registry including patients undergoing TTVI. The TRI-SCORE is a risk model recently proposed to predict in-hospital mortality after tricuspid valve surgery. The TriValve population was stratified based on the TRI-SCORE tertiles. The outcomes of interest were all-cause death and all-cause death or heart failure hospitalization. Procedural complications and changes in NYHA functional class were also reported.

RESULTS

Among the 634 patients included, 223 patients (35.2%) had a TRI-SCORE between 0 and 5, 221 (34.8%) had 6 or 7, and 190 (30%) had ≥8 points. Postprocedural blood transfusion, acute kidney injury, new atrial fibrillation, and in-hospital mortality were more frequent in the highest TRI-SCORE tertile. Postprocedure length of stay increased with a TRI-SCORE increase. A TRI-SCORE ≥8 was associated with an increased risk of 30-day all-cause mortality and all-cause mortality and the composite endpoint assessed at a median follow-up of 186 days (OR: 3.00; 95% CI: 1.38-6.55; HR: 2.17; 95% CI: 1.78-4.13; HR: 2.08, 95% CI: 1.57-2.74, respectively) even after adjustment for procedural success and EuroSCORE II or Society of Thoracic Surgeons Predicted Risk of Mortality. The NYHA functional class improved across all TRI-SCORE values.

CONCLUSIONS

In the TriValve registry, the TRI-SCORE has a suboptimal performance in predicting clinical outcomes. However, a TRISCORE ≥8 is associated with an increased risk of clinical events and a lack of prognostic benefit after successful TTVI.

Tricuspid regurgitation: Frequency, clinical presentation, management and outcome among patients with severe left-sided valvular heart disease in Europe. Insights from the ESC-EORP Valvular Heart Disease II survey

AIMS

Tricuspid regurgitation (TR) is commonly observed in patients with severe left-sided valvular heart disease (VHD). This study sought to assess TR frequency, management and outcome in this population.

METHODS AND RESULTS

Among 6883 patients with severe native left-sided VHD or previous left-sided valvular intervention enrolled in the EURObservational Research Programme prospective VHD II survey, moderate or severe TR was very frequent in patients with severe mitral VHD (30% when mitral stenosis, 36% when mitral regurgitation [MR]), especially in patients with secondary MR (46%), and rare in patients with severe aortic VHD (4% when aortic stenosis, 3% when aortic regurgitation). An increase in TR grade was associated with a more severe clinical presentation and a poorer 6-month survival (p < 0.0001). Rates of concomitant tricuspid valve (TV) intervention at the time of left-sided heart valve surgery were high at the time of mitral valve surgery (50% when mitral stenosis, 41% when MR). Concordance between class I indications (patients with severe TR) for concomitant TV surgery at the time of left-sided valvular heart surgery according to guidelines and real-practice decision-making was very good (88% overall, 95% in patients operated on for MR).

CONCLUSION

In this large international prospective survey among patients with severe left-sided VHD, moderate/severe TR was frequent in patients with mitral valve disease and was associated with a poorer outcome as TR grade increased. In patients with severe TR, compliance to guidelines for class I indications for concomitant TV surgery at the time of left-sided heart valve surgery was very good.

Implications of tricuspid regurgitation and right ventricular volume overload in patients with heart failure with preserved ejection fraction

AIMS

The aim of this study was to assess the pathophysiological implications of severe tricuspid regurgitation (TR) in patients with heart failure with preserved ejection fraction (HFpEF) by using tricuspid transcatheter edge-to-edge repair (T-TEER) as a model of right ventricular (RV) volume overload relief.

METHODS AND RESULTS

This prospective interventional single arm trial (NCT04782908) included patients with invasively diagnosed HFpEF. The following parameters were prospectively assessed before and after T-TEER: left ventricular (LV) diastolic properties by invasive pressure-volume loop recordings; biventricular time-volume curves and function as well as septal curvature by cardiac magnetic resonance imaging; strain analyses for timing of septal motion. Overall, 20 patients (median age 78, interquartile range [IQR] 72-83 years, 65% female) were included. T-TEER reduced TR by a median of 2 (of 5) grades (IQR 2-1). T-TEER increased LV stroke volume and LV end-diastolic volume (LVEDV) (p < 0.001), without increasing LV end-diastolic pressure (LVEDP) (p = 0.094), consequently diastolic function improved with a reduction in LVEDP/LVEDV (p = 0.001) and a rightward shift of the end-diastolic pressure-volume relationship. The increase in LVEDV correlated with a decrease in RV end-diastolic volume (p < 0.001) and LV transmural pressure increased (p = 0.028). Secondary to a decrease in early RV filling, improvements in early LV filling were observed, correlating with an alleviation of leftwards bowing of the septum (p < 0.01, respectively).

CONCLUSION

Diastolic LV properties in patients with HFpEF and severe TR are importantly determined by ventricular interaction in the setting of RV volume overload. T-TEER reduces RV volume overload and improves biventricular interaction and physiology.

Prognostic value of mitral valve regurgitation in patients with heart failure with mildly reduced ejection fraction

BACKGROUND

Although mitral valve regurgitation (MR) is a common valvular heart disease in patients with heart failure (HF), there is a paucity of data on the characterization and outcomes of patients with HF with mildly reduced ejection fraction (HFmrEF) and concomitant MR.

METHODS

From 2016 to 2022, consecutive patients hospitalized with HFmrEF (i.e., left ventricular ejection fraction from 41% to 49% and signs and/or symptoms of HF) were retrospectively included at one institution. Patients with MR were compared with patients without MR. Further risk stratification was performed according to MR severity and etiology (i.e., primary vs. secondary MR). The primary end point was all-cause mortality at 30 months (median follow-up), and the key secondary end point was hospitalization for worsening HF.

RESULTS

Of 2181 patients hospitalized with HFmrEF, 59% presented with mild, 10% with moderate, and 2% with severe MR. MR was associated with increased all-cause mortality at 30 months (HR = 1.756; 95% CI 1.458-2.114; p = 0.001), with higher risk in more advanced stages. Furthermore, MR patients had higher risk of HF-related re-hospitalization at 30 months (HR = 1.560; 95% CI 1.172-2.076; p = 0.002). Even after multivariable adjustment, mild, moderate, and severe MR were still associated with all-cause mortality. Finally, the risk of all-cause mortality was lower in patients with secondary MR compared with patients with primary MR (HR = 0.592; 95% CI 0.366-0.956; p = 0.032).

CONCLUSION

MR is common in HFmrEF and independently associated with higher risk of all-cause mortality and HF hospitalization.

Atrial secondary tricuspid regurgitation: pathophysiology, definition, diagnosis, and treatment

Atrial secondary tricuspid regurgitation (A-STR) is a distinct phenotype of secondary tricuspid regurgitation with predominant dilation of the right atrium and normal right and left ventricular function. Atrial secondary tricuspid regurgitation occurs most commonly in elderly women with atrial fibrillation and in heart failure with preserved ejection fraction in sinus rhythm. In A-STR, the main mechanism of leaflet malcoaptation is related to the presence of a significant dilation of the tricuspid annulus secondary to right atrial enlargement. In addition, there is an insufficient adaptive growth of tricuspid valve leaflets that become unable to cover the enlarged annular area. As opposed to the ventricular phenotype, in A-STR, the tricuspid valve leaflet tethering is typically trivial. The A-STR phenotype accounts for 10%-15% of clinically relevant tricuspid regurgitation and has better outcomes compared with the more prevalent ventricular phenotype. Recent data suggest that patients with A-STR may benefit from more aggressive rhythm control and timely valve interventions. However, little is mentioned in current guidelines on how to identify, evaluate, and manage these patients due to the lack of consistent evidence and variable definitions of this entity in recent investigations. This interdisciplinary expert opinion document focusing on A-STR is intended to help physicians understand this complex and rapidly evolving topic by reviewing its distinct pathophysiology, diagnosis, and multi-modality imaging characteristics. It first defines A-STR by proposing specific quantitative criteria for defining the atrial phenotype and for discriminating it from the ventricular phenotype, in order to facilitate standardization and consistency in research.

Characteristics and outcomes of patients with tricuspid regurgitation and advanced heart failure

AIMS

To evaluate the role of tricuspid regurgitation in advanced heart failure.

METHODS

The multicenter observational HELP-HF registry enrolled consecutive patients with heart failure and at least one 'I NEED HELP' criterion evaluated at four Italian centers between January 2020 and November 2021. Patients with no data on tricuspid regurgitation and/or receiving tricuspid valve intervention during follow-up were excluded. The population was stratified by no/mild tricuspid regurgitation vs. moderate tricuspid regurgitation vs. severe tricuspid regurgitation. Variables independently associated with tricuspid regurgitation, as well as the association between tricuspid regurgitation and clinical outcomes were investigated. The primary outcome was all-cause mortality.

RESULTS

Among the 1085 patients included in this study, 508 (46.8%) had no/mild tricuspid regurgitation, 373 (34.4%) had moderate tricuspid regurgitation and 204 (18.8%) had severe tricuspid regurgitation. History of atrial fibrillation, any prior valve surgery, high dose of furosemide, preserved left ventricular ejection fraction, moderate/severe mitral regurgitation and pulmonary hypertension were found to be independently associated with an increased likelihood of severe tricuspid regurgitation. Estimated rates of 1-year all-cause death were of 21.4, 24.5 and 37.1% in no/mild tricuspid regurgitation, moderate tricuspid regurgitation and severe tricuspid regurgitation, respectively (log-rank P  < 0.001). As compared with nonsevere tricuspid regurgitation, severe tricuspid regurgitation was independently associated with a higher risk of all-cause mortality (adjusted hazard ratio 1.38, 95% confidence interval 1.01-1.88, P  = 0.042), whereas moderate tricuspid regurgitation did not.

CONCLUSION

In a contemporary, real-world cohort of patients with advanced heart failure, several clinical and echocardiographic characteristics are associated with an increased likelihood of severe tricuspid regurgitation. Patients with severe tricuspid regurgitation have an increased risk of mortality.

Epidemiology, pathophysiology, diagnosis and management of chronic right-sided heart failure and tricuspid regurgitation. A clinical consensus statement of the Heart Failure Association (HFA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC

Right-sided heart failure and tricuspid regurgitation are common and strongly associated with poor quality of life and an increased risk of heart failure hospitalizations and death. While medical therapy for right-sided heart failure is limited, treatment options for tricuspid regurgitation include surgery and, based on recent developments, several transcatheter interventions. However, the patients who might benefit from tricuspid valve interventions are yet unknown, as is the ideal time for these treatments given the paucity of clinical evidence. In this context, it is crucial to elucidate aetiology and pathophysiological mechanisms leading to right-sided heart failure and tricuspid regurgitation in order to recognize when tricuspid regurgitation is a mere bystander and when it can cause or contribute to heart failure progression. Notably, early identification of right heart failure and tricuspid regurgitation may be crucial and optimal management requires knowledge about the different mechanisms and causes, clinical course and presentation, as well as possible treatment options. The aim of this clinical consensus statement is to summarize current knowledge about epidemiology, pathophysiology and treatment of tricuspid regurgitation in right-sided heart failure providing practical suggestions for patient identification and management.

Global Public Health Burden of Heart Failure: An Updated Review

Heart failure (HF) is a rapidly growing public health issue with an estimated prevalence of 64 million people globally. Although the incidence of HF has stabilised worldwide and seems to be declining in developed countries, the prevalence is increasing due to the ageing of the population, improved survival after MI and improved treatment and survival of patients with HF. Yet, HF remains associated with high mortality and morbidity, poor quality of life and functional capacity, and confers a substantial burden to the healthcare system. The prevalence, incidence, mortality and morbidity rates reported show geographical variations, depending on the different aetiologies and clinical characteristics observed among patients with HF. In this review, we provide an overview of the global epidemiology of HF with updated data on prevalence, incidence, mortality and morbidity worldwide.