Characteristics and outcomes of patients with atrial versus ventricular secondary tricuspid regurgitation undergoing tricuspid transcatheter edge-to-edge repair - Results from the TriValve registry

Long-Term Outcomes of Surgical and Transcatheter Interventions for Tricuspid Regurgitation: A Comprehensive Review

Impacting more than 70 million people worldwide, tricuspid regurgitation (TR) refers to the retrograde flow of blood from the right ventricle to the right atrium due to the improper closure of the tricuspid valve. Depending on the severity of TR, signs and symptoms can range from asymptomatic to features of right heart failure, including dyspnea, exercise intolerance, peripheral edema, and ascites. Severe features such as these necessitate treatment. In recent years, advancements in management, including surgical and transcatheter interventions, have taken prominence, leading to improved short-term outcomes in this patient population. However, there is still a dearth of evidence regarding the long-term outcomes of surgical and transcatheter interventions for TR. This comprehensive review aims to present clinicians with recent findings from pivotal clinical studies on interventional clinical outcomes in an effort to help guide their judgment when it comes to deciding the best course of treatment for their patients.

Advanced echocardiography and cluster analysis to identify secondary tricuspid regurgitation phenogroups at different risk

INTRODUCTION AND OBJECTIVES

Significant secondary tricuspid regurgitation (STR) is associated with poor prognosis, but its heterogeneity makes predicting patient outcomes challenging. Our objective was to identify STR prognostic phenogroups.

METHODS

We analyzed 758 patients with moderate-to-severe STR: 558 (74±14 years, 55% women) in the derivation cohort and 200 (73±12 years, 60% women) in the external validation cohort. The primary endpoint was a composite of heart failure hospitalization and all-cause mortality.

RESULTS

We identified 3 phenogroups. The low-risk phenogroup (2-year event-free survival 80%, 95%CI, 74%-87%) had moderate STR, preserved right ventricular (RV) size and function, and a moderately dilated but normally functioning right atrium. The intermediate-risk phenogroup (HR, 2.20; 95%CI, 1.44-3.37; P<.001) included older patients with severe STR, and a mildly dilated but uncoupled RV. The high-risk phenogroup (HR, 4.67; 95%CI, 3.20-6.82; P<.001) included younger patients with massive-to-torrential tricuspid regurgitation, as well as severely dilated and dysfunctional RV and right atrium. Multivariable analysis confirmed the clustering as independently associated with the composite endpoint (HR, 1.40; 95%CI, 1.13-1.70; P=.002). A supervised machine learning model, developed to assist clinicians in assigning patients to the 3 phenogroups, demonstrated excellent performance both in the derivation cohort (accuracy=0.91, precision=0.91, recall=0.91, and F1 score=0.91) and in the validation cohort (accuracy=0.80, precision=0.78, recall=0.78, and F1 score=0.77).

CONCLUSIONS

The unsupervised cluster analysis identified 3 risk phenogroups, which could assist clinicians in developing more personalized treatment and follow-up strategies for STR patients.

Tricuspid Regurgitation Disease Stages and Treatment Outcomes After Transcatheter Tricuspid Valve Repair

BACKGROUND

Tricuspid transcatheter edge-to-edge repair (T-TEER) has emerged as a treatment option for patients with severe tricuspid regurgitation (TR). However, randomized trials have not shown a survival benefit, possibly because of the inclusion of patients in an early or too advanced disease stage.

OBJECTIVES

The authors sought to investigate the association between disease stage and outcomes following T-TEER.

METHODS

In total, 1,885 patients with significant TR were analyzed, including 585 conservatively treated individuals and 1,300 patients who received T-TEER. Patients were evaluated as part of the prospective EuroTR (European Registry of Transcatheter Repair for Tricuspid Regurgitation) registry and grouped into early, intermediate, and advanced disease stage. Disease stage was based on left and right ventricular function, renal function, and natriuretic peptide levels. The stratification was validated in an external cohort. The primary endpoint was 1-year mortality.

RESULTS

Overall, 395 patients (21% [395/1,885]) were categorized as early, 1,173 patients (62% [1,173/1,885]) as intermediate, and 317 patients (17% [317/1,885]) as advanced disease stage. In patients with early and advanced disease, mortality did not differ between interventional and conservative treatment (early-stage HR: 0.78; 95% CI: 0.34-1.80; P = 0.54; advanced stage HR: 1.06; 95% CI: 0.71-1.60; P = 0.78). However, mortality was significantly lower in patients undergoing percutaneous treatment with intermediate disease stage (HR: 0.73; 95% CI: 0.52-0.99; P = 0.03).

CONCLUSIONS

Compared to medically treated controls, T-TEER was associated with 1-year survival at intermediate stage disease but not at early or advanced disease stages. The timing of T-TEER with regard to disease stages might be crucial to optimize treatment benefits.

Simplified Outcome Prediction in Patients Undergoing Transcatheter Tricuspid Valve Intervention by Survival Tree-Based Modelling

BACKGROUND

Patients with severe tricuspid regurgitation (TR) typically present with heterogeneity in the extent of cardiac dysfunction and extra-cardiac comorbidities, which play a decisive role for survival after transcatheter tricuspid valve intervention (TTVI).

OBJECTIVES

This aim of this study was to create a survival tree-based model to determine the cardiac and extra-cardiac features associated with 2-year survival after TTVI.

METHODS

The study included 918 patients (derivation set, n = 631; validation set, n = 287) undergoing TTVI for severe TR. Supervised machine learning-derived survival tree-based modelling was applied to preprocedural clinical, laboratory, echocardiographic, and hemodynamic data.

RESULTS

Following univariate regression analysis to pre-select candidate variables for 2-year mortality prediction, a survival tree-based model was constructed using 4 key parameters. Three distinct cluster-related risk categories were identified, which differed significantly in survival after TTVI. Patients from the low-risk category (n = 261) were defined by mean pulmonary artery pressure ≤28 mm Hg and N-terminal pro-B-type natriuretic peptide ≤2,728 pg/mL, and they exhibited a 2-year survival rate of 85.5%. Patients from the high-risk category (n = 190) were defined by mean pulmonary artery pressure >28 mm Hg, right atrial area >32.5 cm2, and estimated glomerular filtration rate ≤51 mL/min, and they showed a significantly worse 2-year survival of only 52.6% (HR for 2-year mortality: 4.3, P < 0.001). Net re-classification improvement analysis demonstrated that this model was comparable to the TRI-Score and outperformed the EuroScore II in identifying high-risk patients. The prognostic value of risk phenotypes was confirmed by external validation.

CONCLUSIONS

This simple survival tree-based model effectively stratifies patients with severe TR into distinct risk categories, demonstrating significant differences in 2-year survival after TTVI.

3D transoesophageal echocardiographic assessment of acute reverse remodelling of the tricuspid annulus after transcatheter edge-to-edge repair

AIMS

Our study aims to evaluate the acute remodelling of the tricuspid valve annulus immediately after the tricuspid transcatheter edge-to-edge repair (T-TEER) by using intraprocedural transoesophageal 3D echocardiography.

METHODS AND RESULTS

We prospectively enrolled 62 consecutive symptomatic patients with at least severe tricuspid regurgitation (TR), who underwent T-TEER with the TriClip System between March 2021 and June 2024. The following parameters were assessed using a multiplanar reconstruction analysis performed off-line using a 3D data set: septal-lateral (SL) and antero-posterior (AP) annulus diameters; annulus area; annulus perimeter; and eccentricity index. The acute procedural success was achieved in 85.5%. We observed an acute reduction in SL (from a median of 43 to 38 mm, P < 0.0001), AP (from a median of 46 to 45 mm, P < 0.0001), area (from a median of 17.9 to 15.95 cm2, P < 0.0001), perimeter (from a median of 145.5 to 137 mm, P < 0.0001), and eccentricity index (from 0.92 to 0.87, P < 0.0001). The tricuspid valve (TV) annulus was progressively larger in patients with higher residual TR. Analysis of the subgroups according to procedural success showed an acute inverse remodelling of the TV annulus independent of the acute procedural success.

CONCLUSION

The TV geometry necessitates the use of 3D echocardiography for accurate assessment of annular remodelling post T-TEER. The reduction in TR grade and TV annulus dimensions begins immediately after TriClip implantation. Concurrently, the baseline TV geometry influences the procedural results.

Atrial Functional Tricuspid Regurgitation (AFTR) Is Associated with Better Outcome After Tricuspid Transcatheter Edge-to-Edge Repair (T-TEER) Compared to Ventricular FTR (VFTR)

Background: Transcatheter tricuspid edge-to-edge repair (T-TEER) is widely used to treat atrial (AFTR) and ventricular (VFTR) functional tricuspid regurgitation (FTR). Methods: The outcome of 136 patients treated with T-TEER for severe AFTR or VFTR was analyzed using a composite endpoint of all-cause death and rehospitalization for decompensated heart failure. AFTR was defined as TR in the context of left ventricular ejection fraction ≥50%, right ventricular fractional area change (RVFAC) ≥ 35% and sPAP ≤ 50 mmHg. Results: Patients with VFTR (N = 109) and AFTR (N = 27, 19.9%) were both elderly (82.0 {IQR: 74.5-84.5} vs. 82.0 {IQR: 75.0-84.0} years, p = 0.98) and had similar interventional risk according to the EuroScore II (6.1 {4.0-9.8} vs. 4.7 {3.6-9.6} %, p = 0.3). Atrial fibrillation was equally frequent in both groups (89.9 vs. 88.9%, p = 0.88). AFTR patients were significantly more often female (56.0 vs. 77.8%, p = 0.04) and had lower NT-proBNP (3600.0 {1706.0-6302.0} vs. 1988.0 {1034.8-3723.3} pg/mL, p < 0.01). While RVFAC (29.5 ± 8.6 vs. 42.1 ± 4.3%, p < 0.01) and LVEF (48.5 ± 12.3 vs. 58.6 ± 8.0%, p < 0.01) were expectedly lower in patients with VFTR, right atrial dilation (RA volume: 126.7 ± 56.5 vs. 127.6 ± 74.2 mL, p = 0.99) was similar. Successful T-TEER with TR reduction ≥ 2 degrees (96.3 vs. 92.6%, p = 0.34) was observed in both groups, and residual TR ≤ II was equally frequent (94.5 vs. 96.3%, p = 1.0). The incidence of the 1-year composite endpoint was significantly higher (34.3 vs. 12.0%) in patients with VFTR (log-rank p = 0.02). AFTR was inversely associated with the composite endpoint (HR: 0.21, 95% CI: 0.06-0.7, p < 0.01) in multivariate Cox regression. Conclusions: Despite equally effective TR reduction through T-TEER, a better outcome was observed in patients with AFTR.

The Use of 3D-Echo in Edge-to-Edge Percutaneous Tricuspid Valve Repair

The tricuspid valve (TV) is a complex anatomical entity. As surgical treatment for isolated tricuspid regurgitation has traditionally been associated with high peri- and post-operative mortality, advances in percutaneous transcatheter techniques of repair and replacement of the TV are emerging as safe and effective alternatives. This review summarizes the current evidence on the use of three-dimensional echocardiography to assist transcatheter-edge-to-edge repair (TEER) in patients with tricuspid regurgitation.

Transcatheter Edge-to-Edge Repair for Severe Isolated Tricuspid Regurgitation: The Tri.Fr Randomized Clinical Trial

Importance

Correction of tricuspid regurgitation using tricuspid transcatheter edge-to-edge repair (T-TEER) in addition to guideline-directed optimized medical therapy (OMT) may improve clinical outcomes.

Objective

To evaluate the efficacy of T-TEER + OMT vs OMT alone in patients with severe, symptomatic tricuspid regurgitation.

Design, Setting, and Participants

Investigator-initiated, prospective, randomized (1:1) trial evaluating T-TEER + OMT vs OMT alone in adult patients with severe, symptomatic tricuspid regurgitation. The trial was conducted at 24 centers in France and Belgium (March 2021 to March 2023; latest follow-up in April 2024).

Intervention

Patients were randomized to T-TEER + OMT or OMT alone.

Main Outcomes and Measures

The primary outcome was a composite clinical end point at 1 year comprising change in New York Heart Association class, change in patient global assessment, or occurrence of major cardiovascular events. Tricuspid regurgitation severity was the first of 6 secondary outcomes analyzed in a hierarchical closed-testing procedure, including Kansas City Cardiomyopathy Questionnaire (KCCQ) score, patient global assessment, and a composite outcome of all-cause death, tricuspid valve surgery, KCCQ score improvement, or time to hospitalization for heart failure.

Results

Of 300 enrolled patients (mean age, 78 [SD, 6] years, 63.7% women), 152 were allocated to T-TEER + OMT and 148 to OMT alone. At 1 year, 109 patients (74.1%) in the T-TEER + OMT group had an improved composite score compared with 58 patients (40.6%) in the OMT-alone group. Massive or torrential tricuspid regurgitation was found in 6.8% of patients in the T-TEER + OMT group and in 53.5% of those in the OMT-alone group (P < .001). Mean overall KCCQ summary score at 1 year was 69.9 (SD, 25.5) for the T-TEER + OMT group and 55.4 (SD, 28.8) for the OMT-alone group (P < .001). The win ratio for the composite secondary outcome was 2.06 (95% CI, 1.38-3.08) (P < .001).

Conclusions and Relevance

T-TEER reduces tricuspid regurgitation severity and improves a composite score driven by improved patient-reported outcome measures in patients with severe, symptomatic tricuspid regurgitation.

Trial Registration

ClinicalTrials.gov Identifier: NCT04646811.

Utility of the Ratio Between the Size of the Right Atrium and the Right Ventricle at End-Systole to Diagnose Atrial Secondary Tricuspid Regurgitation

BACKGROUND

In the multiparametric framework for diagnosing atrial secondary tricuspid regurgitation (A-STR), an end-systolic (ES) right atrial (RA)-to-right ventricular (RV) volume or area ratio ≥1.5 supports the diagnosis of A-STR over the ventricular secondary tricuspid regurgitation phenotype (V-STR). However, this threshold value has never been tested.

METHODS

A single-center study was conducted, prospectively enrolling consecutive patients with secondary tricuspid regurgitation who underwent two- and three-dimensional echocardiography.

RESULTS

A total of 350 patients were enrolled (mean age, 75 ± 13 years; 65% women). Although patients with A-STR and V-STR presented similar degrees of secondary tricuspid regurgitation and comparable RA size, the ES RA/RV volume ratio was significantly larger in A-STR than in V-STR (1.75 [interquartile range, 1.35-2.45] vs 1.18 [interquartile range, 0.81-1.66], respectively; P < .001). On receiver operating characteristic analysis, the ES RA/RV volume ratio showed a significantly higher predictive power for A-STR (area under the curve [AUC], 0.73; 95% CI, 0.68-0.78) compared with RA maximum volume (AUC, 0.6; 95% CI, 0.54-0.66; P = .01), RA minimum volume (AUC, 0.59; 95% CI, 0.53-0.65; P = .007), and ratio of RA minimum volume to RV end-diastolic volume (AUC, 0.57; 95% CI, 0.51-0.63; P < .001). However, the predictive power of the ES RA/RV volume ratio (AUC, 0.73; 95% CI, 0.68-0.78) and the ES RA/RV area ratio (AUC, 0.76; 95% CI, 0.71-0.81) for the diagnosis of A-STR was similar (P = .58). The threshold value for ES RA/RV volume ratio that best distinguished between A-STR and V-STR was 1.40 (AUC, 0.68; 95% CI, 0.63-0.73), whereas for ES RA/RV area ratio, it was 1.6 (AUC, 0.64; 95% CI, 0.59-0.69). A multivariable model that included either ES RA/RV volume ratio or ES RA/RV area ratio, along with LV ejection fraction, RV ejection fraction, RV ES volume, and pulmonary artery systolic pressure, resulted in an AUC of 0.97 for differentiating between A-STR and V-STR.

CONCLUSIONS

ES RA/RV volume ratio ≥ 1.4 and ES RA/RV area ratio ≥ 1.6 support the diagnosis of A-STR over V-STR.

Atrial Secondary Tricuspid Regurgitation: Insights Into the EuroTR Registry

BACKGROUND

Atrial secondary tricuspid regurgitation (A-STR) has been proposed as an important etiologic subentity of secondary tricuspid regurgitation (STR). Patients with A-STR are frequently treated using transcatheter tricuspid valve edge-to-edge repair (T-TEER).

OBJECTIVES

The aims of this study were to evaluate prevalence and outcomes following T-TEER for severe A-STR and to compare the results to patients with nonatrial STR.

METHODS

The study included patients from the EuroTR (European Registry of Transcatheter Repair for Tricuspid Regurgitation) registry who underwent T-TEER for STR from 2016 until 2022. A-STR was defined as a ratio of end-systolic right atrial area to right ventricular area ≥1.5 in the presence of preserved right ventricular function (tricuspid annular plane systolic excursion >17 mm). The primary study endpoint was 2-year survival free from heart failure hospitalization. Secondary endpoints were 2-year survival, tricuspid regurgitation (TR) reduction at discharge and 1-year follow-up as well as changes in NYHA functional class.

RESULTS

This study included 641 patients (50% women) with a mean age of 79 ± 7 years. The overall prevalence of A-STR was 31% (n = 196). A-STR was associated with a higher prevalence of atrial fibrillation, less frequent comorbidities, better biventricular function, less leaflet tenting, and larger atria. Although TR severity was comparable at baseline, patients with A-STR had more effective procedural TR reduction (TR ≤2+ in 86.9% vs 80.4% of those with nonatrial STR; P = 0.005). Although NYHA functional class improved in both STR subetiologies, the symptomatic burden was lower in patients with A-STR at the latest available follow-up (NYHA functional class ≥III in 46% of patients with nonatrial STR vs 38% in those with A-STR; P = 0.033). Beyond that, A-STR was associated with higher 2-year survival rates free from heart failure hospitalization (66.3% [Q1-Q3: 58.2%-75.5%] vs 47.5% [Q1-Q3: 41.7%-54.7%] in patients with nonatrial STR; P < 0.001). Median survival follow-up was 379 days [Q1-Q3: 155-697 days].

CONCLUSIONS

A-STR is a common phenotype of STR and is associated with effective TR reduction and symptomatic reduction after T-TEER.

Atrial Functional Tricuspid Regurgitation: A Comprehensive Review of Pathophysiology, Diagnosis, and Management Strategies

Atrial fibrillation (AF), the most prevalent sustained cardiac arrhythmia, is intricately linked with atrial functional tricuspid regurgitation (AFTR), a condition distinguished from ventricular functional tricuspid regurgitation by its unique pathophysiological mechanisms and clinical implications. This review article delves into the multifaceted aspects of AFTR, exploring its epidemiology, pathophysiology, diagnostic evaluation, and management strategies. Further, we elucidate the mechanisms underlying AFTR, including tricuspid annular dilatation, right atrial enlargement, and dysfunction, which collectively contribute to the development of tricuspid regurgitation in the absence of significant pulmonary hypertension or left-sided heart disease. The section on diagnostic evaluation highlights the pivotal role of echocardiography, supplemented by cardiac magnetic resonance (CMR) imaging and computed tomography (CT), in assessing disease severity and guiding treatment decisions. Management strategies for AFTR are explored, ranging from medical therapy and rhythm control to surgical and percutaneous interventions, underscoring the importance of a tailored, multidisciplinary approach. Furthermore, the article identifies gaps in current knowledge and proposes future research directions to enhance our understanding and management of AFTR. By providing a comprehensive overview of AFTR, this review aims to raise awareness among healthcare professionals and stimulate further research to improve patient care and outcomes in this increasingly recognized condition.

Tricuspid regurgitation: a contemporary review

Tricuspid regurgitation (TR), an underrecognized disease, overlooked by clinicians for many years due to its assumed benign nature. Recent epidemiological studies suggest significant TR may be seen in up to 6% of elderly patients. An increase in prevalence is expected due to the higher incidence of various clinical predictors of TR progression. Increasing severity of TR is associated with worse outcomes with a novel morphologic classification providing a more refined prediction of outcomes. Advances in cardiac imaging, particularly echocardiography, are integral to the diagnosis of disease severity which not only includes quantitation of TR, but also an assessment of the right atrium, right ventricle and pulmonary arterial circulation. Once identified and quantified, TR management requires a multi-disciplinary heart team management including structural imagers, heart failure specialists, electrophysiologist, cardiac surgeons and interventionalists. Data to support medical therapies are lacking although guidelines support the management of congestive signs and symptoms, as well as comorbidities such as left heart failure and rhythm management. The risks of surgical interventions are slowly improving, however, transcatheter therapies are now available to treat patients with high surgical risk. This manuscript will provide a state-of-art review of this fast-moving field, including current scientific evidences, but also upcoming perspectives with multiple ongoing clinical studies.

Relevance of residual tricuspid regurgitation for right ventricular reverse remodelling after tricuspid valve intervention in patients with severe tricuspid regurgitation and right-sided heart failure

AIMS

Right ventricular reverse remodelling (RVRR) is linked to improved survival in patients with severe tricuspid regurgitation (TR) and right-sided heart failure who underwent interventional treatment. However, the role of residual TR on RVRR remains unclear. In this analysis the impact of residual TR on RVRR after interventional TR treatment, which was validated by two independent cohorts at four sites using echocardiography or cardiac magnetic resonance (CMR) imaging, was investigated.

METHODS AND RESULTS

Overall, 253 patients who were treated for severe TR and right-sided heart failure using different treatment modalities (tricuspid transcatheter edge-to-edge repair [T-TEER], transcatheter tricuspid valve annuloplasty, orthotopic transcatheter TV replacement [TTVR], heterotopic TTVR) were included. Three-dimensional echocardiographic and CMR-based assessment of RVRR and clinical evaluation of decongestion or exercise capacity were performed at baseline and 30 days after the procedure. Mortality was analysed at 1 year after transcatheter tricuspid valve intervention (TTVI). In patients with residual TR ≤1+ pronounced reduction of right ventricular end-diastolic and end-systolic volumes was observed. In patients with residual TR ≥2+ the effect of RVRR gradually decreased with higher residual TR reinforcing the relevance of optimal procedural results for RVRR. These findings were validated in two independent cohorts. In contrast to RVRR, residual TR ≤1+ and 2+ were associated with similar 1-year survival. RVRR was only observed after T-TEER or orthotopic TTVR, but not after heterotopic TTVR as expected. However, all three treatment modalities were accompanied by significant decongestion and functional improvement at 30-day follow-up.

CONCLUSION

In patients with severe TR and right-sided heart failure undergoing TTVI, superior procedural results were associated with more pronounced RVRR.

Advances in the Assessment of Patients With Tricuspid Regurgitation: A State-of-the-Art Review on the Echocardiographic Evaluation Before and After Tricuspid Valve Interventions

Tricuspid regurgitation (TR) can have a significant impact on the health and mortality of a patient. Unfortunately, many patients with advanced right-sided heart failure are not referred for isolated tricuspid valve (TV) surgery in a timely manner. This delayed referral has resulted in a high in-hospital mortality rate and significant undertreatment. Fortunately, transcatheter TV intervention (TTVI) has emerged as a safe and effective alternative to surgery, successfully reducing TR severity and improving patients' quality of life. Current guidelines emphasize the importance of assessing TR severity and its impact on the right heart chambers for selecting the appropriate intervention. However, the echocardiographic assessment of both right chambers and TV anatomy, along with TR severity, poses specific challenges, leading to the underestimation of TR severity. Recently, three-dimensional echocardiography has become crucial to enhance the characterization of TR severity. Moreover, it is essential to evaluate residual TR after TTVI to gauge the intervention's success and predict the patient's prognosis. This review provides a thorough evaluation of the echocardiographic parameters used to assess TR severity before and after TTVI. It presents a critical analysis of the accuracy and reliability of these parameters, highlighting their strengths and limitations to establish standardized diagnostic criteria and treatment protocols for TR, which will inform clinical decision-making and improve patient outcomes.

Imaging and mechanisms of heart failure with preserved ejection fraction: a state-of-the-art review

Understanding of the pathophysiology of heart failure with preserved ejection fraction (HFpEF) has advanced rapidly over the past two decades. Currently, HFpEF is recognized as a heterogeneous syndrome, and there is a growing movement towards developing personalized treatments based on phenotype-guided strategies. Left ventricular dysfunction is a fundamental pathophysiological abnormality in HFpEF; however, recent evidence also highlights significant roles for the atria, right ventricle, pericardium, and extracardiac contributors. Imaging plays a central role in characterizing these complex and highly integrated domains of pathophysiology. This review focuses on established evidence, recent insights, and the challenges that need to be addressed concerning the pathophysiology of HFpEF, with a focus on imaging-based evaluations and opportunities for further research.

Assessment of the Right Ventricle Function in Patients With Significant Tricuspid Regurgitation: A Review

Tricuspid regurgitation (TR) is an increasingly prevalent condition, especially in older populations, and presents significant challenges due to its association with right heart failure, hospital admissions, and high mortality rates. The management of TR has evolved, with new percutaneous valve repair and replacement techniques emerging alongside traditional surgical approaches. However, accurately assessing right ventricular (RV) function-a key prognostic factor in TR-remains difficult due to the RV's unique anatomy and sensitivity to loading conditions. Current echocardiographic methods, such as Tricuspid Annular Plane Systolic Excursion (TAPSE), S' wave analysis, and RV fractional area change (FAC), offer valuable insights but have limitations, particularly regarding load dependence and incomplete assessment of RV function. Advances in 3D echocardiography and myocardial strain imaging provide more comprehensive evaluations, yet challenges persist in integrating these measures in routine clinical practice. The review highlights the importance of a multimodal approach to RV assessment in TR patients, considering both the right atrium and pulmonary artery interactions, and explores potential future tools such as myocardial work and dynamic testing to improve prognostic accuracy and patient outcomes.

TRIVALVE Score: A Risk Score for Mortality/Hospitalization Prediction in Patients Undergoing Transcatheter Tricuspid Valve Intervention

BACKGROUND

Transcatheter tricuspid valve intervention (TTVI) has been increasingly adopted in recent years for the treatment of patients with tricuspid regurgitation (TR). However, no dedicated risk stratification has been established for patients undergoing TTVI.

OBJECTIVES

The aim of the present study was to propose a dedicated risk score for patients affected by severe TR undergoing TTVI.

METHODS

The score was derived from the TRIVALVE (International Multisite Transcatheter Tricuspid Valve Therapies Registry; NCT03416166) registry, according to data availability. A stepwise model approach was used on predictor variables to develop a scoring system for predicting 12-month mortality or rehospitalization using multivariable logistic regression. Internal discrimination, calibration, and validation were assessed using receiver-operating characteristic curve analysis and bootstrapping with 1,000 resamples.

RESULTS

A total of 483 patients were included in the study, with an overall 12-month mortality or rehospitalization rate of 19% (n = 94). The final risk score, ranging from 0 to 4.5, included the following 5 parameters (adjusted for age and gender): 1) atrial fibrillation at baseline; 2) glomerular filtration rate <30 mL/min; 3) elevated gamma-glutamyl transferase/bilirubin levels; 4) signs of right heart failure; and 5) left ventricular ejection fraction <50%. The bias-corrected area under the receiver-operating characteristic curve was 68% (95% CI: 62%-75%). A cutoff value of 2.5 demonstrated sensitivity of 65.4% and specificity of 60.5% for the outcome.

CONCLUSIONS

The present study proposes a dedicated risk score for patients undergoing TTVI, providing an additional and simple tool for heart teams to select the best therapy for patients affected by severe TR.

Predictors of residual tricuspid regurgitation after interventional therapy: an automated deep-learning CT analysis

Computed tomography (CT) is used as a valuable tool for device selection for interventional therapy in tricuspid regurgitation (TR). We aimed to evaluate predictors of TR reduction using CT and automated deep learning algorithms. Patients with severe to torrential TR and CTs prior to either percutaneous annuloplasty (PA) or tricuspid transcatheter edge-to-edge repair (T-TEER) were enrolled. CTs were analyzed using automated deep learning algorithms to assess tricuspid valve anatomy, right heart morphology, and function. Outcome parameters comprised post-interventional TR ≤ 1 and all-cause mortality. 84 patients with T-TEER (n = 32) or PA treatment (n = 52) were enrolled. Patients with a post-interventional TR ≤ 1 presented lower tenting heights and smaller tenting angles compared to patients with a TR > 1. Tenting height showed the best accuracy for post-interventional TR > 1 with an AUC of 0.756 (95% CI 0.560-0.951) in the T-TEER and 0.658 (95% CI 0.501-0.815) in the PA group, consistent with a suggested threshold of 6.8 mm and 9.2 mm, respectively. Patients with a post-interventional TR ≤ 1 exhibited a mortality of 4% and those with a TR > 1 of 12% during a follow-up of 331 ± 300 and 370 ± 265 days, respectively (p = 0.124). To conclude, tenting is associated with procedural outcomes and should be considered during screening for interventional TR therapy.

Effects of tricuspid transcatheter edge-to-edge repair on tricuspid annulus diameter - Data from the TriValve registry

AIMS

T-TEER is an effective therapy for the treatment of tricuspid regurgitation (TR). However, the effects of leaflets clipping on tricuspid valve annulus (TA) have not been investigated in detail. The aim of this study is to investigate the effects of tricuspid transcatheter edge-to-edge repair (T-TEER) on TA diameter.

METHODS AND RESULTS

The TriValve registry (Transcatheter Tricuspid Valve Therapies, NCT03416166) collected 556 patients from 22 European and North American centres undergoing transcatheter tricuspid valve interventions from 2016 to 2022. Patients undergoing T-TEER with available pre- and post-procedural data on TA diameter measured in the apical 4-chamber view on transthoracic echocardiography were selected for this study. Primary end-point was the reduction of TA diameter after T-TEER. A total of 186 patients were included in the study. In 115 patients (62%) TA diameter was reduced by at least 1 mm as compared to baseline. A significant reduction of TA dimension was observed following T-TEER (mean 2.3 mm [from pre-procedural diameter 46.7 mm to post-procedural diameter 44.4 mm], p < 0.001). In particular, the greatest reduction was observed in those with T-TEER in antero-septal commissure (mean 2.7 mm [from 47.1 mm to 44.4 mm], p < 0.001) as compared to those combining both antero-septal and postero-septal commissures (mean 1.4, from 46.0 mm to 44.6 mm, P = 0.06). A significant reduction of TA dimension was recorded in patients with 1 or 2 clips implanted but not in those patients with ≥3 clips implanted.

CONCLUSIONS

In almost two third of patients T-TEER reduces TA diameter in addition to leaflet approximation.

CONDENSED ABSTRACT

The effects of tricuspid transcatheter edge-to-edge repair (T-TEER) on tricuspid valve annulus (TA) have not been studied in details. This study investigates TA diameter as measured in apical 4-chamber view on transthoracic echocardiography before and after T-TEER. A total of 186 patients from the TriValve registry were included in the study. The study results show that 62% of patients have a TA reduction after T-TEER, especially in those receiving 1 or 2 clips in the antero-septal commissure. These suggest that T-TEER reduces tricuspid regurgitation not only by approximation of leaflets, but also by TA diameter reduction.

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.

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.