Impact of catheter ablation on functional tricuspid regurgitation in patients with atrial fibrillation

Impact of Mitral Regurgitation on Outcomes of Catheter Ablation for AF With Left Ventricular Systolic Dysfunction

BACKGROUND

Atrial fibrillation (AF) and left ventricular (LV) systolic dysfunction (LVSD) may be associated with function mitral and tricuspid regurgitation (FMR/FTR). Prior studies have largely assessed impact of MR on AF ablation outcomes in the presence of preserved LV ejection fraction.

OBJECTIVES

This study sought to determine the impact of FMR on the outcomes of catheter ablation (CA) in patients with AF and LVSD.

METHODS

We examined baseline clinical characteristics, CA outcomes, and change in echocardiographic parameters (FMR and FTR severity, LV and left atrial [LA] dimensions, LVEF) at baseline and 12 months in individuals with AF and LVSD with at least mild FMR undergoing CA. Patients with primary mitral valve disease were excluded.

RESULTS

235 patients (age 62.8 years,16.2% female, NYHA functional class III (Q1-Q3: II-III)) underwent CA and were categorized by FMR severity at baseline (mild n = 117; moderate/severe n = 118). Baseline characteristics were comparable irrespective of degree of FMR, other than lower LVEF (LVEF 29% [Q1-Q3: 22.8%-35.0%] vs 35% [Q1-Q3: 30.0%-41.0%]; P < 0.001) and increased tricuspid regurgitation in moderate/severe MR (22%) vs mild MR (8%, P < 0.001). LA size did not differ significantly across FMR groups (P = 0.233). At 12 months following CA, recurrent atrial arrhythmia occurred in 101 of 235 (43.0%) including 42.7% in mild vs 43.2% in moderate-to-severe MR (P = 0.940). The severity of FMR did not influence arrhythmia recurrence (OR: 1.15; 95% CI: 0.54-1.86; P = 0.601) nor LV recovery (OR: 1.07; 95% CI: 0.67-1.25; P = 0.153). After CA, 89% of those with significant FMR and 85% with significant FTR exhibited ≥1 grade reduction at 12 months. Change in LV dimensions was associated with MR responders (OR: 0.93; 95% CI: 0.87-0.99; P = 0.022) with a greater reduction in LV size at 12 months in MR improvement (-5.0 (Q1-Q3: -9.3 to -1.0) vs non-improvement -1.0 (Q1-Q3: -5.0 to 2.5), P = 0.004) whereas change in LA size was not (OR: 0.98; 95% CI: 0.97-1.03; P = 0.984).

CONCLUSIONS

In patients with AF and LVSD, the degree of FMR did not impact the success of ablation. There was a significant reduction in FMR and FTR at 12 months following CA. Patients with AF and LVSD should be strongly considered for AF ablation irrespective of the degree of mitral regurgitation.

Right atrial reverse remodeling after pulmonary vein isolation: Analyzing changes in volume and function using cardiac magnetic resonance imaging

BACKGROUND

Successful pulmonary vein isolation (PVI) promotes left atrial (LA) reverse remodeling, but its effect on right atrial (RA) remodeling remains unclear.

OBJECTIVE

The purpose of this study was to assess the impact of radiofrequency (RF) PVI on RA volumes and function in patients with atrial fibrillation by using cardiac magnetic resonance imaging.

METHODS

Forty-three patients with atrial fibrillation (32 (74.4%) males; mean age 61±7 years) undergoing first RF PVI, without atrial flutter ablation, underwent 3 cardiac magnetic resonance scans: pre-PVI, early (<72 hours) post-PVI, and 3 months post-PVI. Indexed atrial volumes (RA maximal/minimal volume index and LA maximal/minimal volume index) and function were derived from 2- and 4-chamber cine images, with longitudinal atrial strain analyzed using feature tracking.

RESULTS

Early post-PVI, RA minimal volume index significantly decreased (from 28.7±10.3 to 26.0±9.9 mL/m2; P=.03) while RA emptying fraction significantly increased (from 37.3%±11.5% to 41.7%±10.1%; P=.03). At 3 months, both RA minimal volume index and RA maximal volume index showed further significant reductions compared with baseline (from 28.7±10.3 to 24.8±8.8 mL/m2; P=.002 and from 45.2±11.8 to 40.3±11.9 mL/m2; P<.001, respectively). During this period, RA functional improvement persisted, as evidenced by RA reservoir and contractile strain (from 16.2%±4.1% to 18.9%±3.6%; P=.003 and from 6.6%±2.6% to 8.3%±2.8%; P=.005, respectively). LA volumes remained unchanged early post-PVI, but at 3 months, LA maximal volume index significantly decreased compared with baseline (from 46.1±13.0 to 39.1±11.3 mL/m2; P<.001). LA function, demonstrated by reservoir and contractile strain, was significantly diminished early post-PVI, which persisted at 3 months compared with baseline (from 18.6%±4.0% to 17.0%±3.4%; P=.04 and from 8.5%±3.0% to 6.9%±2.4%; P<.01, respectively).

CONCLUSION

This study demonstrates that RF PVI results in reverse biatrial remodeling, with significant reductions observed in RA and LA volumes. RA function showed a significant improvement post-PVI, while LA function demonstrated persistent impairment at 3 months, possibly because of LA ablation scarring.

Multimodality Imaging in the Management of Tricuspid Valve Regurgitation

Approximately 5% of elderly patients suffer from moderate or severe tricuspid valve regurgitation, which is an independent predictor of high morbidity and mortality. Surgical treatment of isolated tricuspid valve regurgitation has been associated with elevated fatality rate, leading to a growing interest in minimal invasive, transcatheter-based therapies such as transcatheter edge-to-edge repair and transcatheter valve replacement. Nevertheless, despite high procedural efficacy and safety of transcatheter-based therapies, a number of challenges limit their rapid adoption in routine clinical practice. In particular, the wide range of transcatheter approaches to address the significant variability in tricuspid valve pathology challenges the reproducibility of clinical outcomes. Multimodality imaging is pivotal for grading the regurgitation severity, determining the underlying pathology, assessing RV function and pulmonary pressures, identifying concomitant cardiac disease, and selecting the most beneficial treatment modality and access. This article reviews the role of different imaging modalities in guiding the management of patients with significant tricuspid valve regurgitation.

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.

Sinus rhythm restoration reverses tricuspid regurgitation in patients with atrial fibrillation: a systematic review and meta-analysis

BACKGROUND

Tricuspid regurgitation (TR) is a common valvular heart disease worldwide, and current guidelines for TR treatment are relatively conservative, as well as with detrimental outcomes. Restoration of sinus rhythm was reported to improve the TR severity in those TR patients with atrial fibrillation (AF). However, relevant research was limited. The aim of this meta-analysis was to evaluate the clinical outcomes of restoration of sinus rhythm in TR patients with AF.

METHODS

In this study, PubMed, Web of Science, and Scopus databases were searched for study enrollment until July 2023. This study was designed under the guidance of Preferred Reporting Items for Systematic Reviews and Meta-Analyses. These studies containing the patient's baseline characteristics, surgical procedure, and at least one of the clinical outcomes were included. The primary endpoint was TR grade during follow-up after restoration of sinus rhythm.

RESULTS

Out of 1074 records, 6 were enrolled. Restoration of sinus rhythm is associated with a reduction of TR severity (TR grade, odds ratio 0.11, 95% confidence interval (CI): 0.01 to 1.28, P = 0.08, I2 = 83%; TR area, mean difference (MD) -2.19 cm2, 95% CI: -4.17 to -0.21 cm2, P = 0.03, I2 = 96%). Additionally, remolding of right heart with a significant reduction of tricuspid valve annulus diameter (MD -0.36 cm, 95%CI: -0.47 to -0.26 cm, P < 0.00001, I2 = 29%) and right atrium volume index (MD -11.10 mL/m2, 95%CI: -16.81 to -5.39 mL/m2, P = 0.0001, I2 = 79%) was observed during follow-up.

CONCLUSIONS

In conclusion, rhythm-control therapy could reduce TR severity in AF patients with TR and is associated with right heart remodeling.

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.

Tricuspid Regurgitation Management for Heart Failure

There is growing evidence that severe tricuspid regurgitation (TR) impacts clinical outcomes in a variety of cardiovascular disease states. The late presentation of patients with advanced TR highlights the underappreciation of the disease, as well as the pitfalls of current guideline-directed medical management. Given the high in-hospital mortality associated with isolated tricuspid valve surgery, transcatheter options continue to be explored with the hope of improved survival and reduced heart failure hospitalizations. In this review, we explore the physiology of TR, discuss the etiologic classes of TR, and explore the transcatheter options for treatment and who might benefit from device therapy.

Predictors and outcomes of tricuspid regurgitation improvement after radiofrequency catheter ablation for persistent atrial fibrillation

INTRODUCTION

Little has been reported on the predictors and outcomes of improvement of tricuspid regurgitation (TR) after radiofrequency catheter ablation (RFCA) for persistent atrial fibrillation (AF).

METHODS

We enrolled 141 patients with persistent AF and moderate or severe TR assessed by transthoracic echocardiography (TTE) who underwent an initial RFCA between February 2015 and August 2021. These patients underwent follow-up TTE at 12 months after the RFCA, and were categorized into two groups based on the improvement (defined as at least one-grade improvement of TR) and non-improvement of TR: IM group and Non-IM group, respectively. We compared the patient characteristics, ablation procedures, and recurrences after the RFCA between the two groups. In addition, we examined the major event (defined as admission for heart failure or all-cause death) more than 12 months after the RFCA.

RESULTS

IM group consisted of 90 patients (64%). A multivariate analysis revealed that age <71 years old and absence of late recurrence (LR, defined as recurrence of atrial tachyarrhythmia between 3 and 12 months after the RFCA) were independently associated with the improvement of TR after the RFCA. Furthermore, IM group had the higher incidence of major event-free survival than Non-IM group.

CONCLUSIONS

Relatively young age and absence of LR were good predictors of improvement of TR after the RFCA for persistent AF. In addition, the improvement of TR was related to better clinical outcomes.