Tricuspid Regurgitation Management for Heart Failure

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.

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.

Development and validation of an integrated prognostic model for all-cause mortality in heart failure: a comprehensive analysis combining clinical, electrocardiographic, and echocardiographic parameters

BACKGROUND

Accurate risk prediction in heart failure remains challenging due to its complex pathophysiology. We aimed to develop and validate a comprehensive prognostic model integrating demographic, electrocardiographic, echocardiographic, and biochemical parameters.

METHODS

We conducted a retrospective cohort study of 445 heart failure patients. The cohort was randomly divided into training (n = 312) and validation (n = 133) sets. Feature selection was performed using LASSO regression followed by backward stepwise Cox regression. A nomogram was constructed based on independent predictors. Model performance was assessed through discrimination, calibration, and decision curve analyses. Random survival forest analysis was conducted to validate variable importance.

RESULTS

During a median follow-up of 4.14 years, 142 deaths (31.91%) occurred. Our model development followed a systematic approach: initial feature selection using LASSO regression identified 15 potential predictors, which were further refined to nine independent predictors through backward stepwise Cox regression. The final predictors included age, NYHA class, left ventricular systolic dysfunction, atrial septal defect, aortic valve annulus calcification, tricuspid regurgitation severity, QRS duration, T wave offset, and NT-proBNP. The integrated model demonstrated good discrimination for 2-, 3-, and 5-year mortality prediction in both training (AUCs: 0.726, 0.755, 0.809) and validation cohorts (AUCs: 0.686, 0.678, 0.706). Calibration plots and decision curve analyses confirmed the model's reliability and clinical utility across different time horizons. A nomogram was constructed for individualized risk prediction. Kaplan-Meier analyses of individual predictors revealed significant stratification of survival outcomes, while restricted cubic spline analyses demonstrated non-linear relationships between continuous variables and mortality risk. Random survival forest analysis identified the top five predictors (age, NT-proBNP, QRS duration, tricuspid regurgitation severity, NYHA), which were compared with our nine-variable model, confirming the superior performance of the integrated model across all time points.

CONCLUSIONS

Our integrated prognostic model showed robust performance in predicting all-cause mortality in heart failure patients. The model's ability to provide individualized risk estimates through a nomogram may facilitate clinical decision-making and patient stratification.

CLINICAL TRIAL NUMBER

Not applicable.

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.

Valvular Heart Disease-A New Evolving Paradigm

Valvular heart disease is one of the most common cardiovascular diseases today and may result in severe limiting symptoms, a shortened lifespan, and, in some cases, sudden death. It is important to identify significant valve disease because intervention can restore quality of life and in many instances increase longevity. In most patients, the diagnosis of significant valvular heart disease can be made on the basis of a physical examination, yet nearly half of the patients who could benefit from interventions are not being recognized or referred. There have been major improvements in both the diagnosis and treatment of patients with valvular heart disease, with noninvasive echocardiography available to confirm the presence and severity of valve disease, better and more durable surgical procedures, and the advent of catheter-based therapies. There are now national guidelines to aid clinicians in the optimal timing of the intervention, which are presented. However, it is now recognized that the long-standing volume or pressure overload from valve disease can result in incipient ventricular dysfunction even before the onset of symptoms or a drop in ejection fraction; therefore, there is an impetus to recognize and to treat these patients earlier and earlier in the disease natural history. A shared decision-making process should play a key role in the final decision for therapy, outlining the goals and risks of possible intervention coupled with the patient's own needs and expectations.

Long-term outcomes with medical therapy, transcatheter repair, or surgery for isolated tricuspid regurgitation: a systematic review and network meta-analysis

BACKGROUND

Several transcatheter tricuspid valve (TV) repair devices for tricuspid regurgitation (TR) have emerged. However, few studies have compared transcatheter TV repair with medical therapy (MT) alone or isolated TV surgery.

METHODS

PubMed and EMBASE were searched in February 2024. Studies comparing at least any of the following 2 were included: MT, surgical TV repair, surgical TV replacement, or transcatheter TV repair. The primary outcome was long-term mortality (≧ 1 year). The secondary outcomes were short-term mortality (30-day or in-hospital mortality) and periprocedural complications. We performed a network meta-analysis using a random effects model.

RESULTS

A total of 25,831 patients from 22 studies (one randomized trial and 21 observational studies) were included. MT alone was associated with higher long-term mortality compared to surgical TV repair (HR [95% CI] 1.72 [1.34-2.23]), surgical TV replacement (HR [95% CI] 1.49 [1.14-1.96]), and transcatheter TV repair (HR [95% CI] 1.52 [1.30-1.78]). Long-term mortality was comparable between transcatheter and surgical interventions. Transcatheter TV repair had a lower risk of short-term mortality (versus surgical TV repair; RR [95% CI] 0.40 [0.22-0.72], versus surgical TV replacement; RR [95% CI] 0.35 [0.19-0.66]) and lower rates of periprocedural complications, including new pacemaker implantation, renal complications, cardiogenic shock than surgical interventions.

CONCLUSIONS

MT alone for TR was associated with higher long-term mortality compared to surgical or transcatheter TV interventions. Transcatheter TV repair had better periprocedural outcomes compared to surgical interventions with similar long-term mortality. Despite the possibility of selection bias, transcatheter TV repair appears to be an attractive option for TR treatment.

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.

Registries on transcatheter edge-to-edge repair in heart failure: Current evidence and future perspectives

AIMS

Secondary mitral regurgitation (SMR) and tricuspid regurgitation (TR) are the most common valvular heart diseases in patients with heart failure (HF). Transcatheter edge-to-edge repair (TEER) devices designed for treating MR and TR have been successfully tested in randomized controlled trials, but methodological issues have often challenged their interpretation. This manuscript aimed to provide an overview of TEER registries on SMR and TR in HF, highlighting their key features, describing clinical characteristics and outcomes of patients receiving these devices, and exploring the available data limitations.

METHODS AND RESULTS

PubMed, Web of Science, and EMBASE were searched for registries reporting on TEER in SMR or TR. Registries were excluded if single-centre and with <100 patients. Twenty-six registries (46% prospective, 12% ongoing), including a total cohort of 18 925 patients, were retrieved for TEER in SMR, and six registries (50% retrospective, 33% ongoing) reported on the use of TEER for TR in a total cohort of 1412 patients. Limited geographical representativity outside North America and Europe, high number of missing values, and inconsistency in data reporting were the main existing evidence limitations.

CONCLUSION

Registries on TEER represent a key data source in a setting where it is difficult to conduct randomized controlled trials. However, limitations in design, patient characterization, and outcomes reporting restrain their use. A novel conceptual framework for future prospective TEER registries, as proposed in this document, might inform current practice, address relevant clinical questions and future trial design.

Transcatheter Caval Implantation for Severe Tricuspid Regurgitation

PURPOSE OF REVIEW

We describe the evolution of caval valve implantation (CAVI) as a treatment for severe symptomatic tricuspid regurgitation (TR) in the high surgical risk patient.

RECENT FINDINGS

Surgical treatment of severe TR is often limited by the high surgical risk of the patients who tend to develop severe secondary TR. Coaptation, annuloplasty, and orthotopic replacement strategies are all limited by annular and leaflet geometry, prior valve repair, and the presence of cardiac implantable device leads. CAVI appears to be a treatment strategy for severe symptomatic TR that improves functional capacity and quality of life while also reducing edema and ascites and improving cardiac output. Chronic kidney disease is a common comorbidity of patients with severe TR; zero-contrast CAVI has been described. Severe TR is undertreated, yet common in the elderly structural heart disease population. The evolution of CAVI as a viable treatment for severe TR underscores the deleterious systemic contribution of backwards flow to morbidity and mortality. There are good safety and efficacy outcomes from registry data using the TricValve platform. Randomized controlled trials for CAVI versus medical therapy for severe TR are ongoing.

Incidence, Time Course, and Outcomes of Worsening Tricuspid Regurgitation Following Transvenous Cardiac Implantable Electronic Device Implantation

Data regarding the incidence, time course, and outcomes of worsening tricuspid regurgitation (TR) after transvenous cardiac implantable electronic device (CIED) implantation are limited. We screened 834 consecutive patients who underwent first-time transvenous CIED implantation. After excluding patients without preoperative or follow-up echocardiography (n = 361) and patients with severe TR before implantation (n = 15), the present study population consisted of 458 patients. Worsening TR was defined as moderate or more TR that was newly developed or increased by at least 1 grade compared with baseline. During the median follow-up period of 2.1 years, worsening TR occurred in 93 patients (20%). The cumulative incidence of worsening TR was 10.2% at 1 year and 18.6% at 3 years. Of the 67 patients with worsening TR who underwent follow-up echocardiography, excluding those who underwent tricuspid valve surgery, 76% showed improvement in TR severity, with 70% having none or mild TR. On the landmark analysis, the 5-year cumulative incidence of all-cause death and heart failure hospitalization was significantly higher in patients with worsening TR at 1 year than those without worsening TR at 1 year (24.8% vs 11.4%, p = 0.002 and 35.2% vs 17.9%, p = 0.012, respectively). When considering worsening TR as a time-dependent covariate, worsening TR was significantly associated with an increased risk of all-cause death and heart failure hospitalization after adjustment for the differences in baseline patient characteristics (hazard ratio 1.99, 95% confidence interval 1.21 to 3.27, p = 0.006 and hazard ratio 2.64, 95% confidence interval 1.59 to 4.37, p <0.001, respectively). In conclusion, worsening TR after transvenous CIED implantation was not uncommon and had a dynamic nature with an improvement in the majority of patients, suggesting the functional etiology. Nonetheless, worsening TR was independently associated with an increased risk for mortality and heart failure hospitalization.

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.

Tricuspid Regurgitation Complicating Heart Failure: A Novel Clinical Entity

With the escalating incidence of heart failure, accurate diagnosis is paramount for tailored therapeutic interventions. The tricuspid valve, particularly tricuspid regurgitation, once relegated as the "forgotten valve", has gained prominence due to increasing evidence implicating severe tricuspid valve disease in the prognosis of diverse cardiovascular conditions. This review delineates recent significant advancements in imaging modalities, transcatheter interventions, and epidemiological and pathophysiological insights regarding tricuspid regurgitation complicating heart failure. A comprehensive understanding of these innovative concepts and technologies can significantly improve patient outcomes.

Structural Cardiac Interventions in Patients With Heart Failure: JACC Scientific Statement

Pathologic left ventricular remodeling and valvular heart disease may contribute to the clinical presentation and outcomes of patients presenting with heart failure, and limit the effectiveness of guideline-directed medical therapy. Although surgical interventions including surgical ventricular restoration techniques and valve repair or replacement are effective therapies, there is growing evidence that transcatheter interventions may be options for patients with persistent symptoms of heart failure despite optimal medical therapy, where surgical options may be limited. This scientific statement will review the current available and investigational percutaneous strategies for the management of structural contributors to heart failure: dilated left ventricular cardiomyopathies and valvular heart disease.

Contemporary pharmacological treatment and management of heart failure

The prevention and treatment strategies for heart failure (HF) have evolved in the past two decades. The stages of HF have been redefined, with recognition of the pre-HF state, which encompasses asymptomatic patients who have developed either structural or functional cardiac abnormalities or have elevated plasma levels of natriuretic peptides or cardiac troponin. The first-line treatment of patients with HF with reduced ejection fraction includes foundational therapies with angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors and diuretics. The first-line treatment of patients with HF with mildly reduced ejection fraction or with HF with preserved ejection fraction includes SGLT2 inhibitors and diuretics. The timely initiation of these disease-modifying therapies and the optimization of treatment are crucial in all patients with HF. Reassessment after initiation of these therapies is recommended to evaluate patient symptoms, health status and left ventricular function, and timely referral to a HF specialist is necessary if a patient has persistent advanced HF symptoms or worsening HF. Lifestyle modification and treatment of comorbidities such as diabetes mellitus, ischaemic heart disease and atrial fibrillation are crucial through each stage of HF. This Review provides an overview of the management strategies for HF according to disease stages that are derived from the recommendations in the latest US and European HF guidelines.

Transcatheter Therapy for the Tricuspid Valve: A Focused Review of Edge-to-Edge Repair and Orthotopic Valve Replacement

PURPOSE OF REVIEW

Patients with severe tricuspid regurgitation (TR) are at risk for significant morbidity and mortality. Transcatheter tricuspid valve interventions (TTVI) may offer patients less invasive treatment alternatives to surgery. This review evaluates the most common class of device currently used worldwide to treat TR, tricuspid transcatheter edge-to-edge repair (T-TEER) and orthotopic transcatheter tricuspid valve replacement (TTVR), both of which are now approved in the USA and Europe.

RECENT FINDINGS

The first pivotal randomized clinical trial, TRILUMINATE, demonstrated that T-TEER can safely reduce TR and is associated with improved health status outcomes. However, results of this trial have raised questions about whether this device can provide sufficient TR reduction to impact clinical outcomes. Orthotopic TTVR has recently gained attention with initial data suggesting near-complete TR elimination. The current review examines the technical features and anatomic limitations of the most commonly used devices for T-TEER and orthotopic TTVR, discusses the current clinical data for these devices, and offers a theoretical construct for device selection.

A comprehensive overview of surgical and transcatheter therapies to treat tricuspid regurgitation in patients with heart failure

PURPOSE OF REVIEW

The unique pathophysiologic considerations of severe tricuspid regurgitation (TR) have led to advancements in surgical and transcatheter treatments. The purpose of this review is to highlight the current surgical and transcatheter tricuspid valve interventions (TTVI) to functional TR.

RECENT FINDINGS

Surgical repair with ring annuloplasty consistently demonstrates better outcomes than surgical replacement or other repair approaches. However, surgical uptake of TR correction remains relatively low, and operative mortality rates are still high owing to multiple comorbidities and advanced tricuspid valve disease/right ventricular dysfunction at time of referral. Pivotal trials for tricuspid transcatheter edge-to-edge repair (T-TEER) and transcatheter TV replacement (TTVR) indicate improved quality of life compared to medical therapy alone for high-surgical-risk patients with severe symptomatic TR. Trials are underway to assess caval valve implantation (CAVI), which holds hope for many severe TR patients who are not ideal candidates for T-TEER or orthotopic TTVR. Peri-procedural optimization of right ventricular function remains critical to promote both device success and patient outcomes.

SUMMARY

Clinical outcomes after surgical TV intervention are poor, often due to intervening late in the disease course of TR. TTVI covers a treatment gap for patients deemed inoperable or high-surgical-risk, but earlier referral for TV interventions is still important prior to patients developing multiorgan dysfunction from chronic untreated TR.