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Tomaselli M, Radu DN, Badano LP, Perelli FP, Heilbron F, Cascella A, Gavazzoni M, Hădăreanu DR, Mihaila S, Oliverio G, Penso M, Caravita S, Baratto C, Fisicaro S, Parati G, Muraru D. Right Atrial Remodeling and Outcome in Patients with Secondary Tricuspid Regurgitation. J Am Soc Echocardiogr 2024; 37:495-505. [PMID: 38218553 DOI: 10.1016/j.echo.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/31/2023] [Accepted: 01/03/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND In patients with secondary tricuspid regurgitation (STR), right atrial remodeling (RAR) is a proven marker of disease progression. However, the prognostic value of RAR, assessed by indexed right atrial volume (RAVi) and reservoir strain (RAS), remains to be clarified. Accordingly, the aim of our study is to investigate the association with outcome of RAR in patients with STR. METHODS We enrolled 397 patients (44% men, 72.7 ± 13 years old) with mild to severe STR. Complete two-dimensional and speckle-tracking echocardiography analysis of right atrial and right ventricular (RV) size and function were obtained in all patients. The primary end point was the composite of death from any cause and heart failure hospitalization. RESULTS After a median follow-up of 15 months (interquartile range, 6-23), the end point was reached by 158 patients (39%). Patients with RAS <13% and RAVi >48 mL/m2 had significantly lower survival rates compared to patients with RAS ≥13% and RAVi ≤48 mL/m2 (log-rank P < .001). On multivariable analysis, RAS <13% (hazard ratio, 2.11; 95% CI, 1.43-3.11; P < .001) and RAVi > 48 mL/m2 (hazard ratio, 1.49; 95% CI, 1.01-2.18; P = .04) remained associated with the combined end point, even after adjusting for RV free-wall longitudinal strain, significant chronic kidney disease, and New York Heart Association class. Secondary tricuspid regurgitation excess mortality increased exponentially with values of 18.2% and 51.3 mL/m2 for RAS and RAVi, respectively. In nested models, the addition of RAS and RAVi provided incremental prognostic value over clinical, conventional echocardiographic parameters of RV size and function and RV free-wall longitudinal strain. CONCLUSIONS In patients with STR, RAR was independently associated with mortality and heart failure hospitalization. Assessment of RAR could improve risk stratification of patients with STR, potentially identifying those who may benefit from optimization of medical therapy and a closer follow-up.
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Affiliation(s)
- Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Daniela N Radu
- Carol Davila University of Medicine and Pharmacy, Prof. Dr. C. C. Iliescu Institute, Bucharest, Romania
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
| | - Francesco P Perelli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Francesca Heilbron
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Andrea Cascella
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Diana R Hădăreanu
- Department of Cardiology, Clinical Emergency County Hospital of Craiova, Craiova, Romania
| | - Sorina Mihaila
- Cardiology Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania; Cardiology and Cardiovascular Surgery Department, Emergency and University Hospital, Bucharest, Romania
| | - Giorgio Oliverio
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Marco Penso
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Samantha Fisicaro
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Hinojar R, Fernández-Golfín C, González Gómez A, García-Martin A, Monteagudo JM, García Lunar I, García Sebastian C, Pardo A, Sanchez Recalde A, Zamorano JL. STREI: a new index of right heart function in isolated severe tricuspid regurgitation by speckle-tracking echocardiography. Eur Heart J Cardiovasc Imaging 2024; 25:520-529. [PMID: 37956101 DOI: 10.1093/ehjci/jead305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/03/2023] [Accepted: 11/04/2023] [Indexed: 11/15/2023] Open
Abstract
AIMS Right ventricular (RV) performance determines clinical management in severe tricuspid regurgitation (TR). Right atrial (RA) function complements RV assessment in TR. This study aimed to design a novel index by speckle-tracking echocardiography (STREI index) integrating RA and RV strain information and to evaluate the clinical utility of combining RV and RA strain for prediction of cardiovascular (CV) outcomes. METHODS AND RESULTS Consecutive patients with at least (≥) severe TR evaluated in the Heart Valve Clinic (n = 300) were prospectively included. An additional independent TR cohort was included for external validation (n = 50). STREI index was developed with the formula: [2 ∗ RV-free wall longitudinal strain (RV-FWLS)] + reservoir RA strain (RASr). The composite endpoint included hospital admission due to heart failure and all-cause mortality. A total of 176 patients with ≥severe TR were finally included. STREI index identified a higher percentage of patients with RV dysfunction compared with conventional parameters. After a median follow-up of 2.2 years (interquartile range: 12-41 months), a total of 38% reached the composite endpoint. STREI values were predictors of outcomes independently of TR severity and RV dimensions. The combination of prognostic cut-off values of RASr (<10%) and RV-FWLS (>-20%) (STREI stratification) stratified four different groups of risk independently of TR severity, RV dimensions, and clinical status (adj HR per stratum 1.89 (1.4-2.34), P < 0.001). Pre-defined cut-off values achieved similar prognostic performance in the validation cohort (n = 50). CONCLUSION STREI index is a novel parameter of RV performance that independently predicts CV events. The combination of RA and RV strain stratifies better patients' risk, reflecting a broader effect of TR on right heart chambers.
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Affiliation(s)
- Rocio Hinojar
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar Km 9.100, Madrid 28034, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Carretera de Colmenar Km 9.100, Madrid, Spain
| | - Covadonga Fernández-Golfín
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar Km 9.100, Madrid 28034, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Carretera de Colmenar Km 9.100, Madrid, Spain
- CIBERCV, Instituto de Salud Carlos III (ISCIII), Spain
| | - Ariana González Gómez
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar Km 9.100, Madrid 28034, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Carretera de Colmenar Km 9.100, Madrid, Spain
| | - Ana García-Martin
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar Km 9.100, Madrid 28034, Spain
| | - Juan Manuel Monteagudo
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar Km 9.100, Madrid 28034, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Carretera de Colmenar Km 9.100, Madrid, Spain
| | - Inés García Lunar
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Cristina García Sebastian
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar Km 9.100, Madrid 28034, Spain
| | - Ana Pardo
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar Km 9.100, Madrid 28034, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Carretera de Colmenar Km 9.100, Madrid, Spain
| | - Angel Sanchez Recalde
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar Km 9.100, Madrid 28034, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Carretera de Colmenar Km 9.100, Madrid, Spain
| | - Jose Luis Zamorano
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar Km 9.100, Madrid 28034, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Carretera de Colmenar Km 9.100, Madrid, Spain
- CIBERCV, Instituto de Salud Carlos III (ISCIII), Spain
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Muraru D, Badano LP, Hahn RT, Lang RM, Delgado V, Wunderlich NC, Donal E, Taramasso M, Duncan A, Lurz P, De Potter T, Zamorano Gómez JL, Bax JJ, von Bardeleben RS, Enriquez-Sarano M, Maisano F, Praz F, Sitges M. Atrial secondary tricuspid regurgitation: pathophysiology, definition, diagnosis, and treatment. Eur Heart J 2024; 45:895-911. [PMID: 38441886 PMCID: PMC11095052 DOI: 10.1093/eurheartj/ehae088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/03/2024] [Accepted: 01/30/2024] [Indexed: 03/16/2024] Open
Abstract
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.
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Affiliation(s)
- Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, Milan 20126, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Piazzale Brescia 20, Milan 20149, Italy
| | - Luigi P Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, Milan 20126, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Piazzale Brescia 20, Milan 20149, Italy
| | - Rebecca T Hahn
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Roberto M Lang
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, Chicago, IL, USA
| | - Victoria Delgado
- Department of Cardiology, Hospital University Germans Trias I Pujol, Badalona, Spain
| | | | - Erwan Donal
- CHU Rennes, Inserm, University of Rennes 1, Rennes, France
| | - Maurizio Taramasso
- Department of Cardiac Surgery, HerzZentrum Hirslanden Zürich, Zürich, Switzerland
| | - Alison Duncan
- Heart Division, The Royal Brompton Hospital, London, UK
| | - Philipp Lurz
- Department of Cardiology, Heart Center Leipzig, Leipzig, Germany
- Department of Cardiology and Heart Valve Center, Universitätsmedizin Johannes Gutenberg-University, Langenbeckstr, Mainz 55131, Germany
| | | | - José L Zamorano Gómez
- Department of Cardiology, University Hospital Ramón y Cajal, Ctra Colmenar Viejo Km 9.1, Madrid, Spain
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ralph Stephan von Bardeleben
- Department of Cardiology and Heart Valve Center, Universitätsmedizin Johannes Gutenberg-University, Langenbeckstr, Mainz 55131, Germany
| | | | - Francesco Maisano
- Valve Center IRCCS Ospedale San Raffaele, Cardiac Surgery, University Vita Salute, Milan, Italy
| | - Fabien Praz
- Department of Cardiology, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Marta Sitges
- Cardiovascular Institute, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- CIBER, Centro de Investigación Biomédica en Red, Barcelona, Spain
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4
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Badano LP, Muraru D. Make Right Heart Remodeling in Secondary Tricuspid Regurgitation as Simple as Possible, But Not Simpler. JACC Cardiovasc Imaging 2024:S1936-878X(24)00058-5. [PMID: 38520426 DOI: 10.1016/j.jcmg.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 02/01/2024] [Indexed: 03/25/2024]
Affiliation(s)
- Luigi P Badano
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy; Department of Cardiology, IRCCS Istituto Auxologico Italiano, Milan, Italy.
| | - Denisa Muraru
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy; Department of Cardiology, IRCCS Istituto Auxologico Italiano, Milan, Italy
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5
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Galloo X, Fortuni F, Meucci MC, Butcher SC, Dietz MF, Prihadi EA, Cosyns B, Delgado V, Bax JJ, Ajmone Marsan N. Association of right atrial strain and long-term outcome in severe secondary tricuspid regurgitation. Heart 2024; 110:448-456. [PMID: 37903557 DOI: 10.1136/heartjnl-2023-323084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/23/2023] [Indexed: 11/01/2023] Open
Abstract
OBJECTIVE Severe secondary tricuspid regurgitation (STR) causes significant right atrial (RA) volume overload, resulting in structural and functional RA-remodelling. This study evaluated whether patients with severe STR and reduced RA function, as assessed by RA-reservoir-strain (RASr), show lower long-term prognosis. METHODS Consecutive patients, from a single centre, with first diagnosis of severe STR and RASr measure available, were included. Extensive echocardiographic analysis comprised measures of cardiac chamber size and function, assessed also by two-dimensional speckle-tracking strain analysis. Primary outcome was all-cause mortality, analysed from inclusion until death or last follow-up. The association of RASr with the outcome was evaluated by Cox regression analysis and Akaike information criterion. RESULTS A total of 586 patients with severe STR (age 68±13 years; 52% male) were included. Patients presented with mild right ventricular (RV) dilatation (end-diastolic area 13.8±6.5 cm2/m2) and dysfunction (free-wall strain 16.2±7.2%), and with moderate-to-severe RA dilatation (max area 15.0±5.3 cm2/m2); the median value of RASr was 13%. In the overall population, 10-year overall survival was low (40%, 349 deaths), and was significantly lower in patients with lower RASr (defined by the median value): 36% (195 deaths) for RASr ≤13% compared with 45% (154 deaths) for RASr >13% (log-rank p=0.016). With a median follow-up of 6.6 years, RASr was independently associated with all-cause mortality (HR per 5% RASr increase:0.928; 95% CI 0.864 to 0.996; p=0.038), providing additional value over relevant clinical and echocardiographic covariates (including RA size and RV function/size). CONCLUSIONS Patients with severe STR presented with significant RA remodelling, and lower RA function, as measured by RASr, was independently associated with all-cause mortality, potentially improving risk stratification in these patients.
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Affiliation(s)
- Xavier Galloo
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Cardiology, UZ Brussel, Brussel, Belgium
| | - Federico Fortuni
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Cardiology, Ospedale Nuovo San Giovanni Battista, Foligno, Umbria, Italy
| | - Maria Chiara Meucci
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Steele C Butcher
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Marlieke F Dietz
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Edgard A Prihadi
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Cardiology, Ziekenhuisnetwerk Antwerpen, Antwerpen, Belgium
| | | | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Cardiology, University Hospital Germans Trias i Pujol, Badalona, Catalunya, Spain
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Heart Center, TYKS Turku University Hospital, Turku, Varsinais-Suomi, Finland
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
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Tomaselli M, Badano LP, Muraru D. Right atrial function, a mostly ignored but very valuable parameter in patients with secondary tricuspid regurgitation. Heart 2024; 110:389-390. [PMID: 37932022 DOI: 10.1136/heartjnl-2023-323426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Affiliation(s)
- Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
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Mangieri A, Gitto M. Navigating the Heterogeneous Landscape of Atrial Functional Tricuspid Regurgitation. JACC Cardiovasc Interv 2024; 17:88-90. [PMID: 38199756 DOI: 10.1016/j.jcin.2023.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 01/12/2024]
Affiliation(s)
| | - Mauro Gitto
- IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
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Bourg C, Curtis E, Donal E. Navigating upstream and downstream: Unleashing the prognostic potential of RVFWLS/PASP ratio in severe tricuspid regurgitation. Int J Cardiol 2023; 388:131114. [PMID: 37315740 DOI: 10.1016/j.ijcard.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 06/07/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Corentin Bourg
- Department of Cardiology, University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes F-35000, France
| | - Elizabeth Curtis
- Department of Cardiology, University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes F-35000, France
| | - Erwan Donal
- Department of Cardiology, University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes F-35000, France.
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