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Jain A, Gebhardt B, Subramani S, Mehrotra M, Gaber M, Ramakrishna H. Tricuspid Regurgitation: Analysis of Outcomes and Risk Assessment. J Cardiothorac Vasc Anesth 2024; 38:1397-1408. [PMID: 38523023 DOI: 10.1053/j.jvca.2024.02.040] [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: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/26/2024]
Affiliation(s)
- Ankit Jain
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA
| | - Brian Gebhardt
- Department of Anesthesiology and Perioperative Medicine, University of Massachusetts Medical Center, Worcester, MA
| | - Sudhakar Subramani
- Department of Anesthesiology and Perioperative Medicine, University of Iowa, Iowa City, IA
| | - Mayank Mehrotra
- Department of Anesthesiology and Perioperative Medicine (Mehrotra) Mercy Health, Rockford, IL
| | - Mohamed Gaber
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Onohara D, Silverman M, Suresh KS, Xu D, He Q, King CL, Tom SK, Kalra K, Padala M. An Animal Model of Functional Tricuspid Regurgitation by Leaflet Tethering Using Image-Guided Chordal Encircling Snares. J Cardiovasc Transl Res 2024; 17:417-425. [PMID: 37615887 DOI: 10.1007/s12265-023-10424-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023]
Abstract
Several interventional therapies are in development to treat functional tricuspid regurgitation. Most have failed to achieve adequate efficacy, as animal models of this lesion are lacking. We developed a new image-guided technique in swine, by tethering the tricuspid valve chordae using echo-guided chordal encircling snares. Five swine underwent baseline echocardiographic assessment of tricuspid valve function, followed by echo-guided placement of snares that encircle the chordae inserting into the anterior and posterior tricuspid valve leaflets. Tethering these snares and stabilizing them on the right ventricle caused the regurgitant fraction to increase from 8.48±5.38% to 48.76±12.5%, and the valve tenting area to increase from 60.26±52.19 to 160.9±86.92 mm2. Image-guided chordal encircling snares could reproducibly induce clinically significant levels of functional tricuspid regurgitation and create a valve geometry like that seen in patients, providing a new animal model for use to study novel interventional devices.
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Affiliation(s)
- Daisuke Onohara
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at the Emory University Hospital Midtown, Atlanta, GA, USA
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Silverman
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at the Emory University Hospital Midtown, Atlanta, GA, USA
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Kirthana Sreerangathama Suresh
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at the Emory University Hospital Midtown, Atlanta, GA, USA
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Dongyang Xu
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at the Emory University Hospital Midtown, Atlanta, GA, USA
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Qi He
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at the Emory University Hospital Midtown, Atlanta, GA, USA
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Chase L King
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at the Emory University Hospital Midtown, Atlanta, GA, USA
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephanie K Tom
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at the Emory University Hospital Midtown, Atlanta, GA, USA
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Kanika Kalra
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Maisano F, Hahn R, Sorajja P, Praz F, Lurz P. Transcatheter treatment of the tricuspid valve: current status and perspectives. Eur Heart J 2024; 45:876-894. [PMID: 38426859 DOI: 10.1093/eurheartj/ehae082] [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: 08/02/2023] [Revised: 01/13/2024] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Transcatheter tricuspid valve interventions (TTVI) are emerging as alternatives to surgery in high-risk patients with isolated or concomitant tricuspid regurgitation. The development of new minimally invasive solutions potentially more adapted to this largely undertreated population of patients, has fuelled the interest for the tricuspid valve. Growing evidence and new concepts have contributed to revise obsolete and misleading perceptions around the right side of the heart. New definitions, classifications, and a better understanding of the disease pathophysiology and phenotypes, as well as their associated patient journeys have profoundly and durably changed the landscape of tricuspid disease. A number of registries and a recent randomized controlled pivotal trial provide preliminary guidance for decision-making. TTVI seem to be very safe and effective in selected patients, although clinical benefits beyond improved quality of life remain to be demonstrated. Even if more efforts are needed, increased disease awareness is gaining momentum in the community and supports the establishment of dedicated expert valve centres. This review is summarizing the achievements in the field and provides perspectives for a less invasive management of a no-more-forgotten disease.
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Affiliation(s)
- Francesco Maisano
- Division of Cardiac Surgery and Valve Center, IRCCS Ospedale San Raffaele, Università Vita Salute, Via Olgettina 60, 20132 Milano, Italy
| | - Rebecca Hahn
- Department of Medicine, Columbia University Irving Medical Center, New York, 161 Fort Washington Avenue, 10032 New York, NY, USA
| | - Paul Sorajja
- Minneapolis Heart Institute at Abbott Northwestern Hospital, 920 East 28th Street, Suite 100, 55407 Minneapolis, MN, USA
| | - Fabien Praz
- Bern University Hospital, University of Bern, Anna-Seiler-Haus Freiburgstrasse 20, 3010 Bern, Switzerland
| | - Philipp Lurz
- Department of Cardiology, Universitätsmedizin Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany
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Tagliari AP, Taramasso M. Investigating the unmet need for the treatment of tricuspid regurgitation. Expert Rev Cardiovasc Ther 2023:1-12. [PMID: 37144916 DOI: 10.1080/14779072.2023.2211265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Tricuspid regurgitation has been increasingly recognized as a clinically relevant entity with long-term prognostic impact on quality of life and survival. Despite this, there are still some unmet clinical needs regarding the management of tricuspid regurgitation that require further investigation. AREAS COVERED This review addresses current evidence for the treatment of tricuspid regurgitation, focusing primarily on new catheter-based technologies. In addition, we discuss recent registries and clinical trial results. EXPERT OPINION A multimodality and multiparametric integrative approach has been preconized to assess tricuspid regurgitation mechanism and severity, and new technologies have been developed to address the main causative factors of tricuspid regurgitation. Matching the right device to the right patient and deciding when is the best time for intervention are major challenges in the management of tricuspid regurgitation.
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Affiliation(s)
- Ana Paula Tagliari
- Cardiovascular Surgery Department, Hospital São Lucas da PUC/RS, Porto Alegre 90619-900, Brazil
- Cardiovascular Surgery Department, Hospital Mãe de Deus, Porto Alegre 90880-0481, Brazil
| | - Maurizio Taramasso
- HerzZentrum Hirslanden Zurich Clinic of Cardiac Surgery, 8008 Zurich, Switzerland
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Chen Q, Bowdish ME, Malas J, Roach A, Gill G, Rowe G, Thomas J, Emerson D, Trento A, Egorova N, Chikwe J. Isolated Tricuspid Operations: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis. Ann Thorac Surg 2023; 115:1162-1170. [PMID: 36696939 DOI: 10.1016/j.athoracsur.2022.12.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/05/2022] [Accepted: 12/10/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Population-level data are limited regarding contemporary practice and outcomes of isolated tricuspid operations. We evaluated this using The Society of Thoracic Surgeons Adult Cardiac Surgery Database. METHODS We identified 14,704 isolated tricuspid operations from The Society of Thoracic Surgeons Adult Cardiac Surgery Database from July 1, 2011 to June 30, 2020. After excluding patients with endocarditis, tricuspid stenosis, emergent/emergent salvage status, previous heart transplants, and missing tricuspid operation type, 6507 patients remained. Endpoints were operative mortality and composite major comorbidities (permanent stroke, renal failure, prolonged ventilation > 24 hours, deep sternal wound infection, cardiac reoperations, and new permanent pacemaker implantation). RESULTS Isolated tricuspid operations increased from 2012 (983 cases) to 2019 (2155 cases, P < .001). Median annual center volume was 2 cases (range, 1-81). In the final cohort (n = 6507; median age, 65 years; 38.5% men), 40% had New York Heart Association class III/IV heart failure and 24% had nonelective operations. The operative mortality was 7.3% (1.7% in patients without these risk factors), and new permanent pacemaker implant rate was 10.8%. In the multivariable analysis, factors associated with operative mortality included New York Heart Association class III/IV heart failure (odds ratio [OR], 1.57), nonelective operations (OR, 1.91), tricuspid replacement (OR, 1.56), annual center volume ≤ 5 cases (OR, 1.37), and higher model for end-stage liver disease scores (all P < .05). Beating heart operation was associated with a lower adjusted risk of pacemaker implant (OR, 0.69), renal failure (OR, 0.75), and blood transfusions (OR, 0.8) compared with full cardioplegic arrest (all P < .05). CONCLUSIONS Isolated tricuspid repair was associated with lower adjusted mortality and morbidities than replacement. Beating heart operation was associated with lower adjusted major morbidities. The preoperative model for end-stage liver disease scores may identify high-risk patients, and early referral to higher volume centers may help improve outcomes.
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Affiliation(s)
- Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jad Malas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Amy Roach
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - George Gill
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Georgina Rowe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jason Thomas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alfredo Trento
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Sala A, Beneduce A, Maisano F. Transcatheter and surgical treatment of tricuspid regurgitation: Predicting right ventricular decompensation and favorable responders. Front Cardiovasc Med 2022; 9:980639. [PMID: 36237912 PMCID: PMC9551023 DOI: 10.3389/fcvm.2022.980639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/12/2022] [Indexed: 12/03/2022] Open
Abstract
Isolated tricuspid regurgitation (TR) has gained increasing recognition in recent years both in the surgical and in the cardiological community. Left untreated, isolated TR significantly worsens survival. Despite being a strong predictor of negative prognosis, interventions to correct TR are rarely performed due to increased surgical risk and late patient presentation. Recently, the ultimate focus has been on patient selection, surgical or transcatheter indication, and correct timing. Furthermore, of paramount importance is the identification of predictors of outcome following treatment, in order to discriminate between favorable and unfavorable responders and guide the decision-making process of the most adequate treatment for every patient.
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Affiliation(s)
- Alessandra Sala
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Beneduce
- Department of Cardiology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Maisano
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
- *Correspondence: Francesco Maisano
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Colombo A, Maisano F. A new tool for the forgotten valve: a score to predict the risk of surgery. Eur Heart J 2021; 43:663-665. [PMID: 34849713 DOI: 10.1093/eurheartj/ehab799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Antonio Colombo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Francesco Maisano
- Faculty of Medicine, Vita e Salute San Raffaele University, Milan, Italy.,Department of Cardiac Surgery IRCCS, San Raffaele Scientific Institute, Milan, Italy
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