Robotic Totally Endoscopic Tricuspid Valve Surgery: Early Results and Midterm Outcomes

OBJECTIVE

Although robotic cardiac surgery is becoming more widely adopted for mitral valve procedures, robot-assisted tricuspid valve (TV) surgery is less common. We describe clinical and echocardiographic outcomes for 70 isolated and concomitant TV repair (TVr) cases.

METHODS

Patients who underwent robotic totally endoscopic TV surgery at our institution were retrospectively reviewed. The da Vinci Si or Xi robot (Intuitive Surgical, Sunnyvale, CA, USA) was used for all cases, employing an 8 to 10 mm working port and using cardiopulmonary bypass on a beating heart. Early and midterm outcomes were reviewed, along with echocardiogram results when available.

RESULTS

Between 2014 and 2024, 70 patients underwent TVr. Fourteen cases were isolated TV procedures and 56 were concomitant with mitral surgery. The mean patient age was 67 ± 14.4 years, 57% were female, and 11 patients (16%) had previous heart surgery. TVr with an annuloplasty band occurred in 97% of patients, 1 patient had a tissue valve replacement, and there were no conversions to sternotomy. Early mortality occurred in 1 patient (1.4%) with an observed to expected ratio of 0.4. Early postoperative echocardiography revealed none to mild residual tricuspid regurgitation (TR) in 65 patients (93%). Clinical follow-up was completed in 97% of patients. All-cause mortality occurred in 14 patients (20%), 11 of which were noncardiac, including cancer, gastrointestinal bleed, end-stage renal disease, SARS-CoV-2 infection, and drug overdose. Follow-up echocardiography results were available for 46 patients (66%) at a mean of 45 months, showing moderate or more recurrent TR in 6 patients (9%).

CONCLUSIONS

Robot-assisted totally endoscopic TV surgery, for both isolated and concomitant TV disease, is a safe and effective approach. The sternal-sparing nature allows for rapid recovery and positive midterm outcomes.

Prognostic scores in patients with severe tricuspid regurgitation: An external validation study

BACKGROUND

Four scores have been published in 2022 for assessing mortality risk of patients with tricuspid regurgitation (TR): the TRI-SCORE, those reported by Hochstadt and Wang and the TRIO score. Our objective was to perform an external validation of available scores for predicting mortality and the combined endpoint of mortality and heart failure (HF) admission, in an independent cohort of patients with severe TR and to compare their discriminative ability.

METHODS

Discriminative ability of the scores for predicting events was assessed by means of receiver operating characteristics (ROC) curves.

RESULTS

The validation cohort retrospectively included 614 consecutive patients (69 ± 13 years, 72% women) with severe TR studied with echocardiography in a tertiary care hospital and followed for up to 14 years (median 5 years, p25-75 2-7 years), with 358 deaths and 620 HF admissions on follow-up. Discriminative abilities for predicting death (C-statistic .72 [95% CI .68-.76] for the TRI-SCORE; .75 [.71-.78] for the Hochstadt score; .72 [.68-.76] for the Wang score; and .74 [.70-.78] for the TRIO score, p < .0005 for all) or the combined endpoint (C-statistic .74 [.70-.78]; .74 [.70-.78], .73 [.69-.77] and .76 [.72-.80], respectively, p < .0005 for all) on follow-up were statistically significant for all of them. Paired comparisons among them for predicting both endpoints were all non-significant.

CONCLUSIONS

All tested scores showed significant and similar discriminative ability for predicting the combined endpoint of mortality or HF admission in this independent validation study of patients with severe TR.

Prognostic value of right atrial function in patients with significant tricuspid regurgitation

AIMS

Although right ventricular (RV) dysfunction is associated with adverse outcomes in tricuspid regurgitation (TR), the potential role of right atrial (RA) function is unknown. We aimed to investigate the relationship between RA function and clinical outcomes in patients with significant TR.

METHODS

This retrospective study included 169 outpatients with moderate or severe TR due to left-sided heart diseases who underwent transthoracic echocardiography between June 2020 and April 2023 (average age, 75 ± 10 years; male, 40%). Patients with atrial fibrillation were excluded from this study due to the inaccuracy of the evaluation using 2D speckle-tracking echocardiography. RA function was compared between patients with and without events, which were defined as all-cause mortality or hospitalization due to heart failure. RA function was calculated as RA global longitudinal strain (RAGLS) with the 2D speckle-tracking echocardiography.

RESULTS

During a median follow-up of 13 months, 19 patients had events (all-cause mortality: 14 cases, hospitalization due to heart failure: 5 cases). RAGLS was lower in patients with events than in those without events (13% ± 10% vs. 18% ± 9%, P = 0.02). When the patients were categorized into two groups [low RAGLS ≤ 16.2% vs. high RAGLS > 16.2%, high RA volume index (RAVI) ≥ 50 mL/m2 vs. low RAVI < 50 mL/m2], Kaplan-Meier curves showed that patients with low RAGLS had higher event rates than those with high RAGLS (log-rank test, P = 0.003). Patients with high RAVI had higher event rates than those with low RAVI (log-rank test, P < 0.001). In the multivariate Cox regression analysis, low RAGLS (≤16.2%) was significantly associated with events in a model that included RV dysfunction (RV fractional area change ≤ 35%) or high RAVI (≥50 mL/m2) (hazard ratio: 4.55, 95% confidence interval: 1.51-13.71, P < 0.01; hazard ratio: 4.57, 95% confidence interval: 1.52-13.79, P < 0.01, respectively).

CONCLUSIONS

RAGLS is associated with all-cause mortality and hospitalization due to heart failure in patients with significant TR. Our results suggest that RA function is a sensitive marker for identifying the risk stratification of significant TR.

Prevalence and contributing factors associated with tricuspid regurgitation among patients underwent echocardiography assessment

BACKGROUND

Tricuspid regurgitation (TR) is common in patients evaluated by echocardiography. However, the prevalence and contributing factors of the disease remain limited. This hospital-based study was designed to analyze adult patients first diagnosed with tricuspid regurgitation by Doppler echocardiography to determine the prevalence and characteristics of clinically meaningful TR.

METHODS

A total of 22,317 patients over the age of 18 who underwent echocardiography at the Cardiac Ultrasound Center of the First Affiliated Hospital of Guangdong Pharmaceutical University from July 1, 2015 to December 31, 2019 were collected. We collected basic information about the patients, including age, gender, history of heart disease, etc. Patients with valvular heart disease were assessed by transthoracic echocardiography. According to the degree of regurgitation and regurgitation, TR was divided into 6 grades (0-5). Pericardial effusion was recorded and bilateral atrial and ventricular diameters were measured. Logistic regression analysis was used to assess risk factors for significant TR (≥ grade 2 reflux).

RESULTS

A total of 2299 significant TR cases were found in people over 18 years old, accounting for 10.3% of the total population. The occurrence of TR was found to be closely related to age. The prevalence rates of significant TR in different groups were: 3.3% in the younger than 45-year-old group, 4.1% in the 46-55-year-old group, 5.8% in the 56-65-year-old group, 10.1% in the 66-75-year-old group, and the prevalence of significant TR rose directly to 22.3% in patients over 75-year-old group. Further logistic regression analysis showed that male, age, pacemaker, congenital heart disease, pericardial effusion, pulmonary hypertension, mitral regurgitation, left ventricular diastolic dysfunction and aortic regurgitation were associated with the occurrence of significant TR. Both RVD and RA-1 were effective predictors of significant TR, with RVD ≥ 33.5 mm having a sensitivity of 0.638, specificity of 0.675, and ROC curve area of 0.722. The sensitivity of RA1 ≥ 45.5 mm was 0.652, the specificity was 0.699, and the area under the ROC curve was 0.736.

CONCLUSIONS

TR is common in people undergoing echocardiography. Gender, age, pacemaker implantation, congenital heart disease, pericardial effusion, pulmonary hypertension, mitral insufficiency, and aortic insufficiency are the influencing factors of TR.

Overview of 2024 FDA Advisory Panel Meeting on the TriClip transcatheter tricuspid valve repair system

Tricuspid regurgitation (TR) is common and associated with significant mortality and morbidity. Because the effectiveness and safety of medical and surgical treatments are limited, there is a significant unmet need for the treatment of this disease. Therefore, there is a growing market for percutaneous devices that offer safer, less invasive, and more effective treatment options in this patient population. On February 13, 2024, the US Food and Drug Administration (FDA) convened a meeting of the Circulatory System Devices Panel to discuss the safety and effectiveness of the TriClip Transcatheter Valve Repair System (Abbott, Santa Clara, CA, USA). Several important points were discussed, including newly published data from the TRILUMINATE Pivotal study, the use of patient-oriented outcomes for device approval, and a discussion about training requirements and rollout plans when approving a breakthrough device. In this manuscript, we summarize the data presented by the sponsor and FDA and describe the deliberations and discussions during the meeting.

Heart failure with preserved ejection fraction: diagnosis, risk assessment, and treatment

The aetiology of heart failure with preserved ejection fraction (HFpEF) is heterogenous and overlaps with that of several comorbidities like atrial fibrillation, diabetes mellitus, chronic kidney disease, valvular heart disease, iron deficiency, or sarcopenia. The diagnosis of HFpEF involves evaluating cardiac dysfunction through imaging techniques and assessing increased left ventricular filling pressure, which can be measured directly or estimated through various proxies including natriuretic peptides. To better narrow down the differential diagnosis of HFpEF, European and American heart failure guidelines advocate the use of different algorithms including comorbidities that require diagnosis and rigorous treatment during the evaluation process. Therapeutic recommendations differ between guidelines. Whilst sodium glucose transporter 2 inhibitors have a solid evidence base, the recommendations differ with regard to the use of inhibitors of the renin-angiotensin-aldosterone axis. Unless indicated for specific comorbidities, the use of beta-blockers should be discouraged in HFpEF. The aim of this article is to provide an overview of the current state of the art in HFpEF diagnosis, clinical evaluation, and treatment.

Impact of Leaflet-to-Annulus Index on Residual Regurgitation Following Transcatheter Edge-to-Edge Repair of the Tricuspid Valve

Background: The mismatch between tricuspid valve (TV) leaflet length and annulus dilation, assessed with the septal-lateral leaflet-to-annulus index (SL-LAI), predicts residual tricuspid regurgitation (TR) following tricuspid transcatheter edge-to-edge-repair (T-TEER). When posterior leaflet grasping is required, the anterior-posterior leaflet-to-annulus index (AP-LAI) may offer additional information. Methods: This single-center retrospective cohort study included all patients referred for T-TEER with severe and symptomatic TR with high surgical risk from April 2021 to March 2024. Patients were categorized into 'optimal result' ( Collapse

Key Words

• leaflet-to-annulus index
• transcatheter edge-to-edge repair
• tricuspid regurgitation
• tricuspid valve

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Affiliation(s)

Fausto Pizzino Fondazione Toscana G. Monasterio, Ospedale del Cuore, 54100 Massa, Italy; (F.P.); (A.D.); (M.B.); (G.B.); (U.P.); (S.B.); (M.M.)
Giancarlo Trimarchi Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy; (G.T.); (G.D.B.); (C.Z.)
Andreina D’Agostino Fondazione Toscana G. Monasterio, Ospedale del Cuore, 54100 Massa, Italy; (F.P.); (A.D.); (M.B.); (G.B.); (U.P.); (S.B.); (M.M.)
Michela Bonanni Fondazione Toscana G. Monasterio, Ospedale del Cuore, 54100 Massa, Italy; (F.P.); (A.D.); (M.B.); (G.B.); (U.P.); (S.B.); (M.M.)
Giovanni Benedetti Fondazione Toscana G. Monasterio, Ospedale del Cuore, 54100 Massa, Italy; (F.P.); (A.D.); (M.B.); (G.B.); (U.P.); (S.B.); (M.M.)
Umberto Paradossi Fondazione Toscana G. Monasterio, Ospedale del Cuore, 54100 Massa, Italy; (F.P.); (A.D.); (M.B.); (G.B.); (U.P.); (S.B.); (M.M.)
Rachele Manzo Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy;
Rosangela Capasso Department of Clinical and Molecular Medicine, Division of Cardiology, Sapienza University of Rome, 00185 Rome, Italy;
Gianluca Di Bella Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy; (G.T.); (G.D.B.); (C.Z.)
Concetta Zito Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy; (G.T.); (G.D.B.); (C.Z.)
Scipione Carerj Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy; (G.T.); (G.D.B.); (C.Z.)
Sergio Berti Fondazione Toscana G. Monasterio, Ospedale del Cuore, 54100 Massa, Italy; (F.P.); (A.D.); (M.B.); (G.B.); (U.P.); (S.B.); (M.M.)
Massimiliano Mariani Fondazione Toscana G. Monasterio, Ospedale del Cuore, 54100 Massa, Italy; (F.P.); (A.D.); (M.B.); (G.B.); (U.P.); (S.B.); (M.M.)

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GLIDE Score: Scoring System for Prediction of Procedural Success in Tricuspid Valve Transcatheter Edge-to-Edge Repair

BACKGROUND

Tricuspid valve transcatheter edge-to-edge repair (T-TEER) is the most widely used transcatheter therapy to treat patients with tricuspid regurgitation (TR).

OBJECTIVES

The aim of this study was to develop a simple anatomical score to predict procedural outcomes of T-TEER.

METHODS

All patients (n = 168) who underwent T-TEER between January 2017 and November 2022 at 2 centers were included in the derivation cohort. Additionally, 126 patients from 2 separate institutions served as a validation cohort. T-TEER was performed using 2 commercially available technologies. Core laboratory assessment of procedural transesophageal echocardiograms was used to determine septolateral and anteroposterior coaptation gap, leaflet morphology, septal leaflet length and retraction, chordal structure density, tethering height, en face TR jet morphology and TR jet location, image quality, and the presence of intracardiac leads. A scoring system was derived using univariable and multivariable logistic regression. Endpoints assessed were immediate postprocedural TR reduction ≥2 grades and TR grade moderate or less.

RESULTS

The median age was 82 years (Q1-Q3: 78-84 years); 48% of patients were women; and patients presented with severe (55%), massive (36%), and torrential (8%) TR. Five variables (septolateral coaptation gap, chordal structure density, en face TR jet morphology, TR jet location, and image quality) were identified as best predicting procedural outcome and were incorporated in the GLIDE (Gap, Location, Image quality, density, en-face TR morphology) score (range 0-5). TR reduction ≥2 grades and TR grade moderate or less were observed in >90% of patients with GLIDE scores of 0 and 1 and in only 5.6% and 16.7% of those with GLIDE scores ≥4. The GLIDE score was then externally validated in a separate cohort (area under the curve: 0.77; 95% CI: 0.69-0.86). TR reduction significantly correlated with functional improvement assessed by NYHA functional class and 6-minute walk distance at 3 months.

CONCLUSIONS

The GLIDE score is a simple, 5-component score that is readily obtained during patient imaging and can predict successful T-TEER.

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.

How Right is the Right Ventricle in Predicting Cardiac Mortality in Cardiac Failure: A 6-year Prospective Cohort Study

Aim

Two-dimensional speckle tracking echocardiography (2D-STE) and three-dimensional echocardiography (3DE) may overcome many limitations of the conventional 2D echocardiography (2DE) in assessing right ventricular (RV) function. We sought to determine whether characteristics of the right atrium and right ventricle as measured by 2D-STE and 3DE are associated with cardiac mortality in patients with ischemic heart failure, over a 6-year follow-up.

Materials and Methods

The inclusion criteria were ischemic cardiomyopathy with left ventricular ejection fraction of <40% diagnosed using standard 2DE, 2D-STE, and 3DE examination. Patients were followed for 6 years, and cardiac mortality was recorded.

Results

The study sample comprised a total of 54 participants. During the period of follow-up, 24% (13/54) died. The 2DE models showed that being older, having a higher body mass index (BMI), having higher systolic pulmonary artery pressure (SPAP), and a lower RV global longitudinal strain were associated with cardiac mortality in our cohort after 6-year follow-up. Finally, the 3DE models showed that in addition to being older, having higher BMI, having a higher SPAP baseline, lower baseline 3DE RV stroke volume, and larger 3DE RV end-diastolic volume and 3DE RV end-systolic volume were associated with cardiac mortality over 6-year follow-up.

Conclusion

This study provides evidence that RV dysfunction as seen on 2D-STE and 3DE could be associated with increased risk of cardiac-related mortality in patients with heart failure over 6 years.

Device therapy for patients with atrial fibrillation and heart failure with preserved ejection fraction

Device therapy is a nonpharmacological approach that presents a crucial advancement for managing patients with atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF). This review investigated the impact of device-based interventions and emphasized their potential for optimizing treatment for this complex patient demographic. Cardiac resynchronization therapy, augmented by atrioventricular node ablation with His-bundle pacing or left bundle-branch pacing, is effective for enhancing cardiac function and establishing atrioventricular synchrony. Cardiac contractility modulation and vagus nerve stimulation represent novel strategies for increasing myocardial contractility and adjusting the autonomic balance. Left ventricular expanders have demonstrated short-term benefits in HFpEF patients but require more investigation for long-term effectiveness and safety, especially in patients with AF. Research gaps regarding complications arising from left ventricular expander implantation need to be addressed. Device-based therapies for heart valve diseases, such as transcatheter aortic valve replacement and transcatheter edge-to-edge repair, show promise for patients with AF and HFpEF, particularly those with mitral or tricuspid regurgitation. Clinical evaluations show that these device therapies lessen AF occurrence, improve exercise tolerance, and boost left ventricular diastolic function. However, additional studies are required to perfect patient selection criteria and ascertain the long-term effectiveness and safety of these interventions. Our review underscores the significant potential of device therapy for improving the outcomes and quality of life for patients with AF and HFpEF.

Tricuspid Regurgitation and Clinical Outcomes in Heart Failure With Reduced Ejection Fraction

BACKGROUND

Tricuspid regurgitation (TR) is common and is associated with poor outcomes in patients with heart failure (HF). However, data with adjudicated events from fully characterized patients with heart failure with reduced ejection fraction (HFrEF) are lacking.

OBJECTIVES

This study sought to explore the association between mild or moderate/severe TR and clinical outcomes of patients with HFrEF.

METHODS

GALACTIC-HF (Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure) was a double-blind, placebo-controlled randomized trial comparing omecamtiv mecarbil vs placebo in patients with symptomatic HFrEF.

RESULTS

Among the 8,232 patients analyzed in the GALACTIC-HF trial, 8,180 (99%) had data regarding baseline TR (none: n = 6,476 [79%], mild: n = 919 [11%], and moderate/severe: n = 785 [10%]). The primary composite outcome of a first HF event or cardiovascular death occurred in 2,368 (36.6%) patients with no TR, 353 (38.4%) patients with mild TR, and 389 (49.6%) patients with moderate/severe TR. Moderate/severe TR was independently associated with a higher relative risk of the primary composite outcome compared with either no TR (adjusted HR: 1.12 [95% CI: 1.01-1.26]; P = 0.046) or no/mild TR (adjusted HR: 1.14 [95% CI: 1.02-1.27]; P = 0.025) driven predominantly by HF events. The association between moderate/severe TR and clinical outcomes was more pronounced in outpatients with worse renal function, higher left ventricular ejection fraction, and lower N-terminal pro-B-type natriuretic peptide and bilirubin levels. The beneficial treatment effect of omecamtiv mecarbil vs placebo on clinical outcomes was not modified by TR.

CONCLUSIONS

In symptomatic patients with HFrEF, baseline moderate/severe TR was independently associated with cardiovascular death or HF events driven predominantly by HF events. The beneficial treatment effect of omecamtiv mecarbil on the primary outcome was not modified by TR.

Characteristics and outcomes of patients with tricuspid regurgitation and advanced heart failure

AIMS

To evaluate the role of tricuspid regurgitation in advanced heart failure.

METHODS

The multicenter observational HELP-HF registry enrolled consecutive patients with heart failure and at least one 'I NEED HELP' criterion evaluated at four Italian centers between January 2020 and November 2021. Patients with no data on tricuspid regurgitation and/or receiving tricuspid valve intervention during follow-up were excluded. The population was stratified by no/mild tricuspid regurgitation vs. moderate tricuspid regurgitation vs. severe tricuspid regurgitation. Variables independently associated with tricuspid regurgitation, as well as the association between tricuspid regurgitation and clinical outcomes were investigated. The primary outcome was all-cause mortality.

RESULTS

Among the 1085 patients included in this study, 508 (46.8%) had no/mild tricuspid regurgitation, 373 (34.4%) had moderate tricuspid regurgitation and 204 (18.8%) had severe tricuspid regurgitation. History of atrial fibrillation, any prior valve surgery, high dose of furosemide, preserved left ventricular ejection fraction, moderate/severe mitral regurgitation and pulmonary hypertension were found to be independently associated with an increased likelihood of severe tricuspid regurgitation. Estimated rates of 1-year all-cause death were of 21.4, 24.5 and 37.1% in no/mild tricuspid regurgitation, moderate tricuspid regurgitation and severe tricuspid regurgitation, respectively (log-rank P  < 0.001). As compared with nonsevere tricuspid regurgitation, severe tricuspid regurgitation was independently associated with a higher risk of all-cause mortality (adjusted hazard ratio 1.38, 95% confidence interval 1.01-1.88, P  = 0.042), whereas moderate tricuspid regurgitation did not.

CONCLUSION

In a contemporary, real-world cohort of patients with advanced heart failure, several clinical and echocardiographic characteristics are associated with an increased likelihood of severe tricuspid regurgitation. Patients with severe tricuspid regurgitation have an increased risk of mortality.

Tricuspid Regurgitation and Right Heart Failure: The Role of Imaging in Defining Pathophysiology, Presentation, and Novel Management Strategies

During the last few years, there has been a substantial shift in efforts to understand and manage secondary or functional tricuspid regurgitation (TR) given its prevalence, adverse prognostic impact, and symptom burden associated with progressive right heart failure. Understanding the pathophysiology of TR and right heart failure is crucial for determining the best treatment strategy and improving outcomes. In this article, we review the complex relationship between right heart structural and hemodynamic changes that drive the pathophysiology of secondary TR and discuss the role of multimodality imaging in the diagnosis, management, and determination of outcomes.

A multifunctional soft robot for cardiac interventions

In minimally invasive endovascular procedures, surgeons rely on catheters with low dexterity and high aspect ratios to reach an anatomical target. However, the environment inside the beating heart presents a combination of challenges unique to few anatomic locations, making it difficult for interventional tools to maneuver dexterously and apply substantial forces on an intracardiac target. We demonstrate a millimeter-scale soft robotic platform that can deploy and self-stabilize at the entrance to the heart, and guide existing interventional tools toward a target site. In two exemplar intracardiac procedures within the right atrium, the robotic platform provides enough dexterity to reach multiple anatomical targets, enough stability to maintain constant contact on motile targets, and enough mechanical leverage to generate newton-level forces. Because the device addresses ongoing challenges in minimally invasive intracardiac intervention, it may enable the further development of catheter-based interventions.

Association of Functional Tricuspid Regurgitation and All-Cause Mortality in Ischemic Heart Failure Varies by Left Atrial Size: A Prospective Cohort Study

This study aimed to evaluate whether the mortality risk of tricuspid regurgitation (TR) varies by left atrial (LA) size in patients with heart failure (HF). In total, 2,234 patients with ischemic HF were included. Participants were categorized as normal LA group and LA enlargement group based on the guideline recommendations, and in each group, patients were further classified as non/mild TR group and moderate/severe TR group according to echocardiographic examination. All-cause mortality was used as the only end point, and comparisons were conducted between the TR degree groups stratified by LA size status. Propensity-matched analyses and restricted cubic splines were performed to verify the robustness of the results. Of 2,234 patients with ischemic HF participants, 1,002 (44.9%) had LA enlargement and 294 (13.2%) had moderate/severe TR. After a median follow-up of 3.02 years (7,140 person-years), 453 patients (20.3%) died. After adjusting for the covariates, the higher mortality risk of moderate/severe TR was only observed in the normal LA diameter group (hazard ratio 1.64, 95% confidence interval 1.02 to 2.65) rather than the LA enlargement group (hazard ratio 0.96, 95% confidence interval 0.69 to 1.34). A significant interaction of TR degree was observed between the normal LA size group and the LA enlargement group. The relation was consistent in the propensity-matching cohort and in the restricted cubic splines analysis. In conclusion, mortality rate and prevalence of moderate/severe TR were high in patients with ischemic HF. Moderate/severe TR is significantly associated with all-cause mortality in those with normal LA diameter. The mechanisms underlying these observations merit further investigation.

TRI-SCORE is superior to EuroSCORE II and STS-Score in mortality prediction following transcatheter edge-to-edge tricuspid valve repair

BACKGROUND

The development of transcatheter tricuspid edge-to-edge repair for tricuspid regurgitation is a therapeutic milestone but a specific periprocedural risk assessment tool is lacking. TRI-SCORE has recently been introduced as a dedicated risk score for tricuspid valve surgery.

AIMS

This study analyzes the predictive performance of TRI-SCORE following transcatheter edge-to-edge tricuspid valve repair.

METHODS

180 patients who underwent transcatheter tricuspid valve repair at Ulm University Hospital were consecutively included and stratified into three TRI-SCORE risk groups. The predictive performance of TRI-SCORE was assessed throughout a follow-up period of 30 days and up to 1 year.

RESULTS

All patients had severe tricuspid regurgitation. Median EuroSCORE II was 6.4% (IQR 3.8-10.1%), median STS-Score 8.1% (IQR 4.6-13.4%) and median TRI-SCORE 6.0 (IQR 4.0-7.0). 64 patients (35.6%) were in the low TRI-SCORE group, 91 (50.6%) in the intermediate and 25 (13.9%) in the high-risk groups. The procedural success rate was 97.8%. 30-day mortality was 0% in the low-risk group, 1.3% in the intermediate-risk and 17.4% in the high-risk groups (p < 0.001). During a median follow-up of 168 days mortality was 0%, 3.8% and 52.2%, respectively (p < 0.001). The predictive performance of TRI-SCORE was excellent (AUC for 30-day mortality: 90.3%, for one-year mortality: 93.1%) and superior to EuroSCORE II (AUC 56.6% and 64.4%, respectively) and STS-Score (AUC 61.0% and 59.0%, respectively).

CONCLUSION

TRI-SCORE is a valuable tool for prediction of mortality after transcatheter edge-to-edge tricuspid valve repair and its performance is superior to EuroSCORE II and STS-Score. In a monocentric cohort of 180 patients undergoing edge-to-edge tricuspid valve repair TRI-SCORE predicted 30-day and up to one-year mortality more reliably than EuroSCORE II and STS-Score. AUC area under the curve, 95% CI 95% confidence interval.

Tricuspid Regurgitation and Right Heart Failure: The Role of Imaging in Defining Pathophysiology, Presentation, and Novel Management Strategies

During the last few years, there has been a substantial shift in efforts to understand and manage secondary or functional tricuspid regurgitation (TR) given its prevalence, adverse prognostic impact, and symptom burden associated with progressive right heart failure. Understanding the pathophysiology of TR and right heart failure is crucial for determining the best treatment strategy and improving outcomes. In this article, we review the complex relationship between right heart structural and hemodynamic changes that drive the pathophysiology of secondary TR and discuss the role of multimodality imaging in the diagnosis, management, and determination of outcomes.

Stressed Blood Volume in Severe Tricuspid Regurgitation: Implications for Transcatheter Treatment

BACKGROUND

Although tricuspid transcatheter edge-to-edge repair (TEER) has been suggested to improve outcomes in patients with tricuspid regurgitation (TR), patients remain at substantial residual risk after the intervention. Total blood volume is divided between the unstressed volume, filling the vascular space, and stressed blood volume (SBV), generating intravascular pressure. SBV is an important mediator of hemodynamic derangements in heart failure and might pose an attractive adjunctive treatment target.

OBJECTIVES

The aim of this study was to investigate the role of SBV in patients with severe TR and its implications for tricuspid TEER.

METHODS

In total, 279 patients underwent right heart catheterization prior to TEER. SBV was estimated from hemodynamic variables fit to a comprehensive cardiovascular model.

RESULTS

Estimated stressed blood volume (eSBV) was associated with obesity, renal and hepatic dysfunction and cardiac remodeling (P < 0.05 for all). Hemodynamically, eSBV correlated with pulmonary artery and cardiac filling pressures as well as right ventricular-pulmonary artery coupling (P < 0.05 for all). After TEER, patients with eSBV greater than the median demonstrated less reduction in right atrial pressures, peripheral edema, and ascites compared with lower eSBV patients (P < 0.05 for all). Higher eSBV was an independent predictor of the occurrence of death and heart failure hospitalization during a median follow-up duration of 618 days (P < 0.05 for all).

CONCLUSIONS

In patients with severe TR, eSBV is associated with obesity, renal and liver dysfunction, more severe heart failure, attenuated reduction of venous congestion after TEER, and adverse clinical outcomes. Estimation of SBV should be incorporated in future trials in the field to identify patients in need of adjunctive therapies.

The long-term clinical course of moderate tricuspid regurgitation

BACKGROUND

To evaluate the long-term clinical outcome of a cohort of patients suffering from moderate tricuspid regurgitation (TR), regardless of its etiology.

METHODS

Clinical and echocardiographic follow-up were assessed in 250 patients diagnosed with moderate TR between January 2016 and July 2020. TR progression at follow-up was defined as TR grade increase to at least severe. The primary endpoint was all-cause death; secondary endpoints were cardiovascular (CV) death and the composite of heart failure (HF) hospitalization plus tricuspid valve (TV) intervention.

RESULTS

After a median follow-up of 3.6 years, TR progression occurred in 84 patients (34%). At multivariate analyses, atrial fibrillation (AF, OR 1.81, CI 1.01-3.29, p = 0.045) and right ventricular end-diastolic diameter (RVEDD, OR 2.19, CI 1.26-3.78, p = 0.005) were independent predictors of TR progression. The primary endpoint occurred in 59 patients (24%) and was significantly more frequent in the group with TR progression (p = 0.009). At multivariate analyses, chronic kideney disease (OR 2.80, CI 1.30-6.03, p = 0.009), left ventricular ejection fraction (OR 0.97, CI 0.94-0.99, p = 0.041) and TR progression (OR 2.32, CI 1.31-4.12, p = 0.004) were independent predictors of the primary outcome. Moreover, both the secondary endpoints of CV death and HF hospitalization plus TV intervention were more frequent in the TR progression group (p = 0.001 and p < 0.001, respectively).

CONCLUSIONS

Moderate TR progresses in a significant proportion of patients over a long-term follow-up, leading to a worse prognosis. TR progression is an independent determinant of hard clinical events and AF and RVEDD are associated with TR progression.

Unmet Needs in the Assessment of Right Ventricular Function for Severe Tricuspid Regurgitation

Tricuspid regurgitation (TR) is a highly prevalent valvular heart disease that has been long overlooked, but lately its independent association with adverse cardiovascular outcomes was recognized. The time point to intervene and repair the tricuspid valve is defined by the right ventricular (RV) dilation and dysfunction that comes up at a later stage. While guidelines favor tricuspid valve repair before severe RV dysfunction ensues, the definition of RV dysfunction in a universal manner remains vague. As a result, the candidates for transcatheter or surgical TR procedures are often referred late, when advanced RV dysfunction is established, and any derived procedural survival benefit is attenuated. Thus, it is of paramount importance to establish a universal means of RV function assessment in patients with TR. Conventional echocardiographic indices of RV function routinely applied have fundamental flaws that limit the precise characterization of RV performance. More recently, novel echocardiographic indices such as strain via speckle-tracking have emerged, demonstrating promising results in the identification of early RV damage. Additionally, evidence of the role of alternative imaging modalities such as cardiac computed tomography and cardiac magnetic resonance, for RV functional assessment in TR, has recently arisen. This review provides a systematic appraisal of traditional and novel multimodality indices of RV function in severe TR and aims to refine RV function assessment, designate future directions, and ultimately, to improve the outcome of patients suffering from severe TR.

Feasibility and Efficacy of Transcatheter Tricuspid Valve Repair in Patients with Cardiac Implanted Electrical Devices and Trans-Tricuspid Leads

BACKGROUND

Transcatheter tricuspid valve repair using the edge-to-edge-technique (TEER) has emerged as an alternative therapy in patients with severe tricuspid regurgitation (TR) and high surgical risk. This study aimed to evaluate the feasibility and efficacy of tricuspid valve TEER in patients with cardiac implanted electric devices (CIEDs).

METHODS

All patients who underwent tricuspid valve TEER at our center were retrospectively included. Patients were classified according to the presence of CIEDs. Procedure success was defined as implantation of at least one clip and the reduction of TR of at least one grade. Procedure success and intrahospital outcome were compared between the two groups.

RESULTS

One-hundred and six consecutive patients underwent tricuspid TEER (age 80.1 ± 6.4 years, male = 42; 39.6%). Among them, 25 patients (23.6%, age 80.6 ± 7.3 years, male = 14; 56%) had CIEDs. Patients with CIEDs had a significantly lower left ventricular ejection fraction (LV-EF) compared to those without CIEDs (47.2 ± 15% vs. 56.2 ± 8.2%, p = 0.004, respectively). Moreover, arterial hypertension was more common in patients with CIEDs (96% vs. 79%, p = 0.048). The success of the procedure did not differ between the non-CIED vs. CIED group (93.8% vs. 92%, p = 0.748). Furthermore, the number and position of implanted clips, the duration of the procedure, the post-procedural pressure gradient across the tricuspid valve, and post-procedural TR severity were comparable between both groups.

CONCLUSION

Tricuspid valve TEER is feasible and efficient in patients with CIEDs. The success of the procedure, as well as the intrahospital outcome were comparable between patients with and without CIEDs.

Prevalence, clinical characteristics and outcomes of heart failure patients with or without isolated or combined mitral and tricuspid regurgitation: An analysis from the ESC-HFA Heart Failure Long-Term Registry

AIM

Mitral regurgitation (MR) and tricuspid regurgitation (TR) are common in patients with heart failure (HF). The aim of this study was to investigate prevalence, clinical characteristics and outcomes of patients with or without isolated or combined MR and TR across the entire HF spectrum.

METHODS AND RESULTS

The ESC-HFA EORP HF Long-Term Registry is a prospective, multicentre, observational study including patients with HF and 1-year follow-up data. Outpatients without aortic valve disease were included and stratified according to isolated or combined moderate/severe MR and TR. Among 11 298 patients, 7541 (67%) had no MR/TR, 1931 (17%) isolated MR, 616 (5.5%) isolated TR and 1210 (11%) combined MR/TR. Baseline characteristics were differently distributed across MR/TR categories. Compared to HF with reduced ejection fraction, HF with mildly reduced ejection fraction was associated with a lower risk of isolated MR (odds ratio [OR] 0.69; 95% confidence interval [CI] 0.60-0.80), and distinctly lower risk of combined MR/TR (OR 0.51; 95% CI 0.41-0.62). HF with preserved ejection fraction (HFpEF) was associated with a distinctly lower risk of isolated MR (OR 0.42; 95% CI 0.36-0.49), and combined MR/TR (OR 0.59; 95% 0.50-0.70), but a distinctly increased risk of isolated TR (OR 1.94; 95% CI 1.61-2.33). All-cause death, cardiovascular death, HF hospitalization and combined outcomes occurred more frequently in combined MR/TR, isolated TR and isolated MR versus no MR/TR. The highest incident rates were observed in isolated TR and combined MR/TR.

CONCLUSION

In a large cohort of outpatients with HF, prevalence of isolated and combined MR and TR was relatively high. Isolated TR was driven by HFpEF and was burdened by an unexpectedly poor outcome.

Assessment of Right Ventricle Function and Tricuspid Regurgitation in Heart Failure: Current Advances in Diagnosis and Imaging

Right ventricular (RV) systolic dysfunction increases mortality among heart failure patients, and therefore, accurate diagnosis and monitoring is paramount. RV anatomy and function are complex, usually requiring a combination of imaging modalities to completely quantitate volumes and function. Tricuspid regurgitation usually occurs with RV dysfunction, and quantifying this valvular lesion also may require multiple imaging modalities. Echocardiography is the first-line imaging tool for identifying RV dysfunction, with cardiac MRI and cardiac computed tomography adding valuable additional information.

Transcatheter Tricuspid Valve Replacement With a Dedicated Device in a Patient With 2 Endocardial Leads

A 79-year-old woman with a history of dilated cardiomyopathy who required a permanent peacemaker, recently upgraded to implantable cardioverter-defibrillator cardiac resynchronization therapy, was admitted for right heart failure. On echocardiography, torrential tricuspid regurgitation was noted, with 2 leads across the valve. After multidisciplinary evaluation, a dedicated transcatheter valve replacement was successfully implanted. (Level of Difficulty: Intermediate.).

Prognostic value of functional tricuspid regurgitation quantified by cardiac magnetic resonance in heart failure

AIMS

Quantitative assessment of tricuspid regurgitation (TR) is challenging, and the prognostic implications of cardiac magnetic resonance (CMR)-quantified measures of TR remain unclear in patients with heart failure with reduced ejection fraction (HFrEF). This study investigated the prognostic value of functional TR quantified by CMR in patients with HFrEF.

METHODS AND RESULTS

A total of 262 patients with HFrEF who underwent CMR were analysed. Patients who had primary TR, who had acute HF, or for whom cardiac surgery was planned were excluded. TR volume and fraction were indirectly calculated via subtracting methods. The primary outcome was defined as a composite of all-cause death and hospitalization for HF. Renal outcome was defined as a composite of a decrease in estimated glomerular filtration rate ≥50% or progression to end-stage renal disease. During the follow-up period (median 921 days), 62 primary outcomes and 48 renal outcomes occurred. When divided into two or three groups based on TR fraction in Kaplan-Meier analysis, patients with higher TR fractions showed worse primary outcomes and renal outcomes than those with lower TR fractions. In Cox regression analysis, a 10% increase in TR fraction was significantly associated with primary outcome [hazard ratio (HR) 1.49, 95% confidence interval (CI) 1.29-1.73, P < 0.001] and renal outcome (HR 1.31, 95% CI 1.12-1.55, P = 0.001). TR fraction exhibited a strong positive linear relationship with primary outcomes and renal outcomes in restricted cubic spline curves.

CONCLUSION

CMR-quantified measures of TR were independently associated with adverse clinical outcomes in patients with HFrEF.

Transcatheter mitral and tricuspid interventions-the bigger picture: valvular disease as part of heart failure

The prevalence of mitral (MR) and tricuspid regurgitation (TR), especially in heart failure (HF) populations, is high. However, the distinct role of atrioventricular valve diseases in HF, whether they are merely indicators of disease status or rather independent contributors in a vicious disease cycle, is still not fully understood. For decades, tricuspid regurgitation (TR) was considered an innocent bystander subsequent to other heart or lung pathologies, thus, not needing dedicated treatment. Recent increasing awareness towards the role of atrioventricular valve diseases has revealed that MR and TR are, in fact, independent predictors of outcome in HF, thus, warranting attention in the HF treatment algorithm. This awareness arose, especially, with the development of minimally invasive transcatheter solutions providing new treatment options, which can also be used for patients considered as having increased surgical risk. However, outcomes of such transcatheter treatments have, in part, been sub-optimal and likely influenced by the status of the concomitant HF disease. Thus, this review aims to summarize data on the current understanding regarding the role of MR and TR in HF, how HF impacts outcomes of transcatheter MR and TR interventions, and how the understanding of this relationship might help to identify patients that benefit most from these therapies, which have proven to be lifesaving in properly selected candidates.

Functional Mitral and Tricuspid Regurgitation across the Whole Spectrum of Left Ventricular Ejection Fraction: Recognizing the Elephant in the Room of Heart Failure

Functional mitral regurgitation (FMR) and tricuspid regurgitation (FTR) occur due to cardiac remodeling in the presence of structurally normal valve apparatus. Two main mechanisms are involved, distinguishing an atrial functional form (when annulus dilatation is predominant) and a ventricular form (when ventricular remodeling and dysfunction predominate). Both affect the prognosis of patients with heart failure (HF) across the entire spectrum of left ventricle ejection fraction (LVEF), including preserved (HFpEF), mildly reduced (HFmrEF), or reduced (HFrEF). Currently, data on the management of functional valve regurgitation in the various HF phenotypes are limited. This review summarizes the epidemiology, pathophysiology, and treatment of FMR and FTR within the different patterns of HF, as defined by LVEF.

Comparison of outcomes between transcatheter tricuspid valve repair and surgical tricuspid valve replacement or repair in patients with tricuspid insufficiency

BACKGROUND

Tricuspid regurgitation is associated with significant morbidity and mortality, but with limited treatment options. The objective of this study is to compare the demographic characteristics, complications, and outcomes of transcatheter tricuspid valve repair (TTVr) versus surgical tricuspid valve replacement (STVR) or surgical tricuspid valve repair (STVr), using real-world data from the National Inpatient Sample (NIS) database.

METHODS AND RESULTS

Our study analyzed data from the National Inpatient Sample (NIS) database from 2016 to 2018 and identified 92, 86, and 84 patients with tricuspid insufficiency who underwent STVr, STVR, and TTVr, respectively. The mean ages of patients who received STVr, STVR, and TTVr were 65.03 years, 66.3 years, and 71.09 years, respectively, with TTVr patients significantly older than those who received STVr (P < 0.05). Patients who received STVr or STVR had higher mortality rates (8.7% and 3.5%, respectively) compared to those who received TTVr (1.2%). Patients who underwent STVr or STVR were also more likely to experience perioperative complications, including third-degree atrioventricular block (8.7% STVr vs. 1.2% TTVr, P = 0.329; 38.4% STVR vs. 1.2% TTVr, P < 0.05), respiratory failure (5.4% STVr vs. 1.2% TTVr, P = 0.369; 15.1% STVR vs. 1.2% TTVr, P < 0.05), respiratory complications (6.5% STVr vs. 1.2% TTVr, P = 0.372; 19.8% STVR vs. 1.2% TTVr, P < 0.05), acute kidney injury (40.2% STVr vs. 27.4% TTVr, P = 0.367; 34.9% STVR vs. 27.4% TTVr, P = 0.617), and fluid and electrolyte disorders (44.6% STVr vs. 22.6% TTVr, P = 0.1332; 50% STVR vs. 22.6% TTVr, P < 0.05). In addition, the average cost of care and the average length of hospital stay were higher for patients who underwent STVr or STVR than for those who received TTVr (USD$37995 ± 356008.523 STVr vs. USD$198397 ± 188943.082 TTVr, P < 0.05; USD$470948 ± 614177.568 STVR vs. USD$198397 ± 188943.082 TTVr, P < 0.05; 15.4 ± 15.19 STVr vs. 9.6 ± 10.21 days TTVr, P = 0.267; 24.7 ± 28.81 STVR vs. 9.6 ± 10.21 days TTVr, P < 0.05).

CONCLUSION

TTVr has shown to have favorable outcomes compared to STVr or STVR, but more research and clinical trials are required to help formulate evidence-based guidelines for the role of catheter-based management in tricuspid valve disease.

[Interventional treatment of heart failure : Stents and valves]

The pharmacotherapy of heart failure has evolved in recent years and with the aid of new classes of drugs symptomatic and prognostic improvements can be achieved in patients with heart failure. Heart failure is particularly frequently associated with coronary artery disease or higher grade, often functional valve defects. In the context of the underlying disease, the operative risk is often increased, so that interventional treatment is preferred over surgical treatment options in interdisciplinary heart teams. Promising approaches with very different challenges are emerging for interventional myocardial revascularization and percutaneous correction of high-grade aortic valve stenosis or functional mitral or tricuspid valve regurgitation. It has consistently been shown that an elaborate diagnostic work-up and differentiated patient selection are decisive to achieve a prognostic or symptomatic benefit in these patients using interventional treatment. While awaiting further study data on this topic, the integration of a multidisciplinary heart team is essential to ensure a complementary and balanced therapeutic approach for patient-centered care in this complex patient population.

Tricuspid valve anatomy of massive to torrential tricuspid regurgitation: Computed tomography analysis

BACKGROUND

We aimed to comprehensively assess tricuspid valve anatomy and to determine factors associated with the more advanced stages beyond severe TR (i.e., massive to torrential).

METHODS

We retrospectively analyzed the pre-procedural cardiac CT images in patients with ≥severe TR using 3mensio software. The tricuspid valve annulus size, right-atrial and right-ventricular dimensions, tenting height, and leaflet angles were measured.

RESULTS

A total of 103 patients were analyzed. The mean effective regurgitant orifice area was 61.7 ​± ​31.5 ​mm², vena contracta was 13.1 ​± ​4.6 ​mm, and massive/torrential TR was observed in 62 patients. Compared to patients with severe TR, patients with massive/torrential TR had a larger tricuspid annulus area (18.6 ​± ​3.4 ​cm² vs. 20.6 ​± ​5.3 ​cm², p ​= ​0.037), right atrial short-axis diameter (66.1 ​± ​9.1 ​mm vs. 70.6 ​± ​9.9 ​mm, p ​= ​0.022), increased tenting height (8.8 ​± ​3.6 ​mm vs. 10.7 ​± ​3.7 ​mm, p ​= ​0.014), and greater leaflet angles (anterior leaflet: 22 ​± ​9° vs. 32 ​± ​13°, p ​< ​0.001; posterior leaflet: 22 ​± ​11° vs. 30 ​± ​11°, p ​= ​0.003). In the multivariable logistic regression model, the angle of anterior leaflet (OR 1.08, 95%CI 1.03-1.14, p ​= ​0.004) and posterior leaflet (OR 1.07, 95%CI 1.02-1.13, p ​= ​0.007) were associated with massive/torrential TR. Additionally, patients with massive/torrential TR more often had TR jets from non-central/non-anteroseptal commissure (34% vs. 76%, p ​< ​0.001). In the multivariable model, the greater angle of the leaflets and more elliptical annulus were associated with non-central/non-anteroseptal TR jets.

CONCLUSIONS

Anterior and posterior leaflet angles are significant factors associated with massive/torrential TR. Furthermore, leaflet angles and ellipticity of the tricuspid valve are associated with the location of TR jets.

Transcatheter tricuspid valve intervention: to repair or to replace?

PURPOSE OF REVIEW

The burden of tricuspid regurgitation (TR) is high in the aging population, almost 4% in the age group over 75 have moderate or more TR. This carries a poor prognosis and an increased incidence of mortality, prolonged hospitalization, and rehospitalization in symptomatic patients with severe TR is observed. Percutaneous tricuspid valve intervention has emerged as a viable therapeutic option, with an increasingly large toolbox of both tricuspid repair and replacement devices. The optimal strategy, timing and patient selection for transcatheter intervention are yet to be determined. This review focuses on the current strengths and limitations of transcatheter tricuspid repair vs. replacement, drawing on lessons learned from surgery.

RECENT FINDINGS

Early outcome studies have been published in the last 2 years for many of the new percutaneous tricuspid valve devices. We have summarized these results and compared them to surgical tricuspid valve repair and replacement. We found that surgical data shows a tendency to better outcome with tricuspid valve repair compared to replacement. For transcatheter interventions studies comparing repair and replacement are lacking but both interventions show good procedural success rates and are efficient in reducing the grade of tricuspid regurgitation.

SUMMARY

Transcatheter tricuspid valve interventions offer a safe and effective alternative to tricuspid surgery or medical therapy. The decision between valve replacement and repair should be based on patient anatomy, operator experience and device availability until head-to-head comparison of different devices are available.

A validated score to predict one-year and long-term mortality in patients with significant tricuspid regurgitation

Aims

Most patients with significant (defined as ≥ moderate) tricuspid regurgitation (TR) are treated conservatively. Individual mortality rates are markedly variable. We developed a risk score based on comprehensive clinical and echocardiographic evaluation, predicting mortality on an individual patient level.

Methods and results

The cohort included 1701 consecutive patients with significant TR, half with isolated TR, admitted to a single hospital, treated conservatively. We derived a scoring system predicting 1-year mortality and validated it using k-fold cross-validation and with external validation on another cohort of 5141 patients. Score utility was compared with matched patients without significant TR. One-year mortality rate was 31.3%. The risk score ranged 0-17 points and included 11 parameters: age (0-3), body mass index ≤ 25 (0-1), history of liver disease (0-2), history of chronic lung disease (0-2), estimated glomerular filtration rate (0-5), haemoglobin (0-2), left-ventricular ejection fraction (0-1), right-ventricular dysfunction (0-1), right atrial pressure (0-2), stroke volume index (SVI) (0-1) and left-ventricular end-diastolic diameter (0-1). One-year mortality rates increased from 0 to 100%, as the score increased up to ≥16. Areas under the receiver operating curves were 0.78, 0.70, and 0.73, for the original, external validation, and external validation with SVI measured cohorts. The score remained valid in subpopulations of patients with quantified RV function, quantified TR and isolated TR. Significant TR compared to no TR, affected 1-year mortality stronger with higher scores, with a significantly positive interaction term.

Conclusion

We suggest a robust risk score for inpatients with significant TR, assisting risk stratification and decision-making. Our findings underscore the burden of TR providing benchmarks for clinical trial design.

Safety of transesophageal echocardiography during transcatheter edge-to-edge tricuspid valve repair: A single-center experience

Objectives

We aimed to determine transesophageal echocardiography (TEE) related complications during Transcatheter edge-to-edge tricuspid valve repair (TTVR).

Background

Transesophageal echocardiography is essential to guide structural heart disease (SHD) interventions. TTVR has become an evolving procedure for high-risk patients not suitable for surgery. Whether this complex procedure is associated with TEE related complications is not known so far.

Methods

We retrospectively analyzed 64 consecutive patients undergoing TTVR between 2019 and 2021 with the TriClip system (Abbott, Chicago, IL, USA) at our center. All procedures were performed under general anesthesia (GA). TEE related complications were classified as major and minor complications.

Results

Transesophageal echocardiography related complications were observed in two patients (3.1%) with one major complication (1.6%) and one minor complication (1.6%). In one patient perforation of the esophageal mucosa requiring red blood cell transfusion was observed, the other patient had hematemesis due to minor esophageal and gastric lesions without the need for blood transfusion. Both patients recovered during hospital stay with no persistent symptoms at discharge.

Conclusions

Transesophageal echocardiography related complications during TTVR are clinically relevant occurring in 3.1% of the patients. Further investigations are needed to identify potential risk factors and patients at high risk to develop a TEE related complication in the course of TTVR.

Prognostic value of blood pressure and resting heart rate in patients with tricuspid regurgitation

Background

The prognostic value of blood pressure (BP) and resting heart rate (RHR) in tricuspid regurgitation (TR) patients is unknown.

Aims

This study aimed to investigate the associations of BP and RHR with all-cause mortality in patients with TR.

Methods

A total of 2,013 patients with moderate or severe TR underwent echocardiography and BP measurement. The associations of routinely measured BP and RHR with 2-year all-cause mortality were analyzed.

Results

The cohort had 45.9% male patients and a mean age of 62.5 ± 15.9 years. At the 2-year follow-up, 165 patient deaths had occurred. The risk of death decreased rapidly, negatively correlating with systolic blood pressure (SBP) up to 120 mmHg and diastolic blood pressure (DBP) up to 70 mmHg. For RHR, the risk increased in direct proportion, starting at 80 beats per min. After adjusting for age, sex, body mass index (BMI), diabetes, coronary heart disease, pulmonary hypertension, estimated glomerular filtration rate (eGFR), and NYHA class, SBP [hazard ratio (HR):0.89; 95% CI:0.823-0.957 per 10 mmHg increase; P =0.002], DBP (HR:0.8; 95% CI:0.714-0.908 per 10 mmHg increase; P < 0.001), and RHR (HR: 1.1; 95% CI: 1.022-1.175 per 10 beats per min increase; P = 0.011) were independently associated with all-cause mortality. These associations persisted after further adjustments for echocardiographic indices, medications, serological tests, and etiologies.

Conclusion

In this cohort of patients with TR, routinely measured BP and RHR were associated with all-cause mortality independently. However, further large-scale, high-quality studies are required to validate our findings.

Evolution of tricuspid valve regurgitation after implantation of a leadless pacemaker - a single center experience, systematic review and meta-analysis

Introduction

Conventional transvenous pacemaker leads may interfere with the tricuspid valve leaflets, tendinous chords, and papillary muscles, resulting in significant tricuspid valve regurgitation (TR). Leadless pacemakers (LLPMs) theoretically cause less mechanical interference with the tricuspid valve apparatus. However, data on TR after LLPM implantation are sparse and conflicting. Our goal was to investigate the prevalence of significant TR before and after LLPM implantation.

Methods

Patients who received a leadless LLPM (Micra™ TPS, Medtronic) between May 2016 and May 2021 at our center were included in this observational study if they had at least a pre‐ and postinterventional echocardiogram (TTE). The evolution of TR severity was assessed. Following a systematic literature review on TR evolution after implantation of a LLPM, data were pooled in a random‐effects meta‐analysis.

Results

We included 69 patients (median age 78 years [interquartile range (IQR) 72–84 years], 26% women). Follow‐up duration between baseline and follow‐up TTE was 11.4 months (IQR 3.5–20.1 months). At follow‐up, overall TR severity was not different compared to baseline (p = .49). Six patients (9%) had new significant TR during follow‐up after LLPM implantation, whereas TR severity improved in seven patients (10%). In the systematic review, we identified seven additional articles that investigated the prevalence of significant TR after LLPM implantation. The meta‐analysis based on 297 patients failed to show a difference in significant TR before and after LLPM implantation (risk ratio 1.22, 95% confidence interval 0.97–1.53, p = .11).

Conclusion

To date, there is no substantial evidence for a significant change in TR after implantation of a LLPM.

Adverse Prognostic Impact of Even Mild or Moderate Tricuspid Regurgitation: Insights from The National Echocardiography Database of Australia

BACKGROUND

The prevalence and prognostic impact of tricuspid regurgitation (TR) remains incompletely characterized.

METHODS

The distribution of TR severity was analyzed in 439,558 adults (mean age 62.1 ±17.8 years, 51.5% men) being investigated for heart disease, from 2000-2019, by 25 centers contributing to the National Echocardiography Database of Australia. Survival status and cause of death were ascertained, in all adults, from the National Death Index of Australia. The relationship between TR severity and mortality was examined.

RESULTS

Of those studied, 311,604 (70.9%) had no/trivial TR; 94,172 (21.4%) mild TR; 26,056 (5.9%) moderate TR; and 7,726 (1.8%) severe TR. During a median 4.1 years (interquartile range 2.2-7.0 years) follow up, 109,004 died (49% from cardiovascular causes). Moderate or greater TR was associated with older age and female sex (p<0.001). Individuals with moderate and severe TR had a 2.0- to 3.2-fold increased risk of all-cause long-term mortality after adjustment for age and sex, compared to those with no/trivial TR (p<0.001 for both comparisons). Even those with mild TR had a significantly increased risk for mortality (HR 1.29, 95% CI 1.27-1.31). In fully adjusted models, including for RV systolic pressure, atrial fibrillation and significant left-heart disease, there remained a 1.24 to 2.65-fold increased risk of mortality with mild (HR 1.24, 95% CI 1.23-1.26), moderate (HR 1.72, 95% CI 1.68-1.75) or severe TR (HR 2.65, 95% CI 2.57-2.73), compared to those with no/trivial TR (p<0.001 for all).

CONCLUSIONS

TR is a common condition in adults referred for echocardiography. Moreover, even in the presence of other cardiac disease, increasing grades of TR are independently associated with increasing risks of CV and all-cause mortality. Furthermore, we show that even mild TR is independently associated with a significant increase in mortality.

Transcatheter Tricuspid Valve Replacement With the EVOQUE System: 1-Year Outcomes of a Multicenter, First-in-Human Experience

OBJECTIVES

The aim of this study was to report the midterm outcomes at 1 year in the expanded first-in-human experience with the transfemoral EVOQUE system (Edwards Lifesciences) for tricuspid regurgitation (TR).

BACKGROUND

Untreated TR is associated with excess mortality and morbidity. The first-in-human experience with the EVOQUE tricuspid valve replacement system reported favorable 30-day outcomes with no mortality in a compassionate use population.

METHODS

Twenty-seven patients with severe TR were treated with the EVOQUE system in a compassionate use experience at 7 centers between May 2019 and July 2020. All patients had clinical right-sided heart failure (HF) and were deemed inoperable and unsuitable for transcatheter edge-to-edge repair by the institutional heart teams. The clinical outcomes collected included all-cause mortality, symptom status, TR severity, HF hospitalization, and major adverse cardiovascular events.

RESULTS

At baseline, all patients (age: 77 ± 8 years, 89% female) were at high surgical risk (mean Society of Thoracic Surgeons score: 8.6% ± 5.5%), with 89% New York Heart Association functional class III/IV. TR was predominantly functional in etiology (19/27, 70%). At 1 year, mortality was 7% (2/27), 70% of patients were New York Heart Association functional class I/II, and 96% and 87% of patients had a TR grade ≤2+ and ≤1+, respectively. Between 30 days and 1 year, 2 patients experienced HF hospitalizations, and 1 patient required a new pacemaker implantation.

CONCLUSIONS

In this early, compassionate use experience, the transfemoral transcatheter EVOQUE tricuspid valve replacement system demonstrated durable efficacy, persistent improvement in symptom status, and low rates of mortality and HF hospitalizations at a 1-year follow-up. Further studies are underway to validate its efficacy.

Prevalence and Prognostic Importance of Massive Tricuspid Regurgitation in Patients Undergoing Tricuspid Annuloplasty With Concomitant Left-Sided Valve Surgery: A Study on Rheumatic Valvular Heart Disease

BACKGROUND

The presence of tricuspid regurgitation (TR) is very common in patients with concomitant left-sided valve disease. Recent studies have advocated an additional grading of massive TR that is beyond severe. The present study sought to characterize the spectrum of TR in patients undergoing tricuspid annuloplasty (TA) and to evaluate the prognostic value of TR severity for post-operative outcome following TA.

METHODS

A total of 176 patients who underwent TA with combined left-sided valve surgery, secondary to rheumatic valvular heart disease, were prospectively evaluated. The severity of TR was quantified by effective regurgitant orifice area (EROA) using the proximal isovelocity surface area method. Patients were categorized as having non-massive TR (EROA < 0.6 cm2) or massive TR (EROA ≥ 0.6 cm2). Adverse outcome was defined as all-cause mortality or heart failure requiring hospital admission following TA.

RESULTS

A total of 55 (31%) patients were considered to have massive TR. Patients with massive TR had a greater right ventricular dimension but a smaller left ventricular dimension compared with those with non-massive TR. After a median follow-up of 39 months, 35 adverse events occurred. Cox-regression analysis showed that both continuous EROA and dichotomized EROA (massive vs. non-massive TR) were independently associated with adverse events even after multivariable adjustment. Further, Harrell C index demonstrated that the addition of massive TR provided better discrimination ability of a prediction model to known prognosticators following TA.

CONCLUSIONS

Massive TR is common and up to 31% of study population had massive TR. Massive TR was associated with adverse outcome in patients undergoing TA. Classification of the severity of TR by quantitative measures and identification of massive TR in patients with concomitant left-sided valve disease are essential when considering the optimal timing of corrective surgery.

Prevalence, Characteristics, and Impact of Frailty in Patients with Functional Tricuspid Regurgitation

Little is known as regards frailty in patients with functional tricuspid regurgitation (FTR). Thus, in this study, we aimed to investigate the prevalence, characteristics, and impact of frailty on patients with severe FTR.This prospective study included 110 consecutive patients with severe FTR who were assessed via transthoracic echocardiography at an outpatient clinic. Patients were dichotomized using short physical performance battery (SPPB). To better understand the whole picture of frailty in patients with FTR, other frailty scales were also assessed (frailty checklist, clinical frailty scale, gait speed, and Columbia frailty scale). The primary endpoint was the combination of all-cause mortality and heart failure hospitalization.According to each definition of frailty, 28%-46% were identified to be frail. Those with SPPB score of < 9 were older, had greater New York Heart Association (NYHA) functional classification, and had lower albumin level and estimated glomerular filtration rate compared with those with SPPB score of ≥ 9. They also have smaller tricuspid valve coaptation depth and worse right ventricular fractional area change (RV-FAC) than those with SPPB score of ≥ 9 despite having similar TR severity. The primary endpoint at 1 year was noted in 31% of patients. The SPPB score has excellent discriminatory performance for predicting the primary endpoint (area under the curve 0.82, 95% confidence interval [CI] 0.76-0.91) in receiver operating characteristic analysis and was independently associated with the primary endpoint after adjustment in multivariate analysis (adjusted hazard ratio 0.81, 95% CI, 0.73-0.90; P < 0.001).Frailty has been widely prevalent in the elderly patient population with FTR; in fact, it has been determined to be strong parameter for poor outcomes.

Global epidemiology of valvular heart disease

Valvular heart disease (VHD) is a major contributor to loss of physical function, quality of life and longevity. The epidemiology of VHD varies substantially around the world, with a predominance of functional and degenerative disease in high-income countries, and a predominance of rheumatic heart disease in low-income and middle-income countries. Reflecting this distribution, rheumatic heart disease remains by far the most common manifestation of VHD worldwide and affects approximately 41 million people. By contrast, the prevalence of calcific aortic stenosis and degenerative mitral valve disease is 9 and 24 million people, respectively. Despite a reduction in global mortality related to rheumatic heart disease since 1900, the death rate has remained fairly static since 2000. Meanwhile, deaths from calcific aortic stenosis have continued to rise in the past 20 years. Epidemiological data on other important acquired and congenital forms of VHD are limited. An ageing population and advances in therapies make an examination of the changing global epidemiology of VHD crucial for advances in clinical practice and formulation of health policy. In this Review, we discuss the global burden of VHD, geographical variation in the presentation and clinical management, and temporal trends in disease burden.