Prognostic Impact and Late Evolution of Untreated Moderate (2/4+) Functional Tricuspid Regurgitation in Patients Undergoing Aortic Valve Replacement

Three-Dimensional Transthoracic Echocardiography for Semiautomated Analysis of the Tricuspid Annulus: Validation and Normal Values

BACKGROUND

The expansion of tricuspid valve (TV) interventions has underscored the need for accurate and reproducible three-dimensional (3D) transthoracic echocardiographic (TTE) tools for evaluating the tricuspid annulus and for 3D normal values of this structure. The aims of this study were to develop new semi-automated software for 3D TTE analysis of the tricuspid annulus, compare its accuracy and reproducibility against those of multiplanar reconstruction (MPR) reference, and determine normative values.

METHODS

Three-dimensional TTE images of 113 patients with variable degrees of tricuspid regurgitation were analyzed using the new semiautomated software and conventional MPR methodology (as the reference standard), each by three independent readers. For each measured parameter, intertechnique agreement was assessed using linear regression and Bland-Altman analyses, and interreader variability using intraclass correlation coefficients and coefficients of variation. Additionally, 3D TTE data sets of 789 subjects from the WASE (World Alliance Societies of Echocardiography) study were analyzed using this new software to determine normal values for each tricuspid annular (TA) parameter.

RESULTS

Semiautomated measurements showed excellent agreement with MPR reference values for all TA measurements: high correlations (all r values >0.8) and minimal biases. All measurements were more reproducible than with MPR: higher intraclass correlation coefficients (0.94-0.96 vs 0.82-0.90) and lower coefficients of variation (5%-12% vs 8%-18%). Sex- and age-related differences were identified in 3D normal values of most TA parameters. Dynamic analysis showed that TA parameters vary throughout the cardiac cycle, reaching minimal values at end-systole and maximum values in late diastole.

CONCLUSIONS

Novel software for semiautomated analysis of TA geometry and dynamics provides accurate and reproducible measurements. Normal values of TA dimensions, parsed by sex and age, are reported.

Papillary muscle approximation in chronic ovine functional tricuspid regurgitation

OBJECTIVE

Isolated tricuspid ring annuloplasty remains the surgical standard for functional tricuspid regurgitation repair but offers suboptimal results when right ventricular dilation and remodeling along with papillary muscle displacement is present. Addressing subvalvular remodeling with papillary muscle approximation may improve clinical outcomes.

METHODS

Functional tricuspid regurgitation and biventricular dysfunction were induced in 8 healthy sheep by rapid ventricular pacing (200-240 bpm) for 27 ± 6 days. Subsequently, animals underwent cardiopulmonary bypass for implantation of sonomicrometry crystals on the tricuspid annulus, right ventricle, and papillary muscle tips. Papillary approximation sutures were anchored between anterior-posterior and anterior-septal papillary muscles and externalized through right ventricular free wall to epicardial tourniquets. After weaning from cardiopulmonary bypass, sequential papillary muscle approximations were performed. Simultaneous hemodynamic, sonomicrometry, and echocardiographic data were collected at baseline and after each papillary muscle approximation.

RESULTS

With rapid pacing, right ventricular fractional area change decreased from 59 ± 6% to 38 ± 8% (P < .001), whereas tricuspid annulus diameter increased from 2.4 ± 0.3 cm to 3.3 ± 0.6 cm (P = .003). Tricuspid regurgitation (0-4+) increased from +0 ± 0 to +3.3 ± 0.7 (P < .001). Both anterior-posterior and anterior-septal papillary muscle approximation significantly reduced functional tricuspid regurgitation from +3.3 ± 0.7 to +2 ± 0.5 and +1.9 ± 0.6, respectively (P < .001). Reduction of tricuspid insufficiency with both subvalvular interventions was associated with decreased distance of the anterior papillary muscle to the annular centroid.

CONCLUSIONS

Papillary muscle approximations were effective in reducing severe ovine functional tricuspid regurgitation associated with right ventricular dilation and papillary muscle displacement. Further studies are needed to evaluate efficacy of this adjunct to ring annuloplasty in repair of severe functional tricuspid regurgitation.

Progression of Chronic Kidney Disease and All-Cause Mortality in Patients with Tricuspid Regurgitation

Aim: The impact of chronic kidney disease (CKD) on patient-related outcomes in patients with tricuspid regurgitation (TR) is well known. However, the impact of the progression of CKD in patients with TR and potentially modifiable risk factors of progressing CKD is unknown. Methods: 444 consecutive adult patients with TR and CKD stage 1−4 admitted in an inpatient setting between January 2010 and December 2017 were included. During a median follow-up of two years, eGFR and survival status were collected. Independent risk factors for CKD progression and all-cause mortality were determined. Patient survival statuses were grouped according to different combinations of the presence or absence of CKD progression and the TR grade. Results: Progression of CKD (OR 2.38 (95% confidence interval 1.30−4.35), p = 0.005), the grade of TR (OR 2.38 (1.41−4.00), p = 0.001) and mitral regurgitation (OR 1.72 (1.20−2.46), p = 0.003) were independent risk factors for all-cause mortality. Haemoglobin at admission (OR 0.80 (0.65−0.99), p = 0.043) and the presence of type 2 diabetes (OR 1.67 (1.02−2.73), p = 0.042) were independent risk factors for CKD progression. The combination of the status of CKD progression and the TR grade showed a stepwise pattern for all-cause mortality (p < 0.001). Patients with CKD progression and TR grade 1 had comparable all-cause mortality with patients without CKD progression but with TR grade 2 or 3. Even in patients with TR grade 1, the risk for all-cause mortality doubled if CKD progression occurred (OR 2.49 (95% CI 1.38−4.47), p = 0.002). Conclusion: CKD progression appears to be a risk factor for all-cause mortality in patients with TR. Anaemia and diabetes are potential modifiers of CKD progression.

Transcatheter Tricuspid Valve-in-Valve Procedure-An Illustrative Case Report and Review

Severe tricuspid commitment is no longer understood as merely a marker of disease but is now widely thought of as a significant contributor to cardiac morbidity and mortality. However, isolated tricuspid valve surgery remains rare and to this day continues to be associated with the highest surgical risk among all valve procedures and high operative mortality rates, especially in reoperations. Therefore, the development of tricuspid transcatheter procedures is as necessary as it was for the other valves a couple of years ago. Recently, multiple percutaneous therapies have been developed for the management of severe tricuspid disease, initially only repair and more recently replacement, thus creating a new branch for the management of patients who have already undergone surgery and who present with dysfunctional bioprostheses. The purpose of this review and report is to demonstrate current and possible future challenges, and to show that the valve-in-valve procedure of the tricuspid valve is feasible and safe, and now can be performed in all its range, in the smallest to the largest sizes of presentation, without incurring the untoward risks of conventional surgery.

Impact of tricuspid regurgitation severity and repair on aortic valve replacement

BACKGROUND

Aortic stenosis is one of the most prevalent valve diseases but is rarely accompanied by tricuspid regurgitation. Our objective was to analyse the impact of tricuspid regurgitation severity and its surgical treatment on prognosis of patients undergoing aortic valve replacement.

METHODS

Retrospective cohort study including all patients presenting with aortic stenosis with some degree of tricuspid regurgitation between 2001 and 2018. Patients were divided into groups according to the degree of tricuspid regurgitation.

RESULTS

From a sample of 8,080 patients with aortic stenosis, 143 (1,8%) presented with more than trace tricuspid regurgitation. Among patients with mild, moderate, or severe tricuspid regurgitation, we observed no differences in 30-day (15,1 vs 14,8 vs 8,7%;p=0,727), 12-month (51,2 vs 56 vs 55%;p=0,892) or 5-year (64 vs 73,3 vs 66,7%;p=0,798) survival. Aortic valve replacement plus tricuspid annuloplasty, when compared with aortic valve replacement only was associated with longer ICU stay (9 vs 3 days;p=0,043) but not higher 30-day (0 vs 15,5%;p=0,112), 12-month (38,5 vs 54,3%;p=0,278) or 5-year mortality (57,1 vs 67.1%;p=0,594). Only history of liver disease and postoperative major morbidity were independent predictors of survival 30 days, 12 months and 5 years after surgery.

CONCLUSIONS

Severity of tricuspid regurgitation in patients with aortic stenosis was not associated with increased mortality. Tricuspid annuloplasty did not improve survival in this subset of patients but was associated with increased postoperative morbidity.

Postoperative outcome after reoperative isolated tricuspid valve surgery-is there a predictor for survival?

OBJECTIVES

Reoperative tricuspid valve (TV) surgery is considered high risk even in the absence of additional concomitant cardiac procedures. The purpose of this study was to evaluate preoperative clinical parameters as predictors for survival after isolated reoperative TV surgery.

METHODS

From January 2005 to January 2019, 85 patients (mean age: 66.7 ± 10.3 years, 34 male) with severe isolated TV regurgitation and prior cardiac surgery were referred to our centre for elective or urgent TV repair/replacement; patients with endocarditis were excluded. We retrospectively analysed preoperative hepatorenal function [reflected by widely used clinical and laboratory parameters and the Model of End-stage-Liver Disease excluding International Normalized Ratio (MELD-XI) score] as a predictor for postoperative survival.

RESULTS

At hospital admission, the patients' average preoperative New York Heart Association class was 2.9 ± 0.6, left ventricular ejection fraction 52.5 ± 10.6%, mean pulmonary artery pressure 24.7 ± 8.0 mmHg, creatinine 115.4 ± 66.6 μmol/l, bilirubin 20.0 ± 19.6 μmol/l and the mean MELD-XI score was 13.3 ± 4.0 μmol/l. The mean follow-up was 5.4 ± 4.2 years. Thirty-day mortality was 5%, 5-year survival was 60.6 ± 5.4% and 10-year survival was 42.9 ± 6.5%. The multivariable Cox regression analysis evaluated the MELD-XI score [hazard ratio (HR 1.144, confidence interval 95% 1.0-1.3, P = 0.005] and diabetes mellitus (HR 2.27, confidence interval 95% 1.0-5.0, P = 0.04) as significant predictors for excess mortality while age and mean pulmonary artery pressure did not reliably predict clinical outcome.

CONCLUSIONS

Hepatorenal dysfunction was one main factor accounting for limited postoperative survival in our patient cohort. The MELD-XI score is easy to calculate and seems to reliably predict the perioperative risk in patients with prior cardiac surgery and indication for TV surgery.

Tricuspid regurgitation and in-hospital outcomes after transcatheter aortic valve replacement in high-risk patients

BACKGROUND

The prognostic impact of tricuspid regurgitation (TR) following transcatheter aortic valve replacement (TAVR) is uncertain, and the management of patients with severe aortic stenosis and significant TR undergoing TAVR is unclear.

METHODS

Retrospective study investigating the role of TR severity on hospital outcomes in high risk patients with severe aortic stenosis undergoing TAVR.

RESULTS

A total of 174 participants were included in the present study. The median age was 84 years and 48% were women. The median (IR) STS score was 7.3 (4.7-13.6). The pre-procedural mean (SD) aortic valve area (AVA) was 0.69 (0.2) cm2 and the average (SD) peak and mean gradients were 71 [23]/42 [15] mmHg. Pre TAVR, 28.7% of patients had significant (moderate or severe) TR. Significant TR pre-TAVR increased the risk of in-hospital cardiovascular (CV) and all-cause and mortality [adjusted relative risk (RR) (95% CI): 14.67 (1.35-159.51) and 5.09 (1.14-22.72), respectively], and those with severe TR post-TAVR had longer hospital stay [median (IR): 9.9 (2.9-17.0) days]. No improvement or worsened TR (greater than mild) post-TAVR was associated with higher CV and all-cause mortality [adjusted RR (95% CI): 21.5 (1.81-255.96) and 8.19 (1.67-40.29), respectively]. Right ventricular systolic pressure (RVSP) was independently associated with TR severity pre and post TAVR.

CONCLUSIONS

Significant TR was common among patients undergoing high risk TAVR, and is associated with increased in hospital mortality and longer hospital stay. Patients with elevated RVSP and persistent moderate or severe TR after TAVR are at higher risk of in hospital death.

Prognostic role of moderate functional tricuspid regurgitation in length of hospitalization in patients undergoing isolated coronary artery bypass grafting

Functional tricuspid regurgitation (FTR) is defined as abnormal systolic tricuspid leakage with normal valve structures, and its prognostic role and management in patients with left-heart valve disease is well known. Due to paucity of data on FTR in patients with ischemic heart disease, the aim of our prospective study was to compare the prognostic effect of FTR between patients with moderate FTR and those with less-than-moderate FTR undergoing isolated coronary artery bypass graft (CABG) surgery. This prospective cohort study included all the patients who were candidate for isolated CABG and were referred for preoperative transthoracic echocardiography between April 2018 and November 2018. Patients were categorized into two groups: less-than-moderate FTR and moderate FTR. The endpoints of the study were the prognostic effect of FTR on short-term mortality and morbidities as a composite endpoint, as well as length of hospitalization, length of intensive care unit (ICU) stay, and ventilation time. Of a total of 410 patients, 363 patients (mean age = 62.4 years, 63.7% men) entered our final analysis. Logistic regression analysis demonstrated that composite endpoints of short-term mortality and morbidities was not significantly different between the two groups, but moderate FTR had a statistically significant effect on length of hospitalization (P = 0.002) and the ventilation time (P = 0.048). This effect, however, did not persist after adjustments for probable known confounders. Our study indicated no significant prognostic effect for preoperative FTR versus less-than-moderate FTR on short-term mortality and morbidities, as well as length of hospitalization, length of ICU stay, and the ventilation time.

Surgical Therapy for Patients with Severe Aortic Stenosis in the Era of Transcatheter Aortic Valve Replacement

Aortic stenosis (AS) is the most common valvular heart disease and is most frequently recognized among elderly people. Surgical aortic valve replacement (SAVR) is the most effective therapy, but its indication is sometimes difficult, and is impossible for high operative risk patients. Transcatheter aortic valve replacement (TAVR) was recently approved in Japan for high risk and inoperable patients with severe AS. TAVR is a less invasive method because it does not require a cardiopulmonary bypass and is associated with excellent surgical outcomes. In Western countries, the indication of TAVR has already been extended to moderate operative risk patients with severe AS, and is going to be further extended to low risk patients. The number of patients undergoing TAVR is increasing progressively, and there are effective alternative therapies for patients with severe AS. Selection of these surgical methods will be important in the near future. In regard to low operative risk patients especially, not only operative mortality, but also long-tern mortality and morbidity and quality of life should be taken into consideration. It is considered that some comorbidities in AS patients will be revealed to have an impact on surgical outcomes at the time when these surgical methods are selected. In this review, we examine end-stage renal disease on hemodialysis, functional tricuspid regurgitation, and sigmoid septum, and give an outline of what influence SAVR and TAVR have on the surgical outcomes of severe AS patients.

Role of 3-Dimensional Echocardiography in the Comprehensive Evaluation of the Tricuspid Valve in Patients With Tricuspid Regurgitation

Three-dimensional echocardiography is one of the most promising methods for the diagnosis of valvular heart disease, and recently has become an essential clinical tool owing to the continued development of real-time transesophageal echocardiography (TEE) technology. And now an era of renewed interest and enthusiasm surrounding the diagnosis and treatment of valvular heart disease has come, which is driven by emerging trans-catheter procedures. Nonetheless, little or no attention has been given to the treatment of tricuspid regurgitation (TR). The application of 3D-TEE is useful for simultaneous visualization of all 3 leaflets in order to grasp the whole picture of the tricuspid valve (TV; “en face” view). The implications of 3-D assessment of TV annulus, leaflets, and morphology involve an improved understanding of both the mechanics and treatment of TR. This method has been useful for surgical management, including accurate measurement of tricuspid annular diameter and prediction of the post-surgical outcome. Moreover, this method may be indispensable for detailed and comprehensive evaluation of the TV in patients with TR who are candidates for trans-catheter tricuspid procedures. In addition, color Doppler 3D-TEE has been valuable to identify the location of the regurgitant orifice and the severity of the TR. It is now clear that this method will enhance the diagnosis and management of TR patients.

Implications of Concomitant Tricuspid Regurgitation in Patients Undergoing Transcatheter Aortic Valve Replacement for Degenerated Surgical Aortic Bioprosthesis: Insights From the PARTNER 2 Aortic Valve-in-Valve Registry

OBJECTIVES

The aim of this study was to assess the implications of concomitant tricuspid regurgitation (TR) in patients undergoing valve-in-valve (VIV) transcatheter aortic valve replacement.

BACKGROUND

Patients undergoing VIV transcatheter aortic valve replacement with concomitant TR may have worse outcomes, and optimal management remains undetermined.

METHODS

The multicenter PARTNER 2 (Placement of Aortic Transcatheter Valves) VIV trial enrolled patients with symptomatic degenerated surgical aortic bioprostheses who were at high risk for reoperation. Outcomes were assessed between patients with mild or no TR versus moderate or severe TR.

RESULTS

A total of 237 patients underwent VIV procedures (mean age 78.7 ± 10.8 years, mean Society of Thoracic Surgeons score 9.1 ± 4.8%). In this cohort, 162 patients (68.4%) had mild or no TR, and 75 patients (31.6%) had moderate or severe TR. Although there was no difference in New York Heart Association functional class III or IV symptomatic status (89.3% vs. 91.4%; p = 0.62) or moderate or severe right ventricular dysfunction (9.4% vs. 16.9%; p = 0.11), patients with moderate or severe TR were more likely to be at high surgical risk, with a Society of Thoracic Surgeons score of >8 (62.7% vs 46.9%; p = 0.02). There was no difference in a composite endpoint of death and rehospitalization between moderate or severe TR and mild or no TR, either at 30 days (10.7% vs. 9.9%; p = 0.85) or at 1-year follow-up (24.1% vs. 23.2%; p = 0.80). There was a significant reduction in overall moderate or severe TR from baseline at 30 days (31.1% vs. 21.1%; p = 0.002), which was sustained at 1-year follow-up (38.0% vs. 22.8%; p = 0.004).

CONCLUSIONS

Despite higher predicted surgical risk, the presence of TR was not a predictor of long-term outcomes. Importantly, there was significant reduction in TR severity at both short- and long-term follow-up. In selected patients undergoing VIV transcatheter aortic valve replacement, it may be appropriate to conservatively manage concomitant TR.

Predictors of Persistent Tricuspid Regurgitation after Transcatheter Aortic Valve Replacement in Patients with Baseline Tricuspid Regurgitation

Objective

This study sought to analyze outcomes in patients with moderate-severe tricuspid regurgitation (TR) undergoing transcatheter aortic valve replacement (TAVR). The consequences of uncorrected significant TR in patients undergoing TAVR remain undefined.

Methods

Between 2009 and 2014, 369 patients underwent TAVR at our institution, and 58 of these had baseline moderate-severe TR. Preoperative, 30-day, and 1-year transthoracic echocardiograms were analyzed. Predictors of persistent TR at 30 days and survival were assessed.

Results

Fifty-eight patients with baseline moderate-severe TR underwent TAVR. Transcatheter aortic valve replacement resulted in significant reductions in pulmonary artery pressures and TR severity (100% vs 64%; P < 0.001) at 30 days. This was sustained at 1 year and was associated with significant improvements in stroke volume index and New York Heart Association functional class. No changes in right ventricular function or size were noted. The only independent predictor of persistent moderate-severe TR at 30 days was preoperative atrial fibrillation [AF; odds ratio (OR), 4.56; 95% confidence interval, 1.1–18.3; P = 0.033]. Independent predictors of overall long-term survival included AF (OR, 0.41; P = 0.001) and chronic lung disease (OR, 0.47; P = 0.011), but not baseline moderate-severe TR. In patients with baseline moderate-severe TR, persistent moderate-severe TR at 30 days was associated with worsened overall survival (log-rank P = 0.02).

Conclusions

Baseline moderate-severe TR is not uncommon in patients undergoing TAVR, and frequently improves. However, the presence of AF suggests that that TR is likely to persist after TAVR and is also indicative of a poor long-term outcome. Whether redirecting such patients to surgery for concomitant tricuspid valve repair will further improve outcomes requires further study.

Current transcatheter devices to treat functional tricuspid regurgitation with discussion of issues relevant to clinical trial design

Functional or secondary tricuspid regurgitation (TR) has seen increased attention in recent times as relationships with clinically-relevant outcomes have come to light. Despite the association of increased mortality with significant TR, the disease remains under-recognized and thus relatively untreated. In addition, the disease itself has not been extensively studied and the interactions between annular dilatation, right heart disease and pulmonary hypertension are poorly understood. However, the high mortality and recurrence rate with current surgical replacement or repair techniques is well recognised, opening the door to transcatheter therapies for functional TR. The current perspective reviews the rationale for transcatheter solutions, describes some of the current approaches and discusses the ongoing questions of a poorly-studied condition which may limit the design of clinical trials for this disease.

Revisit of Functional Tricuspid Regurgitation; Current Trends in the Diagnosis and Management

Current knowledge of functional tricuspid regurgitation (FTR) as a progressive entity, worsening the prognosis of patients irrespective of its aetiology, has led to renewed interest in the pathophysiology and assessment of FTR. For the proper management of FTR, not only its severity, but also the mechanisms, the mode of leaflet coaptation, the degree of tricuspid annulus enlargement and leaflet tenting, and the haemodynamic consequences for right atrial and right ventricular morphology and function have to be taken into account. A better assessment of the anatomy and function of tricuspid apparatus and tricuspid regurgitation severity should help with the appropriate selection of patients who will benefit from either surgical tricuspid valve repair/replacement or a percutaneous procedure, especially among patients who are to undergo or have undergone primary left-sided valvular surgery. In this article, we review the anatomy, pathophysiology and the use of imaging techniques to assess patients with FTR, as well as the various treatment options for FTR, including emerging transcatheter procedures. The limitations affecting the current approach to FTR patients and the unmet clinical needs for their management have also been discussed.