Edge-to-edge repair for tricuspid valve regurgitation. Preliminary echo-data from the Tricuspid Regurgitation IMAging (TRIMA) study

Background

The natural history of tricuspid valve regurgitation (TR) is characterized by dismal prognosis and high in-hospital mortality when treated with isolated surgery. We report preliminary procedural and echocardiographic results of our experience with the TriClip System in a cohort of “real-life” patients with functional tricuspid regurgitation.

Methods

From June 2020 to March 2022, 27 consecutive patients with > moderate TR have been screened, 12 underwent transcatheter TriClip repair. The anatomical feasibility was established through a complete transthoracic (TTE) and transesophageal echocardiogram (TEE), and a dedicated CT scan for the right cardiac chambers. The procedure was conducted under general anesthesia, guided by TEE and fluoroscopy.

Results

A total of 12 subjects (83% female) with significant comorbidities and at high surgical risk were included. The mean age was 82±4 years with an average EuroSCORE II of 8.5±4%. TR included functional (75%) and (25%) mixed etiology (lead-induced and functional) and all patients were classified as at least NYHA functional class III. Nine patients (75%) had severe, two patients (17%) massive and one patient (8%) torrential TR.

The implant and procedural success were achieved in all cases, implanting one device in 8 patients (67%) and two in 4 patients (33%). The device was positioned antero-septal in 83% (10of12) and postero-septal in 50% (6of12) of cases. A TR reduction of≥1 grade after procedure was achieved in all patients; 5 (42%) subjects had moderate, 6 (50%) mild, and one patient (8%) with previous torrential TR treated with two clips had severe post-procedural TR because of partial leaflet detachment 48-hours post-procedure. On TTE, significant reductions in effective regurgitant orifice area (0.61±0.28 to 0.31±0.22 cm2; p<0.001) and regurgitant volume (56.3±16.7 to 27.5±16.6ml; p<0.001) occurred between baseline and before hospital discharge. We also observed a significant reduction of tricuspid annulus diameter (43.8±5.6 to 39.8±4.2 mm; p<0.001), right ventricular basal diameter (47.2±6.8 to 42.9±4.5 mm; p=0.001), right atrial area (28.8±8.8 to 26.7±9.4 cm2; p=0.033). While 3 patients demonstrated a reduced TAPSE/PASP ratio (<0.31 mmHg) before the intervention, the overall ratio significantly improved after device placement (0.37±0.1 to 0.46±0.1 mmHg; p=0.011). At 30-days-follow-up, there was significant and sustained improvement in NYHA class with all patients reaching class II or less without additional reported hospitalizations.

Conclusion

In this single center experience, we have shown that treatment with the edge-to-edge TriClip device is safe and effective and is associated with marked clinical benefits and reduced rates of hospitalizations. The resulting echocardiographic improvements indicate leaflet grasping does not just significantly reduce the grade of TR, but also affects adjacent structures and improves right ventricular afterload adaptation.

Funding Acknowledgement

Type of funding sources: None.

Many hands make light work. Echocardiography and computed tomography results from the Tricuspid Regurgitation IMAging (TRIMA) study

Background

Anatomic knowledge of the tricuspid valve (TV) is the first step in the diagnostic algorithm of patients with tricuspid regurgitation (TR), who are candidates for transcatheter tricuspid valve intervention (TTVI). Currently, echocardiography and computed tomography (CT) are available instruments to study the TV anatomy, guide the decision-making process and support the development of novel transcatheter therapies.

Purpose

The Tricuspid Regurgitation IMAging (TRIMA) study aimed to correlate CT parameters to commonly used echocardiographic variables.

Methods

This prospective, single-center study enrolled 22 consecutive patients with TR equal to or greater than severe (≥3+). All patients underwent transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE) and cardiac CT study, in order to obtain anatomical dimensions of the tricuspid annulus and quantification of right-chambers remodeling and function. Novel CT scan measurements were analyzed. Correlation between measurements on echocardiography and CT imaging was assessed.

Results

Severe TR (3+) was present in 27.4% patients, massive (4+) in 4.8% and torrential (5+) in 3.2%. The mean right ventricle (RV) length, RV mid diameter, and right atrium area were 60.81±9.11 mm, 41.27±7.67 mm and 31.72±9.66 cm2, respectively. Tricuspid annular plane excursion, fractional area change, longitudinal myocardial velocity (S') were 16.09±3.25 mm, 33.36±9.47% and 9.18±1.94 cm/sec, respectively. The annular dimensions obtained by CT scan were generally observed to reduce from diastole to systole, except for eccentricity, angles and distance between the postero-septal and antero-posterior commissure and distance between centroid and antero-posterior commissure. A Kruskal-Wallis test showed a stepwise increase in the tricuspid anatomical regurgitant orifice area (AROA) values by CT across the expanded TR grades by TEE, χ2(2)=6,466, p=0.039. Using the Pearson correlation coefficient, we found a relationship between the AROA and TR grade (r=0.593; p<0.004), as well as ARO-perimeter and TR grade (r=0.470; p<0.027). Additionally, a significant correlation was found between septal lateral annulus diameter obtained by TEE and CT (r=0.637; p=0.001). Anyway, no correlations were found between novel CT variables and TR grade or RV function assessed by echocardiogram, as well as between CT systo-diastolic annulus variability and RV function.

Conclusions

Standard echocardiographic study provide invaluable information about the anatomy and function of the right-chambers, as well as an accurate grade of TR. Conventional and novel variables derived by CT scan may step up the anatomical assessment of the complex morphology of the TV apparatus, thanks to the high spatial resolution of the technique. Therefore, an integrated multimodality assessment is the key point of the screening process of TR candidates for TTVI.

Funding Acknowledgement

Type of funding sources: None.

The MIDA quantitative international registry: prognostic implications of moderately elevated pulmonary artery pressure

Funding Acknowledgements

Type of funding sources: None.

Background

  Pulmonary hypertension is a frequent complication of severe degenerative mitral regurgitation (DMR) associated with major outcome implications. However, whether pulmonary hypertension is linked with worse outcome in less that severe MR is uncertain and even more unsubstantiated is the link of elevated systolic pulmonary artery pressure (sPAP) < 50mmHg with clinical presentation and outcome.

Purpose

To assess the outcome implication of sPAP elevation, even moderate, among mitral regurgitation severity subgroups.

Methods

The MIDA-Quantitative (MIDA-Q) unprecedented registries included 7373 consecutive patients (age 64 ± 17 years, 45% women, follow-up 5.5 ± 3.4 years) with isolated DMR diagnosed at tertiary (European/North-American/Middle East) centers in which systolic pulmonary artery pressure (sPAP) was measured prospectively at baseline. Long-term survival overall, under medical management and post-mitral surgery was analyzed.

Results

 Elevated pulmonary pressure (sPAP >50mmHg) was observed in 1371 patients (19%, mean 63 ± 13mmHg) and moderate increase in pulmonary pressure (35< sPAP < 50mmHg) in 1874 patients (25%, mean 41 ± 14mmHg), with no/mild MR in 4067 (50%), moderate in 2073 (25%), and severe or above in 2047 (25%), mean ERO 0.24 ± 24cm2, RVol 37 ± 35mL and posterior leaflet prolapse in 34%. sPAP severe but also moderate both strongly and independently linked to more severe clinical presentation, with more dyspnea, more AFib, and impaired renal function (P ≤ 0.0001). <SPAP< >By sPAP categories,  35 < sPAP< 50mmHg (vs. 35mmHg) was independently associated with worse outcome under medical management adjusted-HR 1.62[1.40-1/87], with considerable excess-mortality for sPAP > 50mmHg (vs. <35mmHg) adjusted-HR 2.54[2.17-2.96], all P < 0.0001. As continuous variable, sPAP was associated with worse outcome adjusted-HR 1.25[1.21-1.29], P < 0.0001 per 10mmHg-increase. Mitral valve surgery (performed in 2378 patients, 32%) improved outcome without alleviating completely higher mortality associated with sPAP > 50mmHg (P < 0.0001).

Conclusion

In this very large international cohort of patients with DMR of all range and prospective sPAP grading, higher sPAP is associated at diagnosis with more severe clinical presentation. Long term, sPAP > 50mmHg but also 35-50mmHg is independently of all confounders, associated with worse mortality. Thus careful assessment and consideration for mitral surgery/transcatheter therapy is warranted even in patients with sPAP <50mmHg.</SPAP< > Abstract Figure. Survival stratified by sPAP Categories  Abstract Figure. Postop survival by sPAP Categories

The MIDA quantitative mortality risk score: prognostic model in floppy mitral valves

Background

The Mitral Regurgitation International Database (MIDA) score is a validated tool for Degenerative Mitral Regurgitation (DMR) management, being able to position a given patient within a continuous spectrum of short and long term mortality. However, whether this score may be applicable and incremental in the entire span of Floppy Mitral Valves (FMV), regardless of DMR severity, remains unsubstantiated.

Methods

The MIDA-Quantitative (MIDA-Q) unprecedented registries include 8187 consecutive patients (age 64±17 years, 45% women, follow-up 5.5±3.4 years) with isolated degenerative mitral valve disease diagnosed at tertiary (European/ North-American/ Middle Eastern) centers in whom DMR severity used both integrative and quantitative grading. The MIDA-Q Score ranged from 0 to 15 depending on accumulating risk factors. Long-term survival overall, under medical management and post-mitral surgery was analysed.

Results

By quantitative grading, MR was no/trivial in 1938 (24%), mild in 1423 (17%), moderate in 2027 (25%) and severe in 2799 (34%), with ERO 0.24±24cm2, RVol 37±35mL, and posterior leaflet prolapse in 49%. MIDA-Q Scores stratified in 8 categories were 0 (score 0, n=851), 1 (score 1–2, n=1301), 2 (score 3–4, n=2043), 3 (score 5–6, n=1581), 4 (score 7–8, n=1273), 5 (score 9–10, n=718), 6 (score 11–12, n=331) and 7 (score 13–15, n=89). In the whole MIDA-Q population (n=8187 patients), 5-year survival under medical management with Scores categories 0–1, 2–4, and 5–7 was 96±1%, 73±1%, and 61±3% respectively (P<0.0001). Five-year mortality ranged from 3% with MIDA Q-score 0 to 95% with MIDA Q-score 13–15 (P<0.0001). After mitral surgery, 1-year mortality with Scores categories 0–1, 2–4, and 5–7 was 0%, 1%, and 6% respectively and 5-year post-operative survival was 99±1%, 94±1%, and 82±2% (all P<0.0001). In models including age, sex and all guideline-provided prognostic markers, the EuroScoreII and the MIDA Score without DMR severity, the MIDA-Q Score provided incremental prognostic information (P<0.001).

Conclusion

This unheard international cohort of patients with FMV and prospective mitral severity quantitative grading, enables for the first time the calculation of a MIDA-Q Score, highly determinant of survival after diagnosis of FMV with any degree of DMR, that may be very useful for mitral valve prolapse management.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Mayo Fundation Figure 1

Association between platelet reactivity and long-term bleeding complications following percutaneous coronary intervention in patients with and without diabetes

Background

The association between diabetes mellitus (DM) and bleeding complications following percutaneous coronary intervention (PCI) is controversial. We hypothesized that on-treatment platelet reactivity may have a role in the bleeding risk stratification of such patients.

Purpose

To investigate the role of low platelet reactivity (LPR) in the long-term bleeding risk stratification among patients with and without diabetes undergoing PCI.

Methods

In this observational, retrospective single-center study, 472 patients undergoing PCI for stable coronary artery disease were included. All patients were treated with dual antiplatelet therapy with aspirin and clopidogrel. Platelet reactivity was assessed using the VerifyNow P2Y(12) assay and LPR was defined by values of platelet reactivity unit (PRU) ≤178. Primary endpoint was the occurrence of all bleeding events at 5 years stratified by DM status and LPR.

Results

Out of the study population included, 30.5% had DM (N=144). LPR was numerically less frequent in patients with DM compared to those without (29.2% vs 37.6%; p=0.077). Overall, 11.9% of patients experienced a bleeding complication at 5-year follow-up; 44.6% of events were classified as major bleedings. The incidence of bleeding events per 1000 patients-year was 34.5 (95% CI 22.3–53.5) in DM and 24.2 (95% CI 17.3–33.8) in no DM (p=0.24). A stepwise increase in the crude rates of bleeding complications was observed across patients with and without DM and LPR (log-rank p=0.004), with those having both conditions being at the highest risk of events (Figure). LPR had a similar value for stratifying the risk of bleeding in patients with and without diabetes (p value for interaction between diabetes and LPR status=0.45).

Conclusions

Approximately 1 out of 3 patients undergoing PCI for stable coronary artery disease on clopidogrel has LPR. The assessment of LPR provides a significant incremental value for the prediction of bleeding events irrespective from DM status. While the presence of DM per se does not increase the risk of bleeding complications, the coexistence of DM and LPR identifies the subgroup at the highest risk of events who could benefit from a short-term and less intensive antiplatelet regimen.

Funding Acknowledgement

Type of funding sources: None.

Myocardial native T1 mapping and correlations with clinical and CMR parameters in patients with systemic sclerosis

Funding Acknowledgements

Type of funding sources: None.

Background

Systemic sclerosis (SSc) is a connective tissue disease characterized by diffuse vascular lesions and fibrosis, also affecting the heart. Cardiovascular magnetic resonance (CMR) can detect replacement myocardial fibrosis by late gadolinium enhancement (LGE) and interstitial myocardial fibrosis/edema by T1 mapping techniques.

Purpose

To evaluate the prevalence of cardiac involvement by native T1 mapping and its correlation with clinical and CMR parameters in SSc patients.

Methods

Fifty-one consecutive SSc patients (mean age 51.8 ± 13.7 years, 42 females) and 51 healthy subjects matched for age and sex underwent clinical, bio-humoral assessment, and CMR at 1.5T (Signa Artist, GE Healthcare ). The imaging protocol included: cine, T1 mapping by MOLLI, T2 mapping by multi-echo fast-spin-echo sequence, LGE, and STIR T2-weighted sequences. Native T1 and T2 values were assessed in all 16 myocardial segments and the global value was the mean.

Results. Global native T1 values were significantly higher in SSc patients than in healthy subjects (1076.4 ± 50.7 vs 1033.3 ± 31.9 ms; P < 0.0001).

As in healthy subjects, in patients native T1 values were significantly lower in males than in females (1033.4 ± 38.3 vs 1085.6 ± 48.6 ms; P = 0.004) and inversely correlated with age (R=-0415; P = 0.002).

Twenty-three (45.1%) patients had an increased global heart T1 value (>1060 ms in males and >1085 ms in females). Of them, 14 patients (60.9 %) showed positive LGE. Frequency of cardiovascular risk factors, indices of disease activity and chronicity, biochemical parameters, and cardio-active therapy were comparable between patients with normal and elevated T1. Compared to patients with normal T1 value, patients with elevated T1 had significantly higher left ventricular (LV) end-diastolic volume index (76.8 ± 13.3 vs 69.2 ± 11.8, P = 0.050), LV stroke volume index (49.7 ± 6.4 vs 44.4 ± 6.9 ml/m2; P = 0.010), LV cardiac output (3.6 ± 0.5  vs 3.0 ± 0.6 l/min /m2; P < 0.0001), and global heart T2 values (60.1 ± 3.6 vs 55.7 ± 3.1 ms; P < 0.0001).

Replacement myocardial fibrosis was detected in 24 (47.1%) patients and they showed significantly higher global heart native T1 values (Figure 1A).

Positive T2-weighted images for myocardial oedema were found in 5 (9.8%) patients, all with increased global heart native T1 value. Patients with oedema had significantly higher native global heart T1 values (Figure 1B).

Conclusion

Elevated native T1 values measured by CMR are frequent in SSc patients and they are associated with inflammation, replacement fibrosis, and increased LV dimension. CMR T1 mapping seems to be a sensitive parameter to include in the routine clinical assessment of SSc patients for detecting earlier pejorative cardiac involvement, although prospective data are recommended.

Abstract Figure.

P529Efficacy and safety of S-ICD implantation without use of defibrillation threshold testing: a retrospective multicentric observational study

Introduction

The subcutaneous ICD (S-ICD) is a valid alternative to transvenous systems (TV-ICD) for the treatment of life-threatening arrhythmias, and the extravascular position of the lead allows a significant reduction of the risk of infection. Current guidelines recommend defibrillation threshold testing (DFT) at the time of S-ICD implantation (class I). Although randomised trials have proven the safety of TV-ICD implantation with no DFT, it is unclear whether such an approach could be adopted for S-ICD as well. The PRAETORIAN score, based on post-implantation chest X-ray, can accurately predict a high defibrillation threshold after S-ICD implantation. The aim of this retrospective multicentre study was to evaluate the efficacy and safety of S-ICD implantation with no DFT.

Methods

We enrolled 203 consecutive patients undergoing S-ICD implantation in six different centres between October 2012 and January 2019. It was left at discretion of the operator whether performing or not DFT at the time of the procedure. Baseline device settings were collected, and the PRAETORIAN score was retrospectively calculated whenever chest X-ray was available. Both remote or in-clinic device interrogation reports were systemically analysed, and all the shocks and arrhythmia episodes identified. All the patients provided consent form and ethical approval was obtained.

Results

The population (mean age 57.6 ± 14.2) was divided in two groups, based on whether DFT was performed at the time of the S-ICD implantation: 72 patients (35.4%) underwent DFT (DFT+ group), while 131 patients (64.5%) did not (DFT- group). In the DFT- group, mean LVEF was lower (32 ± 8% vs 42 ± 17%, p < 0.0001) and prevalence of diabetes mellitus and atrial fibrillation higher compared to the DFT+ group (27.5% vs 13.9%, p = 0.04 and 38.9% vs 19.44%, p = 0.007; respectively). In addition, the indication for S-ICD was more frequently primary prevention in the DFT- vs DFT+ group (70.8% vs 90.8%, p = 0.0004; respectively). No differences in terms of device programming were identified between the two cohorts. The PRAETORIAN score was significantly higher in the DFT- vs DFT+ patients (50 ± 26 vs 36 ± 18, p = 0.032; respectively). After a median follow-up of … months, we observed 5 appropriate shocks in 3 patients from the DFT+ group vs. 15 shocks in 8 patients from the DFT- group (p = 0.81). All the life-threatening arrhythmias were successfully recognised and treated by the device. DFT was complicated by pulseless electrical activity in one patient. One patient in the DFT- group suffered from an episode of ventricular tachycardia requiring a total of 4 shocks for being terminated. Six patients in the DFT- group died for non-arrhythmic causes. On the Kaplan-Meier analysis, cumulative survival was comparable between the two groups (log rank p value = 0.13).

Conclusions

This study suggests that implantation of S-ICD with no DFT might be reasonable. These results should be confirmed in prospective randomised trials.

Differential effect of everolimus on progression of early and late cardiac allograft vasculopathy in current clinical practice

Randomized trials showed that mTOR inhibitors prevent early development of cardiac allograft vasculopathy (CAV). However, the action of these drugs on CAV late after transplant is controversial, and their effectiveness for CAV prevention in clinical practice is poorly explored. In this observational study we included 143 consecutive heart transplant recipients who underwent serial intravascular ultrasound (IVUS), receiving either everolimus or mycophenolate as adjunctive therapy to cyclosporine. Ninety-one recipients comprised the early cohort, receiving IVUS at weeks 3-6 and year 1 after transplant, and 52 the late cohort, receiving IVUS at years 1 and 5 after transplant. Everolimus independently reduced the odds for early CAV (0.14 [0.01-0.77]; p = 0.02) but it did not appear to influence late CAV progression. High-dose statins were found to be associated with reduced CAV progression both early and late after transplant (p ≤ 0.05). Metabolic abnormalities, such as high triglycerides, were associated with late, but not with early CAV progression. By highlighting a differential effect of everolimus and metabolic abnormalities on early and late changes of graft coronary morphology, this observational study supports the hypothesis that everolimus may be effective for CAV prevention but not for CAV treatment, and that risk factors intervene in a time-dependent sequence during CAV development.