Transthoracic and transoesophageal echocardiography for tricuspid transcatheter edge-to-edge repair: a step-by-step protocol.

Tricuspid regurgitation (TR) carries an unfavourable prognosis and often leads to progressive right ventricular (RV) failure. Secondary TR accounts for over 90% of cases and is caused by RV and/or tricuspid annulus dilation, in the setting of left heart disease or pulmonary hypertension. Surgical treatment for isolated TR entails a high operative risk and is seldom performed. Recently, transcatheter edge-to-edge repair (TEER) has emerged as a low-risk alternative treatment in selected patients. Although the experience gained from mitral TEER has paved the way for the technique's adaptation to the tricuspid valve (TV), its anatomical complexity necessitates precise imaging. To this end, a comprehensive protocol integrating 2D and 3D imaging from both transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) plays a crucial role. TTE allows for an initial morphological assessment of the TV, quantification of TR severity, evaluation of biventricular function, and non-invasive haemodynamic evaluation of pulmonary circulation. TOE, conversely, provides a detailed evaluation of TV morphology, enabling precise assessment of TR mechanism and severity, and represents the primary method for determining eligibility for TEER. Once a patient is considered eligible for TEER, TOE, alongside fluoroscopy, will guide the procedure in the catheterization lab. High-quality TOE imaging is crucial for patient selection and to achieve procedural success. The present review examines the roles of TTE and TOE in managing patients with severe TR eligible for TEER, proposing the step-by-step protocol successfully adopted in our centre.

Effect of inferior caval valve implantation on circulating immune cells and inflammatory mediators in severe tricuspid regurgitation.

BACKGROUND: Interventional valve implantation into the inferior vena cava (CAVI) lowers venous congestion in patients with tricuspid regurgitation (TR). We evaluated the impact of a reduction of abdominal venous congestion following CAVI on circulating immune cells and inflammatory mediators. METHODS: Patients with severe TR were randomized to optimal medical therapy (OMT) + CAVI (n = 8) or OMT (n = 10). In the OMT + CAVI group, an Edwards Sapien XT valve was implanted into the inferior vena cava. Immune cells and inflammatory mediators were measured in the peripheral blood at baseline and three-month follow-up. RESULTS: Leukocytes, monocytes, basophils, eosinophils, neutrophils, lymphocytes, B, T and natural killer cells and inflammatory markers (C-reactive protein, interferon-gamma, interleukin-2, -4, -5, -10, and tumor necrosis factor-alpha) did not change substantially between baseline and three-month follow-up within the OMT + CAVI and OMT group. CONCLUSION: The present data suggest that reduction of venous congestion following OMT + CAVI may not lead to substantial changes in systemic inflammation within a short-term follow-up. CLINICAL TRIAL REGISTRATION: NCT02387697.

Rigid ring vs. flexible band for tricuspid valve repair in patients with tricuspid valve regurgitation: A systematic review and meta-analysis.

Background & objectives: Rigid ring and Flexible band are techniques used to repair tricuspid valve regurgitation. The comparison between both techniques' effectiveness is controversial in the literature. We conducted this systematic review and meta-analysis to compare the safety and efficacy of rigid ring versus flexible band for tricuspid valve repair in patients with tricuspid valve regurgitation. Methods: We conducted a PRISMA-compliant systematic review and meta-analysis. A systematic search was performed in major databases, including PubMed, Scopus, Web of Science, and Cochrane CENTRAL to identify relevant published studies. Data were extracted and analyzed using Stata (version 17 for Mac) and Revman (version 5.4 for Windows). Results: Twelve studies were included in this meta-analysis. Total number of patients was 4259. The rigid ring wasn't superior to the flexible band in terms of postoperative tricuspid regurgitation RR 0.74, 95 % CI (0.43-1.27) (P = 0.29). However, the results were not homogeneous. After employing sensitivity analysis, the significance of the pooled effect estimate didn't change, showing no significant difference between the two annuloplasty RR 0.72, 95%CI (0.45-1.15). On the other hand, the rigid ring was associated with a higher bypass time than the flexible band (RR 4.85, P = 0.00). There were no differences between the two groups in terms of hospital stay, ICU stays, prolonged ventilation, mechanical ventilation time, annuloplasty size, stroke, concomitant mitral valve surgery, concomitant aortic valve surgery, atrial fibrillation, pacemaker implantation, low cardiac output, in-hospital death, or late death (all P > 0.05). Conclusion: Our study findings suggested no difference between rigid ring compared to flexible band regarding the rates of postoperative tricuspid regurgitation; however, rigid ring may encompass a higher bypass time. Therefore, further research is required to ensure our findings.

Sinus rhythm restoration reverses tricuspid regurgitation in patients with atrial fibrillation: a systematic review and meta-analysis.

BACKGROUND: Tricuspid regurgitation (TR) is a common valvular heart disease worldwide, and current guidelines for TR treatment are relatively conservative, as well as with detrimental outcomes. Restoration of sinus rhythm was reported to improve the TR severity in those TR patients with atrial fibrillation (AF). However, relevant research was limited. The aim of this meta-analysis was to evaluate the clinical outcomes of restoration of sinus rhythm in TR patients with AF. METHODS: In this study, PubMed, Web of Science, and Scopus databases were searched for study enrollment until July 2023. This study was designed under the guidance of Preferred Reporting Items for Systematic Reviews and Meta-Analyses. These studies containing the patient's baseline characteristics, surgical procedure, and at least one of the clinical outcomes were included. The primary endpoint was TR grade during follow-up after restoration of sinus rhythm. RESULTS: Out of 1074 records, 6 were enrolled. Restoration of sinus rhythm is associated with a reduction of TR severity (TR grade, odds ratio 0.11, 95% confidence interval (CI): 0.01 to 1.28, P = 0.08, I2 = 83%; TR area, mean difference (MD) -2.19 cm2, 95% CI: -4.17 to -0.21 cm2, P = 0.03, I2 = 96%). Additionally, remolding of right heart with a significant reduction of tricuspid valve annulus diameter (MD -0.36 cm, 95%CI: -0.47 to -0.26 cm, P < 0.00001, I2 = 29%) and right atrium volume index (MD -11.10 mL/m2, 95%CI: -16.81 to -5.39 mL/m2, P = 0.0001, I2 = 79%) was observed during follow-up. CONCLUSIONS: In conclusion, rhythm-control therapy could reduce TR severity in AF patients with TR and is associated with right heart remodeling.

Transcatheter Tricuspid Valve Intervention for the Treatment of Tricuspid Regurgitation with TriClip: All You Need to Know.

Severe tricuspid regurgitation (TR) is a common pathology in the daily practice of a cardiologist. This disease entity is associated with significant morbidity and mortality if left untreated. Classically, surgical repair or replacement were the only therapeutic options present and were often not performed due to high postprocedural mortality. Transcatheter tricuspid valve intervention has emerged as a novel and effective therapeutic option for the treatment of significant TR. Several devices have been developed with different mechanisms of action. In this review, we will provide an overview of transcatheter edge-to-edge repair of TR using the TriClip device (Abbott, Santa Clara, CA, USA).

Right atrial and right ventricular strain: prognostic value depends on the severity of tricuspid regurgitation.

AIMS: Assessing right heart function is challenging, particularly when significant tricuspid regurgitation (TR) is present. Among available echocardiographic techniques for assessment, literatures suggests that strain imaging may be more reliable and less susceptible to loading conditions. Thus, we aimed to assess the validity of RA and RV strain relative to conventional metrics as well as their utility in predicting patient outcomes in TR. METHODS: We studied 262 consecutive patients (mean age 74 ± 11.2 years, 53% male) who underwent same-day echocardiography and right heart catheterization between 2018 and 2023. We compared right heart strain to traditional metrics of RV function and subsequently correlated RA and RV strain to heart failure (HF)-related death or hospitalization, whichever came first. RESULTS: Over a mean follow-up of 34 ± 15 months, there were 103 deaths and HF hospitalizations. Both RA and RV strain were correlated with echocardiographic and invasive measures of right heart function. Across all patients, preserved RA strain was associated with lower risk of adverse outcomes (HR 0.763, 95% CI 0.618-0.943). Similarly, preserved RV strain was correlated with better outcomes, though this was only statistically significant in patients without severe TR or pulmonary hypertension (HR 2.450, 95% CI 1.244-4.825). Moreover, abnormal ratios of RV strain to pulmonary pressures and RV size were significantly correlated with adverse outcomes (p < 0.05 each). CONCLUSION: RA and RV strain are independently correlated with echocardiographic and invasive measures of cardiac function. Moreover, preserved RA and RV strain are likely associated with better clinical outcomes.

Effects of Implantable Cardioverter-Defibrillator Leads on the Tricuspid Valve and Right Ventricle: A Randomized Trial.

BACKGROUND: There are no randomized data to inform the extent to which transvenous cardiac leads cause tricuspid regurgitation (TR). OBJECTIVES: This study sought to determine the effect of a transvenous implantable cardioverter-defibrillator (TV-ICD) on TR severity, and secondarily, on right ventricular (RV) size and function. METHODS: We evaluated TR severity before and 6 months after implantable cardioverter-defibrillator insertion in a post hoc analysis of adults randomized to receive a transvenous (n = 252) or subcutaneous implantable cardioverter-defibrillator (S-ICD) (n = 251) device. TR and RV size and systolic function were assessed by echocardiographic images analyzed in a core laboratory. RESULTS: At baseline, at least mild TR was present in 30% of individuals. At 6 months, the proportion of participants with any TR in the TV-ICD group was 42% vs 19% in the S-ICD group (P < 0.001). The proportion with moderate or severe TR was 7% in the TV-ICD group vs 2% in the S-ICD group (P = 0.021). At 6 months, the OR of at least 1 grade worsening of TR in the TV-ICD group as compared with the S-ICD group was 7.2 (95% CI: 3.3-15.8; P < 0.001). There were no differences between groups with respect to RV size or systolic function. CONCLUSIONS: Six months following TV-ICD insertion, there was a 7-fold increase in the risk of at least 1 grade worsening of TR, with 7% of individuals having TR that was moderate or severe. There was no detectable difference in RV size or function; however, longer follow-up is needed.

Significant tricuspid regurgitation is associated with adverse outcomes in patients with transthyretin amyloid cardiomyopathy.

Objectives: Patients diagnosed with transthyretin amyloid cardiomyopathy (ATTR-CM) often experience poor outcomes due to the development of heart failure (HF). Tricuspid regurgitation (TR) has been found to be correlated with adverse outcomes in patients with HF. This study aims to assess whether the presence of significant TR is associated to adverse cardiac outcomes in patients diagnosed with ATTR-CM. Materials and methods: Retrospective study of ATTR-CM patients enrolled in the Institutional Registry of Amyloidosis (NCT01347047). Patients were categorized based on the presence of significant TR (moderate or severe according to current guidelines criteria) or absence of significant TR. All patients were followed up for 2 years to assess the incidence of the composite outcome of death or HF hospitalization. Results: A total of 93 ATTR-CM patients were included. The mean age at diagnosis was 82.5 [IQR 75 - 86] years, 86% were male, and the mean left ventricular ejection fraction was 52% [IQR 43 - 60]. Among them, 32.3% (n = 30) patients had significant TR. Patients with significant TR had higher NTpro-BNP values (5308 vs 2454, pg/mL, p = 0.004), and a lower left ventricular ejection fraction (44 vs. 56%, p = 0.0002) compared to patients without significant TR. The incidence of the primary outcome was higher in patients with significant TR (77% vs. 30%, p<0.001). In a multivariate Cox regression analysis, only NTpro-BNP, as a numerical variable (HR 1.00, 95% CI 1.00005-1.0002, p = 0.001), and significant TR (HR 2.23, 95% CI 1.12-4.42, p=0.021) were independently associated with the composite outcome of death or HF hospitalization. Conclusions: In patients diagnosed with ATTR-CM, the presence of significant TR was associated with worse outcomes.

Objetivos: Los pacientes con diagnóstico de miocardiopatía amiloidótica por transtiretina (ATTR) suelen presentar mal pronóstico, principalmente por el desarrollo de insuficiencia cardiaca (IC). Se ha descrito que la insuficiencia tricúspidea (IT) está relacionada con peor pronóstico en pacientes con IC. Este estudio tiene como objetivo evaluar el impacto pronóstico de la IT significativa en pacientes con diagnóstico de amiloidosis ATTR. Materiales y métodos: Estudio de cohorte retrospectiva. Se incluyeron pacientes con diagnóstico de amiloidosis ATTR pertenecientes al registro institucional de amiloidosis de nuestra institución (NCT01347047). Los pacientes fueron divididos según la presencia o no de IT significativa (moderada o severa, de acuerdo a las guías de práctica clínica actuales). Se realizó un seguimiento con censura a los 2 años para evaluar la incidencia del punto final primario combinado de muerte u hospitalizaciones por IC. Resultados: Se incluyeron 93 pacientes con diagnóstico de amiloidosis ATTR. La mediana de edad fue de 82,5 años [RIC 75-85], 86% fueron hombres. La mediana de fracción de eyección ventricular izquierda fue de 52% [RIC 43-60]. El 32,3% (n=30) de pacientes presentaron IT significativa al momento del diagnóstico de la amiloidosis ATTR. Aquellos con IT significativa tuvieron valores superiore de NT-proBNP (5308 vs. 2454, pg/mL, p=0.004) y menor mediana de fracción de eyección ventricular izquierda (44% vs. 56%, p=0,0002) comparado con los pacientes sin IT significativa. En el seguimiento a 2 años, la incidencia del punto final primario combinado fue mayor en pacientes con IT significativa (77% vs. 30%, p<0,001). En un modelo de regresión de Cox multivariada, solo el NT-proBNP (HR 1,00, 95% CI 1,00005-1,0002, p=0,001) y la IT significativa (HR 2.23, 95% CI 1.12-4.42, p=0.021) estuvieron asociadas de forma independiente con la ocurrencia del punto final primario combinado. Conclusiones: En pacientes con diagnóstico de miocardiopatía amiloidótica por ATTR, la presencia de IT significativa se asoció a peor pronóstico en el seguimiento.

Concomitant Tricuspid Valve Ring Annuloplasty During Mitral Valve Surgery Versus Mitral Valve Surgery Alone: A Systematic Review and Meta-Analysis.

AIM: Although current guidelines recommend concomitant tricuspid annuloplasty for moderate or greater tricuspid regurgitation (TR) and/or dilated annulus, there remains significant variation in undertaking concomitant tricuspid valve surgery (TVA) across different centres. This meta-analysis aimed to compare the clinical outcomes of concomitant tricuspid valve surgery for patients with moderate or greater TR and/or dilated annulus at the time of mitral valve (MV) surgery. METHOD: A systematic review of the literature using six databases. Eligible studies include comparative studies on TVA concomitant with MV surgery versus MV surgery alone. A meta-analysis was performed on studies reporting outcomes of interest to quantify the effects of concomitant tricuspid ring annuloplasty. RESULTS: Two randomised controlled trials and six cohort studies were included in the analysis. 1,941 patients were included in the analysis, of whom, 1,090 underwent concomitant TVA and 851 underwent MV surgery alone. Pooled analysis demonstrated that there was less progression of moderate/severe TR in the concomitant group (3.0% vs 9.6%; odds ratio [OR] 0.29; 95% confidence interval [CI] 0.13-0.55; p=0.0001). There was no significant difference in in-hospital mortality (3.0% vs 3.8%; OR 0.79; 95% CI 0.47-1.34; p=0.38). The rate of permanent pacemaker implantation was higher in the concomitant group although this did not reach statistical significance (7.6% vs 5.3%; OR 1.30; 95% CI 0.85-1.98; p=0.23). Cardiopulmonary bypass was longer in the concomitant TVA group by 20 minutes (mean difference 13.9-26.0; p<0.00001). CONCLUSIONS: Our study demonstrated that concomitant tricuspid ring annuloplasty at the time of MV surgery is associated with a significantly lower rate of TR progression without increasing the operative mortality. There is a trend towards a higher permanent pacemaker implantation rate although this did not reach statistical significance.

4-Year Follow-Up After Transcatheter Tricuspid Valve Replacement Using the EVOQUE System.

Transcatheter tricuspid valve replacement (TTVR) is an increasingly used treatment technique for patients with severe tricuspid regurgitation (TR). Currently, available data from international registries and randomized controlled trials provide outcome data until a maximum follow-up of 2 years after the procedure. This case report presents 4-year follow-up data for an 84-year-old woman who underwent TTVR for torrential TR in 2019. The patient experienced durable TR reduction, symptomatic improvement, right ventricular reverse remodeling, and substantial improvement in liver and kidney function.

Tricuspid Regurgitation in Patients With Heart Failure and Preserved Ejection Fraction: JACC State-of-the-Art Review.

Heart failure with preserved ejection fraction (HFpEF) is associated with high morbidity and mortality. Important risk factors for the development of HFpEF are similar to risk factors for the progression of tricuspid regurgitation (TR), and both conditions frequently coexist and thus is a distinct phenotype or a marker for advanced HF. Many patients with severe, symptomatic atrial secondary TR have been enrolled in current transcatheter device trials, and may represent patients at an advanced stage of HFpEF. Management of HFpEF thus may affect the pathophysiology of TR, and the physiologic changes that occur following transcatheter treatment of TR, may also impact symptoms and outcomes in patients with HFpEF. This review discusses these issues and suggests possible management strategies for these patients.

2023 Korean Society of Echocardiography position paper for the diagnosis and management of valvular heart disease, part II: mitral and tricuspid valve disease.

This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the diagnosis and management of valvular heart diseases with referring to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee sought to reflect national data on the topic of valvular heart diseases published to date through a systematic literature search based on validity and relevance. In the part II of this article, we intend to present recommendations for diagnosis and treatment of mitral valve disease and tricuspid valve disease.

Secondary tricuspid regurgitation: incidence, types, and outcomes in atrial fibrillation vs. sinus rhythm.

BACKGROUND AND AIMS: Incidence and types of secondary tricuspid regurgitation (TR) are not well defined in atrial fibrillation (AFib) and sinus rhythm (SR). Atrial secondary TR (A-STR) is associated with pre-existing AFib; however, close to 50% of patients with A-STR do not have AFib. The aim of this study was to assess incidence, types, and outcomes of ≥ moderate TR in AFib vs. SR. METHODS: Adults with and without new-onset AFib without structural heart disease or ≥ moderate TR at baseline were followed for the development of ≥ moderate TR. Tricuspid regurgitation types were pacemaker, left-sided valve disease, left ventricular (LV) dysfunction, pulmonary hypertension (PH), isolated ventricular, and A-STR. RESULTS: Among 1359 patients with AFib and 20 438 in SR, 109 and 378 patients developed ≥ moderate TR, respectively. The individual types of TR occurred more frequently in AFib related to the higher pacemaker implantation rates (1.12 vs. 0.19 per 100 person-years, P < .001), larger right atrial size (median 78 vs. 53 mL, P < .001), and higher pulmonary pressures (median 30 vs. 28 mmHg, P < .001). The most common TR types irrespective of rhythm were LV dysfunction-TR and A-STR. Among patients in SR, those with A-STR were older, predominantly women with more diastolic abnormalities and higher pulmonary pressures. All types of secondary TR were associated with all-cause mortality, highest in PH-TR and LV dysfunction-TR. CONCLUSIONS: New-onset AFib vs. SR conferred a higher risk of the individual TR types related to sequelae of AFib and higher pacemaker implantation rates, although the distribution of TR types was similar. Secondary TR was universally associated with increased mortality.

Surgical repair for primary tricuspid regurgitation related to trauma.

We report a case of a 45-year-old man presenting with tachycardia and palpitation. Echocardiography indicated severe tricuspid regurgitation. We suspected traumatic tricuspid damage due to high energy trauma in a motor vehicle accident 17 years earlier. He underwent a sternotomy, and his tricuspid valve was repaired with chordal reconstruction, indentation closure, and ring annuloplasty. The postoperative period was uneventful, and he was discharged 10 days after the operation. This report highlights the value of echocardiography for diagnosis of primary tricuspid regurgitation related to trauma, and the importance of early diagnosis to allow surgical intervention before irreversible damage occurs. Learning objective: Traumatic tricuspid regurgitation is a rare cardiovascular complication of blunt chest trauma. The mechanism of the tricuspid valve injury is thought to be secondary to sudden impact causing an anteroposterior compression of the right ventricle by the sternum in end-diastole. This injury is often incidentally identified or can be missed until the patient experiences symptoms of right heart failure resulting from severe tricuspid regurgitation.