Real-World Patient Eligibility and Feasibility of Transcatheter Edge-to-Edge Repair or Replacement Interventions for Tricuspid Regurgitation.

Novel transcatheter therapies for tricuspid regurgitation (TR) appear promising, yet their applicability to an all-comer TR population remains unclear. We aimed to assess the feasibility of emerging transcatheter tricuspid therapies in a real-world population with greater than or equal to moderate symptomatic TR. A total of 178 patients were referred to our center between January 2019 and December 2021 for greater than or equal to moderate symptomatic TR and were classified into 4 groups: Investigative (patients eligible for enrollment in the Triluminate, Clasp TR, and TRISCEND trials), off-label clipping, surgery, and medical treatment. A total of 10.7% of the population were deemed eligible for investigative therapies, 20.2% and 19.7% of patients were offered off-label clipping and surgery, respectively, and 49.4% received medical treatment. Common reasons for investigative therapy-related ineligibility were unsuitable anatomy (large tricuspid annulus or wide leaflet coaptation gap) and the presence of significant comorbidities. Compared with the other groups, the investigative group was less likely to harbor concomitant ≥moderate mitral regurgitation, greater than or equal to moderate right ventricular dysfunction or severe pulmonary hypertension (P < .05). At 1 year, there remained a significant reduction in TR severity in the investigative group (P < .001) in comparison with the medical treatment group. However, the results were comparable to off-label clipping (P = .60) and inferior to surgery (P =.04). Exploratory analyses failed to show evidence of differences in the rates of all-cause mortality (P =.40) and heart failure hospitalizations (P = .94) between all groups. Current real-world eligibility of TR patients for emerging transcatheter therapies remains limited, underscoring the need for continued innovative efforts to offer device therapies to a broader TR cohort.

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.

[Research Progress of Transcatheter Tricuspid Regurgitation Repair Device].

The tricuspid valve has been nicknamed the "forgotten valve" and is often neglected by clinicians. However, tricuspid regurgitation is a common clinical heart valve disease. With the continuous development of transcatheter interventional medical device technology, the treatment of tricuspid regurgitation has gradually attracted attention, and more and more companies are developing interventional medical devices for treating this disease. This review will provide an overview of the current research progress on transcatheter therapy for tricuspid regurgitation repair devices at home and abroad, including the design principles, operational steps, clinical outcomes, and the advantages and disadvantages of these devices.

Assessment of the relationship between central venous pressure waveform and the severity of tricuspid valve regurgitation using data science.

Purpose The relationship between the height of the V wave in the central venous pressure (CVP) waveform and the severity of tricuspid regurgitation (TR) is well known. Their diagnostic ability is unconfirmed. This study explored CVP waveform variations with TR. Methods All patients who underwent preoperative echocardiography and CVP waveform measurements before surgery at our institution were included. Indices were created to capture each feature of the CVP waveform. The median value for each case was obtained and statistically analyzed according to the severity of TR. A deep learning technique, Transformer, was used to handle the complex features of CVP waveforms. Results This study included 436 cases. The values for C wave - Y descent, X descent - Y descent, and V wave - Y descent differed significantly in the Jonckheere-Terpstra test (p = 0.0018, 0.027, and 0.077, respectively). The area under the receiver operating characteristic (ROC) curve (AUC) for X descent - Y descent in two groups, none to moderate TR and severe TR, was 0.83 (95% confidence interval (CI) [0.68, 0.98]). For Transformer, the accuracy of the validation dataset was 0.97. Conclusions The shape of the CVP waveform varied with the severity of TR in a large dataset.

Tricuspid Regurgitation in a Patient with Heart Transplant: Percutaneous Management.

Tricuspid regurgitation (TR) is the most frequent valvular complication after heart transplantation with different clinical sequelae. In its most severe form, it can cause right heart failure with a poor long-term prognosis. Its management is complex, both medical, surgical, and percutaneous. The TricValve system, a bicaval system with two self-expanding valves (superior vena cava and inferior vena cava), dedicated to treating symptomatic IT refractory to medical therapy, is safe and effective in improving quality of life. We present the first heart transplant patient with severe symptomatic TR who underwent successful bicaval valve (TricValve) implantation.

Multimodality Imaging in the Management of Tricuspid Valve Regurgitation.

Approximately 5% of elderly patients suffer from moderate or severe tricuspid valve regurgitation, which is an independent predictor of high morbidity and mortality. Surgical treatment of isolated tricuspid valve regurgitation has been associated with elevated fatality rate, leading to a growing interest in minimal invasive, transcatheter-based therapies such as transcatheter edge-to-edge repair and transcatheter valve replacement. Nevertheless, despite high procedural efficacy and safety of transcatheter-based therapies, a number of challenges limit their rapid adoption in routine clinical practice. In particular, the wide range of transcatheter approaches to address the significant variability in tricuspid valve pathology challenges the reproducibility of clinical outcomes. Multimodality imaging is pivotal for grading the regurgitation severity, determining the underlying pathology, assessing RV function and pulmonary pressures, identifying concomitant cardiac disease, and selecting the most beneficial treatment modality and access. This article reviews the role of different imaging modalities in guiding the management of patients with significant tricuspid valve regurgitation.

Endomyocardial Biopsy Using Rigid Bioptome Technique and the Risk of Tricuspid Regurgitation after Heart Transplantation. / Biópsia Endomiocárdica por Meio de Técnica de Biótomo Rígido e Risco de Regurgitação Tricúspide após Transplante Cardíaco.

Endomyocardial biopsy (EB) is the preferred procedure for post-heart transplant rejection diagnosis. The rigid bioptome technique has been used due to its greater simplicity and has been criticized for the potential risk of tricuspid regurgitation (TR). We aimed to review all the EBs performed by this technique in a tertiary center and estimate the rate of complications and/or aggravation of TR. Cross-sectional, retrospective, anterograde study. Data were collected from 729 EBs performed in 55 post-heart transplant patients with a rigid Scholten Novatome™ bioptome between September 2012 to March 2022. All EBs were performed via the right jugular vein under local anesthesia and through micro-puncture and ultrasound guidance. A total of 729 procedures had an echocardiography performed before and after the procedures. The estimate of TR was categorized as absent, minimal, mild, moderate, and severe. McNemar's chi-square test was used to analyze the degree of pre- and post-EB TR. There was a worsening enough to become moderate or severe post-biopsy TR in two (0.27%) procedures, and there was a slight change in TR from minimal to mild TR in 25 (3.42%) procedures. In 729 percutaneous EBs performed with a rigid bioptome, there was no myocardial perforation, cardiac tamponade or pneumothorax. One death occurred within 24 hours after the procedure for an unknown reason. EB using a rigid bioptome is safe and has not been associated with worsening TR in a follow-up of 729 EBs performed after cardiac transplantation. The overall complication rate, including moderate to severe TR, was 0.81%. The mortality rate was 0.14%.

A biópsia endomiocárdica (BE) é o procedimento de preferência para o diagnóstico de rejeição pós-transplante cardíaco. A técnica de biótomo rígido tem sido usada devido à sua maior simplicidade e tem sido criticada pelo risco potencial de regurgitação tricúspide (RT). Nosso objetivo foi revisar todas as BEs realizadas por meio dessa técnica em um centro terciário e estimar a taxa de complicações e/ou agravamento por RT. Estudo transversal, retrospectivo, anterógrado. Os dados foram coletados de 729 BEs realizadas em 55 pacientes pós-transplante cardíaco, com um biótomo rígido Scholten Novatome™ entre setembro de 2012 e março de 2022. Todas as BEs foram realizadas pela veia jugular direita sob anestesia local e por meio de micropunção e orientação por ultrassom. Um total de 729 procedimentos tiveram ecocardiografia realizada antes e depois dos procedimentos. A estimativa da RT foi categorizada como ausente, mínima, leve, moderada e grave. O teste qui-quadrado de McNemar foi usado para analisar o grau de RT pré e pós-BE. Houve piora suficiente para se tornar RT moderada ou grave pós-biópsia em 2 (0,27%) procedimentos, e houve uma ligeira alteração na RT de mínima para leve em 25 (3,42%) procedimentos. Em 729 BEs percutâneas realizadas com um biótomo rígido, não houve perfuração miocárdica, tamponamento cardíaco ou pneumotórax. Uma morte ocorreu dentro de 24 horas após o procedimento, por motivo desconhecido. A BE com biótomo rígido é segura e não foi associada à piora da RT no acompanhamento de 729 BEs realizadas após transplante cardíaco. A taxa geral de complicações, incluindo RT moderada a grave, foi de 0,81%. A taxa de mortalidade foi de 0,14%.

Comparative analysis of MitraClip/TriClip and PASCAL in transcatheter tricuspid valve repair for tricuspid regurgitation: a systematic review and meta-analysis.

BACKGROUND: The edge-to-edge transcatheter tricuspid valve repair (TTVR) has emerged as a promising technique for the treatment of tricuspid regurgitation (TR). Despite its potential, comparative data on the performance of the novel edge-to-edge devices-MitraClip, PASCAL, and TriClip-remain controversial. In this study, we aim to evaluate the safety and efficacy of these devices in treating TR. METHODS: Five databases were systematically searched up to May 2023, with an updated search conducted in May 2024. Only original studies were included in the analysis and were critically evaluated using an adapted version of the Newcastle-Ottawa Scale (NOS) for observational cohort studies and the Cochrane Risk of Bias (ROB) tool for randomized controlled trials. RESULTS: The database search yielded 2239 studies, out of which 21 studies were included in the final analysis. These studies encompassed a total of 2178 patients who underwent TTVR using either the MitraClip, TriClip, or PASCAL devices. The risk of bias across these studies ranged from moderate to high. No significant differences were found among the three devices in terms of effective regurgitant orifice area (EROA) and tricuspid regurgitant volume. However, TriClip demonstrated statistically superior efficacy in reducing vena contracta compared to both MitraClip and PASCAL (P < 0.01) [TriClip: (MD = -7.4; 95% CI: -9.24, -5.56), MitraClip: (MD = -4.04; 95% CI: -5.03, -3.05), and PASCAL: (MD = -6.56; 95% CI: -7.76, -5.35)]. The procedural success rates and incidence of single leaflet device attachment (SLDA) were similar across all devices. Furthermore, there were no significant differences in mortality, stroke rates, or major bleeding events among the three devices. CONCLUSION: The TriClip outperforms the MitraClip and PASCAL in reducing vena contracta width, indicating greater effectiveness for severe tricuspid regurgitation. All devices show similar safety profiles and procedural success rates. Further research is needed to confirm these results.

Assessment of the Right Ventricle Function in Patients With Significant Tricuspid Regurgitation: A Review.

Tricuspid regurgitation (TR) is an increasingly prevalent condition, especially in older populations, and presents significant challenges due to its association with right heart failure, hospital admissions, and high mortality rates. The management of TR has evolved, with new percutaneous valve repair and replacement techniques emerging alongside traditional surgical approaches. However, accurately assessing right ventricular (RV) function-a key prognostic factor in TR-remains difficult due to the RV's unique anatomy and sensitivity to loading conditions. Current echocardiographic methods, such as Tricuspid Annular Plane Systolic Excursion (TAPSE), S' wave analysis, and RV fractional area change (FAC), offer valuable insights but have limitations, particularly regarding load dependence and incomplete assessment of RV function. Advances in 3D echocardiography and myocardial strain imaging provide more comprehensive evaluations, yet challenges persist in integrating these measures in routine clinical practice. The review highlights the importance of a multimodal approach to RV assessment in TR patients, considering both the right atrium and pulmonary artery interactions, and explores potential future tools such as myocardial work and dynamic testing to improve prognostic accuracy and patient outcomes.

[Clinical characteristics of patients with moderate or severe valvular heart disease].

Objective: To describe the characteristics, etiology and patterns of outpatients and inpatients patients with moderate or severe valvular heart disease (VHD). Methods: This is a cross-sectional study. Outpatients and inpatients with moderate or severe VHD who underwent transthoracic echocardiography for first examination from 1st January 2001 to 1st January 2020 in Southwest Hospital, Army Medical University were enrolled. Data were collected from medical records and big data platform of Southwest Hospital. Characteristics of age and gender, etiology and types of VHD were descriptively analysed. Results: A total of 68 354 patients with moderate or severe VHD were enrolled. The age was 63 (50, 72) years. And 35 706 (52.24%) patients were female. (1) Age characteristics: There was similar age trend between male and female patients with moderate or severe VHD. The number of patients increased firstly and then decreased and reached its peak in the age group of 65-69 years old. The peak age of mitral stenosis patients was 45-49 years, which was earlier than that of whole patients with moderate or severe VHD. The median age of patients with bicuspid aortic valve was 42 years. (2) Gender characteristics: The proportion of tricuspid regurgitation, pulmonary regurgitation, mitral regurgitation, mitral stenosis and valve surgery in female patients with moderate or severe VHD were higher than those in male patients. The proportion of aortic regurgitation, aortic stenosis and bicuspid aortic valve in male patients with moderate or severe VHD were significantly higher than those in female patients (all P<0.05). (3) Etiology: The proportion of rheumatic VHD was 13.07% (8 934/68 354), which was higher than that of degenerative VHD (0.67% (458/68 354)). (4) Types of VHD: Tricuspid regurgitation made contribution to the largest proportion with 60.72% (41 503/68 354), followed by mitral regurgitation, aortic regurgitation, mitral stenosis, pulmonary regurgitation and aortic stenosis. Conclusions: There are certain regional characteristics in the prevalence of moderate or severe VHD in southwest China, suggesting different attention should be paid on the whole process of refined management of moderate or severe VHD.

Sex-based differences in candidacy for transcatheter tricuspid valve intervention.

BACKGROUND: Women have a higher prevalence of tricuspid regurgitation (TR) and present at more advanced stages as compared with men. Given the high operative mortality associated with tricuspid valve (TV) surgery, transcatheter tricuspid valve interventions (TTVI) have emerged as a promising treatment option. We explored sex-based differences among patients with significant TR who would be expected to be eligible for TTVI. METHODS: Between March 2021-2022, 12,677 unique adult patients underwent a transthoracic echocardiogram at our tertiary care institution. Clinical and echocardiographic data were collected for patients with more than moderate TR. The 2021 European Society of Cardiology valve guidelines were used to retrospectively define sub-populations who would have been eligible for TTVI, TV surgery, or medical therapy. Patients were grouped by sex and compared using t-tests, Wilcoxon rank-sum, Pearson chi-square, and Cox regression for survival analysis. RESULTS: Of 569 patients, 52% (296/569) were female. Men had a higher prevalence of left ventricular dysfunction (p < 0.001), mitral regurgitation (p = 0.023), and signs of heart failure (New York Heart Association stage III (p = 0.031)). Women had more isolated TR (p = 0.020) and TR due to severe pulmonary hypertension (p < 0.001). Most patients (74.6% of women, 76.9% of men) were precluded from both transcatheter and surgical intervention due to advanced disease. 10.8% of women and 9.2% of men would have qualified for TTVI (p = 0.511). CONCLUSION: The majority of patients with significant TR presenting to a tertiary care center are not eligible for TTVI. Sex is not a predictor of eligibility for TTVI among patients with significant TR.

EVOQUE Tricuspid Valve Replacement System: State-of-the-Art Screening and Intraprocedural Guidance.

With the recent approval of the transcatheter EVOQUE tricuspid valve replacement system to treat severe, symptomatic tricuspid regurgitation, there is a need to define the appropriate patient population and anatomical considerations for this device. In this consensus document, the authors review these considerations, describe the procedural steps and imaging requirements to ensure technical success, and discuss management of complex intraprocedural circumstances.

Three-Dimensional Geometry Values and Clinical Determinants for the Annulus of the Tricuspid Valve in a Japanese Population.

The tricuspid annulus (TA) is the primary target of tricuspid valve (TV) surgery for tricuspid regurgitation (TR). However, the reference values for TA geometry in the Japanese population is currently unavailable. We aimed to elucidate the geometric reference values of the TA in Japanese individuals using 3-dimensional (3D) echocardiography.We conducted a prospective study using transthoracic 3D echocardiography on 142 healthy Japanese subjects aged between 20 and 79 years. The tricuspid geometric parameters in the late-diastole and the mid-systole were analyzed using custom 3D software (Realview™).After excluding 46 subjects with poor images, data from 96 subjects (67.6%) were analyzed. TA area and circumference showed strong correlations with body surface area (BSA) (P < 0.001 for all), while some of these parameters exhibited weak correlations with age. Gender differences in TV geometry were assessed across 3 age groups: 20-39 years (42 subjects), 40-59 years (28 subjects), and 60-79 years (26 subjects). In the youngest subjects (20-39 years), males had a significantly larger TA area and smaller anterior-posterior and medial-lateral diameters (P < 0.001 for all), even after adjusting for BSA, indicating gender differences of TA geometry. These differences diminished with age.We present reference values for TA geometry by age and gender in a Japanese cohort. BSA may be a suitable metric for indexing the TA parameters. While age-related changes in TA parameters may not be significant, gender differences, particularly in younger individuals, persist even after adjusting for BSA.

Permanent pacemaker implantation after combined mitral- and tricuspid valve surgery: a nationwide multicentre study.

OBJECTIVES: The threshold to perform concomitant tricuspid valve (TV) repair during primary mitral valve (MV) surgery has decreased, based on recent randomized evidence. Based on these developments, the indication for TV repair during MV surgery is expected to increase further. However, concerns have been raised regarding the risk of permanent pacemaker implantation (PPI) during a concomitant procedure. Therefore, we aim to assess the incidence of PPI in combined MV and TV surgery in a nationwide registry. METHODS: The current study uniquely cross-linked the Cardiothoracic and Pacemaker/ICD registry of the Netherlands Heart Registration. Patients undergoing primary MV and TV surgery (± atrial septal defect closure, rhythm surgery, coronary artery bypass grafting) between 1 January and 31 December2021 were included. The primary outcome was PPI within 30 days after surgery. Subgroup analyses were performed for isolated MV and TV surgery and MV repair. The association between concomitant TV surgery and PPI was assessed using multivariable binary logistic regression analyses. RESULTS: A total of 1060 patients (n = 833 MV, n = 227 MV + TV) were included. The overall incidence of PPI was 4.3%. No significant difference in PPI between MV and MV + TV surgery were found (3.7% vs 6.6%, P = 0.06). Concomitant TV surgery was not an independent risk factor for PPI after surgery after adjustment for covariates. These results were robust after sensitivity analyses. CONCLUSIONS: The current study was not able to find a statistical difference between the PPI rate in MV surgery patients and MV + TV surgery patients. Extension of the waiting period prior to PPI, may result in decreased PPI rates.

Tricuspid Valve Transcatheter Edge-to-Edge Repair (TriClip): Initial Outcomes and Experience in Türkiye.

OBJECTIVE: This study aims to assess the efficacy and safety of tricuspid valve (TV) transcatheter edge-to-edge repair (TEER) procedures using the MitraClip or TriClip device in high-risk patients with severe secondary tricuspid regurgitation (TR) and provide Turkish-specific data on procedural outcomes and clinical follow-up. METHODS: This study enrolled 42 high-risk patients with severe secondary TR who underwent transcatheter edge-to-edge repair using either the MitraClip or TriClip device. Patient selection criteria included severe TR, high surgical risk (EuroScore ≥ 8 and Tricuspid Regurgitation Impact Severity Score (TRI-SCORE) ≥ 6), symptomatic despite medical therapy, and anatomical suitability for TriClip. Patients underwent rigorous evaluation by a specialized cardiac team before the procedure, including 2D/3D transesophageal echocardiography to assess eligibility. RESULTS: The study achieved a 100% procedural success rate, defined as successful implantation and at least one-degree reduction in TR severity. Post-procedure assessments revealed that 88.1% of patients had mild to moderate TR, indicating significant improvement, while only 11.9% retained severe TR. During the median follow-up of 11.5 months, rehospitalization occurred in 23.8% of patients, and mortality was observed in 7.1% of patients, demonstrating a favorable safety profile. Comparative analysis between TriClip and MitraClip devices showed similar efficacy and safety outcomes, with no significant differences in procedural durations or complication rates. CONCLUSION: The study demonstrates the effectiveness and safety of TV TEER using TriClip or MitraClip devices in managing severe secondary TR in high-risk patients. Procedure success, improved TR severity, and favorable clinical outcomes were observed, supporting the role of transcatheter techniques in TR management.