Anatomical and electrical remodeling with incomplete left atrial appendage ligation: Results from the LAALA-AF registry.

BACKGROUND: The anatomical, electrical, and clinical impact of incomplete Lariat left atrial appendage ligation remains unclear. METHODS: We studied LAA anatomy pre- and postligation using contrast enhanced-computed tomography (CT) scans in 91 patients with atrial fibrillation (AF) who subsequently underwent catheter ablation (CA). RESULTS: Eleven patients had an incomplete exclusion (12%) with a central leak ranging from 1 to 5 mm. Despite incomplete ligation; the LAA volume were reduced by 67% postprocedurally when compared to preprocedure. In 7 patients with a leak between 1 and 3 mm, there was a 77% reduction in LAA volume beyond the ligation site suggestive of remodeling of the LAA. In 4 patients with larger (4-5 mm) leak the LAA remnants (LAARs) were slightly larger than those with smaller leaks on follow-up CT scan. Three out of the 4 demonstrated LAA electrical activity during CA and underwent isolation of the LAA ostium. Follow-up imaging showed two of these LAARs completely sealed with no communication with the left atrium. There was no significant difference in the AF recurrence rates between the patients who had a leak versus those with complete ligation (4 of 11 [36%] vs. 22 of 80 [27%]; P  =  0.6). Oral anticoagulation was discontinued in all patients with small leaks and 2 patients with large leaks that sealed completely upon follow-up imaging. There were no strokes or TIAs at 12 months. CONCLUSION: Despite incomplete LAA ligation by Lariat device there is significant anatomical and electrical remodeling that resulted in reduction in LAA size, volume, and electrical activity.

Impact of Periprocedural Colchicine on Postprocedural Management in Patients Undergoing a Left Atrial Appendage Ligation Using LARIAT.

INTRODUCTION: Left atrial appendage (LAA) can be effectively and safely excluded using a novel percutaneous LARIAT ligation system. However, due to pericardial catheter manipulation and LAA ligation and subsequent necrosis, postprocedural course is complicated by pericarditis. We intended to evaluate the preprocedural use of colchicine on the incidence of postprocedural pericardial complications. METHODS AND RESULTS: In this multicenter observational study, we included all consecutive patients who underwent LARIAT procedure at the participating centers. Many patients received periprocedural colchicine at the discretion of the physician. We compared the postprocedural outcomes of patients who received prophylactic periprocedural colchicine (colchicine group) with those who did not receive colchicine (standard group). A total of 344 consecutive patients, 243 in the "colchicine group" and 101 in the "standard group," were included. The mean age, median CHADS2VASc score, and HASBLED scores were 70 ± 11 years, 3 ± 1.7, and 3 ± 1.1, respectively. There were no significant differences in major baseline characteristics between the two groups. Severe pericarditis was significantly lower in the "colchicine group" compared to the "standard group" (10 [4%] vs. 16 [16%] P<0.0001). The colchicine group, compared to the standard group, had lesser pericardial drain output (186 ± 84 mL vs. 351 ± 83, P<0.001), shorter pericardial drain duration (16 ± 4 vs. 23 ± 19 hours, P<0.04), and similar incidence of delayed pericardial effusion (4 [1.6%] to 3 [3%], P = 0.42) when compared to the standard group. CONCLUSION: Use of colchicine periprocedurally was associated with significant reduction in postprocedural pericarditis and associated complications.

Sequential Percutaneous LAA Ligation and Pulmonary Vein Isolation in Patients with Persistent AF: Initial Results of a Feasibility Study.

INTRODUCTION: Left atrial appendage (LAA) ligation results in LAA electrical isolation and a decrease in atrial fibrillation (AF) burden. This study assessed the feasibility of combined percutaneous LAA ligation and pulmonary vein isolation (PVI) in patients with persistent AF. METHODS AND RESULTS: A total of 22 patients with persistent AF underwent LAA ligation with the LARIAT device followed by PVI. PVI was confirmed with the demonstration of both entrance and exit block. Patients (n = 10) in sinus rhythm pre- and post-LAA ligation underwent P-wave analysis. Monitoring for AF was performed at 1, 3, and 6 months postablation. LAA ligation was successful in 21 of 22 (95%) patients. The procedure was aborted in one patient due to pericardial adhesions. PVI was performed in 20 of 21 patients. One patient converted to atrial flutter with a controlled ventricular response after LAA ligation and refused subsequent PVI. Demonstration of entrance and exit block was achieved in 19 of 20 patients. At 3 months, 13 of 19 (68.4%) patients were in sinus rhythm. Four patients underwent a second PVI. At 6 months, 15 of 20 (75%) patients were in sinus rhythm. There was a significant decrease in P-wave duration and P-wave dispersion after LAA ligation. Complications with LAA ligation included pericarditis, a delayed pleural effusion, and a late pericardial effusion. CONCLUSIONS: Staged LAA ligation and PVI is feasible and decreases P-wave dispersion. Randomized studies are needed to assess the efficacy of LAA ligation as adjunctive therapy to PVI for maintaining sinus rhythm in patients with persistent AF.

Characterization of pleural effusion after left atrial appendage exclusion using the Lariat procedure.

BACKGROUND: The Lariat procedure is increasingly used for the exclusion of the left atrial appendage (LAA) in atrial fibrillation (AF) patients. There are anecdotal reports of pleural effusions after the Lariat procedure. However, the incidence, demographics, and pathophysiology of these effusions are largely unknown. OBJECTIVE: Characterization of pleural effusions in patients who underwent LAA exclusion using the Lariat procedure. METHODS: We report the incidence, demographics, and clinical and laboratory characteristics of patients from a multicenter prospective registry who underwent the Lariat procedure and subsequently developed pleural effusions. RESULTS: A total of 10 out of 310 (3.2%) patients developed significant pleural effusions after the Lariat procedure. The mean age of these patients was 67 ± 9, ranging from 52 to 78 years and included 5 (50%) males. Nine patients had persistent AF with median CHADS2 score of 2.7 ± 1.2. The LAA was successfully ligated in all these patients. Post-Lariat procedure, 6 patients developed bilateral and 4 patients developed left-sided pleural effusions. Pleural tap revealed transudative in 2 and exudative in 6 patients. The remaining 2 patients responded to active diuresis and behaved clinically like transudative effusions. There is a statistically significant difference between the onset of pleural effusion after the Lariat procedure between tPLE versus ePLE groups (14 ± 1.2 vs. 6 ± 6, P = 0.05). CONCLUSION: Incidence of clinically significant pleural effusion is uncommon after the Lariat procedure and can be either exudative or transudative in nature depending on the underlying mechanisms. More prospective studies are needed to study the pathophysiologic basis of development of pleural effusions after the Lariat procedure.

An Unexpected Outcome of Streptococcus sanguinis Endocarditis Associated With Orthodontic Bracing in a Young Healthy Patient.

We present a case of Streptococcus sanguinis endocarditis in a 26-year-old female following orthodontic bracing. The rarity and debilitating consequences of endocarditis caused by Streptococcus sanguinis are elaborated. The patient exhibited severe regurgitation with the eccentric posteriorly directed flow, leading to significant cardiac strain, further accentuated by systolic flow reversal in the right superior pulmonary vein. Surgical intervention, including mitral valve replacement, was crucial in addressing the underlying infection, restoring valve function, and preventing further complications. However, a second mitral valve replacement was performed due to recurrent bioprosthesis endocarditis. This case underscores the unique challenges of Streptococcus sanguinis endocarditis, emphasizing the need for a multidisciplinary approach and individualized decision-making to optimize patient care.

A Collaborative Case Report Utilizing ChatGPT AI Technology of Traumatic Right Coronary Artery Dissection Resulting in Inferior Wall ST-Elevation Myocardial Infarction.

Traumatic Coronary Artery Dissection (TCAD) is a rare but potentially life-threatening condition that can occur as a result of blunt chest trauma. This case report presents the case of a 67-year-old male who presented to the hospital after a motor vehicle accident with chest pain and ECG showing an inferior wall ST-elevation myocardial infarction. Further imaging revealed a nondisplaced fracture of the right side of C2 and a left 12th rib. Coronary angiography showed a dissection in the distal segment of the right coronary artery. The patient was given heparin and underwent coronary stenting of the right coronary artery. The patient was monitored in the intensive care unit for any post-traumatic complications and was managed conservatively for the cervical fracture. This case report highlights the importance of prompt diagnosis and comprehensive treatment in TCAD cases to improve outcomes and prevent further complications.

A Case of Lactobacillus casei Endocarditis Associated With Probiotic Intake in an Immunocompromised Patient.

Probiotics are microorganisms, typically bacteria, similar to beneficial microbiota found in the human gut, usually consumed as dietary supplements or fermented foods. Although probiotics are generally safe, several cases of bacteremia, sepsis, and endocarditis associated with probiotics have been reported. Here we report a rare case of Lactobacillus casei endocarditis in a 71-year-old female, immunocompromised due to chronic steroid intake, who presented with a productive cough and low-grade fever. Blood cultures grew L. casei resistant to vancomycin and meropenem. Transesophageal echocardiography showed mitral and aortic vegetations; valve replacement was done after successfully removing vegetations. She was treated with a six-week course of daptomycin and recovered.

Tricuspid regurgitation: pathophysiology and management.

Tricuspid regurgitation (TR) is one of the most commonly encountered valvular problems in clinical practice. Although diagnosed easily with echocardiography, it contributes to significant mortality and morbidity when severe. Once thought to be a benign functional valvular abnormality, TR has received more attention in recent years and different treatment options have emerged. However, there is no consensus regarding the superiority of one treatment approach over another. With the development of percutaneous atrioventricular valves, new horizons are open for exploration in the treatment of TR. Clinical indications of treatment are likely to change with increased use of left ventricular assist devices and increased survival of patients with poor right ventricular function. This review discusses the pathophysiology and management of TR along with newer treatment modalities currently under investigation.

The Full Spectrum of Infective Endocarditis: Case Report and Review.

Over the past five decades, the incidence of intravenous drug use- (IVDU-) associated infective endocarditis (IE) has been on the rise in North America. Classically, IVDU has been thought to affect right-sided valves. However, in recent times a more variable presentation of IVDU-associated IE has been reported. Here, we report a case of a patient with a known history of IVDU who presented with clinical symptoms concerning for right- as well as left-sided endocarditis. In addition, we also discuss what should be considered adequate evaluation for patients with suspected endocarditis, and more specifically, what should be the role of transesophageal echocardiography in patients with IE noted on transthoracic echocardiography.

Impact of Radiofrequency Ablation of Atrial Fibrillation on Pulmonary Vein Cross Sectional Area: Implications for the Diagnosis of Pulmonary Vein Stenosis.

INTRODUCTION: Restoration of normal sinus rhythm by radiofrequency ablation (RFA) in atrial fibrillation (AF) patients can result in a reduction of left atrial (LA) volume and pulmonary vein (PV) dimensions. It is not clear if this PV size reduction represents a secondary effect of overall LA volume reduction or true PV stenosis. We assessed the relationship between LA volume reduction and PV orifice area pre- and post-RFA. METHODS: A retrospective cohort study was conducted at a tertiary care academic hospital. Pre- and post-RFA cardiac computed tomography (CT) studies of 100 consecutive AF patients were reviewed. Studies identifying obvious segmental PV narrowing were excluded. Left atrial volumes and PV orifice cross-sectional areas (PVOCA) were measured using proprietary software from the CT scanner vendor (GE Healthcare, Waukesha, WI). RESULTS: The cohort had a mean age of 60 ± 8 years, 73% were male, and 90% were Caucasian. Non-paroxysmal AF was present in 76% of patients with a mean duration from diagnosis to RFA of 55 ± 54 months. Mean procedural time was 244 ± 70 min. AF recurred in 27% at 3 month follow-up. Pre-RFA LA volumes were 132 ± 60 ml and mean PVOCA was 2.89 ± 2.32 cm2. In patients with successful ablation, mean LA volume decreased by 10% and PVOCA decreased by 21%. PVOCA was significantly reduced in patients with successful RFA compared to those who had recurrence (2.18 ± 1.12 vs. 2.8 ± 1.9 cm2, p = 0.04) but reduction in LA volume between groups was not significant (118 ± 42 vs. 133 ± 54 ml, p=0.15). CONCLUSIONS: The study demonstrates that both PV orifice dimensions and LA volume are reduced after successful AF ablation. These data warrant a reassessment of criteria for diagnosing PV stenosis based on changes in PV caliber alone, ideally incorporating LA volume changes.

A dilated inferior vena cava is a marker of poor survival.

BACKGROUND: The inferior vena cava (IVC) morphology is often used to estimate right atrial pressure; however, the association of IVC morphology and outcome is poorly described. METHODS: We evaluated 4383 consecutive outpatients (98% men) undergoing echocardiography at 1 of 3 Veterans Affairs laboratories. RESULTS: Of the 3729 with adequate images, 3295 (88%) had a normal IVC (< 2 cm), 358 (10%) had a dilated IVC that collapsed at least 50% with inspiration, and 76 (2%) had dilated IVC that did not collapse. Compared with patients with a normal IVC, those with a dilated IVC were older (66 +/- 13 vs 69 +/- 12 years if dilated with collapse and 70 +/- 12 years if dilated without collapse, P = .0005) and were more likely to have a history of heart failure (11% vs 18% if dilated with collapse and 38% if dilated without collapse, P < .0001). The 90-day and 1-year survival rates were 99% and 95% for those with a normal IVC, 98% and 91% for those with a dilated IVC with collapse, and 89% and 67% for those with a dilated IVC without collapse (P < .0001). After adjustment for clinical and echocardiographic characteristics including left and right ventricular function and pulmonary artery pressure, a dilated IVC without collapse remained associated with increased mortality: hazard ratio 1.43 (1.29-1.57 compared with a normal IVC, P < .0001). CONCLUSION: A dilated IVC without collapse with inspiration is associated with worse survival in men independent of a history of heart failure, other comorbidities, ventricular function, and pulmonary artery pressure.

Five years of keeping a watch on the left atrial appendage-how has the WATCHMAN fared?

Left atrial appendage closure (LAAC) is a promising site-directed therapy for stroke prevention in patients with non-valvular atrial fibrillation (AF) who are ineligible or contraindicated for long-term oral anticoagulation. A variety of LAAC modalities are available, including percutaneous endocardial occluder devices such as WATCHMANTM (Boston Scientific Corp., Marlborough, MA, USA), and an ever-increasing body of evidence is helping to define the optimal use of each technique. Similarly increased experience with LAAC has revealed challenges such as device-related thrombi and peri-device leaks for which the long-term significance and appropriate management are areas of active investigation. We review the evolution and long-term outcomes with the WATCHMANTM device with particular emphasis on the nuances of its use and its role in the broader landscape of appendageology.

Short and long-term outcomes of percutaneous left atrial appendage suture ligation: Results from a US multicenter evaluation.

BACKGROUND: Published studies of epicardial ligation of left atrial appendage (LAA) have reported discordant results. OBJECTIVE: The purpose of this study was to delineate the safety and efficacy of LAA closure with the LARIAT device. METHODS: This is a multicenter registry of 712 consecutive patients undergoing LAA ligation with LARIAT at 18 US hospitals. The primary end point was successful suture deployment, no leak by intraprocedural transesophageal echocardiography (TEE), and no major complication (death, stroke, cardiac perforation, and bleeding requiring transfusion) at discharge. A leak of 2-5 mm on follow-up TEE was the secondary end point. RESULTS: LARIAT was successfully deployed in 682 patients (95.5%). A complete closure was achieved in 669 patients (98%), while 13 patients (1.8%) had a trace leak (<2 mm). There was 1 death related to the procedure. Ten patients (1.44%) had cardiac perforation necessitating open heart surgery, while another 14 (2.01%) did not need surgery. The risk of cardiac perforation decreased significantly after the introduction of a micropuncture (MP) needle for pericardial access. Delayed complications (pericarditis requiring >2 weeks of treatment with nonsteroidal anti-inflammatory drugs/colchicine and pericardial and pleural effusion after discharge) occurred in 34 (4.78%) patients, and the risk decreased significantly with the periprocedural use of colchicine. Follow-up TEE (n = 480) showed a leak of 2-5 mm in 6.5% and a thrombus in 2.5%. One patient had a leak of >5 mm. CONCLUSION: LARIAT effectively closes the LAA and has acceptable procedural risks with the evolution of the use of the micropuncture needle for pericardial access and the use of colchicine for mitigating the postinflammatory response associated with LAA ligation and pericardial access.

Impact of tricuspid regurgitation on long-term survival.

OBJECTIVES: The goal of this study was to examine mortality associated with tricuspid regurgitation (TR) after controlling for left ventricular ejection fraction (LVEF), right ventricular (RV) dilation and dysfunction, and pulmonary artery systolic pressure (PASP). BACKGROUND: Tricuspid regurgitation is a frequent echocardiographic finding; however, the association with prognosis is unclear. METHODS: We retrospectively identified 5,223 patients (age 66.5 +/- 12.8 years; predominantly male) undergoing echocardiography at one of three Veterans Affairs Medical Center laboratories over a period of four years. Follow-up data were available for four years (mean 498 +/- 402 days). Kaplan-Meier and proportional hazards methods were used to compare differences in survival among TR grades. RESULTS: Mortality increased with increasing severity of TR. The one-year survival was 91.7% with no TR, 90.3% with mild TR, 78.9% with moderate TR, and 63.9% with severe TR. Moderate or greater TR was associated with increased mortality regardless of PASP (hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.16 to 1.49 for PASP >40 mm Hg; HR 1.32, 95% CI 1.05 to 1.62 for PASP < or =40 mm Hg) and LVEF (HR 1.49, 95% CI 1.34 to 1.66 for EF <50%; HR 1.54, 95% CI 1.37 to 1.71 for EF > or =50%). When adjusted for age, LVEF, inferior vena cava size, and RV size and function, survival was worse for patients with moderate (HR 1.17, 95% CI 0.96 to 1.42) and severe TR (HR 1.31, 95% CI 1.05 to 1.66) than for those with no TR. CONCLUSIONS: We conclude that increasing TR severity is associated with worse survival in men regardless of LVEF or pulmonary artery pressure. Severe TR is associated with a poor prognosis, independent of age, biventricular systolic function, RV size, and dilation of the inferior vena cava.

Electrolyte and hemodynamic changes following percutaneous left atrial appendage ligation with the LARIAT device.

PURPOSE: The left atrial appendage (LAA) is a well-known source of atrial natriuretic peptide (ANP) and therefore plays an important role in homeostasis. The neurohormonal impact of epicardial exclusion of the LAA with the LARIAT procedure is unknown. In this proof-of-concept study, we postulated that LAA exclusion would impact homeostasis as evidenced by changes in electrolytes and blood pressure (BP). METHODS: A total of 76 patients who underwent successful LAA exclusion were enrolled in this retrospective observational study utilizing a prospective registry. Electrolytes, BP, and heart rate (HR) were monitored before LARIAT and post-LARIAT (24 and 72 h and 6 months). RESULTS: There was a significant reduction of systolic BP (mmHg) at 24 h (113.3 ± 16.0; p < 0.0001) and 72 h (119.0 ± 18.4 mmHg; p < 0.0001) post-LARIAT when compared with pre-LARIAT BP (138.2 ± 21.3). The reduction in systolic BP persisted at 6-month follow-up (128.8 ± 17.3; p = 0.0005). There was significant reduction in serum sodium (mmol/L) at 24 h (135.4 ± 3.6; p < 0.0001) and 72 h (136.3 ± 3.7; p < 0.001) post-LARIAT when compared to pre-LARIAT (138.7 ± 3.2). The reduction in sodium was not persistent at 6-month follow-up (138.4 ± 3.3; p = 0.453). CONCLUSIONS: LAA exclusion results in an early and persistent decrease in systolic BP. Additionally, there is an early decline in serum sodium, which normalizes at long-term follow-up. The underlying mechanism leading to these changes is not entirely clear; however, it is likely related to neurohormonal changes post LAA exclusion.

Left Atrial Appendage Ligation and Ablation for Persistent Atrial Fibrillation: The LAALA-AF Registry.

OBJECTIVES: This study was intended to evaluate the impact of adding the left atrial appendage (LAA) closure system (LARIAT) procedure to conventional atrial fibrillation (AF) ablation in patients with persistent AF. BACKGROUND: Percutaneous endoepicardial LARIAT may result in both mechanical and electrical exclusion of the LAA and aid in improving the outcomes of catheter ablation by eradicating the LAA triggers and altering the substrate. METHODS: We performed a prospective observational study of patients with persistent AF referred for AF ablation. Patients underwent LAA ligation with LARIAT procedure before undergoing AF ablation (LARIAT group). Age- and sex-matched persistent AF patients undergoing AF ablation during the same time frame were included in the control group (ablation-only group). RESULTS: A total of 138 patients were included in the study, with 69 patients in the LARIAT group. The mean age of the population was 67 ± 10 years, with 96 (70%) men. Left atrial (LA) size, CHADS2, CHADSVasc, and HAS-BLED scores were higher in the LARIAT group when compared with the ablation-only group. There were no differences in the type of lesions during AF ablation between the groups. The primary outcome of freedom from AF at 1 year off antiarrhythmic therapy after 1 ablation procedure was higher in the LARIAT group (45 [65%] vs. 27 [39%]; p = 0.002). More patients in the ablation-only group underwent repeat ablation because of AF recurrence (11 [16%] vs. 23 [33%]; p = 0.018). CONCLUSIONS: In patients with persistent AF, addition of LAA ligation with the LARIAT device to conventional ablation appears to improve the success rate of AF ablation.

Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: Understanding the differences in the location and type of leaks and their clinical implications.

BACKGROUND: Watchman and Lariat left atrial appendage (LAA) occlusion devices are associated with LAA leaks postdeployment. OBJECTIVE: The purpose of this study was to compare the incidence, characteristics, and clinical significance of these leaks. METHODS: We performed a multicenter prospective observational study of all patients who underwent LAA closure. Baseline, procedural, and imaging variables along with LAA occlusion rates at 30-90 days and 1-year postprocedure were compared. RESULTS: A total of 478 patients (219 with the Watchman device and 259 with the Lariat device) with successful implants were included. Patients in the Lariat group had a higher CHADS2 (congestive heart failure, hypertension, age >74 years, diabetes, stroke) score and a larger left atrium and LAA. A total of 79 patients (17%) had a detectable leak at 1 year. More patients in the Watchman group had a leak compared with those in the Lariat group (46 [21%] vs 33 [14%]; P = .019). All the leaks were eccentric (edge effect) in the Watchman group and concentric (gunny sack effect) in the Lariat group. The size of the leak was larger in the Watchman group than in the Lariat group (3.10 ± 1.5 mm vs 2.15 ± 1.3 mm; P = .001). The Watchman group had 1 device embolization requiring surgery and 2 pericardial effusions requiring pericardiocentesis. In the Lariat group, 4 patients had cardiac tamponade requiring urgent surgical repair. Three patients in each group had a cerebrovascular accident and were not associated with device leaks. CONCLUSION: The Lariat device is associated with a lower rate of leaks at 1 year as compared with the Watchman device, with no difference in rates of cerebrovascular accident. There was no correlation between the presence of residual leak and the occurrence of cerebrovascular accident.

Clinical correlates and mortality of hemodynamically significant tricuspid regurgitation.

BACKGROUND AND AIM OF STUDY: Limited data exist regarding the etiologies and prognostic significance of severe tricuspid regurgitation (TR) in the modern medical era. This retrospective chart review examines the causes of, and mortality associated with, hemodynamically significant TR. METHODS: The database of the echocardiography laboratory at a major academic medical center was searched from August 2000 to October 2001, identifying 91 patients (1.2%) with transthoracic echocardiograms demonstrating moderate-severe or severe TR. A total of 77 available charts was reviewed retrospectively for medical history, examination and electrocardiogram findings. The underlying cause of each patient's TR was determined by compiling data from the chart and echocardiogram. All deaths were recorded from the date of echocardiography until September 2002. RESULTS: A cause for TR was determined in 96% of patients. Functional TR due to right ventricular pressure or volume overload was found in 85.5% of patients, while 14.5% had primary TR due to organic abnormalities of the tricuspid valve leaflets. Conditions associated with significant TR included pulmonary hypertension (46%), ischemic cardiomyopathy (25%), non-ischemic dilated cardiomyopathy (8%), Ebstein's anomaly (4%), rheumatic heart disease (4%), endocarditis (4%), tricuspid valve prolapse (2%), and severe mitral valve disease (2%). Of 37 patients (44.6%) who died, 17 (21%) did so within one month of the echocardiogram. CONCLUSION: Among patients presenting to a tertiary medical center, hemodynamically significant TR was more commonly functional than due to organic tricuspid valve disease. The most frequently associated diseases included pulmonary hypertension and cardiomyopathy. Significant TR may be a marker of increased mortality risk as it reflects the severity of underlying disease. Further studies in this area are warranted.