Aortic Arch Debranching and Thoracic Endovascular Aortic Repair (TEVAR) for Type B Aortic Dissection.

BACKGROUND: Since its introduction, thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of type B aortic dissections (TBADs). However, the proximal aspect of the aortic pathology treated may infringe on the origin of the left subclavian artery or even more proximally. Hence, to ensure durable outcomes, the origin of these vessels needs to be covered, but an extra-anatomical bypass is required to perfuse vital branches, known as aortic arch debranching. This series aims to describe and delineate the disparities of aortic arch debranching during TEVAR for TBAD. METHODS: A retrospective review and analysis of a multicenter international database was conducted to identify patients with TBAD treated with TEVAR between 2005 and 2021. Data analyzed included patient demographics, disease characteristics, operative characteristics, and postoperative outcomes with follow-up on mortality and reintervention. All statistical analyses were carried out using IBM SPSS 26. Patient survival was calculated using a Kaplan-Meier survival analysis, and a P value of less than 0.05 was considered statistically significant. RESULTS: A total of 58 patients were included in the analysis, of which 27 (46.6%) presented with complicated disease and 31 were uncomplicated, of which 10 (17.2%) were classed as high risk and 21 (36.2%) low risk. Zone 2 was the most common proximal landing zone for the stent graft. Left subclavian artery bypass was performed selectively (26%), with 1 stroke occurring, likely due to embolic reasons. A further 6 underwent more proximal aortic debranching before TEVAR (10%) and was a significant risk factor for mortality and the number of stents deployed. The overall rates of reintervention and mortality were 17.2% (n = 10) and 29.3% (n = 17). CONCLUSIONS: Aortic arch debranching and TEVAR for TBAD is associated with significant mortality. Future developments to treat aortic arch pathology could incorporate branched graft devices, eliminating the need for debranching, improving stroke rates, and reducing future reinterventions.

Uncomplicated Type B Aortic Dissection: Challenges in Diagnosis and Categorization.

BACKGROUND: Acute type B aortic dissection (TBAD) is a rare disease that is likely under-diagnosed in the UK. As a progressive, dynamic clinical entity, many patients initially diagnosed with uncomplicated TBAD deteriorate, developing end-organ malperfusion and aortic rupture (complicated TBAD). An evaluation of the binary approach to the diagnosis and categorisation of TBAD is needed. METHODS: A narrative review of the risk factors predisposing patients to progression from unTBAD to coTBAD was undertaken. RESULTS: Key high-risk features predispose the development of complicated TBAD, such as maximal aortic diameter > 40 mm and partial false lumen thrombosis. CONCLUSION: An appreciation of the factors that predispose to complicated TBAD would aid clinical decision-making surrounding TBAD.

Cardiothoracic surgery leadership and learning are indispensable to each other.

Cardiothoracic surgery is facing a multitude of challenges in leadership and training on the global scale, these being a complex and aging patient population, shortage of cardiac surgeons, diminishing student interest and trainee enthusiasm, increasingly challenging training obstacles and work-life imbalances, suboptimal job prospects, reports of discrimination and bullying and lack of diversity as well as gap between innovation and technology, clinical application, and training of future surgeons. The survival of cardiac surgery hinges on the leadership attracting and retaining young surgeons into the specialty. Mentoring, leading through example, recognizing the work-life imbalances, adapting to diverse and modern training models and embracing diversity with respect to gender and race, will ultimately be required to create and cultivate a nurturing environment of training and preparing future leaders. The vision for training future generations of cardiothoracic surgeons must rely heavily on strengthening the unity of the heart team. In doing so we can provide the best possible care for our patients and a most fulfilling career for the future generation of cardiac surgeons.

Effect of Transcatheter Aortic Valve Implantation vs Surgical Aortic Valve Replacement on All-Cause Mortality in Patients With Aortic Stenosis: A Randomized Clinical Trial.

Importance: Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical aortic valve replacement and is the treatment of choice for patients at high operative risk. The role of TAVI in patients at lower risk is unclear. Objective: To determine whether TAVI is noninferior to surgery in patients at moderately increased operative risk. Design, Setting, and Participants: In this randomized clinical trial conducted at 34 UK centers, 913 patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk due to age or comorbidity were enrolled between April 2014 and April 2018 and followed up through April 2019. Interventions: TAVI using any valve with a CE mark (indicating conformity of the valve with all legal and safety requirements for sale throughout the European Economic Area) and any access route (n = 458) or surgical aortic valve replacement (surgery; n = 455). Main Outcomes and Measures: The primary outcome was all-cause mortality at 1 year. The primary hypothesis was that TAVI was noninferior to surgery, with a noninferiority margin of 5% for the upper limit of the 1-sided 97.5% CI for the absolute between-group difference in mortality. There were 36 secondary outcomes (30 reported herein), including duration of hospital stay, major bleeding events, vascular complications, conduction disturbance requiring pacemaker implantation, and aortic regurgitation. Results: Among 913 patients randomized (median age, 81 years [IQR, 78 to 84 years]; 424 [46%] were female; median Society of Thoracic Surgeons mortality risk score, 2.6% [IQR, 2.0% to 3.4%]), 912 (99.9%) completed follow-up and were included in the noninferiority analysis. At 1 year, there were 21 deaths (4.6%) in the TAVI group and 30 deaths (6.6%) in the surgery group, with an adjusted absolute risk difference of -2.0% (1-sided 97.5% CI, -∞ to 1.2%; P < .001 for noninferiority). Of 30 prespecified secondary outcomes reported herein, 24 showed no significant difference at 1 year. TAVI was associated with significantly shorter postprocedural hospitalization (median of 3 days [IQR, 2 to 5 days] vs 8 days [IQR, 6 to 13 days] in the surgery group). At 1 year, there were significantly fewer major bleeding events after TAVI compared with surgery (7.2% vs 20.2%, respectively; adjusted hazard ratio [HR], 0.33 [95% CI, 0.24 to 0.45]) but significantly more vascular complications (10.3% vs 2.4%; adjusted HR, 4.42 [95% CI, 2.54 to 7.71]), conduction disturbances requiring pacemaker implantation (14.2% vs 7.3%; adjusted HR, 2.05 [95% CI, 1.43 to 2.94]), and mild (38.3% vs 11.7%) or moderate (2.3% vs 0.6%) aortic regurgitation (adjusted odds ratio for mild, moderate, or severe [no instance of severe reported] aortic regurgitation combined vs none, 4.89 [95% CI, 3.08 to 7.75]). Conclusions and Relevance: Among patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk, TAVI was noninferior to surgery with respect to all-cause mortality at 1 year. Trial Registration: isrctn.com Identifier: ISRCTN57819173.

Mechanical circulatory support-Challenges, strategies, and preparations.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is usually mild, but patients can present with pneumonia, acute respiratory distress syndrome (ARDS), and circulatory shock. Although the symptoms of the disease are predominantly respiratory, the involvement of the cardiovascular system is common. Patients with heart failure (HF) are particularly vulnerable when suffering from COVID-19. AIM OF THE REVIEW: To examine the challenges faced by healthcare organizations, and mechanical circulatory support management strategies available to patients with heart failure, during the COVID-19 pandemic. RESULTS: Extracorporeal membrane oxygenation (ECMO) can be lifesaving in patients with severe forms of ARDS, or refractory cardio-circulatory compromise. The Impella RP can provide right ventricular circulatory support for patients who develop right side ventricular failure or decompensation caused by COVID-19 complications, including pulmonary embolus. HT are reserved for only those patients with a high short-term mortality. LVAD as a bridge to transplant may be a viable strategy to get at-risk patients home quickly. Elective LVAD implantations have been reduced and only patients classified as INTERMACS profile 1 and 2 are being considered for LVAD implantation. Delayed recognition of LVAD-related complications, misdiagnosis of COVID-19, and impaired social and psychological well-being for patients and families may ensue. Remote patient care with virtual or telephone contacts is becoming the norm. CONCLUSIONS: HF incidence, prevalence, and undertreatment will grow as a result of new COVID-19-related heart disease. ECMO should be reserved for highly selected cases of COVID-19 with a reasonable probability of recovery. Special considerations are needed for patients with advanced HF, including those supported by durable LVADs.

Transcatheter aortic valve implantation versus surgical aortic valve replacement during the COVID-19 pandemic-Current practice and concerns.

COVID-19 has had a dramatic impact on the provision of healthcare. COVID-19 can manifest with cardiac and thrombotic presentations. Additionally, patients with cardiovascular comorbidities are at an increased risk of adverse outcomes related to COVID-19 infection. This in turn has led to a significant reduction in the provision of cardiac surgery with alternative management options utilized to address patients with significant disease. In terms of aortic valve disease, transcatheter aortic valve implantation (TAVI) provides advantages over surgical aortic valve replacement in with a lower burden on healthcare resources. COVID-19 also resulted in changes in management strategies and as such TAVI is now being considered in younger- and low-risk patients. However, long term data with regard to TAVI is still unknown, and the use in patient groups that have been excluded in the large pivotal studies that established TAVI as an alternative to surgery has raised specific concerns in the use of TAVI as the preferred treatment choice. With the long term ramification unknown, it is essential that decisions are made with caution.

Aortic valve replacement with sutureless Perceval S valve: A case report of aortic root homograft failure in the setting of Streptococcus constellatus endocarditis.

BACKGROUND: Surgery for failed homograft aortic root replacement with extensive calcification in the setting of endocarditis alone is very challenging. CASE SUMMARY: We report the case of redo aortic valve replacement and mitral valve replacement, in a 39 years old presenting with a rare Streptococcus constellatus endocarditis of a previously implanted homograft root and native mitral valve, where conventional valve replacement proved nonfeasible. S. constellatus had caused severe tissue destruction and the extensive calcification in the homograft prevented conventional valve replacement with sutures. In this case, a sutureless valve provided a useful alternative surgical strategy. DISCUSSION: We consider heavily calcified failed homografts to be a good indication for sutureless (rapid deployment) valves.

Impact of COVID-19 on cardiac surgical training: Our experience in the United Kingdom.

The current evolving global pandemic caused by coronavirus disease-2019 (COVID-19) has dramatically impacted global health care systems, resulting in governments taking unprecedented measures to contain the spread of the infection, with adaptations by health care organizations. Research into understanding the pathophysiology behind this virus, to ascertain best medical management and treatment, has been accelerated to keep up with the rapidly evolving situation. There has been redeployment of medical and nursing staff to the frontlines and redistribution of health care resources. In addition, the cancellation of elective surgery and centralization of services to treat high-risk surgical cases will all, undeniably, have an impact on current surgical training with possible future implications. We aim to explore the impact COVID-19 is having on cardiac surgical training in the UK and what future implications this may have.

Coronary artery bypass vs percutaneous coronary intervention in under 50s.

BACKGROUND: Young patients with coronary artery disease are undergoing percutaneous coronary intervention (PCI) primarily, with a view to deferring coronary artery bypass grafting (CABG). We investigated the validity of this approach, by comparing outcomes in patients ≤50 years undergoing CABG or PCI. METHODS: One hundred consecutive patients undergoing PCI and 100 undergoing CABG in 2004 were retrospectively studied to allow for 5 and 12 years follow-up. The two groups were compared for the primary endpoints of major adverse cardiac or cerebrovascular event (MACCE). RESULTS: Diabetes, peripheral vascular disease, and left ventricular ejection fraction <50% were higher in the CABG group. At 5 years, rates of myocardial infarction (MI) (9% vs 1%, P = .02), repeat revascularization (31% vs 7%, P < .01), and MACCE (34 vs 12, P < .01) were greater in the PCI vs the CABG group. Similarly, at 12 years, rates of MI (27.4% vs 19.4%, P = .19), repeat revascularization (41.1% vs 20.4%, P < .01), and MACCE (51 vs 40, P = .07) were greater in the PCI group. There were no differences in major outcomes in patients with 1 or 2VD, at 5 or 12 years. Rates of MI, revascularization, and MACCE were higher in patients with 3VD undergoing PCI (n = 21; MI, 47.6%; revascularization, 66.7%; and MACCE, 19 events) vs CABG (n = 78; MI, 19.2%; revascularization, 20.5%; and MACCE, 31 events); P < .01, for all end points. CONCLUSIONS: MACCE was lower in young patients undergoing CABG vs PCI at both 5 and 12 years follow-up, primarily as a consequence of patients with 3VD undergoing PCI having more MI and repeat revascularization. CABG should remain the preferred method of revascularization in young patients with 3VD.

Outcomes of Patients Presenting With Non-ST Elevation Myocardial Infarction Who Underwent Surgical Revascularization.

Non-ST-segment elevation myocardial infarction (NSTEMI) is a leading cause of emergency hospitalization across Europe. This study evaluates the in-hospital and mid-term outcomes of patients who underwent coronary artery bypass graft (CABG) after NSTEMI. A retrospective analysis of all cases who underwent isolated CABG after NSTEMI from September 2017 to September 2022 at our center. Patients were stratified according to in-hospital survival. Patient characteristics, operative details, and procedural complications were compared between those who survived and those who did not. Predictors of in-hospital and mid-term mortality were evaluated using logistic and Cox regression modeling. Kaplan-Meier analysis was used to generate a survival curve for all alive patients at the time of discharge. Among 1,011 patients (median age 64 [56 to 72] years, 852 [84.3%] male), 735 (72.7%) underwent urgent, 239 (23.6%) elective, and 37 (3.7%) emergency CABG. The in-hospital mortality was 1.5% (15/1,011 patients). Those who died were more likely to be New York Heart Association class III/IV, have left ventricular ejection fraction <21%, severe renal impairment, peripheral vascular disease (PVD), or poor mobility. Emergency procedures, preoperative ventilation, inotropic support, and intra-aortic balloon pump (IABP) use were also more prevalent among those who died. Logistic regression modeling revealed new postoperative stroke (odds ratio 22.0, 95% confidence interval 3.6 to 135.5, p = 0.001), preoperative IABP use (11.4; 2.4 to 53.7, p = 0.002), new hemodialysis (9.6; 2.7 to 34.7, p <0.001), PVD (5.6; 1.6 to 20.0, p = 0.008), and poor mobility (odds ratio 4.8, 95% confidence interval 1.3 to 18.2, p = 0.022) as independent predictors of in-hospital mortality. In conclusion, new postoperative stroke, preoperative IABP use, new hemodialysis, PVD, and poor mobility are independent predictors of mortality in patients with NSTEMI who underwent isolated CABG.

Surgical management of atrial fibrillation in patients undergoing cardiac surgery: a systematic review of clinical practice guidelines and recommendations.

AIMS: Surgical ablation of atrial fibrillation (AF) has been demonstrated to be a safe procedure conducted concomitantly alongside cardiac surgery. However, there are conflicting guideline recommendations surrounding indications for surgical ablation. We conducted a systematic review of current recommendations on concomitant surgical AF ablation. METHODS AND RESULTS: We identified publications from MEDLINE and EMBASE between January 2011 and December 2022 and additionally searched Guideline libraries and websites of relevant organizations in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of 895 studies screened, 4 were rigorously developed (AGREE-II > 50%) and included. All guidelines agreed on the definitions of paroxysmal, persistent, and longstanding AF based on duration and refraction to current treatment modalities. In the Australia-New Zealand (CSANZ) and European (EACTS) guidelines, opportunistic screening for patients >65 years is recommended. The EACTS recommends systematic screening for those aged >75 or at high stroke risk (Class IIa, Level B). However, this was not recommended by American Heart Association or Society of Thoracic Surgeons guidelines. All guidelines identified surgical AF ablation during concomitant cardiac surgery as safe and recommended for consideration by a Heart Team with notable variation in recommendation strength and the specific indication (three guidelines fail to specify any indication for surgery). Only the STS recommended left atrial appendage occlusion (LAAO) alongside surgical ablation (Class IIa, Level C). CONCLUSION: Disagreements exist in recommendations for specific indications for concomitant AF ablation and LAAO, with the decision subject to Heart Team assessment. Further evidence is needed to develop recommendations for specific indications for concomitant AF procedures and guidelines need to be made congruent.

Acute Decompensated Aortic Stenosis: State of the Art Review.

Aortic stenosis (AS) is a progressive disease that carries a poor prognosis. Patients are managed conservatively until satisfying an indication for transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) based on AS severity and the presence of symptoms or adverse impact on the myocardium. Up to 1 in 3 TAVIs are performed for patients with acute symptoms of dyspnea at rest, angina, and/or syncope - termed acute decompensated aortic stenosis (ADAS) and require urgent aortic valve replacement. These patients have longer hospital length of stay, undergo physical deconditioning, and have a higher rate of acute kidney injury and mortality compared to stable patients with less severe symptoms. There is an urgent need to prevent ADAS and to deliver pathways to manage and improve ADAS-related outcomes. We provide here a contemporary review on epidemiological and pathophysiological aspects of ADAS, with a focus on the impact of ADAS from clinical and economic perspectives. We offer a global overview of the available evidence for treatment of ADAS and with priorities suggested for addressing current gaps in the literature and unmet clinical needs to improve outcomes for AS patients.

Comparing Outcomes Between Surgical and Transcatheter Aortic Valve Replacement in Classical Low-Flow Low-Gradient Aortic Stenosis.

Patients with classic low-flow low-gradient (cLFLG) aortic stenosis (AS) have a poor prognosis but still benefit from aortic valve replacement. There is a paucity of evidence to guide the choice between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). This study compared procedural and midterm outcomes in patients with cLFLG AS between TAVR and SAVR. Patients with cLFLG AS, defined as an aortic valve area ≤1 cm2, mean gradient <40 mm Hg, and left ventricular ejection fraction <50%, were selected from a single center between 2015 and 2020. Inverse probability weighting and regression were used to adjust for differences in baseline characteristics, the nonrandom assignment of treatment modalities, and procedural differences. The primary end point was all-cause mortality. A total of 322 patients (220 TAVR and 102 SAVR) were included. At a follow-up of 4.4 ± 1.5 years, the adjusted hazard ratio (HR) for mortality after inverse probability weighting with SAVR was 0.66, 95% confidence interval (CI) 0.31 to 1.35; p = 0.24. Worse renal function at baseline (per 10 ml/min/m2 increase HR 0.92, 95% CI 0.84 to 1.00, p = 0.04) and multiple valve interventions (HR 5.39, 95% CI 2.62 to 11.12, p <0.001) independently predicted mortality. There was no difference in stroke and permanent pacemaker implantation, but the rates of renal replacement therapy were higher among the SAVR cohort: 13.7% versus 0%; p <0.001. In conclusion, among patients with cLFLG AS, there was no difference in midterm mortality between TAVR and SAVR, supporting the use of either treatment. However, in patients with poor renal function or at risk of renal failure, TAVR may be the preferred option.

Severe hyponatraemia in a patient with a large left atrial myxoma: a case report.

Background: Atrial myxomas (AMs) are the most commonly encountered cardiac tumours. They can be genetically inherited and are commonly found in the left atrium. They usually present with dyspnoea, syncopal episodes, heart failure from mitral valve obstruction, and constitutional symptoms including weight loss, fatigue, and fever. We present a rare case of severe symptomatic hyponatraemia secondary to a large AM and discuss possible aetiology. Case summary: A 75-year-old Caucasian female presented with acute nausea, vomiting, confusion, and drowsiness. She had a background of palpitations for about 20 years. Her blood test results revealed severe hyponatraemia (serum sodium-103 mmol/L). Further investigations for hyponatraemia including serum cortisol and urine biochemistry suggested Syndrome of Inappropriate Anti-Diuretic Hormone (SIADH) secretion. Computer tomography scan revealed an incidental large left AM. Echocardiography confirmed the AM attached to the left side of the inter-atrial septum and occupying the majority of the left atrium. She was treated medically for hyponatraemia and referred for excision of myxoma. She underwent urgent resection of the myxoma once sodium levels were optimized. Postoperatively, her serum sodium remained low but gradually returned to normal on postoperative Day 11. Conclusion: This is only the third reported case of significant hyponatraemia associated with a large AM. It has been previously hypothesized that large left AM stretch the atrium causing release of atrial natriuretic peptide and subsequent hyponatraemia. The excision of myxoma and reduction in left atrial size postoperatively with an improvement in sodium levels suggests an association between the two pathologies.

Concomitant Atrial Fibrillation Procedures During Cardiac Surgery in a UK Center: Reflection of Worldwide Practice?

Background: Guidelines recommend concomitant atrial fibrillation (AF) ablation during cardiac surgery to restore normal sinus rhythm (NSR). The study determines, to what extent patients with AF undergoing cardiac surgery at our institution received a concomitant AF procedure, what these procedures entailed, and short-term outcomes. Methods: A retrospective study of 2,984 patients undergoing cardiac surgery over 18 months. Patients who were in preoperative AF were identified and those who underwent a concomitant AF procedure (Group 1) were compared with those who did not (Group 2). Results: Three hundred and thirteen (10.5%) patients had pre-operative AF; paroxysmal (19.5%), persistent (11.8%), longstanding (63%), unknown (5.8%). 116/313 (37.1%) patients had a concomitant AF procedure: 7.7% patients had a concomitant AF ablation and 29.4% had only a Left Atrial Appendage Occlusion (LAAO). Fewer patients with paroxysmal and persistent AF underwent concomitant AF procedures compared with the ones who had no AF procedures (6.7 vs. 12.8% and 17.6 vs. 31%, respectively). Greater in-hospital survival (99.1 vs. 93.9%, p = 0.025) and survival at a mean follow up of 6 weeks (97.4 vs. 89.3%, p = 0.09) was probably determined by patient's preoperative comorbidities. There were no differences in readmission rates, permanent pacemaker insertion, cerebral events or NSR at discharge or follow-up, between groups. Conclusions: In our center, concomitant AF ablation is performed only in 7.7% of cases, 29.4% had only an LAAO performed at the time of surgery. There was no difference in restoring NSR, cerebral events, or readmission rates compared with patients who had nothing done for their preoperative AF.

Risk Prediction Models for Management of Patients following Acute Aortic Dissection.

Risk prediction of adverse outcomes post aortic dissection is dependet not only on the postdissection-associated clinical factors but on the very foundation of the risk factors that lead up to the dissection itself. There are various such risk factors existing prior to the dissection which impact the postdissection outcomes. In this paper, we review the literature to critically analyze various risk models, burdened by their significant limitations, that attempt to stratify risk prediction based on postdissection patient characteristics. We further review several studies across the literature that investigate the diverse set of predissection risk factors impacting postdissection outcomes. We have discussed and appraised numerous studies which attempt to develop a tool to stratify risk prediction by incorporating the impacts of different factors: malperfusion, blood biochemistry, and perioperative outcomes. The well-validated Penn classification has clearly demonstrated in the literature the significant impact that malperfusion has on adverse outcomes postdissection. Other risk models, already severely hindered by their limitations, lack such validation. We further discuss additional alluded risk factors, including the impact of predissection aortic size, the syndromic and nonsyndromic natures of dissection, and the effects of family history and genetics, which collectively contribute to the risk of adverse outcomes postdissection and prognosis. To achieve the goal of a true risk model, there remains the vital need for appreciation and appropriate consideration for all such aforementioned factors, from before and after the dissection, as discussed in this paper. By being able to incorporate the value of true risk prediction for a patient into the decision-making framework, it will allow a new page of precision medical decision-making to be written.

Tricuspid regurgitation management: a systematic review of clinical practice guidelines and recommendations.

Tricuspid regurgitation (TR) is a highly prevalent condition and an independent risk factor for adverse outcomes. Multiple clinical guidelines exist for the diagnosis and management of TR, but the recommendations may sometimes vary. We systematically reviewed high-quality guidelines with a specific focus on areas of agreement, disagreement, and gaps in evidence. We searched MEDLINE and EMBASE (1 January 2011 to 30 August 2021), the Guidelines International Network International, Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, Google Scholar, and websites of relevant organizations for contemporary guidelines that were rigorously developed (as assessed by the Appraisal of Guidelines for Research and Evaluation II tool). Three guidelines were finally retained. There was consensus on a TR grading system, recognition of isolated functional TR associated with atrial fibrillation, and indications for valve surgery in symptomatic vs. asymptomatic patients, primary vs. secondary TR, and isolated TR forms. Discrepancies exist in the role of biomarkers, complementary multimodality imaging, exercise echocardiography, and cardiopulmonary exercise testing for risk stratification and clinical decision-making of progressive TR and asymptomatic severe TR, management of atrial functional TR, and choice of transcatheter tricuspid valve intervention (TTVI). Risk-based thresholds for quantitative TR grading, robust risk score models for TR surgery, surveillance intervals, population-based screening programmes, TTVI indications, and consensus on endpoint definitions are lacking.