Value of Echocardiographic Right Ventricular and Pulmonary Pressure Assessment in Predicting Transcatheter Tricuspid Repair Outcome.

OBJECTIVES: The aim of this study was to assess the value of echocardiographic right ventricular (RV) and systolic pulmonary artery pressure (sPAP) assessment in predicting transcatheter tricuspid edge-to-edge valve repair (TTVR) outcome. BACKGROUND: RV dysfunction and pulmonary hypertension are associated with poor prognosis and are systematically sought during tricuspid regurgitation evaluation. The value of echocardiographic assessment in predicting TTVR outcome is unknown. METHODS: Data were taken from the TriValve (Transcatheter Tricuspid Valve Therapies) registry, which includes patients undergoing TTVR at 14 European and North American centers. The primary outcome was 1-year survival free from hospitalization for heart failure, and secondary outcomes were 1-year survival and absence of hospital admission for heart failure at 1 year. RESULTS: Overall, 249 patients underwent TTVR between June 2015 and 2018 (mean tricuspid annular plane systolic excursion [TAPSE] 15.8 ± 15.3 mm, mean sPAP 43.6 ± 16.0 mm Hg). Tricuspid regurgitation grade ≥3+ was found in 96.8% of patients at baseline and 29.4% at final follow-up; 95.6% were in New York Heart Association functional class III or IV initially, compared with 34.3% at follow-up (p < 0.05). Final New York Heart Association functional class did not differ among TAPSE and sPAP quartiles, even when both low TAPSE and high sPAP were present. Rates of 1-year survival and survival free from hospitalization for heart failure were 83.9% and 78.7%, respectively, without significant differences according to baseline echocardiographic RV characteristics (TAPSE, fractional area change, and end-diastolic area) and sPAP (p > 0.05 for all). CONCLUSIONS: TTVR provides clinical improvement, with 1-year survival free from hospital readmission >75% in patients with severe tricuspid regurgitation. Conventional echocardiographic parameters used to assess RV function and sPAP did not predict clinical outcome after TTVR.

Cost-Effectiveness of Transcatheter Mitral Valve Repair Versus Medical Therapy in Patients With Heart Failure and Secondary Mitral Regurgitation: Results From the COAPT Trial.

BACKGROUND: The COAPT trial (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) demonstrated that edge-to-edge transcatheter mitral valve repair (TMVr) with the MitraClip resulted in reduced mortality and heart failure hospitalizations and improved quality of life compared with maximally tolerated guideline-directed medical therapy (GDMT) in patients with heart failure and 3 to 4+ secondary mitral regurgitation. Whether TMVr is cost-effective compared with GDMT in this population is unknown. METHODS: We used data from the COAPT trial to perform a formal patient-level economic analysis of TMVr+GDMT versus GDMT alone for patients with heart failure and 3 to 4+ secondary mitral regurgitation from the perspective of the US healthcare system. Costs for the index TMVr hospitalization were assessed using a combination of resource-based accounting and hospital billing data (when available). Follow-up medical care costs were estimated on the basis of medical resource use collected during the COAPT trial. Health utilities were estimated for all patients at baseline and 1, 6, 12, and 24 months with the Short Form Six-Dimension Health Survey. RESULTS: Initial costs for the TMVr procedure and index hospitalization were $35 755 and $48 198, respectively. Although follow-up costs were significantly lower with TMVr compared with GDMT ($26 654 versus $38 345; P=0.018), cumulative 2-year costs remained higher with TMVr because of the upfront cost of the index procedure ($73 416 versus $38 345; P<0.001). When in-trial survival, health utilities, and costs were modeled over a lifetime horizon, TMVr was projected to increase life expectancy by 1.13 years and quality-adjusted life-years by 0.82 years at a cost of $45 648, yielding a lifetime incremental cost-effectiveness ratio of $40 361 per life-year gained and $55 600 per quality-adjusted life-year gained. CONCLUSIONS: For symptomatic patients with heart failure and 3 to 4+ secondary mitral regurgitation, TMVr increases life expectancy and quality-adjusted life expectancy compared with GDMT at an incremental cost per quality-adjusted life-year gained that represents acceptable economic value according to current US thresholds. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01626079.

Improving the echocardiographic assessment of pulmonary pressure using the tricuspid regurgitant signal-The "chin" vs the "beard".

AIM: Transthoracic echocardiography (TTE) is a fundamental investigation for the noninvasive assessment of pulmonary hemodynamics and right heart function. The aim of this study was to assess the correlation and agreement of Doppler calculation of right ventricular systolic pressure (RVSP) and pulmonary vascular resistance (PVR) using "chin" and "beard" measurements of tricuspid regurgitant velocity (TRVmax ), with invasive pulmonary artery systolic pressure (PASP) and PVR. METHODS: One hundred patients undergoing right heart catheterisation (RHC) and near simultaneous transthoracic echocardiography were studied. TRVmax was recorded for "chin" measurement (distinct peak TRVmax signal) and where available (63 patients), "beard" measurement (higher indistinct peak TRVmax signal). RESULTS: Measurable TRV signal was obtained in 96 patients. Mean RVSPchin 54.7 ± 22.7 mm Hg and RVSPbeard 68.6 = 23 ± 26.3 mm Hg (P < .001). There was strong correlation between both RVSPchin and RVSPbeard with invasive PASP (Pearson's r = .9, R2  = 0.82, P < .001 - r = .88, R = .78, P < .001, respectively.). Bland-Altman analysis for RVSPchin and RVSPbeard showed a mean bias of -0.5 mm Hg (95% limits of agreement -21.4 to 20.5 mm Hg) and -10.7 (95% LOA -35.5 to 14.2 mm Hg), respectively. Receiver operator characteristics of TRVmax "chin" and "beard" for diagnosis of pulmonary hypertension was assessed with optimal cut-offs being 2.8 m/s (sensitivity 93%, specificity 87%) and 3.2 m/s (sensitivity 91%, specificity 82%), respectively. There was similar correlation between PVRchin and PVRbeard (r = .87, R2  = 0.75, P < .001 and r = .86, R2  = 0.74, P < .001, respectively). At higher PVR, there was overestimation of calculated PVR using PVRbeard . CONCLUSION: The accuracy of noninvasive measurement of right heart pressures is increased using the "chin" in estimation of both RVSP and PVR.

Assessment for Pulmonary Artery Hypertension Using Clinical and Echocardiographic Criteria in Patients With Systemic Sclerosis.

BACKGROUND: Prognosis of systemic sclerosis (SSc) is affected by pulmonary artery hypertension (PAH). METHODS: Among 202 patients (mean age: 46.1 ± 13.3 years; 177 women) with SSc, those with a tricuspid regurgitation (TR) jet maximal velocity at 2D-echocardiography (2DE) < 2.8m/second were not considered at high risk for PAH, whereas those with a TR velocity >3m/second or between 2.8 and 3m/second and associated with dyspnea were. RESULTS: Among 22 patients at risk, 15 (mean age: 50.4 ± 14.3 years) had definite precapillary PAH on right heart catheterization (RHC). The delay period between recognitions of SSc and PAH was 12.9 ± 5.2 years. Dyspnea was present in all 15 patients, 11 (73.3%) being in the New York Heart Association class III or IV. The 2DE showed normal left ventricular geometrics and function (n = 15), enlargement of the right-sided cardiac chambers (n = 12), increased pulmonary arterial resistances with a TR velocity to pulmonary time-velocity integral ratio of > 0.2 (n = 15) and impaired right ventricle function (n = 15). RHC showed severe PAH in all 15 patients (mean pulmonary artery pressure: 48 ± 17mmHg and mean right atrial pressure: 11.8 ± 4.4mmHg) and a reduced cardiac index (2.2L/m²). There was no statistical difference between patients with and without PAH regarding age, sex ratio, duration from onset of disease, diffuse or cutaneous limited type of SSc, Rodnan severity score and presence of digital ulcerations or autoantibodies. Telangiectasia (P = 0.01) and New York Heart Association class III or IV heart failure (P = 0.001) were more frequent in patients with PAH. CONCLUSION: A combined clinical and Doppler-coupled 2DE screening of PAH risk in patients with SSc is useful to select those who can undergo RHC.

Two- and Three-dimensional Transthoracic Echocardiographic Assessment of Tricuspid Valve Prolapse with Mid-to-Late Systolic Tricuspid Regurgitation.

We present the two-dimensional echocardiographic findings of tricuspid valve prolapse with mid-to-late systolic tricuspid regurgitation and describe the incremental value provided by live/real time three-dimensional transthoracic echocardiography. We also discuss a potential pitfall when assessing the severity of regurgitation in this setting.

Etiology impacts survival in patients with severe aortic regurgitation: results from a cohort of 756 patients.

BACKGROUND AND AIM OF THE STUDY: Severe aortic regurgitation (AR) is caused by a variety of mechanisms, which include the degenerative process, bicuspid aortic valve (BAV), aortic root dilation, endocarditis or a combination of these. Their frequency in a contemporary clinical series, and their impact on survival, are currently unknown. METHODS: The authors' echocardiographic database between 1993 and 2007 was screened for patients with severe AR, and yielded 756 patients. Detailed chart reviews were performed to acquire clinical and demographic data. Mortality data were obtained from the social security death index and analyzed as a function of the condition's etiology. RESULTS: The probable etiologies for AR were: degenerative in 29% of patients, BAV in 10%, aortic root pathology in 11%, endocarditis in 10%, and mixed or unclear mechanism in 40%. Survival was a function of the etiology (p < 0.0001), with degenerative mechanism having the worst prognosis and BAV the best. This differential impact on mortality remained significant after adjusting for age, gender, coronary artery disease, diabetes mellitus, renal insufficiency, left ventricular ejection fraction and aortic valve replacement, using the Cox regression model (p < 0.0001). CONCLUSION: Etiology has a significant independent impact on mortality in patients with severe AR, with the worst survival being seen in degenerative AR.

Tricuspid regurgitation and right ventricular function after mitral valve surgery with or without concomitant tricuspid valve procedure.

OBJECTIVES: To study the effect of mitral valve repair with or without concomitant tricuspid valve repair on functional tricuspid regurgitation and right ventricular function. METHODS: From 2001 to 2007, 1833 patients with degenerative mitral valve disease, a structurally normal tricuspid valve, and no coronary artery disease underwent mitral valve repair, and 67 underwent concomitant tricuspid valve repair. Right ventricular function (myocardial performance index and tricuspid annular plane systolic excursion) was measured before and after surgery using transthoracic echocardiography for randomly selected patients with tricuspid regurgitation grade 0, 1+, and 2+ (100 patients for each grade) and 93 with grade 3+/4+, 393 patients in total. RESULTS: In patients with mild (<3+) preoperative tricuspid regurgitation, mitral valve repair alone was associated with reduced tricuspid regurgitation and mild worsening of right ventricular function. Tricuspid regurgitation of 2+ or greater developed in fewer than 20%, and right ventricular function had improved, but not to preoperative levels, at 3 years. In patients with severe (3+/4+) preoperative tricuspid regurgitation, mitral valve repair alone reduced tricuspid regurgitation and improved right ventricular function; however, tricuspid regurgitation of 2+ or greater returned and right ventricular function worsened toward preoperative levels within 3 years. Concomitant tricuspid valve repair effectively eliminated severe tricuspid regurgitation and improved right ventricular function. Also, over time, tricuspid regurgitation did not return and right ventricular function continued to improve to levels comparable to that of patients with lower grades of preoperative tricuspid regurgitation. CONCLUSIONS: In patients with mitral valve disease and severe tricuspid regurgitation, mitral valve repair alone was associated with improved tricuspid regurgitation and right ventricular function. However, the improvements were incomplete and temporary. In contrast, concomitant tricuspid valve repair effectively and durably eliminated severe tricuspid regurgitation and improved right ventricular function toward normal, supporting an aggressive approach to important functional tricuspid regurgitation.

Assessment of pulmonary arterial hypertension and vascular resistance by measurements of the pulmonary arterial flow velocity curve in the absence of a measurable tricuspid regurgitant velocity in childhood congenital heart disease.

This study aimed to determine mean pulmonary arterial pressure (PAPmean) and pulmonary vascular resistance (PVR) using transthoracic echocardiography (TTE) measurements of the pulmonary artery flow velocity curve in children with pulmonary arterial hypertension (PAH) and congenital heart disease when the tricuspid regurgitant velocity (TRV) is not sufficient. This study enrolled 29 congenital heart disease cases with pulmonary arterial hypertension and 40 healthy subjects followed at our center. The mean age was 66.9 ± 77.9 months in the patient group and 76.3 ± 62.1 months in the control group. A positive correlation was found between TRV and systolic pulmonary arterial pressure (r = 0.394, p = 0.035, 95% confidence interval [CI] = 0.032-0.665), whereas a negative correlation was found between corrected acceleration time (AcTc) and PAPmean (r = -0.559, p = 0.002, 95% CI = -0.768 to -0.242). Furthermore, a negative correlation was found between parameters TRV and AcTc (r = -0.383, p = 0.001, 95% CI = -0.657 to -0.019). Based on the cutoff criterion of 124 ms for AcTc, sensitivity was found to be 79.3% and specificity to be 77.5% in distinguishing between the PAH patients and the healthy control patients (receiver operating characteristic [ROC] area under the curve [AUC] = 0.804, 95% CI = 0.691-0.890, p < 0.0001). The sensitivity and specificity of the concomitant use of AcTc and/or TRV were found to be 90 and 73%, respectively, in distinguishing between the PAH patients and the the healthy control patients. The data obtained by TTE also can be appropriate for measuring PAPmean, PVR, and the vasoreactivity test and for determining the priority of implementing cardiac catheterization even if there is no measurable TRV value.

Cardiovascular magnetic resonance imaging in the assessment of carcinoid heart disease.

Carcinoid disease arises from a low-grade neuroendocrine tumour derived from serotonin-producing enterochromaffin cells. It is the most common tumour affecting the small bowel. The majority of patients who progress to carcinoid syndrome develop cardiac disease selectively involving the right side of the heart, whereas left heart disease is unusual. The most common cause of death is dilatation and dysfunction of the right ventricle. Right ventricular dysfunction is largely secondary to pathological endocardial fibrosis of the tricuspid and pulmonary valves, presenting with regurgitation and stenosis. Average survival falls to only 11 months with the onset of symptoms, but recent evidence suggests that survival can be improved by early surgery in selected individuals. This article reviews the particular role that cardiovascular magnetic resonance imaging has in the management of carcinoid heart disease.

Incorporation of pulmonary vascular resistance measurement into standard echocardiography: implications for assessment of pulmonary hypertension.

Doppler estimation of pulmonary artery systolic pressure (PASP) from tricuspid regurgitation velocity is a simple approach to the detection of pulmonary hypertension but may be influenced by right ventricular stroke volume. We sought the clinical utility of incorporating Doppler calculation of pulmonary vascular resistance (PVR) into determination of pulmonary hypertension in 578 consecutive patients with tricuspid regurgitation. Right atrial pressure was estimated from vena caval dimensions and collapsibility. Pulmonary hypertension was classified on the basis of a) PASP >35 mmHg, b) age-/gender normalized PASP, c) PVR >2 Wood units. The mean PASP was 40 +/- 13 mmHg and PVR was 1.9 +/- 0.8 Wood units. Standard PASP identified pulmonary hypertension in 58%, compared with 36% by age-/gender normalized PASP (P < 0.0001), and 31% by PVR (P < 0.0001). Of patients who had pulmonary hypertension by PASP, 33% were reclassified as normal on the basis of PVR and 6% were reclassified from normal to pulmonary hypertension. PVR is easy to incorporate into a standard echo exam, and identifies a small group with normal PASP as having PAH, and a larger group of apparently increased PASP as normal.

Assessment of the tricuspid valve morphology by transthoracic real-time-3D-echocardiography.

AIM: To demonstrate the feasibility of transthoracic three-dimensional real-time echocardiography (3D-TTE) supplemental to routine assessments of the tricuspid valve and to analyze interrater agreement. METHODS: Twenty healthy subjects and 74 patients with right ventricular failure were examined with conventional 2D and additionally 3D-TTE (SONOS 7500, Philips, Netherlands). The 3D exams were performed and recorded by one of two raters. The recordings were evaluated offline and independently by both raters for visualization of morphological and functional features of the tricuspid valve according to a subjective 3-point scale. Statistical analyses were performed for interrater agreement and for comparison of imaging quality between the two study groups. In addition, we present an illustrative case report. RESULTS: Visualization of the spatial relationship between the tricuspid valve and vicinal structures, of the commissures, the orifice, and entirety of valve depiction were better in the ventricular failure group as compared to the control group. Annular dimensions were equally assessable in both groups, leaflet thickness and mobility were not significantly different. Interrater agreement on assessability was slight for leaflet thickness, fair for leaflet mobility and orifice area, and good for the remaining features. The 3D-TTE exam including offline evaluation took 6.5 minutes on average and maximally 14 minutes. CONCLUSION: 3D-TTE of the tricuspid valve can be performed in addition to routine 2D echocardiography within a reasonable time and with high assessability of important features in patients with right ventricular failure. Interrater agreement was fair to good overall. Thus, its feasibility may encourage prospective studies on its potential for more detailed noninvasive diagnosis and preoperative planning.

[Preoperative assessment of tricuspid valve disease]. / Valoración preoperatoria de la valvulopatía tricuspídea.

The illness to the tricuspid valve from a rheumatic origin, requires an adequate study during the preoperative time. The measurement to the tricuspid valve ring, which is determined by an echocardiography demonstrating a dilation from above 30 mm, has to be considered as an organic disease and not as a functional one. This means that this dilation must be surgically treated with anuloplasty or a valve substitution, otherwise the possibilities of a residual tricuspid regurgitation are very high. It is also important to perform a transjugular liver biopsy in those cases where a moderated or severe tricuspid regurgitation is present, allowing to detect those patients who have a severe hepatic malfunction (coagulophaty) and backing them up during and after the surgical procedure.

Echocardiographic assessment of mitral stenosis and its associated valvular lesions in 205 patients and lack of association with mitral valve prolapse.

To date, the relation between mitral stenosis (MS) and other associated cardiac valvular lesions has been reported by angiography and surgical pathologic study in patients with more advanced disease but has not been studied systematically by two-dimensional echocardiography and Doppler color flow mapping in a large referral population with a broader spectrum of severity. In addition, prior reports have suggested that up to 40% of patients with MS have mitral valve prolapse (MVP); however, because of recent developments in two-dimensional echocardiographic imaging and the definition of MVP, this association must now be reconsidered. The purpose of this study was to explore the association of other valvular lesions with MS and their relation to its severity and in particular to test whether MS is in fact associated with MVP with the frequency reported previously. We reviewed the studies of 205 consecutive patients (aged 61 +/- 14 years; range 26 to 87 years) with MS who were studied from 1992 to 1994 by two-dimensional echocardiography and Doppler color flow mapping to assess valvular stenosis, regurgitation, and MVP in patients with a range of severity of MS (28% mild, 34% moderate, and 38% severe MS based on mitral valve area). MS was associated with at least mild mitral regurgitation in 78% of patients (160/205), and pure MS was correspondingly uncommon (22%). There was an inverse relationship between the severity of MS and the degree of mitral regurgitation (p < 0.001). MS was frequently associated (54% of patients) with significant lesions of other valves, including aortic stenosis (17%), at least moderate aortic regurgitation (8%) and tricuspid regurgitation (38%), and tricuspid stenosis (4%). Tricuspid stenosis was associated with more severe MS (p < 0.01), and tricuspid regurgitation was more common in patients with mixed MS and regurgitation than in those with pure stenosis (60% versus 26% for at least moderate tricuspid regurgitation; p < 0.001). Mitral valve prolapse was present in only one patient (0.5%). Superior systolic bulging of the midportion of the anterior mitral leaflet toward the left atrium (but not superior to the annular hinge points) was seen in 22 patients (11%). Patients with such superior bulging had significantly lower mitral valve scores but a similar degree of mitral regurgitation compared with those without bulging. The majority of patients with MS (78%) have associated mitral regurgitation and significant lesions of the other cardiac valves (54%). The frequency of true MVP associated with chronic MS is much lower than reported previously. This may provide insight into the underlying pathophysiologic process, tending to shorten the chordae tendineae and leaflets to produce stenosis rather than elongate them to produce prolapse.

Doppler echocardiographic assessment of long-term progression of mitral stenosis in 103 patients: valve area and right heart disease.

OBJECTIVES: The purpose of this study was to determine, in a large referral population, the rate of echocardiographic change in mitral valve area (MVA) without interim intervention, to determine which factors influence progression of narrowing and to examine associated changes in the right side of the heart. BACKGROUND: Little information is currently available on the echocardiographic progression of mitral stenosis, particularly on progressive changes in the right side of the heart and the ability of a previously proposed algorithm to predict progression. METHODS: We studied 103 patients (mean age 61 years; 74% female) with serial two-dimensional and Doppler echocardiography. The average interval between entry and most recent follow-up study was 3.3 +/- 2 years (range 1 to 11). RESULTS: During the follow-up period, MVA decreased at a mean rate of 0.09 cm2/year. In 28 patients there was no decrease, in 40 there was only relatively little change (< 0.1 cm2/year) and in 35 the rate of progression of mitral valve narrowing was more rapid (> or = 0.1 cm2/year). The rate of progression was significantly greater among patients with a larger initial MVA and milder mitral stenosis (0.12 vs. 0.06 vs. 0.03 cm2/year for mild, moderate and severe stenosis, p < 0.01). Although the rate of mitral valve narrowing was a weak function of initial MVA and echocardiographic score by multivariate analysis, no set of individual values or cutoff points of these variables or pressure gradients could predict this rate in individual patients. There was a significant increase in right ventricular diastolic area (17 to 18.7 cm2) and tricuspid regurgitation grade (2 + to 3 +; p < 0.0001 between entry and follow-up studies). Progression in right heart disease occurred even in patients with minimal or no change in MVA. Patients with associated aortic regurgitation had a higher rate of decrease in MVA than did those with trace or no aortic regurgitation (0.19 vs. 0.086 cm2/year, p < 0.05). CONCLUSIONS: The rate of mitral valve narrowing in individual patients is variable and cannot be predicted by initial MVA, mitral valve score or transmitral gradient, alone or in combination. Right heart disease can progress independent of mitral valve narrowing.

Right-to-left shunt across atrial septal defect related to tricuspid regurgitation: assessment by transesophageal Doppler echocardiography.

The purpose of this study was to assess the factors involved in the development of the right-to-left (R-L) shunt in patients with atrial septal defect (ASD), especially the role of tricuspid regurgitation (TR). Thirty-one consecutive patients with ASD underwent transesophageal Doppler echocardiography to determine the size of ASD, the shunt flow, and the TR flow, and they were compared with hemodynamics examined by cardiac catheterization. Sixteen patients with the R-L shunt were older (53 +/- 11 vs 34 +/- 9 years; p < 0.001) and had higher pulmonary arterial pressure (36 +/- 17 vs 25 +/- 5 mmHg; p < 0.05) and a greater Qp/Qs (3.6 +/- 1.2 vs 2.4 +/- 0.9 L/min; p < 0.01) as compared with 15 patients with the pure left-to-right shunt. In six of 21 patients with TR, the regurgitant flow oriented toward ASD and blew into the left atrium through the defect. Besides the deviation of TR flow, the prevalences of the maximum diameter of ASD > 2.5 cm and the maximal TR flow area > 4 cm2 were significantly higher in the six patients as compared with patients with TR not related to the R-L shunt (p < 0.05 and p < 0.05), despite the pulmonary arterial pressure being similar in the two groups. Reversal of pressure gradient between the left and right atrium was not observed during the cardiac cycle in all patients. In conclusion, TR is a determinant of the R-L shunt in patients with ASD even in the absence of the reversal of pressure gradient between the left and right atrium.