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JACC. Cardiovascular Interventions Apr 2024
Topics: Humans; Tricuspid Valve; Pulmonary Artery; Treatment Outcome; Tricuspid Valve Insufficiency; Heart Valve Prosthesis Implantation; Cardiac Catheterization
PubMed: 38599704
DOI: 10.1016/j.jcin.2024.02.020 -
JACC. Cardiovascular Interventions Apr 2024Severe tricuspid regurgitation (TR) is a progressive condition associated with substantial morbidity, poor quality of life, and increased mortality. Patients with TR... (Review)
Review
Severe tricuspid regurgitation (TR) is a progressive condition associated with substantial morbidity, poor quality of life, and increased mortality. Patients with TR commonly have coexisting conditions including congestive heart failure, pulmonary hypertension, chronic lung disease, atrial fibrillation, and cardiovascular implantable electronic devices, which can increase the complexity of medical and surgical TR management. As such, the optimal timing of referral for isolated tricuspid valve (TV) intervention is undefined, and TV surgery has been associated with elevated risk of morbidity and mortality. More recently, an unprecedented growth in TR treatment options, namely the development of a wide range of transcatheter TV interventions (TTVI) is stimulating increased interest and referral for TV intervention across the entire medical community. However, there are no stepwise algorithms for the optimal management of symptomatic severe TR before TTVI. This article reviews the contemporary assessment and management of TR with addition of a medical framework to optimize TR before referral for TTVI.
Topics: Humans; Tricuspid Valve Insufficiency; Quality of Life; Heart Valve Prosthesis Implantation; Treatment Outcome; Tricuspid Valve
PubMed: 38599687
DOI: 10.1016/j.jcin.2024.02.034 -
Catheterization and Cardiovascular... May 2024Percutaneous pulmonary valve implantation (PPVI) is a non-surgical treatment for right ventricular outflow tract (RVOT) dysfunction. During PPVI, a stented valve,...
BACKGROUND
Percutaneous pulmonary valve implantation (PPVI) is a non-surgical treatment for right ventricular outflow tract (RVOT) dysfunction. During PPVI, a stented valve, delivered via catheter, replaces the dysfunctional pulmonary valve. Stent oversizing allows valve anchoring within the RVOT, but overexpansion can intrude on the surrounding structures. Potentially dangerous outcomes include aortic valve insufficiency (AVI) from aortic root (AR) distortion and myocardial ischemia from coronary artery (CA) compression. Currently, risks are evaluated via balloon angioplasty/sizing before stent deployment. Patient-specific finite element (FE) analysis frameworks can improve pre-procedural risk assessment, but current methods require hundreds of hours of high-performance computation.
METHODS
We created a simplified method to simulate the procedure using patient-specific FE models for accurate, efficient pre-procedural PPVI (using balloon expandable valves) risk assessment. The methodology was tested by retrospectively evaluating the clinical outcome of 12 PPVI candidates.
RESULTS
Of 12 patients (median age 14.5 years) with dysfunctional RVOT, 7 had native RVOT and 5 had RV-PA conduits. Seven patients had undergone successful RVOT stent/valve placement, three had significant AVI on balloon testing, one had left CA compression, and one had both AVI and left CA compression. A model-calculated change of more than 20% in lumen diameter of the AR or coronary arteries correctly predicted aortic valve sufficiency and/or CA compression in all the patients.
CONCLUSION
Agreement between FE results and clinical outcomes is excellent. Additionally, these models run in 2-6 min on a desktop computer, demonstrating potential use of FE analysis for pre-procedural risk assessment of PPVI in a clinically relevant timeframe.
Topics: Humans; Pulmonary Valve; Heart Valve Prosthesis Implantation; Finite Element Analysis; Risk Assessment; Patient-Specific Modeling; Adolescent; Treatment Outcome; Heart Valve Prosthesis; Risk Factors; Male; Child; Models, Cardiovascular; Retrospective Studies; Prosthesis Design; Female; Cardiac Catheterization; Young Adult; Predictive Value of Tests; Hemodynamics; Stents; Pulmonary Valve Insufficiency; Ventricular Outflow Obstruction; Clinical Decision-Making; Adult
PubMed: 38597297
DOI: 10.1002/ccd.31016 -
Circulation Jun 2024Sodium-glucose cotransporter-2 inhibitors (SGLT2i) consistently improve heart failure and kidney-related outcomes; however, effects on major adverse cardiovascular... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) consistently improve heart failure and kidney-related outcomes; however, effects on major adverse cardiovascular events (MACE) across different patient populations are less clear.
METHODS
This was a collaborative trial-level meta-analysis from the SGLT2i Meta-analysis Cardio-Renal Trialists Consortium, which includes all phase 3, placebo-controlled, outcomes trials of SGLT2i across 3 patient populations (patients with diabetes at high risk for atherosclerotic cardiovascular disease, heart failure [HF], or chronic kidney disease). The outcomes of interest were MACE (composite of cardiovascular death, myocardial infarction , or stroke), individual components of MACE (inclusive of fatal and nonfatal events), all-cause mortality, and death subtypes. Effect estimates for SGLT2i versus placebo were meta-analyzed across trials and examined across key subgroups (established atherosclerotic cardiovascular disease, previous myocardial infarction, diabetes, previous HF, albuminuria, chronic kidney disease stages, and risk groups).
RESULTS
A total of 78 607 patients across 11 trials were included: 42 568 (54.2%), 20 725 (26.4%), and 15 314 (19.5%) were included from trials of patients with diabetes at high risk for atherosclerotic cardiovascular disease, HF, or chronic kidney disease, respectively. SGLT2i reduced the rate of MACE by 9% (hazard ration [HR], 0.91 [95% CI, 0.87-0.96], <0.0001) with a consistent effect across all 3 patient populations (=0%) and across all key subgroups. This effect was primarily driven by a reduction in cardiovascular death (HR, 0.86 [95% CI, 0.81-0.92], <0.0001), with no significant effect for myocardial infarction in the overall population (HR, 0.95 [95% CI, 0.87-1.04], =0.29), and no effect on stroke (HR, 0.99 [95% CI, 0.91-1.07], =0.77). The benefit for cardiovascular death was driven primarily by reductions in HF death and sudden cardiac death (HR, 0.68 [95% CI, 0.46-1.02] and HR, 0.86 [95% CI, 0.78-0.95], respectively) and was generally consistent across subgroups, with the possible exception of being more apparent in those with albuminuria (=0.02).
CONCLUSIONS
SGLT2i reduce the risk of MACE across a broad range of patients irrespective of atherosclerotic cardiovascular disease, diabetes, kidney function, or other major clinical characteristics at baseline. This effect is driven primarily by a reduction of cardiovascular death, particularly HF death and sudden cardiac death, without a significant effect on myocardial infarction in the overall population, and no effect on stroke. These data may help inform selection for SGLT2i therapies across the spectrum of cardiovascular-kidney-metabolic disease.
Topics: Sodium-Glucose Transporter 2 Inhibitors; Humans; Cardiovascular Diseases; Renal Insufficiency, Chronic; Diabetes Mellitus, Type 2; Female; Male; Treatment Outcome; Aged
PubMed: 38583093
DOI: 10.1161/CIRCULATIONAHA.124.069568 -
The European Respiratory Journal Jun 2024The consequences of tricuspid regurgitation (TR) for right ventricular (RV) function and prognosis in pulmonary arterial hypertension (PAH) are poorly described and...
BACKGROUND
The consequences of tricuspid regurgitation (TR) for right ventricular (RV) function and prognosis in pulmonary arterial hypertension (PAH) are poorly described and effects of tricuspid valve repair on the RV are difficult to predict.
METHODS
In 92 PAH patients with available cardiac magnetic resonance (CMR) studies, TR volume was calculated as the difference between RV stroke volume and forward stroke volume, pulmonary artery (PA) stroke volume. Survival was estimated from the time of the CMR scan to cardiopulmonary death or lung transplantation. In a subgroup, pressure-volume loop analysis including two-parallel elastances was applied to evaluate effective elastances, including net afterload (effective arterial elastance ( )), forward afterload (effective pulmonary arterial elastance ( )) and backward afterload (effective tricuspid regurgitant elastance ( )). The effects of tricuspid valve repair were simulated using the online software package Harvi.
RESULTS
26% of PAH patients had a TR volume ≥30 mL. Greater TR volume was associated with increased N-terminal pro-brain natriuretic peptide (p=0.018), mean right atrial pressure (p<0.001) and RV end-systolic and -diastolic volume (both p<0.001). TR volume ≥30 mL was associated with a poor event-free survival (p=0.008). In comparison to , correlated better with indices of RV dysfunction. Lower end-systolic elastance ( ) (p=0.002) and (p=0.030), higher (p=0.001) and reduced / (p<0.001) were found in patients with a greater TR volume. Simulations predicted that tricuspid valve repair increases RV myocardial oxygen consumption in PAH patients with severe TR and low unless aggressive volume reduction is accomplished.
CONCLUSIONS
In PAH, TR has prognostic significance and is associated with low RV contractility and RV-PA uncoupling. However, haemodynamic simulations showed detrimental consequences of tricuspid valve repair in PAH patients with low RV contractility.
Topics: Humans; Tricuspid Valve Insufficiency; Female; Male; Middle Aged; Adult; Pulmonary Arterial Hypertension; Ventricular Function, Right; Stroke Volume; Heart Ventricles; Pulmonary Artery; Prognosis; Aged; Tricuspid Valve; Ventricular Dysfunction, Right; Magnetic Resonance Imaging; Hypertension, Pulmonary; Natriuretic Peptide, Brain
PubMed: 38575159
DOI: 10.1183/13993003.01696-2023 -
JACC. Heart Failure May 2024
Topics: Humans; Tricuspid Valve Insufficiency; Ventricular Dysfunction, Left; Male
PubMed: 38573266
DOI: 10.1016/j.jchf.2024.02.023 -
European Journal of Heart Failure Apr 2024While invasively determined congestion holds mechanistic and prognostic significance in acute heart failure (HF), its role in patients with tricuspid regurgitation...
AIMS
While invasively determined congestion holds mechanistic and prognostic significance in acute heart failure (HF), its role in patients with tricuspid regurgitation (TR)-related right- heart failure (HF) undergoing transcatheter tricuspid valve intervention (TTVI) is less well established. A comprehensive understanding of congestion patterns might aid in procedural planning, risk stratification, and the identification of patients who may benefit from adjunctive therapies before undergoing TTVI. The aim of this study was to investigate the role of congestion patterns in patients with severe TR and its implications for TTVI.
METHODS AND RESULTS
Within a multicentre, international TTVI registry, 813 patients underwent right heart catheterization (RHC) prior to TTVI and were followed up to 24 months. The median age was 80 (interquartile range 76-83) years and 54% were women. Both mean right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP) were associated with 2-year mortality on Cox regression analyses with Youden index-derived cut-offs of 17 mmHg and 19 mmHg, respectively (p < 0.01 for all). However, RAP emerged as an independent predictor of outcomes following multivariable adjustments. Pre-interventionally, 42% of patients were classified as euvolaemic (RAP <17 mmHg, PCWP <19 mmHg), 23% as having left-sided congestion (RAP <17 mmHg, PCWP ≥19 mmHg), 8% as right-sided congestion (RAP ≥17 mmHg, PCWP <19 mmHg), and 27% as bilateral congestion (RAP ≥17 mmHg, PCWP ≥19 mmHg). Patients with right-sided or bilateral congestion had the lowest procedural success rates and shortest survival times. Congestion patterns allowed for discerning specific patient's physiology and specifying prognostic implications of right ventricular to pulmonary artery coupling surrogates.
CONCLUSION
In this large cohort of invasively characterized patients undergoing TTVI, congestion patterns involving right-sided congestion were associated with low procedural success and higher mortality rates after TTVI. Whether pre-interventional reduction of right-sided congestion can improve outcomes after TTVI should be established in dedicated studies.
Topics: Humans; Female; Male; Tricuspid Valve Insufficiency; Aged; Registries; Cardiac Catheterization; Aged, 80 and over; Pulmonary Wedge Pressure; Heart Failure; Severity of Illness Index; Prognosis; Heart Valve Prosthesis Implantation; Tricuspid Valve; Treatment Outcome
PubMed: 38571456
DOI: 10.1002/ejhf.3235 -
Journal of the American College of... Apr 2024
Topics: Humans; Pulmonary Valve; Tetralogy of Fallot; Pulmonary Valve Insufficiency; Treatment Outcome; Heart Valve Prosthesis Implantation; Ventricular Outflow Obstruction
PubMed: 38569761
DOI: 10.1016/j.jacc.2024.02.027 -
Early Outcomes From a Multicenter Transcatheter Self-Expanding Pulmonary Valve Replacement Registry.Journal of the American College of... Apr 2024Transcatheter pulmonary valve replacement (TPVR) with the self-expanding Harmony valve (Medtronic) is an emerging treatment for patients with native or surgically...
BACKGROUND
Transcatheter pulmonary valve replacement (TPVR) with the self-expanding Harmony valve (Medtronic) is an emerging treatment for patients with native or surgically repaired right ventricular outflow tract (RVOT) pulmonary regurgitation (PR). Limited data are available since U.S. Food and Drug Administration approval in 2021.
OBJECTIVES
In this study, the authors sought to evaluate the safety and short-term effectiveness of self-expanding TPVR in a real-world experience.
METHODS
This was a multicenter registry study of consecutive patients with native RVOT PR who underwent TPVR through April 30, 2022, at 11 U.S.
CENTERS
The primary outcome was a composite of hemodynamic dysfunction (PR greater than mild and RVOT mean gradient >30 mm Hg) and RVOT reintervention.
RESULTS
A total of 243 patients underwent TPVR at a median age of 31 years (Q1-Q3: 19-45 years). Cardiac diagnoses were tetralogy of Fallot (71%), valvular pulmonary stenosis (21%), and other (8%). Acute technical success was achieved in all but 1 case. Procedural serious adverse events occurred in 4% of cases, with no device embolization or death. Hospital length of stay was 1 day in 86% of patients. Ventricular arrhythmia prompting treatment occurred in 19% of cases. At a median follow-up of 13 months (Q1-Q3: 8-19 months), 98% of patients had acceptable hemodynamic function. Estimated freedom from the composite clinical outcome was 99% at 1 year and 96% at 2 years. Freedom from TPVR-related endocarditis was 98% at 1 year. Five patients died from COVID-19 (n = 1), unknown causes (n = 2), and bloodstream infection (n = 2).
CONCLUSIONS
In this large multicenter real-world experience, short-term clinical and hemodynamic outcomes of self-expanding TPVR therapy were excellent. Ongoing follow-up of this cohort will provide important insights into long-term outcomes.
Topics: Humans; Adult; Pulmonary Valve; Heart Valve Prosthesis Implantation; Heart Valve Prosthesis; Cardiac Catheterization; Treatment Outcome; Pulmonary Valve Insufficiency; Registries; Prosthesis Design; Retrospective Studies
PubMed: 38569760
DOI: 10.1016/j.jacc.2024.02.010 -
Innere Medizin (Heidelberg, Germany) May 2024Tricuspid regurgitation (TR) leading to right heart failure is prevalent and associated with increased mortality. The significant under-recognition of the disease... (Review)
Review
Tricuspid regurgitation (TR) leading to right heart failure is prevalent and associated with increased mortality. The significant under-recognition of the disease resulted from insufficient medical therapies and the high associated risk of surgical therapy. Over the last decade there has been a rapid development of interventional treatment options so that the disease has increasingly become the focus of attention of specialists in internal medicine and interventional cardiologists. The etiology of TR is differentiated into primary TR, secondary atrial TR, secondary ventricular TR and TR associated with cardiac implantable electronic devices (CIED). The TR was identified as an independent predictor of mortality, independent of associated diseases such as atrial fibrillation, left-sided heart failure or pulmonary hypertension. Even patients with low to moderate TR have a significantly increased risk of mortality. Early diagnostics and estimation of the severity by echocardiography as well as timely referral to a tertiary heart valve center are decisive in order to evaluate possible treatment options before irreversible right ventricular damage and secondary organ dysfunction occur. For transcatheter edge-to-edge repair and transcatheter tricuspid valve replacement there is now first evidence from randomized controlled studies. While the understanding of TR is continuously improving, new tricuspid valve repair and replacement systems are in a state of steady progress. Whether the treatment has an effect on reduction of the mortality and stabilization of right ventricular failure with a reduction in hospitalization, will first be shown in future studies.
Topics: Tricuspid Valve Insufficiency; Humans; Heart Valve Prosthesis Implantation; Tricuspid Valve; Echocardiography
PubMed: 38568315
DOI: 10.1007/s00108-024-01692-5