Tricuspid Regurgitation: From Pathophysiology to New Therapeutic Approaches

Dear Colleagues,

Following the surge of new catheter-based therapies, the tricuspid valve is no longer considered the forgotten valve. An in-depth review of the tricuspid valve anatomy was conducted to implement these new treatments and there is already initial data from clinical trials about their prognostic relevance. However, several aspects regarding tricuspid regurgitation mechanisms and evolution need to be clarified. We already know that tricuspid regurgitation is not as benign as previously believed. Nevertheless, surgical repair has been classically associated with high in-hospital mortality. Therefore, new criteria are needed to optimize the patient selection and timing for intervention. Moreover, due to the growing number of percutaneous treatment options and the increasing interest in surgical repair improvements, selection of the best therapeutic approach for each patient is required. Cardiac imaging may shed light on these aspects, incluing attaining a better understanding of the right ventricular volume overload management, refining key anatomic features for intervention timing and personalization, and predicting posprocedural functional and clinical response, among others. Thus, this Special Issue will encompass all recent advances in tricuspid regurgitation management, with a specific focus on imaging diagnosis.

Dr. Eduardo Pozo Osinalde
Guest Editor

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• tricuspid regurgitation
• right ventricular function
• heart failure
• cardiac imaging
• surgical repair and replacement
• percutaneous intervention
• prognosis

Title: Surgical treatment for isolated tricuspid valve disease: a less invasive approach for better outcomes
Authors:
Affiliation:
Abstract: Objective. The prevalence of significant tricuspid valve (TV) disease is estimated to be up to 3% after the age of 75. It has a strong association with right ventricular remodeling and dysfunction leading to an increased mortality. Nevertheless, surgery for isolated TV disease is rarely performed and this is mainly due to the well-known unsatisfactory outcomes in these high-risk patients. Aim of this study is to analyze our experience in minimally invasive isolated TV surgery (ITVS). Methods. Data regarding right mini-thoracotomy ITVS were prospectively collected from 2006 to 2022. A subgroup analysis was performed comparing late referral patients with the control group of other patients. Five-years survival was assessed using the Kaplan-Meier survival estimate. Results. Eighty-one consecutive patients were enrolled. Mean age was 62±16.1 years, and more than 60% were female. Fifty-seven patients were redo (70.4%), while late referral was recorded in 8 out of 81 patients (9.9%). No cases of major vascular complications, nor of stroke were reported. Median ICU and in-hospital length-of-stay were 1 and 7 days, respectively. 30-day mortality was reported in one patient (1.2%). Five-year Kaplan-Meier survival analysis showed a significant difference between late referral patients and control group (p=0.01); late referral and Euroscore II were found to be significantly associated with reduced mid-term survival (p=0.005 and p=0.01, respectively). Conclusions. To date, perioperative mortality in patients undergoing ITVS is still consistently high, even in high-volume, high-experienced centres, and this accounts for the low rate of referral. Results from our report show that, with a proper multidisciplinary management, an appropriate pre-operative vascular screening and patient allocation to the safest minimally invasive approach, ITVS may offer better results than expected.

Title: interventional treatment of tricuspid regurgitation
Authors: Synetos, Nikolaos Ktenopoulos, O. Katsavos, Α. Apostolos….K. Toutouzas
Affiliation: 1st Department of Cardiology, University of Athens, Athens Medical School

Title: Right ventricular-pulmonary arterial coupling as a predictor of death or heart failure admission in a broad population of patients with severe tricuspid regurgitation.
Authors: Ana Fernández Ruiz; Martín Ruiz Ortiz; Consuelo Fernández-Avilés Irache; Ana Rodriguez Almodóvar; Mónica Delgado Ortega; Fátima Esteban Martínez; Adriana Resúa Collazo; Gloria Heredia Campos; Rafael González Manzanares; José López Aguilera; Juan Carlos Castillo Domínguez; Manuel Anguita Sánchez; Manuel Pan Álvarez-Ossorio; Dolores Mesa Rubio
Affiliation: Cardiology Department. Reina Sofia University Hospital. Córdoba.
Abstract: Background: The right ventricular-pulmonary arterial coupling, evaluated by tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) ratio in prognostic assessment of tricuspid regurgitation (TR) has been studied only in selected populations and mainly for all-cause mortality. Methods: All patients ≥ 18 years with severe TR studied with echocardiography in a tertiary care hospital from 01.01.2008 to 12.31.2017, follow-up until 1.1.2022, were retrospectively included. Association of TAPSE/PASP ratio with the combined endpoint of mortality and heart failure admission in follow-up and comparative discrimination ability with both components of the index was investigated. Results: A total 614 patients (69 ± 13 years, 72% women) were included with a follow-up of up to 14 years (median 5 years, p25-75 2-7 years). There were 359 deaths and 264 patients presented 620 admissions for heart failure. TAPSE/PASP, TAPSE and PASP were associated with the combined event on univariate analysis. The discriminative ability to predict the event was statistically significant for all three, however, the TAPSE/PASP (AUC 0.68 [(95%IC 0.63-0.72)], p<0.0005) performed better than the separate components. After adjusting for other prognostic variables, the TAPSE/PASP remained as an independent predictor (HR 0.113 (0.051-0.250), p<0.0005). However, the higher incremental prognostic value was observed with the inclusion of both components of the index separately in the model. Conclusions: In this cohort of patients with severe TR, TAPSE/PASP ratio was a powerful independent predictor of admissions for heart failure or mortality, and its discriminative power was higher than any of its components separately.