Abstract Aims Non-invasive parameters used to assess right ventricular (RV) function, i.e. tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (FAC), RV ejection fraction (RVEF), and RV free-wall longitudinal strain (RVFWLS) have shown their prognostic implications. However, since they are extremely load dependent, they do not provide an accurate representation of the RV intrinsic performance. On the other end, invasive indices of RV-arterial coupling (RVAC) derived from pressure–volume loops are not routinely performed, rising the urgency for more feasible, and reliable non-invasive estimates of RVAC. To (i) evaluate the prognostic value of echocardiography-derived RVAC surrogates: RVEF/sPAP, RVFWLS/sPAP, TAPSE/sPAP, FAC/sPAP, and RV stroke volume/end-systolic volume (SV/ESV); (ii) identify the cut-off values associated to all-cause mortality; and (iii) compare their prognostic value with that of classical parameters of RV function. Methods and results We prospectively enrolled 366 patients with various cardiac diseases, undergoing clinically indicated comprehensive two- and three-dimensional echocardiography. During a mean follow-up of 7.6 ± 1 years, 80 (21.9%) patients died. At univariable Cox regression, most of the echocardiographic parameters were related to all-cause mortality. The echocardiographic parameters with significance at univariable analysis (P < 0.01) were included in a multivariable regression model. Left ventricular ejection fraction (LVEF), RVEF, TAPSE, RVEF/sPAP, and RVFWLS/sPAP remained independently associated to all-cause mortality (P < 0.05 for all). Subsequently, they were tested in receiving operator characteristics (ROC) curves. At ROC analysis, RVEF/sPAP (area under the curve, AUC = 0.807, P < 0.001) and RVFWLS/sPAP (AUC = 0.743, P < 0.001) showed the greatest predictive value (P < 0.001 between them). However, all RV parameters significantly improved their values after indexing for sPAP (P < 0.01 for all). The best cut-offs to predict the outcome were 1.5 for RVEF/sPAP (specificity 71%, sensitivity 83%) and 0.67 for RVFWLS/sPAP (specificity 72%, sensitivity 68%). At Kaplan–Meier analysis, patients with reduced RVAC (less than the predefined cut-offs) had significantly lower probability of survival (P < 0.001 for all). Conclusions RVAC surrogates provide incremental prognostic value compared to standard RV functional measurements. RVEF/sPAP, with a cut-off value of 1.5, was the best parameter for risk stratification, and was independently related to all-cause mortality.
Conventional echocardiographic parameters such as tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and free-wall longitudinal strain (FWLS) offer limited insights into the complexity of right ventricular (RV) systolic function, while 3D echocardiography-derived RV ejection fraction (RVEF) enables a comprehensive assessment. We investigated the discordance between TAPSE, FAC, FWLS, and RVEF in RV systolic function grading and associated outcomes.
Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial and ventricular functional tricuspid regurgitation (A-FTR and V-FTR) have recently emerged as different phenotypes of FTR. Given the difference in mechanisms that are postulated to be underlying these 2 entities, a different remodeling of tricuspid valve (TV) apparatus can occur and therefore also a specific quantitative approach could be deemed. Aim Aim of this study was to investigate the TV apparatus remodeling in the two different phenotypes of FTR: ventricular (V-FTR) and atrial (A-FTR) and the role of echocardiographic parameters of TV remodeling and TR severity to predict clinical outcomes. Material and methods The present retrospective study included consecutive patients with moderate to severe functional tricuspid regurgitation (FTR) referred for echocardiography in two Italian centers. The composite endpoint of death for any cause and heart failure (HF) hospitalization was used as primary outcome of this analysis. According to more recent guidelines, patients were considered having A-FTR if having history of long- standing atrial fibrillation, without history of pulmonary hypertension and left side heart disease. Results. A total of 180 patients were included. Despite the right atrial volume (RAV) was not different in the 2 groups, in A-FTR tethering height was significantly lower (11.7 ±4.8 mm vs 15.0 ± 5.5 in V-FTR. p <0.01) and the 3D-derived tricuspid annulus (TA) diameters were larger both in end-diastolic and mid-systolic phase (3D-TA-End diastolic- major axis: 45.2 ± 6.2 mm in A-FTR vs 42.8 ± 5.4 in V-FTR. p= 0.04; 3D-TA mid systolic major axis: 41,7 ± 6,4mm in A-FTR vs 37,9 ± 5,1 in V-FTR, P <0,01). 3D-TA-End diastolic- minor axis: 39.7 ± 6.8 vs 37.1 ± 5.2. p= 0.03). Regarding the parameters of severity of FTR. patients with V-FTR had larger vena contracta (VC). either when 2D estimated or 3D (2D-VC-average: 5.3 ± 2.8 mm in A-FTR vs 6.6 ± 3.7 in V-FTR. P= 0.02; 3D-VCA: 0.9 ± 0.4 cm2 vs 1.3 ± 1.1 cm2 p= 0.02); conversely the value of 2D-ERO and regurgitant volume estimated with 2D-PISA method did not show significant difference between the 2 groups (table 1). After a median follow-up of 24 months (IQR: 2-48) 72 patients (40%) reached the primary end-point and 64 (36%) hospitalized for HF. Different predictors of combined end point were found in the 2 groups: tenting height. 2D-VC. 3D-VCA and regurgitant fraction were prognostic correlates in V-FTR; TA dimensions as well as all the parameters of severe TR. including EROA with PISA method were related to the prognosis in A-FTR (table 2). Conclusions Prognostic role of quantitative parameters of FTR in A-FTR and V-FTR is different, thus reaffirming the difference in underlying pathogenic mechanisms and the needing for a more specific diagnostic approach and prognostic stratification in these two FTR phenotypes
Abstract Improvements in procedural technique and intra-procedural imaging have progressively expanded the indications of percutaneous edge-to-edge technique. To date in higher volume centres and by experienced operators MitraClip is used for the treatment of complex anatomies and challenging cases in high risk-inoperable patients. This progressive step is superimposable to what observed in surgery for edge-to-edge surgery (Alfieri’s technique). Moreover, the results of clinical studies on the treatment of patients with high surgical risk and functional mitral insufficiency have confirmed that the main goal to be achieved for improving clinical outcomes of patients with severe mitral regurgitation (MR) is the reduction of MR itself. The MitraClip should therefore be considered as a tool to achieve this goal in addition to medical therapy. Nowadays, evaluation of patient’s candidacy to MitraClip procedure, discussed in local Heart Team, must take into account not only the clinical features of patients but even the experience of the operators and the volume of the centre, which are mostly related to the probability to achieve good procedural results. This ‘relative feasibility’ of challenges cases by experienced operators should always been taken into account in selecting patients for MitraClip. Here, we present a review of the literature available on the treatment of complex and challenging lesions.
The Portico TAVI system (Abbott Vascular, Santa Clara, CA, USA) has been specifically designed to mitigate some of the complications associated with first-generation valves. Most of the data generated from randomized studies comparing transcatheter aortic valve implantation with surgery stem from reported experiences with first generation transcatheter heart valve devices. The aim of this review is to describe the repositionable and retrievable Portico system and its implantation technique, coupled with our single-center experience and to provide a review of the clinical results reported so far in the literature.
We sought to evaluate the differences in prognosis between the atrial (A-STR) and the ventricular (V-STR) phenotypes of secondary tricuspid regurgitation.Consecutive patients with moderate or severe STR referred for echocardiography were enrolled. A-STR and V-STR were defined according to the last ACC/AHA guidelines criteria. The primary endpoint was the composite of all-cause death and heart failure (HF) hospitalizations.A total of 211 patients were enrolled. The prevalence of A-STR in our cohort was 26%. Patients with A- STR were significantly older and with lower NYHA functional class than V-STR patients. The prevalence of severe STR was similar (28% in A-STR vs. 37% in V-STR, p = 0.291). A-STR patients had smaller tenting height (TH) (10 ± 4 mm vs. 12 ± 7 mm, p = 0.023), larger end-diastolic tricuspid annulus area (9 ± 2 cm2 vs. 7 ± 6 cm2/m2, p = 0.007), smaller right ventricular (RV) end-diastolic volumes (72 ± 27 ml/m2 vs. 92 ± 38 ml/m2; p = 0.001), and better RV longitudinal function (18 ± 7 mm vs. 16 ± 6 mm; p = 0.126 for TAPSE, and -21 ± 5% vs. -18 ± 5%; p = 0.006, for RV free-wall longitudinal strain, RVFWLS) than V-STR patients. Conversely, RV ejection fraction (RVEF, 48 ± 10% vs. 46 ± 11%, p = 0.257) and maximal right atrial volumes (64 ± 38 ml/m2 vs. 55 ± 23 ml/m2, p = 0.327) were similar between the two groups. After a median follow-up of 10 months, patients with V-STR had a 2.7-fold higher risk (HR: 2.7, 95% CI 95% = 1.3-5.7) of experiencing the combined endpoint than A-STR patients. The factors related to outcomes resulted different between the two STR phenotypes: TR-severity (HR: 5.8, CI 95% = 1, 4-25, P = 0.019) in A-STR patients; TR severity (HR 2.9, 95% CI 1.4-6.3, p = 0.005), RVEF (HR: 0.97, 95% CI 0.94-0.99, p = 0.044), and RVFWLS (HR: 0.93, 95% CI 0.85-0.98, p = 0.009) in V-STR.Almost one-third of patients referred to the echocardiography laboratory for significant STR have A-STR. A-STR patients had a lower incidence of the combined endpoint than V-STR patients. Moreover, while TR severity was the only independent factor associated to outcome in A-STR patients, TR severity and RV function were independently associated with outcome in V-STR patients.
Abstract A 70–year–old woman was admitted to our Intensive Care Unit (ICU) with high levels Hs–TnT. Coronaries were normal and ventriculography was suggestive for Takotsubo Syndrome (TS). In the acute phase she developed a cardiogenic shock and transthoracic echocardiography (TTE) showed a dilated left ventricle (LV) with iperkinesia of basal segments and biventricular apex and mid –ventricular akinesia, with a severely reduced left ventricular ejection fraction (LVEF 20%). Seven days after admission to Cardiac Rehabilitation Unit, a TTE showed LV apical hypertrophy (max thickness 18 mm), hypokinesia of hypertrophic segments, hypercontractility of basal segments and LVEF 55%. These features could have been suggestive for a coexisting apical hypertrophic cardiomyopathy (HCM). The EKG showed T wave inversions in precordial and inferior leads, not present at admission, this observation being against the presence of a pre–existing unknown HCM. Cardiac Magnetic Resonance (CMR) showed T1 and T2 mapping imagines for oedema in LV infero–lateral, basal segments and apical region, a subepicardial stria of late gadolinium enhancement in infero–lateral basal segment. These patterns were reported as suggestive for myocarditis rather than TS. Recent infectious or autoimmune diseases were excluded. Further TTE showed reversed LV parameters, normal kinesis of all segments, LVEF 66%, with a persistence of negative T waves at EKG. Discussion Our patient developed a classical TS with LV apical ballooning and hyperkinesia of basal segments with uncommon right ventricular hypokinesia. A peculiar finding was the transient apical LV thickness that was seen through TTE, mimicking an apical hypertrophic cardiomyopathy. Such a finding has already been described in few case reports; however, the nature and the physiopathology of that apical thickness was never proved. Through CMR we noted that, in the same region where TTE detected apical hypertrophy, there was a consistent amount of oedema which could be the reason of pseudo–hypertrophy findings. Our experience confirms the importance of integrating CMR in the diagnostic algorithm as already supported in consensus statements. In our case CMR played a key–role in the exclusion of a coexisting apical hypertrophic cardiomyopathy.
