Three-dimensional intracardiac echo-guided transcatheter tricuspid valve replacement.

Background Little is known about acute changes in right ventricular (RV) function and geometry following transcatheter tricuspid edge-to-edge repair (T-TEER) or transcatheter tricuspid valve replacement (TTVR). Pressure-strain-volume loop-derived myocardial work metrics showed associations with myocardial energetics and contractility in conditions accompanied by volume overload, suggesting their potential utility in patients with tricuspid regurgitation (TR). Purpose To define acute changes in RV volumes and RV myocardial work following T-TEER and TTVR using conventional and pressure-strain-volume derived RV work metrics. Methods In this multicenter, observational study, 3D echocardiographic datasets and invasively acquired RV pressures were collected before and after transcatheter tricuspid valve procedure. Using dedicated software (ReVISION, Argus Cognitive) 3D RV volumes and strains were quantified and decomposed to longitudinal, radial and anterio-posterior motion. Forward stroke volume (SV) was calculated by subtracting TR volumes from RV 3D end-diastolic volume (EDV) and end-systolic volume (ESV) difference. Three-dimensional pressure-strain-volume loops were constructed and global RV work-index (RV-Wi) was calculated. Changes in RV parameters before and after the intervention were compared using paired-samples t test. Results Of 37 patients included in this study (65% male), 20 underwent T-TEER and 17 underwent TTVR. Compared to T-TEER patients, patients undergoing TTVR had higher prevalence of torrential TR at baseline but also achieved a higher reduction in TR volumes after the intervention (44 ± 11 ml vs 60 ± 16ml; p = 0,001). Following T-TEER there was a significant reduction in RV EDV (240 ± 93 ml vs 200 ± 80 ml; p < 0.001) and increase in SV (55 ± 34 ml vs 68 ± 26 ml; p = 0.036). Following TTVR there was a significant increase in RV ESV (121 ± 46 vs 146 ± 48, p = 0.003) and no significant change in SV (47 ± 24 ml vs 55 ± 20 ml; p = 0.143). There was significant reduction in RV strain and ejection fraction (EF) (all p < 0.001) primarily driven by reduction of radial motion component in both groups. RV-Wi increased in 35% (7/20) of T-TEER patients and in 18% of (3/17) TTVR patients. Conclusion An acute reduction in RV EF was observed in all patients and was mainly caused by decrease in RV EDV in T-TEER patients and increase in RV ESV in TTVR patients. Despite decrease of conventional metrics of RV function in both groups, an increase in RV-Wi was observed in 27% of all patients.Baseline and follow-up characteristicsCentral Figure

Central MessageBDG unloads the RV volume in acute endocarditis patients after TV resection, but severe tricuspid regurgitation leads to RV dysfunction in the long term.In drug abusers with infective endocarditis, tricuspid valve (TV) replacement involves high recurrence risk.1Arbulu A. Holmes R.J. Asfaw I. Surgical treatment of intractable right-sided infective endocarditis in drug addicts: 25 years experience.J Heart Valve Dis. 1993; 2 (discussion 138-9): 129-137PubMed Google Scholar We have treated these patients with resection of infected tricuspid valve leaflets, TV annular reduction, and bidirectional Glenn shunt (BDG).2Huang S.C. Chi N.H. Wu I.H. Yu H.Y. Wu E.T. Wang S.S. et al.Incorporating a pediatric concept into tricuspid valve endocarditis: one and a half ventricle repair.J Thorac Cardiovasc Surg. 2006; 131: 228-229Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar BDG diverts flow from the superior vena cava (SVC) to pulmonary artery to unload right ventricular (RV). In this study, we report the follow-up of patients with TV endocarditis who received BDG with TV resection.Clinical DataWe retrospectively reviewed the medical records of 4 patients who received BDG and TV resection.2Huang S.C. Chi N.H. Wu I.H. Yu H.Y. Wu E.T. Wang S.S. et al.Incorporating a pediatric concept into tricuspid valve endocarditis: one and a half ventricle repair.J Thorac Cardiovasc Surg. 2006; 131: 228-229Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The study was approved by the Ethical Committee of National Taiwan University Hospital (no. 202108103RINA; approval date September 24, 2021). Informed consent was waived because of deidentified patient data. Three patients successfully overcame their drug addiction in 1 year, and 1 patient was lost to follow-up because of criminal problems (Table 1). Their functional status improved. Moreover, patient 1 delivered a healthy baby 5 years after surgery. However, congestive heart failure progressed after delivery. Because her right atrium (RA) and RV were dilated (right ventricular end-diastolic volume index = 117.7 mL/m2), and RV systolic function deteriorated (right ventricular ejection fraction = 39%), her TV was replaced with a 31-mm porcine valve (Hancock II; Medtronic). After TV replacement and RA closure, the SVC was removed from the pulmonary artery and reanastomosed to the RA through continuous suture. She had sinus rhythm afterwards. Her RA and RV regained their normal sizes 2 years after surgery, with improved functional status.Table 1Clinical course of infective endocarditis after initial treatment with BDG and TV resectionNo.After first operation (BDG + TV resection)Second operation (SVC reconstruction + TVR)OutcomeFc statusSVC/RA pressure, mm HgRhythmYear after BDGFc statusSVC/RA Pressure, mm HgRhythmEcho/MRIFollow-up periodRhythmEchoRARVRVOT antegrade flowTricuspid valveLVRARVTRLV1118/12Sinus7318/12Sinus tachycardiaRBBBDilateDilateRVEDVI = 117.7 mL/m2RVEF:39%Mild PRModerate-to-severe TRLVEF 59% diastolic dysfunction9SinusNormalNormalModerate PG: 26.1 mm HgFair systolic and diastolic function2120/10Sinus7316/10Sinus tachycardiaRBBBDilateDilateRVEDVI = 100.96 mL/m2RVEF: 58%Mild PRSevere TRMild TSMild LV dilatationFair systolic function diastolic dysfunction6SinusNormalNormalMildPG: 24 mm HgFair systolic and diastolic function3116/9Sinus16313/8Sinus tachycardiaRBBBDilateDilateRVDd: 3.9 cmRVFAC: 25%Severe PR, decreased antegrade flowSevere TRSmall LVDiastolic dysfunction0.6SinusDilateDilateMildPG: 17.8 mm HgFair systolic and diastolic functionBDG, Bidirectional Glenn shunt; TV, tricuspid valve; SVC, superior vena cava; TVR, tricuspid valve replacement; Fc status, New York Heart Association functional status; RA, right atrium; MRI, magnetic resonance imaging; RV, right ventricle; RVOT, right ventricular outflow tract; LV, left ventricle; TR, tricuspid regurgitation; RBBB, right bundle branch block; RVEDVI, right ventricular end-diastolic volume index; RVEF, right ventricular ejection fraction; PR, pulmonary regurgitation; LVEF, left ventricular ejection fraction; PG, pressure gradient; TS, tricuspid stenosis; RVDd, right ventricle diastolic diameter; RVFAC, right ventricular functional area change. Open table in a new tab Patient 2 experienced exertional dyspnea 4 years after BDG with TV resection. The maximal oxygen consumption was only 9.77 mL/min/kg (37% of the predicted value). Cardiac magnetic resonance imaging revealed severe RA dilatation, mild RV dilatation (right ventricular end-diastolic volume index = 100.96 mL/m2), and preserved RV contractility (right ventricular ejection fraction = 58%) (Video 1). SVC angiography revealed patent BDG with multiple collateral veins from the right subclavian vein to the inferior vena cava (IVC). She received TV replacement with a 33-mm St Jude Medical Epic porcine bioprosthetic valve, and her SVC was reconnected to the RA by using a 22-mm GORE-TEX graft 7 years after first operation. Her RV size normalized in the first year after surgery. She had sinus rhythm and improved exercise function during follow-up.Patient 3 first experienced exertional dyspnea 2 years after BDG and TV resection. Echocardiography revealed patent BDG, severe RA dilation, RV dilatation (RV diastolic diameter = 3.9 cm), and left ventricle (LV) compression. Decreased antegrade flow in the right ventricular outflow tract was disclosed because of severe tricuspid regurgitation. Atrial fibrillation was also noted. The dyspnea exacerbated during follow-up; hence, her TV was replaced with a 33-mm SJM Masters Series Mechanical Heart Valve 16 years after the first operation. The SVC was re-anastomosed to the RA with continuous suture. She had sinus rhythm afterwards, and her LV compression was relieved, with improved LV diastolic function.DiscussionThe long-term outcomes of BDG and TV resection in adult patients have limited reference. We previously demonstrated that BDG with TV resection provides a good short-term hemodynamic profile2Huang S.C. Chi N.H. Wu I.H. Yu H.Y. Wu E.T. Wang S.S. et al.Incorporating a pediatric concept into tricuspid valve endocarditis: one and a half ventricle repair.J Thorac Cardiovasc Surg. 2006; 131: 228-229Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar and an adequate observation period for infection control and drug abstinence. However, because of severe tricuspid regurgitation, RV unloading after BDG is insufficient in the long term. TV insufficiency causes blood backflow, which leads to progressive right-side chamber dilatation, function deterioration, and decreased right ventricular outflow tract antegrade flow3Chowdhury U.K. Airan B. Sharma R. Bhan A. Kothari S.S. Saxena A. et al.One and a half ventricle repair with pulsatile bidirectional Glenn: results and guidelines for patient selection.Ann Thorac Surg. 2001; 71: 1995-2002Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar (Video 1). TV replacement corrects this and improves functional status.BDG is applied in congenital heart disease with insufficient RV function.4Talwar S. Siddharth B. Choudhary S.K. Airan B. One and half ventricle repair: rationale, indications, and results.Indian J Thorac Cardiovasc Surg. 2018; 34: 370-380Crossref PubMed Scopus (6) Google Scholar BDG failure has several risk factors, such as pulmonary hypertension and elevated left atrial pressure. There was no evidence of pulmonary emboli or pulmonary hypertension in our patients, but all our patients had LV diastolic dysfunction before TV replacement. One patient even had a reduced LV volume due to septal displacement by RV dilatation. Last but not least, the pressure difference in the SVC and IVC could lead to venous collateral circulation, as observed in one of our patients. If venous collateral circulation from the SVC to IVC is significant, the RV workload increases, and BDG lost its unloading function (Figure 1). Because tricuspid insufficiency disappears after TV replacement, RV unloading by using BDG is no longer needed. Thus, we converted one and a half circulation to the biventricular status through the reconnection of the SVC to the RA in all our patients.Figure 1TV endocarditis repaired with (A) BDG and TV resection resulted in TR, collaterals from the subclavian vein to the IVC, decreased RVOT antegrade flow, RA and RV dilatation, and impaired systolic function with compromised LV diastolic function. (B) We took down BDG, reanastomosed the SVC to the RA, and replaced the TV. TV, Tricuspid valve; BDG, bidirectional Glenn shunt; TR, tricuspid regurgitation; IVC, inferior vena cava; RVOT, right ventricular outflow tract; RA, right atrium; RV, right ventricle; LV, left ventricle; SVC, superior vena cava.View Large Image Figure ViewerDownload Hi-res image Download (PPT)In summary, TV resection with BDG can provide a stable hemodynamic condition in the short term and offer an adequate observation period for drug abstinence. In the long-term follow-up, prosthetic TV replacement and SVC reimplantation are needed in case of severe tricuspid insufficiency and worsened RV function. BDG unloads the RV volume in acute endocarditis patients after TV resection, but severe tricuspid regurgitation leads to RV dysfunction in the long term. BDG unloads the RV volume in acute endocarditis patients after TV resection, but severe tricuspid regurgitation leads to RV dysfunction in the long term. In drug abusers with infective endocarditis, tricuspid valve (TV) replacement involves high recurrence risk.1Arbulu A. Holmes R.J. Asfaw I. Surgical treatment of intractable right-sided infective endocarditis in drug addicts: 25 years experience.J Heart Valve Dis. 1993; 2 (discussion 138-9): 129-137PubMed Google Scholar We have treated these patients with resection of infected tricuspid valve leaflets, TV annular reduction, and bidirectional Glenn shunt (BDG).2Huang S.C. Chi N.H. Wu I.H. Yu H.Y. Wu E.T. Wang S.S. et al.Incorporating a pediatric concept into tricuspid valve endocarditis: one and a half ventricle repair.J Thorac Cardiovasc Surg. 2006; 131: 228-229Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar BDG diverts flow from the superior vena cava (SVC) to pulmonary artery to unload right ventricular (RV). In this study, we report the follow-up of patients with TV endocarditis who received BDG with TV resection. Clinical DataWe retrospectively reviewed the medical records of 4 patients who received BDG and TV resection.2Huang S.C. Chi N.H. Wu I.H. Yu H.Y. Wu E.T. Wang S.S. et al.Incorporating a pediatric concept into tricuspid valve endocarditis: one and a half ventricle repair.J Thorac Cardiovasc Surg. 2006; 131: 228-229Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The study was approved by the Ethical Committee of National Taiwan University Hospital (no. 202108103RINA; approval date September 24, 2021). Informed consent was waived because of deidentified patient data. Three patients successfully overcame their drug addiction in 1 year, and 1 patient was lost to follow-up because of criminal problems (Table 1). Their functional status improved. Moreover, patient 1 delivered a healthy baby 5 years after surgery. However, congestive heart failure progressed after delivery. Because her right atrium (RA) and RV were dilated (right ventricular end-diastolic volume index = 117.7 mL/m2), and RV systolic function deteriorated (right ventricular ejection fraction = 39%), her TV was replaced with a 31-mm porcine valve (Hancock II; Medtronic). After TV replacement and RA closure, the SVC was removed from the pulmonary artery and reanastomosed to the RA through continuous suture. She had sinus rhythm afterwards. Her RA and RV regained their normal sizes 2 years after surgery, with improved functional status.Table 1Clinical course of infective endocarditis after initial treatment with BDG and TV resectionNo.After first operation (BDG + TV resection)Second operation (SVC reconstruction + TVR)OutcomeFc statusSVC/RA pressure, mm HgRhythmYear after BDGFc statusSVC/RA Pressure, mm HgRhythmEcho/MRIFollow-up periodRhythmEchoRARVRVOT antegrade flowTricuspid valveLVRARVTRLV1118/12Sinus7318/12Sinus tachycardiaRBBBDilateDilateRVEDVI = 117.7 mL/m2RVEF:39%Mild PRModerate-to-severe TRLVEF 59% diastolic dysfunction9SinusNormalNormalModerate PG: 26.1 mm HgFair systolic and diastolic function2120/10Sinus7316/10Sinus tachycardiaRBBBDilateDilateRVEDVI = 100.96 mL/m2RVEF: 58%Mild PRSevere TRMild TSMild LV dilatationFair systolic function diastolic dysfunction6SinusNormalNormalMildPG: 24 mm HgFair systolic and diastolic function3116/9Sinus16313/8Sinus tachycardiaRBBBDilateDilateRVDd: 3.9 cmRVFAC: 25%Severe PR, decreased antegrade flowSevere TRSmall LVDiastolic dysfunction0.6SinusDilateDilateMildPG: 17.8 mm HgFair systolic and diastolic functionBDG, Bidirectional Glenn shunt; TV, tricuspid valve; SVC, superior vena cava; TVR, tricuspid valve replacement; Fc status, New York Heart Association functional status; RA, right atrium; MRI, magnetic resonance imaging; RV, right ventricle; RVOT, right ventricular outflow tract; LV, left ventricle; TR, tricuspid regurgitation; RBBB, right bundle branch block; RVEDVI, right ventricular end-diastolic volume index; RVEF, right ventricular ejection fraction; PR, pulmonary regurgitation; LVEF, left ventricular ejection fraction; PG, pressure gradient; TS, tricuspid stenosis; RVDd, right ventricle diastolic diameter; RVFAC, right ventricular functional area change. Open table in a new tab Patient 2 experienced exertional dyspnea 4 years after BDG with TV resection. The maximal oxygen consumption was only 9.77 mL/min/kg (37% of the predicted value). Cardiac magnetic resonance imaging revealed severe RA dilatation, mild RV dilatation (right ventricular end-diastolic volume index = 100.96 mL/m2), and preserved RV contractility (right ventricular ejection fraction = 58%) (Video 1). SVC angiography revealed patent BDG with multiple collateral veins from the right subclavian vein to the inferior vena cava (IVC). She received TV replacement with a 33-mm St Jude Medical Epic porcine bioprosthetic valve, and her SVC was reconnected to the RA by using a 22-mm GORE-TEX graft 7 years after first operation. Her RV size normalized in the first year after surgery. She had sinus rhythm and improved exercise function during follow-up.Patient 3 first experienced exertional dyspnea 2 years after BDG and TV resection. Echocardiography revealed patent BDG, severe RA dilation, RV dilatation (RV diastolic diameter = 3.9 cm), and left ventricle (LV) compression. Decreased antegrade flow in the right ventricular outflow tract was disclosed because of severe tricuspid regurgitation. Atrial fibrillation was also noted. The dyspnea exacerbated during follow-up; hence, her TV was replaced with a 33-mm SJM Masters Series Mechanical Heart Valve 16 years after the first operation. The SVC was re-anastomosed to the RA with continuous suture. She had sinus rhythm afterwards, and her LV compression was relieved, with improved LV diastolic function. We retrospectively reviewed the medical records of 4 patients who received BDG and TV resection.2Huang S.C. Chi N.H. Wu I.H. Yu H.Y. Wu E.T. Wang S.S. et al.Incorporating a pediatric concept into tricuspid valve endocarditis: one and a half ventricle repair.J Thorac Cardiovasc Surg. 2006; 131: 228-229Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The study was approved by the Ethical Committee of National Taiwan University Hospital (no. 202108103RINA; approval date September 24, 2021). Informed consent was waived because of deidentified patient data. Three patients successfully overcame their drug addiction in 1 year, and 1 patient was lost to follow-up because of criminal problems (Table 1). Their functional status improved. Moreover, patient 1 delivered a healthy baby 5 years after surgery. However, congestive heart failure progressed after delivery. Because her right atrium (RA) and RV were dilated (right ventricular end-diastolic volume index = 117.7 mL/m2), and RV systolic function deteriorated (right ventricular ejection fraction = 39%), her TV was replaced with a 31-mm porcine valve (Hancock II; Medtronic). After TV replacement and RA closure, the SVC was removed from the pulmonary artery and reanastomosed to the RA through continuous suture. She had sinus rhythm afterwards. Her RA and RV regained their normal sizes 2 years after surgery, with improved functional status. BDG, Bidirectional Glenn shunt; TV, tricuspid valve; SVC, superior vena cava; TVR, tricuspid valve replacement; Fc status, New York Heart Association functional status; RA, right atrium; MRI, magnetic resonance imaging; RV, right ventricle; RVOT, right ventricular outflow tract; LV, left ventricle; TR, tricuspid regurgitation; RBBB, right bundle branch block; RVEDVI, right ventricular end-diastolic volume index; RVEF, right ventricular ejection fraction; PR, pulmonary regurgitation; LVEF, left ventricular ejection fraction; PG, pressure gradient; TS, tricuspid stenosis; RVDd, right ventricle diastolic diameter; RVFAC, right ventricular functional area change. Patient 2 experienced exertional dyspnea 4 years after BDG with TV resection. The maximal oxygen consumption was only 9.77 mL/min/kg (37% of the predicted value). Cardiac magnetic resonance imaging revealed severe RA dilatation, mild RV dilatation (right ventricular end-diastolic volume index = 100.96 mL/m2), and preserved RV contractility (right ventricular ejection fraction = 58%) (Video 1). SVC angiography revealed patent BDG with multiple collateral veins from the right subclavian vein to the inferior vena cava (IVC). She received TV replacement with a 33-mm St Jude Medical Epic porcine bioprosthetic valve, and her SVC was reconnected to the RA by using a 22-mm GORE-TEX graft 7 years after first operation. Her RV size normalized in the first year after surgery. She had sinus rhythm and improved exercise function during follow-up. Patient 3 first experienced exertional dyspnea 2 years after BDG and TV resection. Echocardiography revealed patent BDG, severe RA dilation, RV dilatation (RV diastolic diameter = 3.9 cm), and left ventricle (LV) compression. Decreased antegrade flow in the right ventricular outflow tract was disclosed because of severe tricuspid regurgitation. Atrial fibrillation was also noted. The dyspnea exacerbated during follow-up; hence, her TV was replaced with a 33-mm SJM Masters Series Mechanical Heart Valve 16 years after the first operation. The SVC was re-anastomosed to the RA with continuous suture. She had sinus rhythm afterwards, and her LV compression was relieved, with improved LV diastolic function. DiscussionThe long-term outcomes of BDG and TV resection in adult patients have limited reference. We previously demonstrated that BDG with TV resection provides a good short-term hemodynamic profile2Huang S.C. Chi N.H. Wu I.H. Yu H.Y. Wu E.T. Wang S.S. et al.Incorporating a pediatric concept into tricuspid valve endocarditis: one and a half ventricle repair.J Thorac Cardiovasc Surg. 2006; 131: 228-229Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar and an adequate observation period for infection control and drug abstinence. However, because of severe tricuspid regurgitation, RV unloading after BDG is insufficient in the long term. TV insufficiency causes blood backflow, which leads to progressive right-side chamber dilatation, function deterioration, and decreased right ventricular outflow tract antegrade flow3Chowdhury U.K. Airan B. Sharma R. Bhan A. Kothari S.S. Saxena A. et al.One and a half ventricle repair with pulsatile bidirectional Glenn: results and guidelines for patient selection.Ann Thorac Surg. 2001; 71: 1995-2002Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar (Video 1). TV replacement corrects this and improves functional status.BDG is applied in congenital heart disease with insufficient RV function.4Talwar S. Siddharth B. Choudhary S.K. Airan B. One and half ventricle repair: rationale, indications, and results.Indian J Thorac Cardiovasc Surg. 2018; 34: 370-380Crossref PubMed Scopus (6) Google Scholar BDG failure has several risk factors, such as pulmonary hypertension and elevated left atrial pressure. There was no evidence of pulmonary emboli or pulmonary hypertension in our patients, but all our patients had LV diastolic dysfunction before TV replacement. One patient even had a reduced LV volume due to septal displacement by RV dilatation. Last but not least, the pressure difference in the SVC and IVC could lead to venous collateral circulation, as observed in one of our patients. If venous collateral circulation from the SVC to IVC is significant, the RV workload increases, and BDG lost its unloading function (Figure 1). Because tricuspid insufficiency disappears after TV replacement, RV unloading by using BDG is no longer needed. Thus, we converted one and a half circulation to the biventricular status through the reconnection of the SVC to the RA in all our patients.In summary, TV resection with BDG can provide a stable hemodynamic condition in the short term and offer an adequate observation period for drug abstinence. In the long-term follow-up, prosthetic TV replacement and SVC reimplantation are needed in case of severe tricuspid insufficiency and worsened RV function. The long-term outcomes of BDG and TV resection in adult patients have limited reference. We previously demonstrated that BDG with TV resection provides a good short-term hemodynamic profile2Huang S.C. Chi N.H. Wu I.H. Yu H.Y. Wu E.T. Wang S.S. et al.Incorporating a pediatric concept into tricuspid valve endocarditis: one and a half ventricle repair.J Thorac Cardiovasc Surg. 2006; 131: 228-229Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar and an adequate observation period for infection control and drug abstinence. However, because of severe tricuspid regurgitation, RV unloading after BDG is insufficient in the long term. TV insufficiency causes blood backflow, which leads to progressive right-side chamber dilatation, function deterioration, and decreased right ventricular outflow tract antegrade flow3Chowdhury U.K. Airan B. Sharma R. Bhan A. Kothari S.S. Saxena A. et al.One and a half ventricle repair with pulsatile bidirectional Glenn: results and guidelines for patient selection.Ann Thorac Surg. 2001; 71: 1995-2002Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar (Video 1). TV replacement corrects this and improves functional status. BDG is applied in congenital heart disease with insufficient RV function.4Talwar S. Siddharth B. Choudhary S.K. Airan B. One and half ventricle repair: rationale, indications, and results.Indian J Thorac Cardiovasc Surg. 2018; 34: 370-380Crossref PubMed Scopus (6) Google Scholar BDG failure has several risk factors, such as pulmonary hypertension and elevated left atrial pressure. There was no evidence of pulmonary emboli or pulmonary hypertension in our patients, but all our patients had LV diastolic dysfunction before TV replacement. One patient even had a reduced LV volume due to septal displacement by RV dilatation. Last but not least, the pressure difference in the SVC and IVC could lead to venous collateral circulation, as observed in one of our patients. If venous collateral circulation from the SVC to IVC is significant, the RV workload increases, and BDG lost its unloading function (Figure 1). Because tricuspid insufficiency disappears after TV replacement, RV unloading by using BDG is no longer needed. Thus, we converted one and a half circulation to the biventricular status through the reconnection of the SVC to the RA in all our patients. In summary, TV resection with BDG can provide a stable hemodynamic condition in the short term and offer an adequate observation period for drug abstinence. In the long-term follow-up, prosthetic TV replacement and SVC reimplantation are needed in case of severe tricuspid insufficiency and worsened RV function. Supplementary Datahttps://www.jtcvstechniques.org/cms/asset/70ad3afc-937c-414f-946f-63d87b650860/mmc1.mp4Loading ... Download .mp4 (2.74 MB) Help with .mp4 files Video 1Prominent TR, dilated RA and RV; patent Glenn shunt without junctional stenosis. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00184-5/fulltext. Download .jpg (.08 MB) Help with files Video 1Prominent TR, dilated RA and RV; patent Glenn shunt without junctional stenosis. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00184-5/fulltext. https://www.jtcvstechniques.org/cms/asset/70ad3afc-937c-414f-946f-63d87b650860/mmc1.mp4Loading ... Download .mp4 (2.74 MB) Help with .mp4 files Video 1Prominent TR, dilated RA and RV; patent Glenn shunt without junctional stenosis. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00184-5/fulltext. Download .jpg (.08 MB) Help with files Video 1Prominent TR, dilated RA and RV; patent Glenn shunt without junctional stenosis. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00184-5/fulltext.

Clinically significant tricuspid regurgitation (TR) has historically been managed with either medical therapy or surgical interventions. More recently, percutaneous trans-catheter tricuspid valve (TV) replacement and tricuspid trans-catheter edge-to-edge repair have emerged as alternative treatment modalities. Patients with cardiac implantable electronic devices (CIEDs) have an increased incidence of TR. Severe TR in this population can occur for multiple reasons but most often results from the interactions between the CIED lead and the TV apparatus. Management decisions in patients with CIED leads and clinically significant TR, who are undergoing evaluation for a percutaneous TV intervention, need careful consideration as a trans-venous lead extraction (TLE) may both worsen and improve TR severity. Furthermore, given the potential risks of ‘jailing’ a CIED lead at the time of a percutaneous TV intervention (lead fracture and risk of subsequent infections), consideration should be given to performing a TLE prior to a percutaneous TV intervention. The purpose of this ‘state-of-the-art’ review is to provide an overview of the causes of TR in patients with CIEDs, discuss the available therapeutic options for patients with TR and CIED leads, and advocate for including a lead management specialist as a member of the ‘heart team’ when making treatment decisions in patients TR and CIED leads.

Early outcomes of off-label transcatheter tricuspid valve repair/replacement in the STS/ACC TVT registry.

Cardiac implantable electronic device implantation and function after transcatheter tricuspid valve replacement.

Transcatheter Tricuspid Valve Replacement and Liver Transplantation for Severe Tricuspid Regurgitation and Cirrhosis.

Transcatheter Tricuspid Valve Replacement

Patients with severe symptomatic tricuspid regurgitation (TR) are often deemed ineligible for surgical valve repair due to comorbidities. In this setting, transcatheter tricuspid valve replacement (TTVR) is undergoing development, but delivery technique and prosthesis design have yet to be optimized. We sought to assess the challenges of TTVR and the determinants of venous route using computed tomography (CT) analysis. A total of 195 end-diastolic cardiac CT performed prior to surgical correction of a severe TR (n = 38), transcatheter aortic valve replacement (n = 89), or left atrial appendage closure (n = 68) were analyzed. Patients with TR (n = 68; 19 primary and 49 secondary) were compared with patients without (n = 127). Continuous variables with normal and non-normal distributions were compared using Student t test or Mann-Whitney test respectively. The angle from the tricuspid annulus (TA) to the inferior vena cava was tighter (mean = 101 ± 18°) with a broader range of value (44° to 164°) than to the superior vena cava (mean = 143 ± 9°). Patients with TR had rounder TA (eccentricity index of 0.88 ± 0.08, p < 0.001), with a larger area (p < 0.0001), and septolateral (45.3 ± 8.0mm, p < 0.0001) and anteroposterior (44.4 ± 7.4mm, p < 0.0001) diameters than patients without. The distances from the TA to the coronary sinus, the right ventricular outflow tract, and the moderator band were respectively 11.4 ± 3.8mm, 17.2 ± 3.4mm, and 31.0 ± 6.7mm, without differences between groups. The transjugular access for TTVR is straighter and more reproducible than the transfemoral access. Prosthesis development may be challenged by the close position of the coronary sinus, the presence of a moderator band, and the large TA size of patients with severe TR. • The tricuspid annulus is larger in patients with severe tricuspid regurgitation, confirming existing data. • The coronary sinus ostium is close to the tricuspid annulus, requiring a prosthesis with a short atrial length. • The transjugular venous route may be the preferred access to the tricuspid annulus, straighter with less inter-individual variations than the transfemoral route.

Comparison of Early Outcomes Following Transjugular Transcatheter Tricuspid Valve Replacement Between Large vs Small Annulus.

Torrential tricuspid regurgitation (TR) in inoperable patients remains a major therapeutic challenge. Transcatheter tricuspid valve replacement (TTVR) is emerging as a definitive option, but many patients fail anatomical screening. To assess through a clinical case the feasibility of transcatheter edge-to-edge repair (TEER) as potential strategy to transform a patient deemed non-candidate to TTVR into a good candidate. We report how a 79-year-old man with torrential TR, chronic kidney disease, permanent atrial fibrillation, prior surgical aortic valve replacement, and a dual-chamber pacemaker who was rejected for TTVR after comprehensive screeningdue to large tricuspid annulus became good candidate to TTVR after TEER. TEER was performed with implantation of two devices and initial symptomatic and hemodynamic improvement. Three weeks later, the patient deteriorated, and detachment of one of the devices from the lateral leaflet was demonstrated with recurrent massive TR. TTVR could be performed thanks to the reduction of the neo-annular size and the anchor in the failing TEER device. This case illustrates both the limits of TEER in end-stage TR and the conceptual role of TEER as a temporizing or remodeling strategy that may, in selected patients, reshape leaflet coaptation and annular geometry sufficiently to enable subsequent TTVR. TEER may serve as a bridge-to-TTVR in anatomically marginal candidates, stabilizing patients clinically and modifying valve geometry to meet device-specific criteria. Prospective evaluation is warranted to define which anatomical substrates can benefit from this staged strategy.

Catheter-based treatment of structural heart diseases (SHD) has seen tremendous advances in the past decades, thanks to the development of new devices and advances in imaging techniques. Today, we have an extensive armamentarium of imaging tools for preprocedural planning, intraprocedural guidance and follow-up of SHD. Intraprocedural guidance is based mainly on transoesophageal echocardiography; however, other imaging modalities are used as complementary or alternative techniques, each of them with its strengths and weaknesses. Thus, a multimodality imaging approach provides added values in this setting. As the field of imaging parallels the continuous technical improvements, this review will describe the state of the art imaging techniques, focusing on echocardiography during procedural guidance of the most common catheter-based interventions, providing tips and tricks for interventional cardiologists: in particular, how to guide transseptal crossing; left atrial appendage closure; transcatheter mitral or tricuspid valve repair or replacement; percutaneous closure of patent foramen ovale and atrial defects; and percutaneous closure of paravalvular leaks. Open challenges for the near future are the need for physicians with specific technical skills and competencies in SHD imaging, more attention to high levels of radiation exposure, and optimisation of intraprocedural and post-procedural evaluation.

The aim of this study was to compare the outcomes of tricuspid valve (TV) repair versus replacement for patients with infective endocarditis (IE). In this nationwide population-based cohort study, we identified 704 patients from Taiwan National Health Insurance Research Database who underwent TV surgery due to IE between 2000 and 2013. Of them, 412 (58.5%) underwent TV repair and 292 (41.5%) underwent TV replacement, and their perioperative and late outcomes were analysed. Confounding was reduced using the inverse probability of treatment weighting on propensity score. After inverse probability of treatment weighting, the in-hospital mortality rate between the 2 groups was not significantly different. However, patients who received TV repair had lower rates of perioperative complications, including massive blood transfusion, de novo dialysis and deep wound infection; longer ICU and hospital stays; and higher hospital cost. Regarding late outcomes, TV repair was associated with lower risks of all-cause readmission [subdistribution hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.60-0.78; P < 0.001], readmission for adverse liver outcomes (subdistribution HR 0.75, 95% CI 0.58-0.97; P = 0.025), new permanent pacemaker implantation (subdistribution HR 0.27, 95% CI 0.15-0.48; P < 0.001) and all-cause mortality (HR 0.60, 95% CI 0.51-0.71; P < 0.001) than TV replacement. For IE, TV repair is associated with better early and late outcomes than TV replacement. A repair-first strategy is recommended for patients with IE for whom TV surgery is indicated.

Outcomes after tricuspid valve surgery were initially extremely poor but have improved over time thanks to innovations in diagnostics, guidelines for treatment, emerging surgical experience and technical advances. This chapter provides a contemporary overview of patient and procedural characteristics of tricuspid valve repair and replacement and early and late outcomes in different settings, such as functional tricuspid regurgitation, rheumatic, congenital, carcinoid tricuspid valve disease, iatrogenic tricuspid valve damage, and finally endocarditis of the tricuspid valve. For this purpose a systematic literature review and meta-analysis was conducted including 132 studies published after 2005 and reporting on outcome after tricuspid valve surgery. This thorough review of reported experience with tricuspid valve repair and replacement reveals a strong variation in patient presentation and outcome among the various indications and highlights that tricuspid valve replacement is still associated with high early and late mortality. Innovations in the treatment of tricuspid valve disease are direly needed to improve outcome in this complicated patient population.

BackgroundLead-induced tricuspid regurgitation is one of the complications after permanent pacemaker implantation (PPI) and refers to tricuspid regurgitation (TR) caused by the lead in the right ventricle (RV).ObjectivesTo study the clinical characteristics of severe TR after PPI and the effect of transcatheter tricuspid valve replacement (TTVR) with the guidance of 3-dimensional (3D) printing.MethodsThis study was a single-center, descriptive study. Six patients with severe TR after PPI were enrolled in Xijing Hospital from January 2020 to May 2020. Before TTVR, the 3D printed tricuspid valve (TV) model was used for evaluation in the bench test. LuX-Valve was implanted under the guidance of TEE and x-ray fluoroscopy, and all patients underwent transatrial access. Six patients’ data were collected at baseline, before discharge, and 6 months, 1 year and 2 years after TTVR.ResultsThe LuX-Valve was successfully implanted in 6 patients, TR was significantly reduced to ≤2+, and no deaths or cardiopulmonary bypass occurred during procedures. Three cases were caused by TV expansion: Patient #4 had TR caused by lead adhesion to TV, Patient #2 had TR caused by lead winding, and Patient #6 had TR caused by lead impingement on TV. During the 2-year follow-up, TTE revealed that 5 patients had no/trace regurgitation, and one patient (Patient #5) had mild regurgitation. All 6 patients (100.0%) reached primary endpoints.ConclusionTTVR guided by 3D printing is safe and effective in the treatment of severe TR associated with permanent pacemaker lead, providing prospects and possibilities for the precise treatment of TV-related diseases.Clinical Trial Registration: ClinicalTrials.gov Protocol Registration System (NCT02917980).

Transcatheter Tricuspid Valve Replacement for Recurrent Tricuspid Regurgitation After Tricuspid Transcatheter Edge-to-Edge Repair