Rediscovered and Unforgotten: Transcatheter Interventions for the Treatment of Severe Tricuspid Valve Regurgitation

Tricuspid valve regurgitation is both globally prevalent and undertreated. Historically, surgical intervention for isolated tricuspid regurgitation (TR) was avoided despite the prevalence of TR, largely due to poor surgical outcomes and an incomplete understanding of how it independently affects mortality. Over the past two decades, TR has been shown by several studies to be an independent predictor of worse functional status and poor survival on long-term follow-up. During this same time period, transcatheter interventions for the treatment of valvular heart disease have evolved dramatically. While the transcatheter repair and replacement of the tricuspid valve in patients with severe TR remains in the early stages of investigation relative to the mitral or aortic valve, the field is rapidly expanding. Here, the authors review the field of transcatheter tricuspid valve interventions for severe TR, focusing on the orthotropic devices and valves currently available worldwide

El papel de las intervenciones percutáneas en la insuficiencia tricuspídea en la práctica actual: abordando una enfermedad heterogénea

Se sabe que la insuficiencia tricuspídea (IT) grave está asociada de forma independiente a un pronóstico adverso1. Su importancia se ve reforzada por la prevalencia de esta entidad, sobre todo en la población anciana2. Hasta hace no muchos años, el único tratamiento eficaz que había contra la IT grave aislada era el quirúrgico. No obstante, la mortalidad operatoria sigue siendo alta3. Además, la cirugía se asocia a un índice de recurrencia del 45% a los 5 años4 y los últimos datos de que disponemos sugieren que la cirugía podría no mejorar la supervivencia de los casos graves aislados de IT5. En consecuencia, las guías de práctica clínica recomiendan la cirugía de la IT solo como indicación de clase I con cirugía valvular del lado izquierdo concomitante6. Por otra parte, aquellos pacientes con riesgo quirúrgico prohibitivo asignados a tratamiento conservador muestran resultados desalentadores7. Afortunadamente, la llegada de los dispositivos percutáneos ha ampliado el horizonte de tratamiento de la IT. ABORDAJE DE UNA PATOLOGÍA MULTIMECANÍSTICA La IT es la consecuencia de varios mecanismos fisiopatológicos, como la dilatación del ventrículo derecho (VD) con el correspondiente tethering de las valvas, la dilatación anular tricuspídea con la subsiguiente mala coaptación, fibrilación auricular con resultado de dilatación anular..

The role of percutaneous tricuspid regurgitation interventions in the current clinical practice: tackling a heterogenous disease

Severe tricuspid regurgitation (TR) is known to be independently associated with adverse prognosis.1 Its importance is further emphasized by the prevalence of this entity, particularly in the aging population.2 Until the past few years, surgical management was the only available effective treatment for isolated severe TR. Operative mortality, nonetheless, remains high.3 Moreover, surgery is associated with a 45% recurrence rate after 5 years,4 and recent data suggest that surgery may not improve the survival rate in isolated severe cases of TR.5 Accordingly, guidelines recommend TR surgery as a class 1 indication only with concomitant left-sided valvular surgery.6 Conversely, patients with prohibitive surgical risk managed conservatively were shown to have dismal outcomes.7 Fortunately, the emergence of percutaneous devices expanded the horizon of TR treatment. TACKLING THE MULTI-MECHANISTIC PATHOLOGY TR is the product of various pathophysiological mechanisms including right ventricular (RV) dilatation with consequential leaflet tethering, tricuspid annular dilatation with subsequent mal-coaptation, atrial fibrillation causing further annular dilation through atrial enlargement, and abnormalities in the tricuspid valve leaflets and apparatus. At a certain point, regurgitation itself becomes an etiology through a vicious circle of RV and atrial remodeling. Accordingly, numerous percutaneous devices are being developed for transcatheter tricuspid valve repair (TTVr) and replacement (TTVR)...

Reduction in operator radiation exposure during transradial coronary procedures using a simple lead rectangle

Objectives: Transradial access for percutaneous coronary intervention (PCI) reduces procedural complications however, there are concerns regarding the potential for increased exposure to ionizing radiation to the primary operator. We evaluated the efficacy of a lead-attenuator in reducing radiation exposure during transradial PCI. Methods and results: This was a non-randomized, prospective, observational study in which 52 consecutive patients were assigned to either standard operator protection (n = 26) or the addition of the lead attenuator across their abdomen/pelvis (n = 26). In the attenuator group patients were relatively older with a higher prevalence of peripheral vascular disease (67.9 vs 58.7 p = 0.0292 and 12% vs 7.6% p < 0.001 respectively). Despite similar average fluoroscopy times (12.3 ± 9.8 min vs. 9.3 ± 5.4 min, p = 0.175) and average examination doses (111866 ± 80790 vs. 91,268 ± 47916 Gycm2, p = 0.2688), the total radiation exposure to the operator, at the thyroid level, was significantly lower when the lead-attenuator was utilized (20.2% p < 0.0001) as compared to the control group. Amongst the 26 patients assigned to the lead-attenuator, there was a significant reduction in measured radiation of 94.5% (p < 0.0001), above as compared to underneath the lead attenuator. Conclusions: Additional protection with the use of a lead rectangle-attenuator significantly lowered radiation exposure to the primary operator, which may confer long-term benefits in reducing radiation-induced injury. Advances in knowledge: This is the first paper to show that a simple lead attenuator almost completely reduced the scattered radiation at very close proximity to the patient and should be considered as part of the standard equipment within catheterization laboratories

Mechanical Circulatory Support Devices for the Treatment of Cardiogenic Shock Complicating Acute Myocardial Infarction—A Review

Cardiogenic shock complicating acute myocardial infarction is a complex clinical condition associated with dismal prognosis. Routine early target vessel revascularization remains the most effective treatment to substantially improve outcomes, but mortality remains high. Temporary circulatory support devices have emerged with the aim to enhance cardiac unloading and improve end-organ perfusion. However, quality evidence to guide device selection, optimal installation timing, and post-implantation management are scarce, stressing the importance of multidisciplinary expert care. This review focuses on the contemporary use of short-term support devices in the setting of cardiogenic shock following acute myocardial infarction, including the common challenges associated this practice

The Effect of War on STEMI Incidence: Insights from Intensive Cardiovascular Care Unit Admissions

(1) Background: The impact of armed conflicts on public health is undeniable, with psychological stress emerging as a significant risk factor for cardiovascular disease (CVD). Nevertheless, contemporary data regarding the influence of war on CVD, and especially on acute coronary syndrome (ACS), are scarce. Hence, the aim of the current study was to assess the repercussions of war on the admission and prognosis of patients admitted to a tertiary care center intensive cardiovascular care unit (ICCU). (2) Methods: All patients admitted to the ICCU during the first three months of the Israel–Hamas war (2023) were included and compared with all patients admitted during the same period in 2022. The primary outcome was in-hospital mortality. (3) Results: A total of 556 patients (184 females [33.1%]) with a median age of 70 (IQR 59–80) were included. Of them, 295 (53%) were admitted to the ICCU during the first three months of the war. Fewer Arab patients and more patients with ST-segment elevation myocardial infraction (STEMI) were admitted during the war period (21.8% vs. 13.2%, p p = 0.04, respectively), whereas non-STEMI (NSTEMI) patients were admitted more frequently in the pre-war year (19.3% vs. 25.7%, p = 0.09). In-hospital mortality was similar in both groups (4.4% vs. 3.4%, p = 0.71; HR 1.42; 95% CI 0.6–3.32, p = 0.4). (4) Conclusions: During the first three months of the war, fewer Arab patients and more STEMI patients were admitted to the ICCU. Nevertheless, in-hospital mortality was similar in both groups

Outcomes of Patients Treated with Blood Transfusion in a Contemporary Tertiary Care Medical Center Intensive Cardiac Care Unit

Background: Acutely ill patients treated with blood transfusion (BT) have unfavorable prognoses. Nevertheless, data regarding outcomes in patients treated with BT admitted into a contemporary tertiary care medical center intensive cardiac care unit (ICCU) are limited. The current study aimed to assess the mortality rate and outcomes of patients treated with BT in a modern ICCU. Methods: Prospective single center study where we evaluated mortality, in the short and long term, of patients treated with BT between the period of January 2020 and December 2021 in an ICCU. Outcomes: A total of 2132 consecutive patients were admitted to the ICCU during the study period and were followed-up for up to 2 years. In total, 108 (5%) patients were treated with BT (BT-group) during their admission, with 305 packed cell units. The mean age was 73.8 &plusmn; 14 years in the BT-group vs. 66.6 &plusmn; 16 years in the non-BT (NBT) group, p &lt; 0.0001. Females were more likely to receive BT as compared with males (48.1% vs. 29.5%, respectively, p &lt; 0.0001). The crude mortality rate was 29.6% in the BT-group and 9.2% in the NBT-group, p &lt; 0.0001. Multivariate Cox analysis found that even one unit of BT was independently associated with more than two-fold the mortality rate [HR = 2.19 95% CI (1.47&ndash;3.62)] as compared with the NBT-group, p &lt; 0.0001]. Receiver operating characteristic (ROC) curve was plotted for multivariable analysis and showed area under curve (AUC) of 0.8 [95% CI (0.760&ndash;0.852)]. Conclusions: BT continues to be a potent and independent predictor for both short- and long-term mortality even in a contemporary ICCU, despite the advanced technology, equipment and delivery of care. Further considerations for refining the strategy of BT administration in ICCU patients and guidelines for different subsets of high-risk patients may be warranted

Outcomes of Patients Treated with Blood Transfusion in a Contemporary Tertiary Care Medical Center Intensive Cardiac Care Unit

Background: Acutely ill patients treated with blood transfusion (BT) have unfavorable prognoses. Nevertheless, data regarding outcomes in patients treated with BT admitted into a contemporary tertiary care medical center intensive cardiac care unit (ICCU) are limited. The current study aimed to assess the mortality rate and outcomes of patients treated with BT in a modern ICCU. Methods: Prospective single center study where we evaluated mortality, in the short and long term, of patients treated with BT between the period of January 2020 and December 2021 in an ICCU. Outcomes: A total of 2132 consecutive patients were admitted to the ICCU during the study period and were followed-up for up to 2 years. In total, 108 (5%) patients were treated with BT (BT-group) during their admission, with 305 packed cell units. The mean age was 73.8 ± 14 years in the BT-group vs. 66.6 ± 16 years in the non-BT (NBT) group, p p p p < 0.0001]. Receiver operating characteristic (ROC) curve was plotted for multivariable analysis and showed area under curve (AUC) of 0.8 [95% CI (0.760–0.852)]. Conclusions: BT continues to be a potent and independent predictor for both short- and long-term mortality even in a contemporary ICCU, despite the advanced technology, equipment and delivery of care. Further considerations for refining the strategy of BT administration in ICCU patients and guidelines for different subsets of high-risk patients may be warranted

Outcomes of Redo Transcatheter Aortic Valve Replacement According to the Initial and Subsequent Valve Type

Background: As transcatheter aortic valve (TAV) replacement is increasingly used in patients with longer life expectancy, a sizable proportion will require redo TAV replacement (TAVR). The unique configuration of balloon-expandable TAV (bTAV) vs a self-expanding TAV (sTAV) potentially affects TAV-in-TAV outcome. Objectives: The purpose of this study was to better inform prosthesis selection, TAV-in-TAV outcomes were assessed according to the type of initial and subsequent TAV. Methods: Patients from the Redo-TAVR registry were analyzed using propensity weighting according to their initial valve type (bTAV [n = 115] vs sTAV [n = 106]) and subsequent valve type (bTAV [n = 130] vs sTAV [n = 91]). Results: Patients with failed bTAVs presented later (vs sTAV) (4.9 ± 2.1 years vs 3.7 ± 2.3 years; P < 0.001), with smaller effective orifice area (1.0 ± 0.7 cm2 vs 1.3 ± 0.8 cm2; P = 0.018) and less frequent dominant regurgitation (16.2% vs 47.3%; P < 0.001). Mortality at 30 days was 2.3% (TAV-in-bTAV) vs 0% (TAV-in-sTAV) (P = 0.499) and 1.7% (bTAV-in-TAV) vs 1.0% (sTAV-in-TAV) (P = 0.612); procedural safety was 72.6% (TAV-in-bTAV) vs 71.2% (TAV-in-sTAV) (P = 0.817) and 73.2% (bTAV-in-TAV) vs 76.5% (sTAV-in-TAV) (P = 0.590). Device success was similar according to initial valve type but higher with subsequent sTAV vs bTAV (77.2% vs 64.3%; P = 0.045), primarily because of lower residual gradients (10.3 mm Hg [8.9-11.7 mm Hg] vs 15.2 mm Hg [13.2-17.1 mm Hg]; P < 0.001). Residual regurgitation (moderate or greater) was similar after bTAV-in-TAV and sTAV-in-TAV (5.7%) and nominally higher after TAV-in-bTAV (9.1%) vs TAV-in-sTAV (4.4%) (P = 0.176). Conclusions: In selected patients, no association was observed between TAV type and redo TAVR safety or mortality, yet subsequent sTAV was associated with higher device success because of lower redo gradients. These findings are preliminary, and more data are needed to guide valve choice for redo TAVR