Computed tomography anatomic predictors of outcomes in patients undergoing tricuspid transcatheter edge-to-edge repair.

AIM To identify anatomical computed tomography (CT) predictors of procedural and clinical outcomes in patients undergoing tricuspid transcatheter edge-to-edge repair (T-TEER). METHODS AND RESULTS Consecutive patients undergoing T-TEER between March 2018 to December 2022 who had cardiac CT prior to the procedure were included. CT scans were automatically analyzed using a dedicated software that employs deep learning techniques to provide precise anatomical measurements and volumetric calculations. Technical success was defined as successful placement of at least one implant in the planned anatomic location without single leaflet device attachment. Procedural success was defined as tricuspid regurgitation reduction to moderate or less. Procedural complexity was assessed by measuring the fluoroscopy time. The clinical endpoint was a composite of death, heart failure hospitalization, or tricuspid re-intervention throughout two years. A total of 33 patients (63.6% male) were included. Procedural success was achieved in 22 patients (66.7%). Shorter end-systolic (ES) height between the inferior vena cava (IVC) and tricuspid annulus (TA) (r ​= ​- 0.398, p ​= ​0.044) and longer ES RV length (r ​= ​0.551, p ​= ​0.006) correlated with higher procedural complexity. ES RV length was independently associated with lower technical(adjusted Odds ratio [OR] 0.812 [95% CI 0.665-0.991], p ​= ​0.040) and procedural success (adjusted OR 0.766, CI [0.591-0.992], p ​= ​0.043). Patients with ES right ventricular (RV) length of >77.4 ​mm had a four-fold increased risk of experiencing the composite clinical endpoint compared to patients with ES RV length ≤77.4 ​mm (HR ​= ​3.964 [95% CI, 1.018-15.434]; p ​= ​0,034]). CONCLUSION CT-derived RV length and IVC-to-TA height may be helpful to identify patients at increased risk for procedural complexity and adverse outcomes when undergoing T-TEER. CT provides valuable information for preprocedural decision-making and device selection

Contemporary Approach of Tricuspid Regurgitation: Knowns, Unknowns and Future Challenges.

Severe tricuspid regurgitation (TR) worsens heart failure and is associated with impaired survival. In daily clinical practice, patients are referred late and tricuspid valve (TV) interventions (surgical or transcatheter) are underutilized, which leads to irreversible right ventricular (RV) damage and increases the risk. This article addresses the appropriate timing and modality for an intervention (surgical or transcatheter), and its potential benefits on clinical outcomes. Ongoing randomized controlled trials will provide further insights into the efficacy of transcatheter valve interventions compared to medical treatment

Acute Heart Failure During the Peripartum Period Due to Aggravated Tricuspid Regurgitation.

Latent valvular heart disease may be aggravated or demasked during pregnancy because of physiologic hemodynamic changes, including higher circulating volume, heart rate, and cardiac index, as well as stress during labor. The presence of valvular heart disease increases the risk of maternal and fetal/newborn adverse events. Early diagnosis, risk assessment, and specific management are crucial. We present a case of acute peripartal heart failure caused by idiopathic severe tricuspid regurgitation in a 38-year-old woman

Incidental Arrhythmias During Atrial Fibrillation Screening With Repeat 7-Day Holter ECGs in a Hospital-Based Patient Population.

BACKGROUND Screening for atrial fibrillation (AF) may reveal incidental arrhythmias of relevance. The aim of this study was to describe incidental arrhythmias detected during screening for AF in the STAR-FIB (Predicting SilenT AtRial FIBrillation in Patients at High Thrombembolic Risk) cohort study. METHODS AND RESULTS In the STAR-FIB cohort study, we screened hospitalized patients for AF with 3 repeat 7-day Holter ECGs. We analyzed all Holter ECGs for the presence of the following incidental arrhythmias: (1) sinus node dysfunction, defined as sinus pause of ≥3 seconds' duration; (2) second-degree (including Wenckebach) or higher-degree atrioventricular block (AVB); (3) sustained supraventricular tachycardia of ≥30 seconds' duration; and (4) sustained ventricular tachycardia of ≥30 seconds' duration. We furthermore report treatment decisions because of incidental arrhythmias. A total of 2077 Holter ECGs were performed in 794 patients (mean age, 74.7 years; 49% women), resulting in a mean cumulative duration of analyzable ECG signal of 414±136 hours/patient. We found incidental arrhythmias in 94 patients (11.8%). Among these were sinus node dysfunction in 14 patients (1.8%), AVB in 41 (5.2%), supraventricular tachycardia in 42 (5.3%), and ventricular tachycardia in 2 (0.3%). Second-degree AVB was found in 23 patients (2.9%), 2:1 AVB in 10 (1.3%), and complete AVB in 8 (1%). Subsequently, 8 patients underwent pacemaker implantation, 1 for sinus node dysfunction (post-AF conversion pause of 9 seconds) and 7 for advanced AVB. One patient had an implantable cardioverter-defibrillator implanted for syncopal ventricular tachycardia. CONCLUSIONS Incidental arrhythmias were frequently detected during screening for AF in the STAR-FIB study and resulted in device therapy in 1.1% of our cohort patients

Risk of Cardiac Arrhythmias Among Climbers on Mount Everest.

IMPORTANCE Arterial hypoxemia, electrolyte imbalances, and periodic breathing increase the vulnerability to cardiac arrhythmia at altitude. OBJECTIVE To explore the incidence of tachyarrhythmias and bradyarrhythmias in healthy individuals at high altitudes. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study involved healthy individuals at altitude (8849 m) on Mount Everest, Nepal. Recruitment occurred from January 25 to May 9, 2023, and data analysis took place from June to July 2023. EXPOSURE All study participants underwent 12-lead electrocardiogram, transthoracic echocardiography, and exercise stress testing before and ambulatory rhythm recording both before and during the expedition. MAIN OUTCOME The incidence of a composite of supraventricular (>30 seconds) and ventricular (>3 beats) tachyarrhythmia and bradyarrhythmia (sinoatrial arrest, second- or third-degree atrioventricular block). RESULTS Of the 41 individuals recruited, 100% were male, and the mean (SD) age was 33.6 (8.9) years. On baseline investigations, there were no signs of exertional ischemia, wall motion abnormality, or cardiac arrhythmia in any of the participants. Among 34 individuals reaching basecamp at 5300 m, 32 participants climbed to 7900 m or higher, and 14 reached the summit of Mount Everest. A total of 45 primary end point-relevant events were recorded in 13 individuals (38.2%). Forty-three bradyarrhythmic events were documented in 13 individuals (38.2%) and 2 ventricular tachycardias in 2 individuals (5.9%). Nine arrhythmias (20%) in 5 participants occurred when climbers were using supplemental bottled oxygen, whereas 36 events (80%) in 11 participants occurred at lower altitudes when no supplemental bottled oxygen was used. The proportion of individuals with arrhythmia remained stable across levels of increasing altitude, while event rates per 24 hours numerically increased between 5300 m (0.16 per 24 hours) and 7300 m (0.37 per 24 hours) before decreasing again at higher altitudes, where supplemental oxygen was used. None of the study participants reported dizziness or syncope. CONCLUSION AND RELEVANCE In this study, more than 1 in 3 healthy individuals experienced cardiac arrhythmia during the climb of Mount Everest, thereby confirming the association between exposure to high altitude and incidence of cardiac arrhythmia. Future studies should explore the potential implications of these rhythm disturbances

3-Dimensional Echocardiographic Prediction of Left Ventricular Outflow Tract Area Prior to Transcatheter Mitral Valve Replacement.

BACKGROUND New postprocessing software facilitates 3-dimensional (3D) echocardiographic determination of mitral annular (MA) and neo-left ventricular outflow tract (neo-LVOT) dimensions in patients undergoing transcatheter mitral valve replacement (TMVR). OBJECTIVES This study aims to test the accuracy of 3D echocardiographic analysis as compared to baseline computed tomography (CT). METHODS A total of 105 consecutive patients who underwent TMVR at 2 tertiary care centers between October 2017 and May 2023 were retrospectively included. A virtual valve was projected in both baseline CT and 3D transesophageal echocardiography (TEE) using dedicated software. MA dimensions were measured in baseline images and neo-LVOT dimensions were measured in baseline and postprocedural images. All measurements were compared to baseline CT as a reference. The predicted neo-LVOT area was correlated with postprocedural peak LVOT gradients. RESULTS There was no significant bias in baseline neo-LVOT prediction between both imaging modalities. TEE significantly underestimated MA area, perimeter, and medial-lateral dimension compared to CT. Both modalities significantly underestimated the actual neo-LVOT area (mean bias pre/post TEE: 25.6 mm2, limit of agreement: -92.2 mm2 to 143.3 mm2; P < 0.001; mean bias pre/post CT: 28.3 mm2, limit of agreement: -65.8 mm2 to 122.4 mm2; P = 0.046), driven by neo-LVOT underestimation in the group treated with dedicated mitral valve bioprosthesis. Both CT- and TEE-predicted-neo-LVOT areas exhibited an inverse correlation with postprocedural LVOT gradients (r2 = 0.481; P < 0.001 for TEE and r2 = 0.401; P < 0.001 for CT). CONCLUSIONS TEE-derived analysis provides comparable results with CT-derived metrics in predicting the neo-LVOT area and peak gradient after TMVR