Functional Tricuspid Regurgitation: Behind the Scenes of a Long-Time Neglected Disease

Severe tricuspid valve regurgitation has been for a long time a neglected valve disease, which has only recently attracted an increasing interest due to the notable negative impact on the prognosis of patients with cardiovascular disease. It is estimated that around 90% of tricuspid regurgitation is diagnosed as "functional" and mostly secondary to a primary left-sided heart disease and, therefore, has been usually interpreted as a benign condition that did not require a surgical management. Nevertheless, the persistence of severe tricuspid regurgitation after left-sided surgical correction of a valve disease, particularly mitral valve surgery, has been associated to adverse outcomes, worsening of the quality of life, and a significant increase in mortality rate. Similar results have been found when the impact of isolated severe tricuspid regurgitation has been studied. Current knowledge is shifting the "functional" categorization toward a more complex and detailed pathophysiological classification, identifying various phenotypes with completely different etiology, natural history and, potentially, an invasive management. The aim of this review is to offer a comprehensive guide for clinicians and surgeons with a systematic description of "functional" tricuspid regurgitation subtypes, an analysis centered on the effectiveness of existing surgical techniques and a focus on the emergent percutaneous procedures. This latter may be an attractive alternative to a standard surgical approach in patients with high-operative risk or isolated tricuspid regurgitation.Copyright © 2022 Vinciguerra, Sitges, Luis Pomar, Romiti, Domenech-Ximenos, D'Abramo, Wretschko, Miraldi and Greco

Three-dimensional regional bi-ventricular shape remodeling is associated with exercise capacity in endurance athletes

Aims: Endurance athletes develop cardiac remodeling to cope with increased cardiac output during exercise. This remodeling is both anatomical and functional and shows large interindividual variability. In this study, we quantify local geometric ven-tricular remodeling related to long-standing endurance training and assess its relationship with cardiovascular performance during exercise.Methods: We extracted 3D models of the biventricular shape from end-diastolic cine magnetic resonance images acquired from a cohort of 89 triathlon athletes and 77 healthy sedentary subjects. Additionally, the athletes underwent cardio-pulmonary exercise testing, together with an echocardiographic study at baseline and few minutes after maximal exercise. We used statistical shape analysis to identify regional bi-ventricular shape differences between athletes and non-athletes.Results: The ventricular shape was significantly different between athletes and controls (p < 1e−6). The observed regional remodeling in the right heart was mainly a shift of the right ventricle (RV) volume distribution towards the right ventricular infundibulum, increasing the overall right ventricular volume. In the left heart, there was an increment of left ventricular mass and a dilation of the left ventricle. Within athletes, the amount of such remodeling was independently associated to higher peak oxygen pulse (p < 0.001) and weakly with greater post-exercise RV free wall longitudinal strain (p = 0.03).Conclusions: We were able to identify specific bi-ventricular regional remodeling induced by long-lasting endurance training. The amount of remodeling was associated with better cardiopulmonary performance during an exercise test.This study was partially supported by the Spanish Ministry of Economy and Competitiveness (Grant DEP2013-44923-P, TIN2014-52923-R; Maria de Maeztu Units of Excellence Programme—MDM-2015-0502), el Fondo Europeo de Desarrollo Regional (FEDER), the European Union under the Horizon 2020 Programme for Research, Innovation (Grant agreement No. 642676 CardioFunXion) and Erasmus+Programme (Framework Agreement number: 2013-0040), “la Caixa” Foundation (LCF/PR/GN14/10270005, LCF/PR/GN18/10310003), Instituto de Salud Carlos III (PI14/00226, PI15/00130, PI17/00675) integrated in the “Plan Nacional I+D+I” and AGAUR 2017 SGR Grant no. 1531