Secondary tricuspid regurgitation

Tricuspid regurgitation (TR) can be divided into primary and secondary origins. Primary TR is mostly caused by infective endocarditis, leaflet perforation, entrapment after device placement and congenital abnormalities. The natural cause of secondary (functional) TR is not well-understood and underdiagnoses is likely. Because symptoms such as ascites, edema and hepatomegaly usually manifest at a late state, assessment of TR is challenging requiring a multiparametric approach. Secondary TR can be subdivided into four morphologic types according to the underlying mechanism: Left-heart related TR, precapillary pulmonary hypertension related TR, right ventricular disease related TR and isolated TR

Impact of sleep-disordered breathing treatment on ventricular tachycardia in patients with heart failure

Background: Sleep-disordered breathing (SDB) is a highly common comorbidity in patients with heart failure (HF), and a known risk factor for ventricular tachycardia (VT) development. However, little is known about the impact of SDB treatment on VT burden in HF patients to date. Therefore, this study investigated VT burden, as well as implantable cardioverter-defibrillator (ICD) therapies in HF patients with SDB treatment, in comparison to untreated SDB HF patients. Methods: This retrospective study analyzed VT burden, rate of antitachycardia pacing (ATP), and the number of shocks delivered in a propensity score-matched patient cohort of patients with SDB treatment or control. Patients had moderate or severe SDB (n = 73 per each group; standardized mean difference of 0.08) and were followed for a minimum of one year. In addition, survival over 4 years was assessed. Results: Mean patient age was 67.67 $\pm$ 10.78 and 67.2 $\pm$ 10.10, respectively, with 15.06% and 10.95% of the patients, respectively, being female. Regarding SDB subtypes in the control and SDB treatment group, central sleep apnea was present in 42.46% and 41.09% of the patients, respectively, and obstructive sleep apnea was present in 26.02% and 31.50% of the patients, respectively. Mixed type sleep disorder was present in 31.50% and 27.40% of cases. Among the SDB treatment group, a significantly lower number of VTs (28.8% vs. 68.5%; $\it p$ = 0.01), ATP (21.9% vs. 50.7%; $\it p$ = 0.02), as well as a lower shock rate (5.5% vs. 31.5%; p$\it p$ < 0.01), was observed compared to the control group. Furthermore, the VT burden was significantly lower in the SDB treatment group when compared to the time prior to SDB treatment ($\it p$ = 0.02). Event-free survival was significantly higher in the SDB treatment group (Log-rank $\it p$ < 0.01). Conclusion: SDB treatment in HF patients with ICD leads to significant improvements in VT burden, ATP and shock therapy, and may even affect survival. Thus, HF patients should be generously screened for SDB and treated appropriately

Dynamics of cognitive function in patients with heart failure following transcatheter mitral valve repair

Aims: Interventional transcatheter edge-to-edge mitral valve repair (TMVR) is an established treatment option for patients with severe mitral regurgitation (MR) and high operative risk. Cognitive impairment is one of the most common conditions among often extensive comorbidities in these patients. The specific patterns of cognitive decline and particularly the effect of TMVR are not well described. Thus, this study aimed to investigate into the impact of TMVR on cognitive impairment, exercise capacity, and quality of life. Methods: Cognitive function (executive, naming, memory, attention, language, abstraction, and orientation) was assessed with the standardized Montreal Cognitive Assessment test (MoCA; range between 0 and 30 points) before and 3 months after TMVR in 72 consecutive patients alongside echocardiographic examination and assessment of exercise capacity (six-minute walk test) as well as quality-of-life questionnaires (Minnesota living with heart failure questionnaire, MLHF-Q). Results: Patients’ median age was 81 [76.0; 84.5] years, 39.7% were female with a median EuroScore II of 4.4% [2.9; 7.7]. The assessment of cognitive function showed a significant improvement of the cumulative MoCA-Test result (from 22.0 [19.0; 24.5] to 24 [22.0; 26.0]; $\it p$ < 0.001) with significant changes in the subcategories executive ($\it p$ < 0.001), attention ($\it p$ < 0.001), abstraction ($\it p$ < 0.001), and memory ($\it p$ < 0.001). In addition, quality of life (from 47.5 [25.0; 69.3] to 24.0 [12.0; 40.0]; $\it p$ < 0.001) and exercise capacity (from 220.0 m [160.0; 320.0] to 280.0 m [200.0; 380.0]; $\it p$ = 0.003) increased significantly 3 months after the TMVR procedure. Conclusions: TMVR leads to a significant improvement of cognitive function, exercise capacity, and quality of life in patients with chronic heart failure in 3 months follow up and again highlights the benefit of the evermore established TMVR procedure for patients with high operative risk

Interatrial Thrombus in left-atrial septal pouch prohibiting transseptal puncture for percutaneous mitral valve therapy

An 82-year-old female patient with severe $\underline {mitral regurgitation}$ was referred for evaluation of percutaneous $\underline {mitral valve repair}$. Transoesophageal echocardiography revealed a left-atrial septal pouch (LASP) with an echogenic structure. Following the heart-team decision, $\underline {interventional therapy}$ was therefore discarded. During surgery, a $\underline {thrombus}$ in the LASP was found and carefully resected. Afterward, conventional valve replacement with a biological 31-mm SJM-EPIC prosthesis (Abbott Structural Heart Devices, Santa Clara, CA) was performed. In the fast-evolving field of interventional $\underline {mitral valve}$ therapy, a trans-septal approach is the common strategy. Therefore, careful evaluation of the interatrial septum - which may contain thrombi with transoesophageal echocardiography before intervention - is of crucial importance.Une patiente de 82 ans atteinte d'insuffisance mitrale grave a été orientée vers notre équipe pour évaluer la possibilité d’une réparation mitrale par voie percutanée. L’échocardiographie transœsophagienne a révélé une poche septale atriale gauche (PSAG) échogène. L’équipe de cardiologie a décidé d’écarter la possibilité d’un traitement interventionnel. Au cours de la chirurgie, un thrombus a été détecté dans la PSAG et soigneusement retiré. Par la suite, la valve a été remplacée de la manière classique par une bioprothèse SJM-EPIC de 31 mm (Abbott Structural Heart Devices, Santa Clara, CA). Dans le domaine en constante évolution du traitement interventionnel des troubles mitraux, l’approche trans-septale est la plus courante. Par conséquent, une évaluation rigoureuse du septum interauriculaire – où pourrait se trouver un thrombus – par échocardiographie transœsophagienne avant l’intervention est d’une importance capitale

PASCAL mitral valve repair system versus MitraClip

$\bf Background$ The PASCAL system is a novel device for edge-to-edge treatment of mitral regurgitation (MR). The aim of this study was to compare the safety and efficacy of the PASCAL to the MitraClip system in a highly selected group of patients with complex primary mitral regurgitation (PMR) defined as effective regurgitant orifice area (MR-EROA) $\geq$  0.40 $cm^{2}$, large flail gap ($\geq$ 5 mm) or width ($\geq$ 7 mm) or Barlow's disease. $\bf Methods$ 38 patients with complex PMR undergoing mitral intervention using PASCAL ($\it n$ = 22) or MitraClip ($\it n$ = 16) were enrolled. Primary efficacy endpoints were procedural success and degree of residual MR at discharge. The rate of major adverse events (MAE) according to the Mitral Valve Academic Consortium (MVARC) criteria was chosen as the primary safety endpoint. $\bf Results$ Patient collectives did not differ relevantly regarding pertinent baseline parameters. Patients´ median age was 83.0 [77.5–85.3] years (PASCAL) and 82.5 [76.5–86.5] years (MitraClip). MR-EROA at baseline was 0.70 [0.68–0.83] $cm^{2}$ (PASCAL) and 0.70 [0.50–0.90] $cm^{2}$ (MitraClip), respectively. 3D-echocardiographic morphometry of the mitral valve apparatus revealed no relevant differences between groups. Procedural success was achieved in 95.5% (PASCAL) and 87.5% (MitraClip), respectively. In 86.4% of the patients a residual MR grade $\leq$ 1 + was achieved with PASCAL whereas reduction to MR grade $\leq$ 1 + with MitraClip was achieved in 62.5%. Neither procedure time number of implanted devices, nor transmitral gradient differed significantly. No periprocedural MAE according to MVARC occured. $\bf Conclusion$ In this highly selected patient group with complex PMR both systems exhibited equal procedural safety. MitraClip and PASCAL reduced qualitative and semi-quantitative parameters of MR to an at least comparable extent

A comparative study of 1-year postprocedural outcomes in transcatheter mitral valve repair in advanced primary mitral regurgitation

Both the MitraClip and PASCAL systems offer transcatheter edge-to-edge repair (TEER) solutions for mitral regurgitation. Evidence indicates a lower technical success rate for TEER in complex degenerative mitral regurgitation (DMR) cases. We conducted a retrospective analysis of patients who underwent transcatheter edge-to-edge therapy for primary mitral regurgitation with advanced anatomy, defined as mitral regurgitation effective regurgitant orifice area (MR-EROA) $\geq$0.40 $cm^{2}$ or large flail gap ($\geq$5 mm) or width ($\geq$7 mm) or Barlow’s disease, that completed follow-up after 1 year. Our criteria were met by 27 patients treated with PASCAL and 18 with MitraClip. All patients exhibited a significant, equivalent short-term reduction in MR-EROA, mitral regurgitation vena contracta diameter (MR-VCD), regurgitant volume, and clinical status. At 1 year follow-up, reductions in MR-VCD, regurgitant volume, and MR-EROA remained significant for both groups without significant differences between groups. MR-Grade $\leq$ 1+ was achieved in 18 (66.7%) and 10 (55.6%) patients, respectively. At follow-up, no difference in hospitalization for cardiac decompensation was observed. Overall death was similar in both groups. Our study suggests that both the PASCAL and MitraClip systems significantly reduce mitral regurgitation even in advanced degenerative diseases. Within our limited data, we found no evidence of inferior performance of the PASCAL system

Myocardial adaptation as assessed by speckle tracking echocardiography after isolated mitral valve surgery for primary mitral regurgitation

The risk of left ventricular (LV) and right ventricular (RV) maladaptation after surgery for isolated primary mitral regurgitation (PMR) is poorly defined. We aimed to evaluate LV and RV contractile function using speckle-tracking analysis alongside with quantification of exercise tolerance in patients with PMR after mitral valve surgery. All consecutive patients with symptomatic PMR undergoing mitral valve surgery between July 2015 and May 2017 were prospectively enrolled. Sequential echocardiographic studies along with clinical assessment were performed before and three months after surgery. Mean age in 138 patients was 65.8 $\pm$ 12.7 years, 48.2% (66) of whom were female. Mean LV ejection fraction decreased from 57 $\pm$ 12% to 50 $\pm$ 11% (p < 0.001), LV global longitudinal strain deteriorated from −19.2 $\pm$ 4.1% to −15.7 $\pm$ 3.8% (p < 0.001), and mechanical strain dispersion increased from 88 $\pm$ 12 to 117 $\pm$ 115 ms (p = 0.004). There was a reduction in tricuspid annulus plane systolic excursion from 22 $\pm$ 5 mm to 18 $\pm$ 4 mm (p < 0.001), as well as a slight deterioration of RV free wall mean longitudinal strain from −16.9 $\pm$ 5.6% to −15.7 $\pm$ 4.1% (p = 0.05). The rate of moderate to severe tricuspid regurgitation significantly decreased (p < 0.005). Regarding exercise tolerance, the New York Heart Association class improved (p < 0.001) and the walking distance increased (p < 0.001). During mid-term follow up after surgery for PMR, a deterioration of LV and RV contractile function measures could be observed. However, the clinical status, LV dimensions, and concomitant tricuspid regurgitation improved which in particular imply more effective RV contractile pattern

Cardiovascular magnetic resonance imaging-based right atrial strain analysis of cardiac amyloidosis

$\bf Background:$ Cardiac amyloidosis (CA) manifests in a hypertrophic phenotype with a poor prognosis, making differentiation from hypertrophic cardiomyopathy (HCM) challenging and delaying early treatment. The extent to which magnetic resonance imaging (MRI) quantifies the right atrial strain (RAS) and strain rate (RASR), providing valuable diagnostic information, is not yet clinically established. $\bf Aims:$ This study assesses diagnostic differences in the longitudinal RAS and RASR between CA and HCM patients, control subjects (CTRL) and CA subtypes in addition to the impact of atrial fibrillation (AF) on the right atrial function in CA patients. The RAS and RASR of tricuspid regurgitation (TR) patients are used to assess the potential for diagnostic overlap. $\bf Methods:$ RAS and RASR quantification was conducted via MRI feature-tracking for biopsy-confirmed CA patients with subtypes identified. Strain parameters were compared for CTRL, HCM and TR patients. Post hoc testing identified intergroup differences. $\bf Results:$ In total, 41 CA patients were compared to 47 CTRL, 20 HCM and 31 TR patients. Reservoir (R), conduit and booster RAS and RASRs allow for significant differentiation ($\it p$ 0.8). CA patients with AF, in contrast to sinus rhythm, demonstrated a significantly impaired reservoir RAS and RASR and booster RASR. The discriminative power of RAS for CA vs. TR was insufficient (R: 10.6% $\pm$ 14.3% vs. 7.0% $\pm$ 6.0%, $\it p$ = 0.069). Differentiation between 21 transthyretin and 20 light-chain amyloidosis subtypes was not achievable (R: 0.7% $\pm$ 1.0% vs. 0.7% $\pm$ 1.0%, $\it p$ = 0.827). $\bf Conclusion:$ The MRI-derived RAS and RASR are impaired in CA patients and may support noninvasive differentiation between CA, HCM and CTRL