Renal and hepatic function of patients with severe tricuspid regurgitation undergoing inferior caval valve implantation

Due to progressive abdominal-venous congestion severe tricuspid regurgitation (TR) is a common cause of cardiorenal and cardiohepatic syndrome. We initiated the TRICAVAL study to compare interventional valve implantation into the inferior vena cava (CAVI) versus optimal medical therapy (OMT) in severe TR. In the present subanalysis, we aimed to evaluate the effects of CAVI on clinical signs of congestion, renal and hepatic function. TRICAVAL was an investigator-initiated, randomized trial. Twenty-eight patients with severe TR were randomized to OMT or CAVI using an Edwards Sapien XT valve. Probands who completed the 3-month follow-up (CAVI [n = 8], OMT [n = 10]) were evaluated by medical history, clinical examination, and laboratory testing at baseline, 3 and 12 months. After 3 months, the CAVI group exhibited a significant reduction of body weight (from 80.7 [69.0-87.7] kg to 75.5 [63.8-84.6] kg, p < 0.05) and abdominal circumference (from 101.5 +/- 13.8 cm to 96.3 +/- 15.4 cm, p <= 0.01) and a trend to lower doses of diuretics compared to OMT. Renal and hepatic function parameters did not change significantly. Within a short-term follow-up, CAVI led to an improvement of clinical signs of venous congestion and a non-significant reduction of diuretic doses compared to OMT

Impact of inferior caval valve implantation on severity of tricuspid regurgitation and right heart function

Aims: Severe tricuspid regurgitation (TR) is a common finding in heart failure patients and associated with increased mortality. New interventional therapeutic options are needed as many heart failure patients are unfit for surgery. The TRICAVAL study compared valve implantation into the inferior vena cava (CAVI) with optimal medical therapy (OMT) in patients with severe TR. Here, we report details on the impact of CAVI on TR severity as well as right heart function and morphology. Methods and results: We randomized 28 patients with severe TR to CAVI (n = 14) with transfemoral implantation of an Edwards Sapien XT valve into the inferior vena cava or OMT (n = 14). Inclusion and exclusion criteria were based on anatomical and clinical parameters. Echocardiographic measurements were performed at baseline, at the first postoperative day and one, three, and twelve months after randomization. As proof of concept of an effective sealing of the inferior vena cava, we detected a significant decrease in systolic hepatic vein reflux volume (11.0 [6.2-21.9] mL vs 3.5 [0.6-8.5] mL,P = .016) and hepatic vein diameter (11.5 [10.0-14.8] mm vs 10.0 [9.3-11.8] mm,P = .034) at thirty-day follow-up. However, CAVI had no significant impact on TR, cardiac function, and morphology. Conclusions: Caval valve implantation significantly reduced systolic reflux into the hepatic veins but was not associated with an improvement in cardiac function, morphology, or TR severity

Comparative analysis of phasic left atrial strain and left ventricular posterolateral strain pattern to discriminate Fabry cardiomyopathy from other forms of left ventricular hypertrophy

Background: "Classical" echocardiographic signs of Fabry cardiomyopathy (FC), such as left ventricular hypertrophy (LVH), posterolateral strain impairment (PLSI), and papillary muscle hypertrophy may be of limited diagnostic accuracy in clinical practice. Our aim was to evaluate the diagnostic value of left atrial (LA) strain impairment compared to "classical" echocardiographic findings to discriminate FC. Methods: In standard echocardiographic assessments, we retrospectively analyzed the diagnostic value of the "classical" red flags of FC as well as LA strain in 20 FC patients and in 20 subjects with other causes of LVH. Receiver operating characteristic (ROC) curve analysis was performed to assess the respective diagnostic accuracy. Results: FC was confirmed in 20 patients by genetic testing. In the LVH group, 12 patients were classified by biopsy to have hypertrophic cardiomyopathy, two had hypertensive heart disease, and six LVH combined with borderline myocarditis. Global and regional left ventricular (LV) strain was not significantly different between groups while LA strain was significantly impaired in FC (Left atrial reservoir strain (LASr) 19.1%±8.4 in FC and 25.6%±8.9 in LVH, p = 0.009; left atrial conduction strain (LAScd) -8.4%±4.9 in FC and -15.9%±8.4 in LVH, p < 0.01). LAScd, with an area under the curve (AUC) of .81 (95% confidence interval [CI] .66-.96) showed the highest diagnostic accuracy to discriminate FC. The PLSI pattern showed an AUC of .49, quantification of papillary muscle hypertrophy an AUC of .47. Conclusion: Adding LA strain analysis to a comprehensive echocardiographic work-up of unclear LVH may be helpful to identify FC as a possible cause

Impact of body mass index on worsening of diastolic function and impairment of left atrial strain in the general female urban population: a subanalysis of the Berlin female risk evaluation echocardiography follow-up study

BackgroundThe association of body mass index (BMI) with diastolic dysfunction (DD) is well described in the literature. However, there is conflicting evidence and long-term follow-up data regarding effects of BMI on preclinical DD and left atrial (LA) function are scarce, highlighting the importance of early detection tools, such as myocardial strain.PurposeThe aim of our study was to prospectively analyze the impact of clinical and demographic parameters, especially of BMI, on worsening of diastolic function and left atrial strain (LAS) in an urban population of women with a low prevalence of cardiovascular risk factors.Methods and ResultsAn extensive clinical and echocardiographic assessment comprising the analysis of phasic LAS using two-dimensional speckle-tracking echocardiography (2D STE) was performed in 258 participants of the Berlin Female Risk Evaluation (BEFRI) trial between October 2019 and December 2020 after a mean follow-up period of 6.8 years. We compared clinical and echocardiographic parameters stratifying women by BMI &lt; or ≥25 kg/m2, and we analyzed the impact of demographic characteristics on the worsening of DD and LA mechanics in the longer-term follow-up using univariate and multivariate regression analyses. 248 women were suitable for echocardiographic analysis of LAS using 2D STE. After a mean follow-up time of 6.8 years, LA reservoir strain (LASr) and LA conduit strain (LAScd) were significantly reduced in participants with a BMI ≥25 kg/m2 compared with women with a BMI &lt;25 kg/m2 at baseline (30 ± 8% vs. 38 ± 9%, p &lt; 0.0001; −14 ± 7% vs. −22 ± 8%, p &lt; 0.0001). 28% of the overweighted women presented a deterioration of diastolic function at the time of follow-up in contrast with only 7% of the group with a BMI &lt;25 kg/m2 (p &lt; 0.0001). BMI remained significantly associated with LAS reductions after adjustment for other risk factors in multivariate regression analyses.ConclusionOverweight and obesity are related to impaired LAS and to a worsening of diastolic function after a long-term follow-up in a cohort of randomly selected women

Impact of body mass index on worsening of diastolic function and impairment of left atrial strain in the general female urban population: a subanalysis of the Berlin female risk evaluation echocardiography follow-up study

Background: The association of body mass index (BMI) with diastolic dysfunction (DD) is well described in the literature. However, there is conflicting evidence and long-term follow-up data regarding effects of BMI on preclinical DD and left atrial (LA) function are scarce, highlighting the importance of early detection tools, such as myocardial strain. Purpose: The aim of our study was to prospectively analyze the impact of clinical and demographic parameters, especially of BMI, on worsening of diastolic function and left atrial strain (LAS) in an urban population of women with a low prevalence of cardiovascular risk factors. Methods and Results: An extensive clinical and echocardiographic assessment comprising the analysis of phasic LAS using two-dimensional speckle-tracking echocardiography (2D STE) was performed in 258 participants of the Berlin Female Risk Evaluation (BEFRI) trial between October 2019 and December 2020 after a mean follow-up period of 6.8 years. We compared clinical and echocardiographic parameters stratifying women by BMI < or ≥25 kg/m2, and we analyzed the impact of demographic characteristics on the worsening of DD and LA mechanics in the longer-term follow-up using univariate and multivariate regression analyses. 248 women were suitable for echocardiographic analysis of LAS using 2D STE. After a mean follow-up time of 6.8 years, LA reservoir strain (LASr) and LA conduit strain (LAScd) were significantly reduced in participants with a BMI ≥25 kg/m2 compared with women with a BMI <25 kg/m2 at baseline (30 ± 8% vs. 38 ± 9%, p < 0.0001; −14 ± 7% vs. −22 ± 8%, p < 0.0001). 28% of the overweighted women presented a deterioration of diastolic function at the time of follow-up in contrast with only 7% of the group with a BMI <25 kg/m2 (p < 0.0001). BMI remained significantly associated with LAS reductions after adjustment for other risk factors in multivariate regression analyses. Conclusion: Overweight and obesity are related to impaired LAS and to a worsening of diastolic function after a long-term follow-up in a cohort of randomly selected women

Impact of inferior caval valve implantation on patients with severe secondary tricuspid regurgitation - a randomised prospective trial

Einleitung: Die hochgradige sekundäre Trikuspidalklappeninsuffizienz (TI) stellt ein häufiges Krankheitsbild mit einer hohen Morbidität und Mortalität dar. Insbesondere ältere, multimorbide Patienten mit einem hohen operativen Risiko könnten von neuen, herzkathetergestützten Therapien profitieren. Die TRICAVAL-Studie („Treatment of Severe TRIcuspid Regurgitation in Patients with Advanced Heart Failure with CAval Vein Implantation of the Edwards Sapien XT VALve“) untersuchte dazu die Effekte einer trans-femoralen Herzklappenimplantation (CAVI) in die Vena cava inferior (VCI) verglichen mit einer optimalen medikamentösen Therapie (OMT) bei Patienten mit hochgradiger TI. Die Studie basierte auf der Hypothese, dass CAVI durch Reduktion der abdominal-venösen Stauung und Steigerung des rechtsventrikulären Schlagvolumens die körperliche Leistungsfähigkeit verbessert. Methodik: Die randomisierte, kontrollierte Studie TRICAVAL wurde über einen Nachbeobachtungszeitraum von zwölf Monaten durchgeführt. 28 Patienten wurden nach anatomischen und klinischen Parametern ausgewählt und in die Gruppen CAVI oder OMT randomisiert. Primärer Endpunkt war die maximale Sauerstoffaufnahme (VO2max) als Parameter der kardiopulmonalen Belastbarkeit, sekundäre Endpunkte umfassten den Sechs-Minuten-Gehtest, die New York Heart Association (NYHA) Klasse, den Parameter N-terminal-pro brain natriuretic peptide (NT-pro BNP), die Rechtsherzfunktion, die außerplanmäßige Hospitalisierung und die Lebensqualität. Eine Subanalyse untersuchte die kardiale Morphologie und Funktion sowie den TI-Schweregrad nach CAVI. Ergebnis: Nach drei Monaten wurde eine signifikante Verbesserung von NYHA Klasse und Lebensqualität in der CAVI-Gruppe nachgewiesen. Weitere signifikante Unterschiede in dem primären und den sekundären Endpunkten zeigten sich weder im Vergleich zu den Messungen bei Einschluss noch zwischen beiden Behandlungsgruppen. Nach initial erfolgreicher Implantation traten zwei Klappendislokationen und zwei Stentmigrationen auf, sodass die Patientenrekrutierung vorzeitig beendet wurde. In der Langzeituntersuchung bis zwölf Monate unterschieden sich VO2max, NYHA Klasse und Lebensqualität zwischen CAVI und OMT nicht. In der CAVI-Gruppe waren 57% und in der OMT-Gruppe 29% der Patienten verstorben. Echokardiografisch imponierte nach zwölf Monaten eine signifikante Reduktion des systolischen Lebervenenrefluxes und des Lebervenendiameters nach CAVI im Vergleich zur OMT-Gruppe. Der Schweregrad der TI, die kardiale Funktion und Morphologie wiesen keinen signifikanten Unterschied zwischen beiden Gruppen auf. Zusammenfassung: Mit Reduktion der abdominal-venösen Stauung konnte die suffiziente Abdichtung der VCI nach CAVI gezeigt werden. Eine Zunahme der Leistungsfähigkeit in spiroergometrischen Messungen, ein positives rechtskardiales Remodeling oder eine Verbesserung der TI fanden sich dagegen nicht. Aufgrund relevanter Komplikationen kann CAVI derzeit nicht empfohlen werden.Introduction: Severe secondary tricuspid regurgitation (TI) is a common finding with high morbidity and mortality. In particular elderly, multimorbid patients with high operative risk could benefit from new, transcatheter therapies. The TRICAVAL study (“Treatment of Severe TRIcuspid Regurgitation in Patients with Advanced Heart Failure with CAval Vein Implantation of the Edwards Sapien XT VALve“) evaluated the effect of valve implantations (CAVI) into the inferior vena cava (VCI) via transfemoral access in comparison with optimal medical therapy (OMT) in patients with severe TI. We hypothesized that CAVI may improve exercise capacity by reducing abdominal-venous congestion and increasing right ventricular stroke volume. Methods: The randomized, controlled study TRICAVAL was conducted over a follow-up period of twelve months. Twenty-eight patients were selected by anatomical and clinical parameters and randomized to CAVI or OMT group. The primary endpoint was maximum oxygen uptake (VO2max) as a surrogate marker for physical capacity, secondary endpoints comprised six-minutes walking test, New York Heart Association (NYHA) class, N-terminal-pro brain natriuretic peptide (NT-pro BNP), right heart function, unscheduled hospitalization and quality of life. Cardiac morphology and function as well as TI severity were evaluated in a subanalysis. Results: After three months, improvement of NYHA class and quality of life were observed after CAVI. No further significant inter- or intragroup differences were found in the primary and secondary endpoints. Two valve dislocations and two stent migrations occurred after initially successful implantation; therefore, further recruitment was stopped. In the long-term follow-up of twelve months, VO2max, NYHA class and quality of life did not differ significantly between CAVI and OMT. In the CAVI group 57% of the patients and in the OMT group 29% of the patients died. After twelve months, echocardiographic measurements revealed a significant decrease in systolic hepatic vein reflux volume and hepatic vein diameter after CAVI compared to OMT. TI severity, cardiac function and morphology showed no significant difference between both groups. Conclusion: A sufficient sealing of the VCI was demonstrated by a reduction of abdominal-venous congestion after CAVI. However, we did not observe an increase in physical capacity in spiroergometric measurements, a positive right heart remodelling or a decrease in TI severity. Due to relevant complications, CAVI can currently not be recommended

Progression of electrocardiogram changes in an untreated fabry disease: a case report

Background Fabry disease (FD) is a rare lysosomal storage disorder with multiorgan manifestation and associated with an increased morbidity and mortality. Fabry cardiomyopathy includes left ventricular `hypertrophy' (LVH), cardiac arrhythmias, and heart failure. We report a case of an untreated FD with characteristic findings in electrocardiogram (ECG) over a follow-up period of 10 years. Case summary A 53-year-old man with FD presented to our outpatient department. He suffered from symptomatic ventricular extrasystoles. Echocardiography detected LVH and reduced global longitudinal strain. Twelve years ago, first examination was conducted due to ventricular arrhythmias. Electrocardiogram showed a short PQ minus P-wave (PendQ) interval and negative T-waves. Over time, the number of leads with negative T-waves increased. Moreover, the echocardiography revealed a thickened left ventricular wall. Without any further examinations at that time, the patient was treated for arterial hypertension with proteinuria. Ten years after first symptoms appeared, FD was diagnosed utilizing cardiac magnetic resonance imaging and genetic tests. Hence, enzyme replacement therapy was initiated. Discussion The ECG is a fast diagnostic method and it may - even without additional organ manifestations - provide preliminary suspicion of FD. In particular, as shown in our case, a short PendQ and QT interval indicate FD. Over time, disease progression can be detected through ECG changes. T-waves correlate with an increasing LVH and a reduction in longitudinal function in echocardiographic examinations. Unexplained LVH must be followed by differential diagnosis. In case of confirmed FD, patients should be treated by multidisciplinary teams in experienced centres

Prevalence, one-year-incidence and predictors of carcinoid heart disease

Abstract Background Carcinoid heart disease (CHD) caused by neuroendocrine tumours (NET) is associated with an increased morbidity and mortality due to valvular dysfunction and right sided heart failure. The present study aimed to assess the prevalence and one-year-incidence of CHD in NET patients. Tumour characteristics, laboratory measurements, and echocardiographic findings were evaluated to identify predictors of CHD manifestation. Methods The study was an investigator-initiated, monocentric, prospective trial. Patients with NET without previously diagnosed CHD were included and underwent comprehensive gastroenterological and oncological diagnostics. Echocardiographic examinations were performed at baseline and after one year. Results Forty-seven NET patients were enrolled into the study, 64% of them showed clinical features of a carcinoid syndrome (CS). Three patients presented with CHD at baseline and three patients developed cardiac involvement during the follow-up period corresponding to a prevalence of 6% at baseline and an incidence of 6.8% within one year. Hydroxyindoleacetic acid (5-HIAA) was identified to predict the occurrence of CHD (OR, 1.004; 95% CI, 1.001–1.006 for increase of 5-HIAA), while chromogranin A (CgA), and Kiel antigen 67 (Ki 67%) had no predictive value. Six patients with CHD at twelve-month follow-up revealed a tendency for larger right heart diameters and increased values of myocardial performance index (MPEI) at baseline compared to NET patients. Conclusion The prevalence at baseline and one-year-incidence of CHD was 6–7%. 5-HIAA was identified as the only marker which predict the development of CHD. Graphical Abstrac