Transtricuspid cardiac implantable electronic devices (CIEDs) complicate the management of tricuspid regurgitation (TR). Transcatheter tricuspid valve annuloplasty (TTVA) offers a promising approach due to minimal interaction with leaflets and transvalvular CIEDs, though real-world evidence is limited.

This bi-center, retrospective study includes 204 consecutive patients who underwent TTVA with the Cardioband (Edwards Lifesciences) for severe symptomatic TR. Patients were divided into CIED carriers and non-CIED carriers. CIED carriers were further classified into those with lead-associated TR (LTR-A) and those with TR unrelated to CIED leads (LTR-B).

Among the 204 patients, 41 (20%) were CIED carriers. Of these, 24% had mixed TR etiology (functional and LTR-A), while 76% had predominantly functional TR (LTR-B). Compared to non-CIED-carriers, CIED carriers were more symptomatic (NYHA-FC > II; 93% vs. 89%; p = 0.026) with comparable TR severity at baseline. Intraprocedural success according to the Tricuspid Valve Academic Research Consortium was 68% in CIED carriers and 70% in non-CIED carriers (p = 0.851). LTR-A was associated with poorer TR reduction immediately after TTVA (p = 0.022). Overall safety was comparable, with right ventricular lead dislodgement occurring in one patient. Beyond that, CIED function remained unimpaired. At 30 days, echocardiographic follow-up showed comparable TR reduction (TR ≤ II: 56% vs. 68%; p = 0.219) and NYHA-FU ≤ II (63% vs. 70%; p = 0.524) in CIED-and non-CIED carriers, respectively.

TTVA achieves significant TR reduction, providing a safe and effective therapeutic option for TR treatment in CIED carriers. WHAT IS KNOWN?: TTVA using the Cardioband has been approved for severe, symptomatic TR patients, however data on the safety and efficacy in CIED carriers is lacking. WHAT THE STUDY ADDS?: Intraprocedural success and safety were comparable in CIED and non-CIED carriers treated with TTVA. Subgroup analyses showed a trend towards worse outcome and efficiency of TTVA in patients with LTR-A. Postinterventional CIED interrogations did not show critical technical issues.

Adult patients with transposition of the great arteries (TGA) and an systemic right ventricle (sRV) are at risk for heart failure (HF). In this study, we investigated risk factors for HF hospitalization and developed a novel risk stratification tool to optimize risk prediction for clinical practice.

In this international multicentre study, 522 patients with TGA and an sRV, without history of HF hospitalization, were followed retrospectively for a median of 17.9 years (interquartile range [IQR] 12.9-22.1). HF hospitalization was defined as a hospital admission for HF signs and symptoms with initiation or increase of HF medication. Predictors for HF hospitalization were established using a Cox regression analysis and were used to build a 10-year risk score. Of the 522 patients, 70% had an atrial switch operation and 30% had a congenitally corrected TGA. The median age at time of enrolment was 23.7 years (IQR 19.9-32.1) and 64% were male. During follow-up, 127 patients (24.3%) had at least one HF hospitalization. A risk stratification tool was built using the following independent predictors associated with a 10-year risk of HF hospitalization: age, New York Heart Association functional class ≥II, QRS duration >120 ms, atrial fibrillation, moderate/severe right ventricular dysfunction, with a C-statistic of 0.868 (95% confidence interval 0.823-0.913).

During follow-up, 24.3% of sRV patients had at least one HF hospitalization. Five simple, clinically-accessible variables can be used as a risk score tool to identify patients at higher risk of HF hospitalization.

An aorta-right atrial tunnel (ARAT) is a rare congenital cardiac anomaly that connects the aorta at any coronary sinus to the right atrium. Its cause remains unclear and may involve abnormal origins of the coronary arteries. There is no established link between ARAT and mitral valve prolapse (MVP). Diagnosing ARAT can be challenging, often necessitating multiple imaging techniques, while its management is complex and is further complicated by the association with MVP in our patient.

We report a case of a 46-year-old man admitted for dyspnoea and palpitations. Thirteen years prior, he had been diagnosed with a cardiac murmur. Echocardiography revealed ARAT and MVP complicated by a flail leaflet and severe regurgitation. AngioCT confirmed the right coronary sinus as the origin of the ARAT and demonstrated the right coronary artery (RCA) arising deep within the tunnel. Cardiac catheterisation identified unclassified pulmonary hypertension due to a left-to-right shunt, along with severe mitral regurgitation. Given the unfavourable anatomy for interventional treatment and the patient's decline in surgery despite multiple consultations, our team opted for conservative management. Currently, the patient's clinical status and echocardiographic parameters remain stable.

ARAT is a complex congenital disorder that presents diagnostic and treatment challenges, requiring multimodal imaging and teamwork. Since the RCA originates deep within the tunnel and is associated with MVP complicated by flail leaflet and severe regurgitation, we recommend surgical intervention as the appropriate treatment approach. Considering the patient's preferences, conservative treatment was chosen.

The flow convergence method includes calculation of the proximal isovelocity surface area (PISA) and is widely used to classify mitral regurgitation (MR) with echocardiography. It constitutes a primary decision factor for determination of treatment and should therefore be a robust quantification method. However, it is known for its tendency to underestimate MR and its dependence on user expertise. The present work systematically compares different pulsatile flow profiles arising from different regurgitation orifices using transesophageal echocardiographic (TEE) probe and particle image velocimetry (PIV) as a reference in an in-vitro environment. It is found that the inter-observer variability using echocardiography is small compared to the systematic underestimation of the regurgitation volume for large orifice areas (up to 52%) where a violation of the flow convergence method assumptions occurs. From a flow perspective, a starting vortex was found as a dominant flow pattern in the regurgant jet for all orifice shapes and sizes. A series of simplified computational fluid dynamics (CFD) simulations indicate that selecting a suboptimal aliasing velocity during echocardiography measurements might be a primary source of potential underestimation in MR characterization via the PISA-based method, reaching up to 40%. In this study, it has been noted in clinical observations that physicians often select an aliasing velocity higher than necessary for optimal estimation in diagnostic procedures.

This study aimed to compare two-dimensional, M-mode, color, pulsed-wave Doppler (PWD) and continuous-wave Doppler (CWD) echocardiography, and PWD ultrasonography of the caudal common carotid artery (CCA) in horses with aortic regurgitation (AR).

Warmblood horses without (n = 20) and with mild, moderate, and severe AR (n = 60) were included in the study.

A retrospective descriptive study focused on cardiac dimensions, aortic and CCA Doppler flow. Non-invasive blood pressure and presence of ventricular arrhythmia were recorded. Groups were compared using analysis of variance, chi-square, Spearman's rho, and Kruskal-Wallis tests.

Maximal aortic antegrade flow velocity was higher in horses with moderate and severe AR than in normal horses and higher in those with severe AR than in those with mild AR (P<0.001). Mean (standard deviation) antegrade CCA flow velocities were 0.9 m/s (0.3 m/s) in normal horses and 1.0 m/s (0.2 m/s), 1.2 m/s (0.3 m/s), and 1.5 m/s (0.4 m/s) in horses with mild, moderate, and severe AR, respectively. Retrograde mid-to-end diastolic PWD ultrasonography of the common carotid artery (PWD-CCA) flow occurred in horses with moderate (6/20) and severe (13/20) AR. The presence of pathologic retrograde PWD-CCA flow was associated with presence of increased left ventricular dimensions and pulse pressures >60 mmHg. The CWD regurgitant jet pressure half-time failed to differentiate between AR severity grades.

The limitations of this study included retrospective design with missing values, AR classification system not validated by longitudinal follow-up, and CCA retrograde velocities <10 cm/s not measured.

Pulsed-wave Doppler ultrasonography of the common carotid artery identifies moderate and severe AR in horses with hemodynamic overload. Presence of retrograde PWD-CCA flow was associated with moderate and severe AR and with left ventricular dilation. Quantification of CWD pressure half-time appeared unreliable for AR severity assessment.

Long-term evidence about bioprosthetic tricuspid valve replacement is scarce. This study aims to investigate the long-term clinical outcomes of patients who underwent tricuspid valve replacement with bioprostheses.

This multicentre retrospective study included patients from 10 high-volume centres in 7 different countries, who underwent tricuspid valve replacement with bioprostheses. Echocardiographic and clinical data were reviewed. Long-term outcomes were investigated using Kaplan-Meier estimates, Cox regression, and competing risk analysis.

Of 675 patients, isolated tricuspid valve replacement was performed in 358 patients (53%), while 317 (47%) underwent concomitant procedures. Between these 2 groups, patients who underwent combined procedures reported a significantly higher incidence of infection, atrioventricular block, multi-organ failure, longer intensive care unit and hospital stay and higher 30-day mortality over patients who underwent isolated procedure. The overall 30-day mortality occurred in 70 patients (10.4%) [46 (14.6%) combined vs 24 (6.74%) isolated, P = 0.001]. During the follow-up, there was a continuous rate of attrition due to death, with cumulative incidences of death at 5, 10 and 15 years being 27.2%, 46.2% and 60.6%, respectively. In contrast, the risk of reintervention starts to significantly increase after 10 years of follow-up, with cumulative incidences of reintervention being 6.1%, 10.8% and 23.3%, respectively. Freedom from tricuspid valve reintervention, pacemaker implantation, tricuspid valve endocarditis and major thromboembolic events at 15 years were 56.5%, 77.3%, 84.0% and 86.4%, respectively.

Tricuspid valve replacement with bioprostheses is an effective treatment for valvular disease, despite being associated with relatively high early and long-term mortality. However, the risk of structural valve degeneration rises significantly after 10 years.

Transesophageal echocardiography (TEE) is a valuable tool for diagnosing structural heart diseases, offering superior resolution compared to transthoracic echocardiography. It allows for real-time evaluation of cardiac valves and both systolic and diastolic heart function. Additionally, TEE facilitates the prompt detection of potential complications during cardiac surgeries, such as paravalvular leaks, iatrogenic aortic dissections, and pericardial effusions. Advances in imaging, including 3D echocardiography, have further enhanced the visualization of complex structures like cardiac valves, providing "surgical views" that improve preoperative planning. These features have also made TEE indispensable for postoperative evaluation of cardiac valve repairs and for intraoperative guidance during minimally invasive procedures. This review article aims to summarize the indications for using TEE as an intraoperative tool in cardiac surgery.

Four scores have been published in 2022 for assessing mortality risk of patients with tricuspid regurgitation (TR): the TRI-SCORE, those reported by Hochstadt and Wang and the TRIO score. Our objective was to perform an external validation of available scores for predicting mortality and the combined endpoint of mortality and heart failure (HF) admission, in an independent cohort of patients with severe TR and to compare their discriminative ability.

Discriminative ability of the scores for predicting events was assessed by means of receiver operating characteristics (ROC) curves.

The validation cohort retrospectively included 614 consecutive patients (69 ± 13 years, 72% women) with severe TR studied with echocardiography in a tertiary care hospital and followed for up to 14 years (median 5 years, p25-75 2-7 years), with 358 deaths and 620 HF admissions on follow-up. Discriminative abilities for predicting death (C-statistic .72 [95% CI .68-.76] for the TRI-SCORE; .75 [.71-.78] for the Hochstadt score; .72 [.68-.76] for the Wang score; and .74 [.70-.78] for the TRIO score, p < .0005 for all) or the combined endpoint (C-statistic .74 [.70-.78]; .74 [.70-.78], .73 [.69-.77] and .76 [.72-.80], respectively, p < .0005 for all) on follow-up were statistically significant for all of them. Paired comparisons among them for predicting both endpoints were all non-significant.

All tested scores showed significant and similar discriminative ability for predicting the combined endpoint of mortality or HF admission in this independent validation study of patients with severe TR.

To evaluate the natural course of medically managed ≥ moderate tricuspid regurgitation (TR) of any etiology, identify factors linked to progression and regression, and assess long-term clinical consequences.

Retrospective analysis of 4051 adults with ≥ moderate TR (57.0% moderate, 43.0% severe) from January 1, 2004, to December 31, 2016, having at least one follow-up echocardiogram 6 months or more later. TR change was defined as at least one grade shift in severity, and all-cause mortality was the primary endpoint.

At 1 year, TR regressed in 1499 (37.0%) patients and progressed in 417 (10.3%). Of 1603 with ≥ moderate TR at 1 year, only 346 (21.6%) experienced regression after the first year. Among 586 patients in whom TR regressed to mild or less at 1-year, 285 (48.6%) developed significant TR again long-term. Factors associated with TR progression included atrial fibrillation (odds ratio [OR], 1.55), chronic kidney disease (OR, 1.44), right ventricular dilatation (OR, 1.77), right atrial dilatation (OR, 1.94), pulmonary hypertension (OR, 1.25), and those associated with regression were coronary artery disease, diabetes, hypertension, and left ventricle dysfunction. Mortality was highest in patients whose TR progressed to or remained severe (HRs, 1.73 and 1.92, respectively), followed by those with stable moderate (HR, 1.18), and was lowest in whom TR regressed to mild or less.

In patients with ≥ moderate TR, regurgitation severity improved in one-third and remained unchanged in half at 1 year. Additionally, 10% of patients with moderate TR progressed to severe TR. Severe TR at 1 year was associated with a worse prognosis, with approximately 70% of these being patients whose TR did not improve with medical therapy. Although most improvements occurred within the first year, a considerable number experienced a recurrence afterward.

Indices combining diastolic and systolic tissue Doppler variables, the Ee's' index (E/[e' × s']) and e'a's' index (e'/[a' × s']), have aided detection of myocardial dysfunction and in prediction of poor outcomes in humans with cardiovascular diseases. Studies of Ee's' and e'a's' indices in dogs have not been performed.

Dogs with pulmonary stenosis (PS) have elevated right ventricular (RV) Ee's' and e'a's' indices compared to healthy dogs, which will decrease after pulmonary balloon valvuloplasty (BV) or stent implantation.

Thirty client-owned dogs (15 healthy, 15 with PS).

Cross-sectional study. All dogs had echocardiography performed, including the measurement of RV diastolic and systolic variables and calculation of the Ee's' and e'a's' indices. Dogs with PS had echocardiography performed prior to and after interventional procedures.

The Ee's' index was lower (p = < 0.001) in healthy dogs (median 0.43, range 0.23-0.74) compared to dogs with PS pre-operatively (1.49, 0.28-3.79). The e'a's' index was lower (p = 0.039) in healthy dogs (mean 8.03 ± 3.28) compared to dogs with PS pre-operatively (11.39 ± 4.03). Compared to pre-operative values, the Ee's' index (1.01, 0.36-1.62) and e'a's' index (8.35 ± 3.29) decreased (p = 0.018, p = 0.001, respectively) after pulmonary intervention in dogs with PS.

Dogs with PS have RV myocardial dysfunction that can be measured with Ee's' and e'a's' indices, and these values can be used to monitor response to pulmonary intervention over time. These findings suggest that calculation of Ee's' and e'a's' indices might have clinical importance in long-term management of dogs with PS.

Transcatheter edge-to-edge repair (TEER) is currently indicated in symptomatic patients with severe functional mitral regurgitation (MR) who are not eligible for surgery and who have a high likelihood of responding to treatment. This recommendation is based on two randomized trials suggesting that the benefits of TEER may be limited to patients with severe MR, defined by an effective regurgitant orifice area (EROA) ≥0.40 cm2, and a non-excessively remodelled left ventricle. The randomized RESHAPE-HF2 study recently showed that compared to medical therapy alone, treatment with TEER by MitraClip in patients with symptomatic heart failure and less severe functional MR, with lower EROA (mean 0.23 cm2), is associated with a significant reduction in hospitalizations for heart failure, and an improvement in symptoms and quality of life, without a clear benefit on mortality. However, within the cohort of patients with less severe MR enrolled in the RESHAPE-HF2 study, the benefits of MitraClip compared to medical therapy alone seem more significant in selected patients with characteristics associated with a higher risk of heart failure exacerbation, suggesting the importance of careful selection of patients with symptomatic heart failure and MR who could benefit from TEER.

Atrial fibrosis may act as a substrate for atrial fibrillation (AF) and atrial functional mitral regurgitation (MR); thus, recognition is required to select the optimal therapeutic intervention.

We examined clinical data from 1045 consecutive patients in three centers who underwent catheter ablation for persistent AF between 2020 and 2022. 75 patients met the moderate and severe MR criteria and completed a 1-year follow-up. Voltage mapping during the ablation procedure was reviewed to classify the extent of atrial fibrosis.

Significant atrial fibrosis was found in 34 patients (45.3%), and these patients had a higher prevalence of congestive heart failure (New York Heart Association (NYHA) II-III: 76.5% vs. 36.6%, p < 0.001) and an increased incidence of biatrial enlargement at baseline than the mild fibrosis group. At the 1-year post-ablation period, the entire cohort exhibited a decrease in left atrial size (41.6 ± 6.5 mm vs. 45.5 ± 5.3 mm, p < 0.001), and a significant reduction in MR was achieved in 70.7% of patients. The significant fibrosis group had a higher recurrence rate of atrial arrhythmias (55.9% vs. 22.0%, log-rank p = 0.002) and no significant change in atria size compared with baseline diameters (left atrium, 44.4 ± 6.4 mm vs. 47.2 ± 5.6 mm, p = 0.068; right atrium, 44.7 ± 11.2 mm vs. 46.7 ± 6.2 mm, p = 0.427).

This study revealed a considerable proportion of significant fibrosis in patients with atrial functional MR and AF, leading to limited effectiveness in reducing atrial size following catheter ablation. Optimal intervention to reduce atrial size and recurrent arrhythmias in this population requires further investigation.

Severe tricuspid regurgitation (TR) is associated with high morbidity and mortality. Isolated TR, defined as TR without overt heart disease, is typical and offers limited cardiac treatment options other than interventional repair or replacement. Survival history of cancer or active cancer treatment may lead to an unnecessary delay of TR treatment.

We included all patients diagnosed with severe TR at the Medical University of Vienna between 2003 and 2016 who had normal left ventricular function and no other valvular lesions. Outcome analysis was performed on cancer type, status and the number of organs affected by cancer.

A total of 973 patients were included. 182 (19%) patients had cancer, 52 were active and 130 had a history of cancer at the time of TR diagnosis. Oncologic patients were divided into subgroups of gastrointestinal, skin, glands, gynaecological, breast, urogenital, lung and other cancers. Ten-year mortality of patients with cancer was higher than those without cancer (p < 0.001). Multivariate analysis adjusting for age did not reveal significantly higher mortality in patients with a history of cancer compared to patients without cancer (p = 0.59). Patients with lung, active, or multi-organ cancer showed the highest mortality.

Mortality in patients with severe isolated TR is high and increased by active or multi-organ cancer but not by a history of cancer. These patients should be discussed in interdisciplinary cardio-oncology teams to avoid delaying life-saving treatment of TR and cancer.

Right ventricular-to-pulmonary artery (RV-PA) coupling is an important predictor of long-term survival following transcatheter edge-to-edge repair. However, its impact on survival in patients undergoing indirect mitral annuloplasty is unknown. The study aimed to assess the impact of baseline RV-PA coupling on survival following indirect mitral annuloplasty in heart failure patients.

Patients were classified according to baseline RV-PA coupling: TAPSE (tricuspid annular plane systolic excursion)/PASP (pulmonary artery systolic pressure) > 0.55 (group 1), ≤ 0.55 ≥ 0.32 (group 2) and ≤ 0.32 (group 3). Clinical follow-up and RV function were assessed 3 and 12 months following indirect annuloplasty.

A TAPSE/PASP > 0.55 was found in 19 patients, while 47 patients showed a TAPSE/PASP ≤ 0.55 > 0.32 and 26 a TAPSE/PASP ≤ 0.32. A significant reduction in vena contracta and regurgitant volume compared to baseline was found in all groups at 3-months and 12-months follow-up. One-year mortality was significantly increased in group 3 compared to the other groups (group 1: 0.95, group 2: 0.91, group 3: 0.77; Log-Rank test p = 0.018). In groups 2 and 3 the TAPSE/PASP significantly improved during the 12-months follow-up, while it remained unchanged in group 1 (group 1: baseline = 0.71 ± 0.03, 12-months = 0.67 ± 0.01; group 2: baseline = 0.43 ± 0.06, 12-months: 0.56 ± 0.04; group 3: baseline = 0.25 ± 0.06, 12-months: 0.4 ± 0.03; p < 0.001).

RV-PA uncoupling before indirect mitral annuloplasty is associated with poor survival. However, Carillon device implantation improved right heart function and RV-PA coupling in patients with severe RV dysfunction at baseline. Therefore, Carillon device implantation can be a valuable option for transcatheter treatment of patients with FMR and right heart failure.

Right ventricular-to-pulmonary artery (RV-PA) coupling has recently been shown to be associated with outcome in valvular heart disease. However, longitudinal data on RV dysfunction and reverse cardiac remodeling in patients following transcatheter edge-to-edge mitral valve repair (M-TEER) are scarce.

Consecutive patients with primary as well as secondary mitral regurgitation (MR) were prospectively enrolled and had comprehensive echocardiographic and invasive hemodynamic assessment at baseline. Kaplan-Meier estimates and multivariable Cox-regression analyses were performed, using a composite endpoint of heart failure hospitalization and death.

Between April 2018 and January 2021, 156 patients (median 78 y/o, 55% female, EuroSCORE II: 6.9%) underwent M-TEER. On presentation, 64% showed impaired RV-PA coupling defined as tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP) ratio < 0.36. Event-free survival rates at 2 years were significantly lower among patients with impaired coupling (57 vs. 82%, p < 0.001), both in patients with primary (64 vs. 91%, p = 0.009) and secondary MR (54 vs. 76%, p = 0.026). On multivariable Cox-regression analyses adjusted for baseline, imaging, hemodynamic, and procedural data, TAPSE/PASP ratio < 0.36 was independently associated with outcome (adj.HR 2.74, 95% CI 1.17-6.43, p = 0.021). At 1-year follow-up, RV-PA coupling improved (TAPSE: ∆ + 3 mm, PASP: ∆ - 10 mmHg, p for both < 0.001), alongside with a reduction in tricuspid regurgitation (TR) severity (grade ≥ II: 77-54%, p < 0.001).

TAPSE/PASP ratio was associated with outcome in patients undergoing M-TEER for primary as well as secondary MR. RV-PA coupling, alongside with TR severity, improved after M-TEER and might thus provide prognostic information in addition to established markers of poor outcome.

In patients with degenerative mitral regurgitation (DMR), left ventricular (LV) dysfunction is associated with increased risk of heart failure and excess mortality. LV end-systolic diameter (LVESD) is an established trigger for intervention, yet recommended LVESD thresholds apply poorly to patients with small body size. Whether LV normalization to body surface area (BSA) may be used as a trigger for DMR correction is unknown. We examined the link between LVESD index (LVESDi) and outcome in DMR to identify appropriate thresholds for excess mortality.

This study focuses on 2753 consecutive patients with DMR due to flail leaflets diagnosed in tertiary centres from Europe and the United States, with prospective echocardiographic measurement of LVESD and BSA and long-term follow-up. The primary endpoint was mortality after diagnosis under conservative management. Secondary endpoints were mortality under conservative and surgical management and postoperative mortality of patients who underwent surgery. The optimal LVESDi cut-off for mortality prediction was 20 mm/m2. Irrespective of management type, 10-year survival was lower with LVESDi ≥20 mm/m2 than with LVESDi <20 mm/m2 (both p < 0.001). After covariate adjustment, LVESDi ≥20 mm/m2 was independently predictive of mortality under conservative management (adjusted hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.15-1.75), and with conservative and surgical management (adjusted HR 1.34, 95% CI 1.17-1.54). LVESDi remained associated with poorer postoperative outcome in patients who underwent intervention. LVESDi showed higher incremental predictive value over the baseline model compared to LVESD. The association between LVESDi ≥20 mm/m2 and outcome was consistent in subgroups of patients with DMR.

In severe DMR due to flail leaflets, LVESDi is a marker of risk additive and incremental to LVESD. Its use in clinical practice should lead to earlier referral to mitral valve surgery and improved long-term outcome.

An aging population and an increasing incidence of cardiovascular risk factors form the basis for a global rising prevalence of valvular heart disease (VHD). Research to further our understanding of the pathophysiology of VHD is often confined to the clinical setting. However, in recent years, sophisticated computational models of the cardiovascular system have been increasingly used to investigate a variety of VHD states. Computational modelling provides new opportunities to gain insights into pathophysiological processes that may otherwise be difficult, or even impossible, to attain in human or animal studies. Simulations of co-existing cardiac pathologies, such as heart failure, atrial fibrillation, and mixed valvular disease, have unveiled new insights that can inform clinical research and practice. More recently, advancements have been made in using models for making patient-specific diagnostic predictions. This review showcases valuable insights gained from computational studies on VHD and their clinical implications.

Transthoracic echocardiography (TTE) is widely recognized as one of the principal modalities for diagnosing tricuspid regurgitation (TR). The diagnostic procedures associated with conventional methods are intricate and labor-intensive, with human errors leading to measurement variability, with outcomes critically dependent on the operators' diagnostic expertise. In this study, we present an innovative assessment methodology for evaluating TR severity utilizing an end-to-end deep learning system. This deep learning system comprises a segmentation model of single cardiac cycle TR continuous wave (CW) Doppler spectra and a classification model of the spectra, trained on the TR CW Doppler spectra from a cohort of 11,654 patients. The efficacy of this intelligent assessment methodology was validated on 1500 internal cases and 573 external cases. The receiver operating characteristic (ROC) curves of the internal validation results indicate that the deep learning system achieved the areas under curve (AUCs) of 0.88, 0.84, and 0.89 for mild, moderate, and severe TR, respectively. The ROC curves of the external validation results demonstrate that the system attained the AUCs of 0.86, 0.79, and 0.87 for mild, moderate, and severe TR, respectively. Our study results confirm the feasibility and efficacy of this novel intelligent assessment method for TR severity.

While tricuspid annuloplasty (TAP) is an effective treatment option for tricuspid regurgitation (TR), understanding the echocardiographic factors contributing to recurrent TR can help in developing more effective preventive measures to reduce the rate of recurrent TR after TAP.

This study was designed as a prospective observational cohort study to investigate factors contributing to recurrent TR following surgical tricuspid valve (TV) repair in patients with moderate or severe functional TR caused by left heart valvular disease, with severe mitral regurgitation as the dominant pathology. The study included 66 patients who underwent preoperative two-dimensional (2D) and three-dimensional (3D) echocardiographic assessments. Patients were divided into two groups based on TAP outcomes: the effective TAP group and the recurrent TR group.

The analysis revealed that 3D-derived both septal-lateral diastolic and systolic tricuspid annulus (TA) diameter (odds ratio (OR) 1.77; 95% confidence interval (CI) 1.17-2.68 and OR 1.62; 95% CI 1.14-2.29, respectively), and major axis diastolic TA diameter (OR 1.59; 95% CI 1.15-2.2) had the highest OR among all echocardiographic parameters. The further univariate analysis of predefined echocardiographic values unveiled that the combined effect of heightened 3D-measured TA major axis diastolic diameter and increased right ventricle (RV) basal diameter exhibited the highest OR at 12.8 (95% CI 2.3-72.8) for a recurrent TR. Using ROC analysis, diastolic major axis (area under the curve (AUC) 0.848; cut-off 48.5 mm), septal-lateral systolic (AUC 0.840; cut-off 43.5 mm) and diastolic (AUC 0.840; cut-off 46.5 mm) TA diameter demonstrated the highest predictive value for recurrent TR from all TV parameters.

Recurrent moderate or severe TR after TAP is associated with preoperative TA size, right atrium and RV geometry, but not with changes of RV function. The predictive capacity of 2D-assessed echocardiographic parameters was found to be lower when compared to their corresponding 3D parameters.

Homozygous familial hypercholesterolemia (HoFH) is characterized by elevated low-density lipoprotein cholesterol (LDL-C) and early-onset cardiovascular disease. To assess the therapeutic effects of liver transplantation (LT) on HoFH patients, we observed and analyzed the outcomes of HoFH children after LT.

This prospective cohort study included all LT candidates under 18 years old diagnosed with HoFH at Ren Ji Hospital between November 2017 and July 2021. The patients were followed until October 2023. They were treated according to the standard protocol at our center. We collected data on changes in lipid profiles, clinical manifestations, and cardiovascular complications at different time points, and recorded postoperative recipient and graft survival.

Fourteen HoFH patients with a median age of 7 (2-12) years were included. Preoperatively, xanthomas and arcus corneas occurred in 14 and 3 patients, respectively, with 10 patients showing mild cardiovascular disease. All patients underwent LT. Recipient and graft survival rates were 100% over a median follow-up duration of 35 (27-71) months. Median LDL-C levels dropped from 11.83 (7.99-26.14) mmol/L preoperatively to 2.3 (1.49-3.39) mmol/L postoperative at the last measurement. Thirteen patients discontinued lipid-lowering treatment after LT, while only one patient resumed statins 6 months post-operation. Xanthomas and arcus corneas significantly improved. Cardiovascular complications regressed in five patients, with no progression observed in the others.

LT is a safe and effective treatment for severe HoFH patients beyond lipid-lowering control. Early LT improves prognosis and quality of life while minimizing the risk of cardiovascular complications.

In the realm of innovative medical procedures, TEER (transcatheter edge-to-edge repair) has emerged as a promising field, showcasing significant growth and advancements. Mitral TEER has been performed for the last two decades; in contrast, tricuspid TEER is newer, with long-term outcomes pending. This article aims to provide a comprehensive review of the current literature, with a primary focus on outcomes and potential complications associated with both procedures. Both procedures carry a low risk of complications when done by experienced providers. A team approach involving specialists in cardiology, cardiothoracic surgery, cardiac imaging and heart failure ensures comprehensive care. A unified approach encompassing preprocedural workup, risk assessment, and standardised care throughout the procedure and recovery contributes to successful outcomes.

Background and Objectives: Fibrillinopathies have different phenotypic expression: Marfan-like skeleton features, MLSF; mitral valve prolapse syndrome, MVPS; MASS phenotype, M = mitral valve prolapse, MVP, A = aortic root dilation, S = skeletal features, and the second S = (cutaneous) striae; Marfan Syndrome, MS. The study had the following main objectives: the correlation between disc displacement, DD (a major sign for temporomandibular joint dysfunction, TMDs) on magnetic resonance imaging, MRI, and aortic Z score (a major sign for aortic root dilation) on echocardiography; the predictive value of DD towards aortic Z score. DD had 2 types of severity: DD with reduction (the mild type, DDwR), and DD without reduction (the severe type, DDwoR). Materials and Methods: The type of fibrillinopathy was precised by clinical exam (systemic score), ophthalmic exam (for ectopia lentis), and echocardiography (aortic Z score, MVP). Medical treatment consisted of betablockers, BB (for patients with tachycardia), or angiotensin II receptor blockers, ARB. Surgical treatment was addressed to aortic root aneurysm, and severe mitral regurgitation, MR. DD benefited from dental conservatory treatment or surgical restoration. Results: DD-Z score had a powerful correlation in MASS (Rho = 0.787, p < 0.01), and in MS patients (Rho = 0.819, p < 0.01). For the entire sample, both DDwR-Z score and DDwoR-Z score had a moderate correlation (Rho = 0.469, and respectively 0.669). Furthermore, DD was an important predictor for Z score. DDwoR had a double power of prediction for the Z score compared with DDwR (B coefficient = 1.661 for DDwR and 3.281 for DDwoR). Conclusions: TMDs had a powerful correlation with aortic root dilation in MASS and MS patients from the sample. Likewise, TMDs was a major predictor for aortic root dilation, in the entire sample. In clinical practice, we can utilize an extracardiac finding, TMDs, obtained by a non-invasive technique, MRI, for cardiac severity stratification of fibrillinopathies.

Aortic valve stenosis of any degree is associated with poor outcomes.

The authors aimed to develop a risk prediction model for aortic stenosis (AS) prognosis using machine learning techniques.

A prognostic algorithm was developed using an AS registry of 10,407 patients undergoing echocardiography between 2008 and 2020. Clinical, echocardiographic, laboratory, and medication data were used to train and test a time-to-event model, the random survival forest (RSF), for AS patient's prognosis. The composite outcome included aortic valve replacement or mortality. The SHapley Additive exPlanations method attributed the importance of variables and provided personalized risk assessment. The algorithm was validated in 2 external cohorts of 11,738 and 954 patients with AS.

The median follow-up of the primary cohort was 48 (21-87) months. In this period, 1,116 patients underwent aortic valve replacement, and 5,069 patients died. RSF had an area under the curve (AUC) of 0.83 (95% CI: 0.80-0.86) and 0.83 (95% CI: 0.81-0.84) for outcomes prediction at 1 and 5 years, respectively. Using a cut-off of 50%, the RSF sensitivity and specificity for the composite outcome, were 0.80 and 0.73, respectively. Validation performance in the 2 external cohorts was similar, with AUCs of 0.73 (95% CI: 0.72-0.74) and 0.74 (95% CI: 0.72-0.76), respectively. AS severity, age, serum albumin, pulmonary artery pressure, and chronic kidney disease emerged as the top significant variables in the model.

In patients with AS, a machine learning algorithm predicts outcomes with good accuracy, and prognostic characteristics were identified. The model can potentially guide risk factor modification and clinical decisions to improve patient prognosis.

Aortic regurgitation (AR) may lead to right ventricular dysfunction (RVD), but the prognostic value of RVD in patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear. Our goal was to evaluate the clinical implications, predictors and prognostic significance of RVD in patients with pure AR after TAVR.

In this multicentre prospective study, patients undergoing TAVR were included between January 2019 and April 2021. The patients were divided into four groups according to the results of transthoracic echocardiography pre- and post-TAVR. The primary end point was 2-year all-cause mortality.

A total of 648 patients were divided into four groups: 325 patients (54.3%) in the no RVD group; 106 patients (17.7%) in the new-onset RVD group; 73 patients (12.2%) in the normalized RVD group; and 94 patients (15.7%) in the residual RVD group. At the 2-year follow-up, there were significant differences in all-cause mortality among the four groups (5.2%, 12.3%, 11.0% and 17.0%, respectively; p < 0.05). New-onset RVD was correlated with an increased risk of all-cause death and a composite end point and normalized RVD improved clinical outcomes of baseline RVD. Predictors of new-onset RVD included a higher Society of Thoracic Surgeons score, larger left ventricular end-diastolic volume, lower left ventricular ejection fraction, higher systolic pulmonary artery pressure and smaller RV base diameter.

Changes in periprocedural RVD status significantly affect the risk stratification outcomes after TAVR. Therefore, they may be used as part of decision-making and risk assessment strategies.

ClinicalTrials.gov Protocol Registration System (NCT02917980).

Atrial fibrillation (AF) triggers atrial remodeling, impacting atrial function and ablation efficacy. This remodeling leads to atrial cardiomyopathy and dilatation, linked to mitral regurgitation, forming atrial functional mitral regurgitation (aFMR). Our study explores the relationship between early-stage-aFMR and the atrial electrical architecture, focusing on left atrial bipolar voltage and low-voltage areas (LVAs) in AF patients.

We enrolled 282 patients undergoing redo-PVI after AF recurrence post-PVI. Echocardiography was performed prior to ablation, and only patients with no, mild, or mild-to-moderate aFMR were included. Ablation used radiofrequency and a 3D mapping system, with atrial voltage documented on each atrial wall. LVAs were calculated using high-density maps, and patients were followed for 15 months.

Significant differences in left atrial voltage and LVA extent were observed based on aFMR severity. Patients with aFMR 1 + had significantly lower atrial voltage compared to no-aFMR, but no significant increase in LVAs. Patients with aFMR 2 + showed lower voltage amplitudes in all atrial regions and larger LVAs compared to no-aFMR patients. AF recurrence was significantly higher in the aFMR group (62.9% vs. 48.3%, p = 0.027) within 1 year. aFMR was associated with AF recurrence after adjusting for sex, age, and AF types (HR: 1.517, 95% CI: 1.057-2.184, p = 0.025).

aFMR in AF patients may indicate progressive atrial remodeling and left atrial cardiomyopathy, characterized by reduced atrial voltage and increased LVAs. aFMR is linked to PVI outcomes, suggesting its consideration in AF therapy decision-making.

With an ageing population, the presence of asymptomatic valvular heart disease (VHD) in the community remains unknown. The aim of this study is to determine the prevalence and associated factors of asymptomatic VHD in individuals ≥60 years old and to evaluate the feasibility of echocardiographic screening for VHD in this population.

This was a prospective cohort study conducted between 2007 and 2016 in the UK. Asymptomatic patients with no prior indication for echocardiography were invited to participate and evaluated with a health questionnaire, clinical examination, and transthoracic echocardiography. A total of 10,000 individuals were invited through their general practices. A total of 5429 volunteered to participate, of whom 4237 were eligible for inclusion. VHD was diagnosed in more than a quarter of patients (28.2%). The most common types of VHD were regurgitation of the tricuspid (13.8%), mitral (12.8%), and aortic (8.3%) valves (trivial regurgitation was not included). The rate of prevalence of clinically significant VHD was 2.4% (2.2% moderate and 0.2% severe), with mitral and aortic regurgitation being the most common. The only parameter associated with significant VHD was age (odds ratio 1.07 per 1 year increment, 95% confidence interval 1.05-1.09, P < 0.001). The number needed to scan to diagnose one clinically significant case of VHD is 42 for individuals ≥60 and 15 for those ≥75 years old.

Asymptomatic VHD is present in a significant proportion of otherwise healthy individuals without known VHD over 60 years old. Age is strongly associated with an increased incidence of significant VHD.

Background/Objectives: Mitral regurgitation (MR) affects millions worldwide, necessitating timely intervention. There are significant clinical challenges in the conservative management of MR, leaving a knowledge gap regarding the impact of multidisciplinary decision-making on treatment outcomes. This study aimed to provide insights into the impact of multidisciplinary decision-making on the survival outcomes of MR patients, focusing on conservative approaches. Methods: This study retrospectively analyzes 1365 patients evaluated by an expert multidisciplinary heart team (MDT) in a single center from 2015 to 2022. Treatments included surgery, catheter-based interventions, and conservative management. Propensity matching was utilized to compare surgery and conservative approaches. Results: Surgical intervention was associated with superior long-term survival outcomes compared to conservative and catheter-based treatments, particularly for degenerative MR (DMR). Survival rates of patients deemed by the MDT to have non-severe DMR were comparable to surgical patients (HR 1.07, 95% CI: 0.37-3.12, p = 0.90). However, non-severe functional MR (FMR) patients trended towards elevated mortality risk (HR 1.77, 95% CI: 0.94-3.31, p = 0.07). Pharmacological treatment for DMR was associated with significantly higher mortality compared to surgery (HR 8.0, 95% CI: 1.78-36.03, p = 0.001). Functional MR patients treated pharmacologically exhibited a non-significantly higher mortality risk compared to surgical intervention (HR 1.93, 95% CI: 0.77-4.77, p = 0.20). Conclusions: Survival analysis revealed significant benefits for surgical intervention, contrasting with elevated mortality risks associated with conservative management. "Watchful waiting" may be appropriate for non-severe DMR, while FMR may require closer monitoring. Further research is needed to assess the impact of regular follow-up or delayed surgery on survival rates, as pharmacological therapy has limited long-term efficacy for DMR.

Mitral regurgitation is the most common valvular disease in the developed world, with approximately 24.2 million people being affected worldwide and a higher prevalence in older age groups. Surgical correction of degenerative mitral regurgitation is the standard of care and can restore cardiac function and provide a lasting result, especially when the mitral valve can be repaired. Secondary mitral regurgitation, or functional mitral regurgitation (FMR), describes atrial or ventricular factors leading to poor coaptation of an otherwise non-diseased valve. For FMR, traditional surgery has not produced the same level of benefit. Transcatheter mitral repair and replacement techniques that mimic surgical correction are under investigation. Transcatheter edge-to-edge repair is the only approved catheter-based therapy for FMR in the US. Here, the transcatheter treatment options for FMR are reviewed.

Atrial fibrillation (AF) may increase the risk of adverse maternal and fetal outcomes among pregnant with rheumatic valvular lesions (RHD). We aimed to assess the rate of occurrence of AF in pregnant with RHD and its impact on cardiac and maternal-fetal outcomes compared to those without it.

The study group consisted of pregnant women with RHD and AF (cases) and a matched comparison group of pregnant women with RHD but without AF (controls) was derived from the database of pregnant women with RHD receiving care at our center between 2011 and 2021. Incidence of composite adverse outcomes(maternal death, heart failure, or thrombo-embolic events) and pregnancy outcomes were compared between them.

Seventy-one (5.1%; 95%CI 4.1%-6.4%) pregnant women with RHD had AF during pregnancy and childbirth, most occurring in the late second or early third trimester. New-onset AF was diagnosed in 34 (47.9%) of them. After matching, the incidence of composite outcome was higher in women with AF (77.5% (95%CI 66.3%-85.7%) compared to women without AF (17.3%(95%CI 13.3%-22.1%), P < .001), with seven (9.9%) maternal deaths among cases and two (0.7%) in controls. Heart failure was the most common adverse cardiac event (26.7% vs. 4.2%, P < .001, cases vs controls). Those with AF had higher odds (adjusted OR 56.6 (14.1-226.8)) of adverse cardiac outcomes after adjusting for other risk factors. The frequency of most non-cardiac pregnancy complications was similar in both groups. However, there was a trend towards a higher rate of miscarriage (16.9% vs. 9.9%), small-for-gestational-age babies(16.3 vs. 9.0%), and cesarean rates(31.9% vs. 18.3%) women with AF compared to those who did not experience AF.

Atrial fibrillation in pregnancy among women with RHD was associated with an increased risk of maternal morbidity and mortality, with a trend towards an increase in some non-cardiac pregnancy complications compared to those pregnant women without AF. Our study results provide background data for developing and implementing a pregnancy-specific management strategy tailored to middle-income settings.

Tricuspid valve repair during mitral valve replacement surgery remains a controversial topic. The risk-benefit ratio in some populations remains uncertain, especially in rheumatic heart disease patients. Therefore, we aimed to evaluate the impact of concomitant tricuspid repair on surgical mortality in patients undergoing cardiac surgery due to rheumatic mitral valve disease who have moderate to severe functional tricuspid regurgitation.

This is a prospective cohort study from January 1, 2017, to December 30, 2022. All patients over 18 years of age who underwent cardiac surgery to correct rheumatic mitral valve disease with concomitant moderate to severe tricuspid regurgitation were included. The primary outcome was a surgical death. In an exploratory analysis, clinical and echocardiographic data were obtained 2 years after the procedure.

Of the 144 patients included, 83 (57.6%) underwent tricuspid valve repair. The mean age was 46.2 (±12.3) years with 107 (74.3%) female individuals, the median left ventricular ejection fraction was 61.0% (55-67), and systolic pulmonary artery pressure (sPAP) was 55.0 mmHg (46-74), with 45 (31.3%) individuals with right ventricular dysfunction. The total in-hospital mortality was 15 (10.4%) individuals, and there was no difference between the groups submitted or not to tricuspid repair: 10 (12.0%) vs. 5 (7.5%); p = 0.46, respectively. There was an association with one variable independently: the sPAP value, relative risk 1.04 (1.01-1.07), p = 0.01. The estimated cut-off value of sPAP that indicates higher early mortality through the receiver operating characteristic curve (area 0.70, p = 0.012) was 73.5 mmHg.

Performing tricuspid repair in individuals who were undergoing cardiac surgery to correct rheumatic mitral valve disease was not associated with increased surgical mortality. Our results suggest the safety of tricuspid repair even in this high-risk population, reinforcing the recommendations in current guidelines.

Transcatheter mitral valve replacement (TMVR) represents a novel treatment option for patients with mitral regurgitation (MR), but little is known about the hemodynamic impact of MR elimination following TMVR. We sought to investigate the hemodynamic impact of TMVR on left ventricular (LV) and right ventricular (RV) function using noninvasive pressure-volume loops.

All consecutive patients undergoing TMVR with dedicated devices between May 2016 and August 2022 were enrolled. The end-diastolic and end-systolic pressure-volume relationships were estimated from 26 patients using single-beat echocardiographic measurements at baseline and after TMVR at discharge. RV function was assessed by RV-pulmonary artery (PA) coupling and RV fractional area change. One-year follow-up was available for 19 patients. The prognostic impact of calculated end-diastolic volume at an end-diastolic pressure of 20 mmHg (VPed20) reduction was assessed by Cox regression.

A total of 26 patients (77.0 years [interquartile range 73.9-80.1], N = 17 [65.4%] male) with successful TMVR were included (secondary MR [N = 21, 80.8%]; median LV ejection fraction was 37.0% [interquartile range 30.7-50.7]). At discharge, a decrease in VPed20 (p < 0.001) indicating leftward shift of end-diastolic pressure-volume relationship, and an increase of the end-systolic elastance slope (p = 0.007) were observed after TMVR. No changes were observed for RV-PA coupling (p = 0.19) and RV fractional area change (p = 0.22). At 1-year follow-up, LV contractility (end-systolic elastance) and RV-PA coupling remained stable. Vped20 reduction at discharge was significantly associated with 1-year all-cause mortality or heart failure hospitalization (hazard ratio 0.16, 95% CI 0.04-0.71, p = 0.016).

Noninvasive assessment of pressure-volume loops demonstrated early LV reverse remodeling and improved LV contractility, while RV performance was preserved. These results indicate the potential prognostic impact of complete MR elimination after TMVR.