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Tricuspid regurgitation (TR) has long been a forgotten valve disease of benign reputation. However, TR deserves higher attention and represents a growing public health crisis. Indeed, recent epidemiological data suggest that 1.6 million US residents are affected by moderate or severe TR. Furthermore, large recent cohorts demonstrate that higher degrees of TR are associated with considerable excess mortality, independent of all background clinical and hemodynamic contexts. Finally, analysis of recent cohorts also shows that >90% of patients with moderate or severe TR are never offered surgical treatment and remain untreated. Therefore, TR is frequent, severely impacts outcomes, and is rarely treated, justifying the development of new strategies and methods for its treatment., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: The goal of this study was to determine the impact of catheter ablation in the region of papillary muscles (PMs) and valvular cusps (VC) on mitral, tricuspid, or aortic valve function., Background: Ventricular arrhythmias arising from PMs and VCs often require extensive catheter ablation. Little is known regarding the risk of valve dysfunction after radiofrequency catheter ablation of such arrhythmias., Methods: A retrospective analysis was completed for 149 PM and VC VT/premature ventricular contraction (PVC) ablations from 2008 to 2018 at our institution. Patient and procedural details were collected for VT and PVC ablation cases involving PMs and VCs with available echocardiographic data pre-ablation and post-ablation (within 6 months). Degree of valvular regurgitation (VR) was graded from 0 (none) to 4 (severe), and significant valvular dysfunction was defined as a 2+ change in VR., Results: Of 149 radiofrequency catheter ablation cases, there were 84 (56%) aortic valve cusp ablations, 60 (40%) left ventricular PM ablations, and 5 (3%) right ventricular PM ablations. There were no statistically significant differences between pre-ablation and post-ablation VR severity (p = 0.33). No patients had a 2+ grade change in VR severity when pre-ablation and post-ablation echocardiograms were compared. There were no significant sequelae requiring intervention in the post-ablation period. On follow-up of 36 ± 9 months, for those with a change in VR, the severity had improved to baseline or remained stable., Conclusions: Despite often-times extensive ablation on and around valvular networks, risk of longstanding or permanent valvular dysfunction after VT/PVC ablation is rare., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Vascular complications such as pulmonary hypertension (PH) occur at an increased rate following splenectomy in patients with various hemolytic blood disorders including thalassemia. The goal of this retrospective cross-sectional analysis was to assess the independent association of splenectomy with an elevated tricuspid regurgitation velocity (TRV) in people with homozygous sickle cell disease (HbSS). TRV is a noninvasive screening test for PH and a surrogate marker of prognosis in sickle cell disease (SCD)., Procedure: Data were obtained from the multicenter Walk-PHaSST (treatment of pulmonary hypertension and sickle cell disease with sildenafil therapy) study of PH (NCT00492531). We compared TRV in the cohort of patients with HbSS who were surgically splenectomized with patients who were not surgically splenectomized., Results: We found no significant differences in TRV between the two groups., Conclusions: The lack of difference in TRV between the two groups is most likely because members of the comparator nonsurgical group in many cases experienced autoinfarction of the spleen in childhood. Splenectomy does not seem to confer additional risk for the development of a higher TRV in HbSS, unlike in patients with thalassemia or other hemolytic anemias. This could be an important consideration when weighing the risks and benefits of splenectomy in patients with HbSS., (© 2019 Wiley Periodicals, Inc.)

Background: Functional tricuspid regurgitation (TR) is a common echocardiographic finding in patients with heart failure (HF), and its role in disease progression and prognosis stratification is becoming increasingly relevant in recent years. However, data regarding its association with the burden of HF-readmission is scarce. In this work, we sought to evaluate the association between TR severity and HF-related readmissions following a hospitalization for acute heart failure (AHF)., Methods: We prospectively included a cohort of 2101 patients admitted with the diagnosis of AHF. TR severity was assessed using a multiparametric integrative approach, and classified as none, mild, moderate, and severe. We used negative binomial regression to identify the association between TR grade and HF-related recurrent admissions. The risk associated to severity of TR was expressed as incidence rate ratio (IRR)., Results: At a median follow-up of 2.53 years (IQR: 1.03-4.36), 978 (46.5%) patients died, and 1657 HF-readmissions occurred in 842 patients (40.0%). The proportion of patients with two or more admissions was 18.4%. The proportion of patients with moderate to severe TR was 17.2%. There was a stepwise increase in the incidence of readmissions from none to severe TR. After multivariable adjustment, only patients with severe TR were independently associated with higher risk of recurrent HF admissions (IRR = 1.34, CI 95%: 1.05-1.71; p = .019)., Conclusions: In patients with AHF, severe functional TR is independently associated with an increased risk of long-term recurrent HF hospitalizations., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Concomitant heart failure (HF) and mitral valve disease (MVD) portend significant morbidity and mortality. Although associated Tricuspid regurgitation (TR) is a common occurrence in this scenario, it is not well known whether there are additional prognostic implications. We sought to assess whether coexistent TR is associated with higher readmission rates or increased mortality in patients with HF and MVD. We identified 1,520,871 encounters with a primary diagnosis of HF in the 2013 to 2014 Nationwide Readmission Database. We excluded patients without MVD, patients <18 years old, those with rheumatic heart disease and infective endocarditis. We also excluded patients who were discharged in December, hospital transfers, and cases where follow-up or outcomes were missing. Logistic regression was used to evaluate the association between baseline characteristics (including the presence of tricuspid valve disease), mortality as well as 30-day readmission rates. A total of 221,127 admissions with HF and MVD were identified. Median age was 79 years (IQR, 67 to 87), 55% were female, 2.7% died during hospitalization, and the 30-day readmission rate was 20.3%. Nearly 1/3 had concomitant TR (n = 78,356, 35%). The presence of TR was neither associated with elevated risk of mortality (hazard ratio 0.98, 95% confidence interval 0.93 to 1.04) nor 30-day readmission rate (odds ratio 1.01, 95% confidence interval 0.98 to 1.03). HF accounted for 33% of 30-day readmissions, while combined cardiac causes accounted for 54%. In conclusion concomitant TR in patients with HF and MVD was not associated with worse short-term outcomes in terms of inpatient hospital mortality and 30-day readmission rates., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: This study aimed to identify characteristics, spectrum of tricuspid regurgitation (TR) severity and treatment patterns in patients considered for intervention of severe TR at a tertiary centre. The population being considered for TR intervention is currently not well defined and the role of transcatheter interventions is unclear., Methods: The study involved 87 patients with severe TR considered for intervention from 1 March 2016 to 12 November 2018 at Mayo Clinic. Patients receiving medications alone were compared with those receiving intervention to identify patterns in demographics, clinical/echocardiographic associations and survival., Results: Mean age was 80±9 (56% female), 93% had atrial fibrillation and 64% had chronic kidney disease ≥3 a. Follow-up was 331±276 days; 95% were symptomatic with 6 min walk distance of 270±110 m. Loop diuretics were used in 93%; aldosterone antagonists in 35%. Mean tricuspid annular plane systolic excursion was 15.6±3.8 mm, effective regurgitant orifice area (EROA) 82±32 mm 2 and stroke volume index 39±11 mL/m 2 ; 48% had at least moderate right ventricular (RV) dysfunction, and 75% did not undergo intervention. Patients receiving intervention showed trends towards larger EROA (93±33 vs 75±31 mm 2 ), better right ventricular function and more severe symptoms. Overall group 30-day and 1-year survival were 100% and 76%, respectively., Conclusions: Patients with severe TR considered for intervention are commonly elderly with atrial fibrillation, advanced TR and RV dysfunction; 75% were treated with medications alone and not offered intervention. Patients with greater EROA, better RV function and more severe symptoms were more likely to receive intervention. These findings have implications for future trial design., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The increasing number of cardiac implantable electronic device complications represents a current problem. Abandoned leads are difficult to manage, even because indications to transvenous lead extraction (TLE) cannot be generalized. The aim of the study was to assess the late consequences of previous abandoned leads., Methods: We did a retrospective analysis of clinical data from 3,810 patients undergoing TLE in two high-volume centers (Poland and Italy) in the years 2006-2017. In order to evaluate the effects of lead abandonment, the patients were divided into a group of 582 (15.3%) subjects with abandoned leads (AL) and a group of 3,228 (84.7%) subjects with functional leads (FL)., Results: Infective indications to TLE were predominant in the AL group (61.34% vs 43.4%; P < 0.001). AL was associated with a higher number of leads per patient, longer lead dwell times, more frequent venous occlusion, higher probability of intracardiac lead abrasion, and tricuspid regurgitation (P < 0.001 for all factors). The presence of AL was connected with more frequent technical complications of TLE (odds ratio [OR] 1.617; confidence interval [CI] 1.412-1.852; P = 0.000), lower procedural success rate (OR 0.270; CI 0.199-0.363; P = 0.000), and with higher mortality rate during 3.518 years of follow-up [hazard ratio 1.286; 95% CI (1.062-1.558), P = 0.010]., Conclusions: Presence of previously abandoned leads was associated with the risk of device infections, technical problems during subsequent lead extraction, dysfunction of tricuspid valve, and worse long-term outcomes., (© 2019 Wiley Periodicals, Inc.)

Objective: Owing to mediastinal and cardiac damage burden, the surgical treatment of radiotherapy-related mitral regurgitation (MR) may be associated with high operative risk or might even contraindicated. We evaluated the feasibility and outcome of MitraClip therapy in patients with radiotherapy-related MR as an alternative to surgery., Methods: Based on Doppler Echocardiography, 15 of 33 screened patients underwent MitraClip implantation., Results: Following MitraClip MR improved (residual MR ≤2+) without significant mitral valve stenosis (planimetric area 2.83 ± 0.8 cm 2 , mean gradient 4.6 ± 1.8 mm Hg). All patients completed a 6-month follow-up, while 14 of 15 patients achieved a longer follow-up, ranging from 12 to 72 months (median 24 months, IQR 42 months). At 6-month follow-up we observed NYHA improvement in 13 patients with an increase of 6-min walking covered distance (from 260 ± 34 to 367 ± 70, p < 0.001), sustained moderate or less MR, mild mitral stenosis in 3 patients, and significant systolic Pulmonary Artery Pressure (PAPs) reduction (from 52.5 ± 14 to 42 ± 9, p < 0.01). Sustained clinical improvement and ≤2+ MR was observed in 13 of 14 patients who completed the 12-month follow-up. Two patients died of acute pneumonia (11 months and 60 months, respectively). One patient developed moderate MV stenosis (MVA 1.4 cm 2 ) at last follow-up (48 months) without related clinical instability. Tricuspid regurgitation improved in 12 patients with further improvement at late follow-up in 2 of 3 patient with 3+., Conclusion: MitraClip may be an effective treatment for RT-induced MR, although unexpected late stenosis may occur in the context of sustained reactive mitral apparatus damage following mediastinal radiation., (Copyright © 2018 Hellenic Society of Cardiology. Published by Elsevier B.V. All rights reserved.)

Elevated tricuspid valve regurgitation jet velocity (TRV ≥ 2.5 m/s) is associated with mortality among adults with sickle cell disease (SCD), but correlative biomarkers are not studied according to treatment exposure or genotypes. To investigate the associations between biomarkers and TRV elevation, we examined the relationship between TRV and hemolytic, inflammatory, and cardiac biomarkers, stratified by disease-modifying treatments and SCD genotype. In total, 294 participants with SCD (mean age, 11.0 ± 3.7 years) and 49 hereditary spherocytosis (HS; mean age, 22.9 ± 19.75 years) were included for comparison and enrolled. TRV was elevated in 30.7% of children with SCD overall: 18.8% in HbSC/HbSβ + -thalassemia, 28.9% in untreated HbSS/HbSβ 0 -thalassemia, 34.2% in HbSS/HbSβ 0 -thalassemia hydroxyurea-treated, and 57% in HbSS/HbSβ 0 -thalassemia chronic transfusion treated. TRV was elevated in 10.7% and 27.8% in HS children and adults, respectively. In children with SCD, elevated TRV was correlated with hemoglobin (odds ratio [OR] = 0.78, P = 0.004), lactate dehydrogenase (LDH; OR = 2.52, P = 0.005), and N-terminal pro-brain natriuretic peptide (NT-pro BNP; OR = 1.003, P = 0.004). In multivariable logistic regression, adjusting for genotype, sex, hemolytic index, and treatment, hemoglobin concentration remained the only significant variable associated with elevated TRV in untreated HbSS/HbSβ 0 -thalassemia participants. TRV was not associated with inflammatory markers, other markers of hemolysis, or NT-pro BNP in untreated HbSS/HbSβ 0 -thalassemia. Neither hemoglobin nor LDH was associated with TRV in HbSC/HbSβ + -thalassemia. These results suggest that elevated TRV is influenced by the degree of anemia, possibly reflecting sickling as part of the disease pathophysiology. Prospective studies should monitor hemoglobin concentration as children with SCD age into adulthood, prompting initiation of TRV screening and monitoring., (© 2019 Wiley Periodicals, Inc.)

Background: Tricuspid valve regurgitation (TR) is a common finding immediately after cardiac transplantation. However, there is a scarcity of data regarding its implication if left untreated on long-term outcomes and the role of early surgical repair., Methods: We retrospectively reviewed the Duke University Medical Center transplant database from January 2000 to June 2012 and identified 542 patients who underwent orthotropic heart transplantation. Patients were excluded if they underwent surgical repair for TR during the transplant or if the transplant was part of a multiorgan transplant or redo heart transplantation. TR was assessed intraoperatively after weaning from cardiopulmonary bypass. Independent variables were grade of TR and changes in TR grade during follow-up. TR grades were classified as insignificant (none or mild) versus significant (moderate or severe). Survival and need for posttransplant valve repair during follow-up were assessed., Results: Significant TR was detected in 114 patients (21%) after weaning from cardiopulmonary bypass, with no significant difference in preoperative recipient pulmonary vascular resistance. Significant TR was associated with increased maximum postoperative plasma creatinine (median [interquartile range], 2.2 [1.5 to 3.2] mg/dL vs 1.8 [1.4 to 2.6] mg/dL, p = 0.008), prolonged postoperative stay (median [interquartile range], 12 [9 to 21] days vs 10 [8 to 14] days; p < 0.001), and decreased adjusted survival. Significant TR regressed to insignificant in 91% of recipients by 1 year after transplant. Six recipients (1%) who had significant TR after cardiopulmonary bypass underwent delayed tricuspid valve repair for significant TR during follow-up., Conclusions: Significant TR is a common finding immediately after transplant and is associated with early morbidity and reduced adjusted survival. Most significant TR resolves by 1 year after transplant. Optimal algorithms for follow-up and treatment of significant TR after heart transplantation need to be defined., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Tricuspid regurgitation (TR) has been associated with cardiac rhythm device (CRD) implantation with intracardiac lead insertion. However, data on the incidence of postdevice TR are limited and largely from retrospective studies. We hypothesized that permanent lead implantation would be associated with an increase in TR., Methods: We prospectively included consecutive patients with a clinical indication for CRD. Patients underwent transthoracic echocardiography 1 month before and 1 year after CRD implantation., Results: A total of 328 patients were prospectively enrolled (69 ± 15 years, 38% female). Echocardiograms before and 1 year after CRD were available in 290 patients (15 died, 23 lost to follow-up). Compared with baseline, there was a significant change in TR grade 1 year after CRD insertion (no/trivial TR: 66% vs 29%; mild TR: 29% vs 61%; moderate TR: 3% vs 8%; severe TR 2% vs 2%; P < 0.001 for an increase in TR by at least 1 grade). Compared with baseline, there was a higher prevalence of moderate or severe TR in the 247 patients with CRD without cardiac resynchronization therapy (4% vs 10%, P = 0.004), but no progression in the 43 patients who received cardiac resynchronization therapy (14% vs 11%, P = 1). Multivariable analysis in the patients with less than moderate TR at baseline (n = 274) showed that only a history of atrial fibrillation was independently associated with progression to moderate or severe TR after correction for baseline TR grade (P = 0.013)., Conclusions: One year after endocardial lead insertion, there was a 5% increase in the prevalence of moderate or severe TR, which may be clinically relevant., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: The clinical characteristics, hemodynamic changes and outcomes of lung disease-associated pulmonary hypertension (LD-PH) are poorly defined., Methods: A prospective cohort of PH patients undergoing initial hemodynamic assessment was collected, from which 51 patients with LD-PH were identified. Baseline characteristics and long-term survival were compared with 83 patients with idiopathic pulmonary arterial hypertension (iPAH)., Results: Mean age (±standard deviation) of LD-PH patients was 64 ± 10 years, 30% were female and 78% were New York Heart Association class III-IV. The LD-PH group was older than the iPAH group (64 ± 10 vs 56 ± 18 years, respectively, P = 0.003) with a lower percentage of women (30% vs 70%, P = 0.007). LD-PH patients had smaller right ventricular sizes (P = 0.02) and less tricuspid regurgitation (P = 0.03) by echocardiogram, and lower mean pulmonary arterial pressures (mPAP) (P = 0.01) and pulmonary vascular resistance (PVR) (P = 0.001) at catheterization. Despite these findings, mortality was equally high in both groups (P = 0.16). 5-year survival was lower in patients with interstitial lung disease compared to those with obstructive pulmonary disease (P = 0.05). Among the LD-PH population, those with mild to moderately elevated mPAP and those with PVR <7 Wood units demonstrated significantly improved survival (P = 0.04 and P = 0.001, respectively). Vasoreactivity was not associated with improved survival (P = 0.64). A PVR ≥7 Wood units was associated with increased risk of mortality (hazard ratio (95% confidence interval), 3.59 (1.27-10.19), P = 0.02)., Conclusions: Despite less severe PH and less right heart sequelae, LD-PH has an equally poor clinical outcome when compared to iPAH. A PVR ≥7 Wood units in LD-PH patients was associated with 3-fold higher mortality., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Aims: Tricuspid regurgitation (TR) has been reported to be associated with worse survival in various heart diseases, but there are few data in aortic stenosis (AS)., Methods and Results: In the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis (CURRENT AS) Registry enrolling 3815 consecutive patients with severe AS, there were 628 patients with moderate or severe TR (TR group) and 3187 patients with no or mild TR (no TR group). The study patients were subdivided into the initial aortic valve replacement (AVR) stratum (n = 1197) and the conservative stratum (n = 2618) according to treatment strategy. The primary outcome measure was a composite of aortic valve-related death or hospitalization due to heart failure. The 5-year freedom rate from the primary outcome measure was significantly lower in the TR group than in the no TR group (49.1% vs. 67.3%, P < 0.001). Even after adjusting for confounders, the excess risk of TR relative to no TR for the primary outcome measure remained significant [hazard ratio (HR): 1.25, 95% confidence interval (CI): 1.06-1.48; P = 0.008]. The trend for the excess adjusted risk in the TR group was consistent in the initial AVR and the conservative strata (HR 1.55, 95% CI: 0.97-2.48; P = 0.07; HR 1.22, 95% CI: 1.02-1.46; P = 0.03, respectively). In the initial AVR stratum, the 5-year freedom rate from the primary outcome measure was not different between the two groups with (n = 56) or without (n = 91) concomitant tricuspid annuloplasty (61.5% vs. 72.1%, P = 0.48)., Conclusion: The presence of clinically significant TR concomitant with severe AS is associated with a poor long-term outcome, regardless of the initial treatment strategy., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.)

Objectives: This study sought to analyze patients with tricuspid regurgitation (TR) diagnosed in the community setting (Olmsted County) by Doppler echocardiography to define the prevalence, characteristics, and implications of clinically significant (greater or equal to moderate) TR., Background: The prevalence, cause distribution, and significance of TR are mostly unknown., Methods: All adult residents of Olmsted County, Minnesota, who underwent clinically indicated Doppler echocardiography between 1990 and 2000 were evaluated for presence of greater or equal to moderate TR. The characteristics and outcome of TR carriers was then analyzed., Results: During the study period, 417 community residents were diagnosed with greater or equal to moderate TR corresponding to an U.S. age- and sex-adjusted prevalence of 0.55% with 95% confidence interval (0.50 to 0.60). TR adjusted prevalence was higher in women (p < 0.01) and strongly linked to age (p < 0.0001). Isolated TR (without significant comorbidities, structural left valve disease, pulmonary hypertension, or overt cardiac cause) represented 8.1% of patients with greater or equal to moderate TR. Isolated TR adjusted for age, sex, ejection fraction, atrial fibrillation, and Charlson comorbidity index independently predicted higher mortality (adjusted risk ratio: 1.68; 95% confidence interval: 1.04 to 2.60; p = 0.03) for qualitative definition. Mortality in patients with greater or equal to moderate isolated TR was higher than in the matched cases with trivial TR (p = 0.0014; matching for age, sex, atrial fibrillation, ejection fraction, comorbidity index). Only 2.6% of patients ever had tricuspid valve surgery during follow-up., Conclusions: Clinically significant (greater or equal to moderate) TR is common in community residents diagnosed by Doppler echocardiography and increases with age. Isolated TR is associated with excess mortality, thus TR represents an important public health problem., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Atrioventricular valve failure (moderate or greater regurgitation, or valve operation) is a risk factor for adverse outcomes in patients undergoing Fontan palliation., Objectives: This study determined the incidence of atrioventricular valve failure and its clinical impact on patients undergoing Fontan palliation., Methods: A retrospective cohort longitudinal study was conducted using patient data extracted from an existing bi-national, population-based registry., Results: A total of 1,468 patients who underwent Fontan palliation were identified; complete follow-up data were available for 1,199 patients. Six hundred eighty-six patients had 2 atrioventricular valves, 286 had a single mitral valve, 130 had a common atrioventricular valve, and 97 had a single tricuspid valve. A total of 132 repairs were performed in 110 patients, and 15 replacements were performed in 13 patients. The cumulative incidence of atrioventricular valve failure at 25 years of age for patients with a common atrioventricular, single tricuspid, single mitral, and 2 atrioventricular valves was 56% (95% confidence interval [CI]: 46% to 67%), 46% (95% CI: 31% to 61%), 8% (95% CI: 4% to 12%), and 26% (95% CI: 21% to 30%), respectively. In patients without valve failure, freedom from Fontan failure at 10 and 20 years post-Fontan palliation was 91% (95% CI: 89% to 93%) and 77% (95% CI: 73% to 81%), respectively, compared with 77% (95% CI: 69% to 85%) and 54% (95% CI: 42% to 68%), respectively, in patients with valve failure (hazard ratio: 2.43; 95% CI: 1.74 to 3.39; p < 0.001)., Conclusions: Atrioventricular valve failure occurs frequently in patients undergoing Fontan palliation. Patients with valve failure are twice as likely to have their Fontan circulation fail than those without valve failure., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Tricuspid regurgitation is a common finding in patients with left-sided heart disease with prognostic implications. In addition, isolated tricuspid valve surgery is associated with high mortality and is infrequently performed. Hence, a largely unmet clinical need exists and less invasive therapeutic options are emerging: multiple percutaneous therapies have been developed, including tricuspid valve repair or replacement. This review aims to provide an overview with diagnostic and clinical perspectives, potential challenges and future directions.

Far less attention has been paid to the prognostic effect of right-side heart disease on outcomes after transcatheter aortic valve replacement (TAVR) when compared with the left side. Therefore, we performed a systematic review and meta-analysis on the impact of tricuspid regurgitation (TR) and right ventricular (RV) dysfunction on outcomes after TAVR. We hypothesized that TR and RV dysfunction may have a deleterious effect on outcomes after TAVR. Article revealing the prognostic effect of TR and RV dysfunction on outcomes after TAVR were being integrated. Random or fixed effect model was adopted in accordance with the heterogeneity. There were nine studies with a total of 6466 patients enrolled after a comprehensive literature search of the MEDLINE/PubMed, EMBASE, ISI Web of Science, and Cochrane databases. The overall analysis revealed that moderate or severe TR at baseline increased all-cause mortality after TAVR (HR = 1.79, CI 95% 1.52-2.11, P < 0.001). Both baseline RV dysfunction (HR = 1.53, CI 95% 1.27-1.83, P < 0.001) and presence of RV dilation (HR = 1.83, CI 95% 1.47-2.27, P < 0.001) were associated with all-cause mortality. Both baseline moderate or severe TR and RV dysfunction worsen prognosis after TAVR and careful assessment of right heart function should be done for clinical decision by the heart team before the TAVR procedure., (© 2018 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.)

Valvular heart disease and heart failure remain important causes of cardiovascular disease among women in the United States. Mitral regurgitation, aortic stenosis, and tricuspid regurgitation are the most common valvular lesions among men and women. This review focuses on gender differences in the epidemiology, treatment, and outcomes of mitral regurgitation, aortic stenosis, and tricuspid regurgitation. The authors also review the unique management of valvular heart disease in pregnancy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: The incidence and predictors of tricuspid regurgitation (TR) after permanent pacemaker (PM) implantations have not been well evaluated. We attempted to determine TR's natural course and predictors, especially focusing on the influence of atrial fibrillation (AF)., Methods: Data from 530 patients with dual-chamber PMs were evaluated. The main study outcomes were moderate to severe TR and isolated TR (moderate to severe TR without other structural heart diseases [SHDs]) in follow-up echocardiography., Results: Over a median follow-up period of 7.6 years, moderate to severe TR developed in 14.5% patients. Of those, concomitant SHD was observed in 51.9% of patients, and 48.1% presented with isolated TR. A multivariable analysis identified the independent predictors of moderate to severe TR (diabetes mellitus [DM], chronic lung disease, preexisting mild TR, peripheral artery disease, moderate to severe aortic regurgitation, and persistent AF [PeAF]) and isolated TR (DM, preexisting mild TR, and PeAF). PeAF (n = 67, 12.6%) was an independent predictor of both moderate to severe TR (hazard ratio [HR] 2.59, 95% confidence interval [CI]: 1.22-5.51) and isolated TR (HR 4.54, 95% CI: 1.60-12.90). The patients with PeAF exhibited a higher incidence of moderate to severe TR (21.8% vs 12.9% vs 11.6% PeAF, paroxysmal AF, and without AF, respectively) and isolated TR (18.6% vs 6.6% vs 4.2%, respectively) during the follow-up., Conclusion: Moderate to severe TR after PM implantations developed with or without the influence of concomitant SHD. Patients with PeAF exhibited a higher risk of moderate to severe TR after PM implantations., (© 2018 Wiley Periodicals, Inc.)

Compared with the vast literature concerning the prevalence, pathophysiology, and outcome of left valvular disease, the data concerning tricuspid regurgitation (TR) is very limited. In this review we summarized the present data concerning these important issues. We show that TR is as prevalent as aortic stenosis in the community, with increasing prevalence with age, and much more common in women. We review the present knowledge concerning the pathogenesis of TR, focusing on functional TR. We show that functional TR is multifactorial, resulting from both RV remodeling and pulmonary hypertension, and/or atrial fibrillation resulting in right atrial dilatation. We demonstrate that RV remodeling, mostly in the mid segment, will result in tethering. On the other side, right atrial remodeling will mostly result in pure annular dilatation and loss of valvular/annular coverage reserve. Finally, due to the heterogeneous nature of TR we review the outcome data for each presentation of TR and show that in most contexts TR is associated with very poor outcome, even when adjusted for left ventricular systolic, and diastolic function, pulmonary pressure, and RV dysfunction.

Objectives: The aims of this study were to detect and quantify acute increases in tricuspid regurgitation (TR) severity following transvenous lead extraction (TLE) and to evaluate the associated risk factors., Background: Although established as a safe and effective method for lead removal, TLE is sometimes complicated by TR., Methods: In 208 consecutive patients undergoing TLE, acute changes in TR severity were assessed by transesophageal echocardiography. A significant acute TR increase (TRI) was defined as a ≥1 grade increase in TR severity and post-extraction TR severity that was moderate or greater., Results: Overall, 266 ventricular leads (mean lead age, 11.8 ± 7.3 years) were extracted from the 208 patients. A significant acute TRI was observed in 24 (11.5%) of these patients. Acute TRI was associated with longer lead implant duration, extraction of pacemaker rather than defibrillator leads, anatomic injury to the tricuspid valve (TV), and longer post-extraction hospital stays. Multivariate analysis yielded only lead implant duration as an independent predictor of TLE-related acute TRI (odds ratio: 1.05; 95% confidence interval: 1.01 to 1.11; p = 0.046). When the patients were divided into 4 subgroups according to quartiles of lead age, there was a graded elevation in the rates of acute TRI (p trend = 0.048) and TV injury (p trend = 0.009) with lead implant duration., Conclusions: Following TLE, TV damage and acute TRI were commonly detected by transesophageal echocardiography, particularly in patients with advanced lead age. Lead abandonment strategies, which prolong implantation duration of future leads requiring extraction, should consider the potential long-term deleterious impact on TV function., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: To evaluate the risk factors influencing the development of significant (moderate and severe) tricuspid regurgitation (TR), and its impact on all-cause mortality in large registry of referral centre., Methods and Results: In 1000 patients (mean age 68 ± 13 years; 50.9% male) with documented significant TR, clinical, and echocardiographic data were retrospectively analysed when the echocardiogram showed none/mild TR. Patients with congenital heart disease were excluded. The study population was divided into quartiles according to the time interval between the two echocardiograms: Group 1: ≤1.2 years, n = 251; Group 2: 1.3-4.7 years, n = 248, Group 3: 4.8-8.9 years, n = 251; Group 4: ≥9.0 years, n = 250. Baseline age [odds ratio (OR) 1.02], presence of pacemaker and defibrillator lead (OR 1.59), presence of mild (vs. none) TR (OR 8.96), reduced tricuspid annulus plane systolic excursion (OR 0.86), and tricuspid annulus dilation (OR 1.06) were independently associated with development of significant TR in a short period of time. Any valvular surgery (without concomitant tricuspid surgery) occurring between both echocardiograms was also associated with a higher risk of fast development of significant TR (OR 1.58). During a median follow-up of 2.9 years after the second echocardiogram (with significant TR), 42.1% patients died. Patients with fast development of significant TR showed worse survival than patients with slower significant TR development (log rank P = 0.001). Fast development of significant TR was independently associated with all-cause mortality (hazard ratio per preceding year of development: 0.92, confidence interval 0.90-0.94; P < 0.001)., Conclusion: By identifying patients at increased risk of developing significant TR, close echocardiographic surveillance can be indicated permitting effective therapy at an earlier stage to improve survival.

Aims: Although concomitant mitral regurgitation (MR) and tricuspid regurgitation (TR) are frequently present in patients with aortic stenosis (AS), outcome data are scarce and treatment strategies are controversial. The aim of the present study was to assess the presentation and outcome of patients with AS and coexisting MR and TR., Methods and Results: Eighty-nine consecutive patients with severe AS and at least moderate MR (72 functional and 17 degenerative) were included and followed. Seventy-five patients were symptomatic at presentation. Sixty of these had severe symptoms (New York Heart Association class ≥3). Nine additional patients had an indication for valve procedures during follow-up. However, 35 patients were managed conservatively. Isolated aortic valve intervention was performed in 29 patients (22 valve replacement and 7 transcatheter aortic valve replacement) and concomitant mitral valve surgery in 20 patients. For the assessment of outcome, overall survival (i.e. time from study entry to death from any cause) was assessed: adjusted survival was significantly higher for patients undergoing any valve procedure as compared with patients managed conservatively (P = 0.032). Surgical treatment of severe concomitant MR was associated with improved survival in an unadjusted population but did not reach statistical significance after propensity adjustment. 14 of 36 patients who had concomittant moderate-to-severe tricuspid regurgitation (TR) underwent surgery of which 7 (50 %) died within 3 months postoperatively. On the other hand, only 1 of 35 (3%) with no or mild TR undergoing surgery died within 3 months post-operatively (P < 0.001)., Conclusion: Presence of MR in patients with severe AS characterizes a high-risk population. Timely aortic valve intervention confers a survival benefit and concomitant mitral valve surgery should be considered according to operative risk. The additional presence of significant TR is associated with dismal outcomes, regardless of the treatment strategy.

Aim: Significant tricuspid regurgitation (TR) is common in heart failure (HF) and portends poor prognosis. We sought to determine whether the poor outcome results from the TR itself, or whether the TR is a surrogate marker of advanced left-sided myocardial or valvular heart disease., Methods and Results: We studied 639 patients admitted for acute HF. The relationship between TR severity and the endpoint of readmission for HF or mortality was assessed after adjustment for multiple clinical and echocardiographic parameters. Higher TR grade was associated with higher congestion score and with other cardiac abnormalities including reduced left ventricular systolic function, moderate or severe mitral regurgitation, pulmonary hypertension (PH, defined as pulmonary artery systolic pressure ≥ 50 mmHg), and right ventricular dysfunction (all P < 0.001). Only 7% of patients with moderate or severe TR were free of other cardiac lesions. In adjusted models, moderate or severe TR was not associated with readmission for HF or mortality [hazard ratio (HR) 1.24, 95% confidence interval (95% CI) 0.97-1.57]. Patients with moderate/severe TR had similar risk for HF readmission or death compared with patients with trivial/mild TR when PH was not present (HR 1.17; 95% CI 0.78-1.75, P = 0.40) whereas the risk was higher in moderate/severe TR and PH (HR 1.78; 95% CI 1.34-2.36, P < 0.0001)., Conclusion: Patients presenting with symptomatic HF and significant TR have multiple coexisting cardiac abnormalities. TR provides no additive risk in the presence of normal or mildly elevated pulmonary pressures. However, it is associated with excess rehospitalizations and mortality in patients with PH.

Background: Cardiopulmonary disease is a major cause of morbidity and mortality in persons with sickle cell disease (SCD). Tricuspid regurgitant jet velocity (TRJV) and predicted forced expiratory volume in 1 s (FEV1%) predicted are independently associated with death in SCD. The goal of this study was to determine the prevalence of elevated TRJV and the association, if any, between TRJV and FEV1% predicted among persons with sickle cell anaemia (SCA) in Nigeria., Methods: Using a cross-sectional design, we enrolled 100 adult Nigerians (≥15 y) with SCA. We screened participants using Doppler echocardiogram to determine their TRJV and assessed their lung function with spirometry., Results: The prevalence of elevated TRJV was 6%, with 74% of participants having low FEV1% predicted (<70%). TRJV was negatively correlated with FEV1%, but this finding was not statistically significant (Spearman's ρ=-0.0263, p=0.8058)., Conclusions: We found a low prevalence of elevated TRJV and a trend in association between TRJV and FEV1% predicted in Nigerian adults with SCA. Our findings underscore the need to explore further the relationship between SCD and cardiopulmonary disease in adults.

Background: Transthoracic echocardiography (TTE) is used to estimate pulmonary artery systolic pressure, but an adequate tricuspid regurgitation velocity (TRV) needed to calculate pulmonary artery systolic pressure is not always present. It is unknown whether the absence of a measurable TRV signifies normal pulmonary artery pressure., Methods and Results: We extracted hemodynamic, TTE, and clinical data from Vanderbilt's deidentified electronic medical record in all patients referred for right heart catheterization between 1998 and 2014. Pulmonary hypertension (PH) was defined as mean pulmonary artery pressure ≥25 mm Hg. We examined the prevalence and clinical correlates of PH in patients without a reported TRV. We identified 1262 patients with a TTE within 2 days of right heart catheterization. In total, 803/1262 (64%) had a reported TRV, whereas 459 (36%) had no reported TRV. Invasively confirmed PH was present in 47% of patients without a reported TRV versus 68% in those with a reported TRV ( P <0.001). Absence of a TRV yielded a negative predictive value for excluding PH of 53%. Right ventricular dysfunction, left atrial dimension, elevated body mass index, higher brain natriuretic peptide, diabetes mellitus, and heart failure were independently associated with PH among patients without a reported TRV., Conclusions: PH is present in almost half of patients without a measurable TRV who are referred for both TTE and right heart catheterization. Clinical and echocardiographic features of left heart disease are associated with invasively confirmed PH in subjects without a reported TRV. Clinicians should use caution when making assumptions about PH status in the absence of a measurable TRV on TTE., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Aims: Conduction abnormalities (CA), in particular complete atrioventricular block (CAVB), requiring permanent pacemaker (PPM) implantation, are frequent complications after transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis (AS). However, the potential mechanisms are still incompletely understood. The objective of this retrospective study was to determine further predictors of CAVB after TAVI in patients without the known predictors., Methods and Results: This study included patients without prior CA/PPM who underwent TAVI of a balloon-expandable valve (Sapien or Sapien XT or Sapien 3). Of 563 patients (81.2 ± 6.9 years, 245 men [43.5%], logistic EuroSCORE 22.2 ± 14.1%, STS PROM 5.9 [3.4-8.0]) who were treated by TAVI at our institution between July 2008 and January 2016, 61 (10.8%) developed a permanent CAVB after the procedure. In a multivariable logistic regression analysis moderate/severe tricuspid regurgitation (TR) (OR 2.05; 95% CI 1.18-3.55; p = 0.010) was identified as an independent predictor for new CAVB after TAVI. Moreover, patients with more pronounced TR presented with increased left and right ventricular overload (left ventricular (LV) end-diastolic diameter, LV end-diastolic pressure), pulmonary pressures, NT-proBNP, and prevalence of mitral regurgitation ≥II, whereas LV ejection fraction, TAPSE and cardiac output were decreased., Conclusions: PPM implantation is a frequent complication in patients undergoing TAVI. Increasing severity of TR seems to be a consequence of left and right ventricular overload caused by severe AS and is a significant predictor of new CAVB after TAVI., Condensed Abstract: Conduction abnormalities (CA) requiring permanent pacemaker (PPM) implantation, are frequent complications after transcatheter aortic valve implantation (TAVI). This study included patients without prior CA/PPM who underwent TAVI. Of 563 patients 61 (10.8%) developed a permanent CAVB after the procedure. In a multivariable logistic regression analysis moderate/severe tricuspid regurgitation (TR) (OR 2.05; 95% CI 1.18-3.55; p = 0.010) was identified as an independent predictor for new CAVB. Therefore, in patients with moderate/severe TR utmost care should be taken to avoid procedural factors conducive to mechanical irritation of the conduction system, resulting in pacemaker dependency., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Heart valve surgery guidelines suggest that tricuspid valve annuloplasty may be beneficial in patients with a tricuspid annulus (TA) ≥40 mm even in the absence of functional tricuspid regurgitation (TR) at the time of surgery for left-sided valve lesions (class 2a). Given the broad spectrum of degenerative diseases that affect the atrioventricular valves, we hypothesize that this measurement might not be predictive of TR after mitral valve (MV) repair., Methods: The diameter of the TA was measured preoperatively in a cohort of 312 consecutive patients who had isolated MV repair for degenerative diseases. The mean TA diameter was 36 mm (95% confidence interval [CI], 35-37 mm). TA ≥40 mm was present in 80 patients. The median duration of echocardiographic follow-up was 6.7 years (interquartile range, 5.4-8.4 years), and was 100% complete. The main study endpoint was postoperative TR of moderate or greater degree., Results: Thirty patients had new or persistent TR at some point during follow-up. The probability of postoperative TR at 7 years was 6.6% (95% CI, 4.6%-9.4%) for all patients, 6.8% (95% CI, 4.6%-10.4%) for TA <40 mm, and 6.0% (95% CI, 2.9%-12.2%) for TA ≥40 mm. Preoperative TA diameter was not associated with the odds of postoperative TR in either the univariable or multivariable regression models. In these analyses, preoperative TR was the strongest predictor of postoperative TR., Conclusions: TA ≥40 mm is not predictive of the development of postoperative TR after MV repair for degenerative diseases., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Aims: Severe tricuspid regurgitation (TR) is common in patients with right-sided heart failure (HF) and causes substantial morbidity and mortality. Treatment options beyond medical therapy are limited for high-risk patients. Transcatheter edge-to-edge tricuspid valve (TV) repair showed procedural safety and short-term efficacy. Impact on mid-term outcome is unclear. This dual-centre observational study evaluates the mid-term safety, efficacy and clinical outcome after edge-to-edge TV repair for severe TR in patients with HF., Methods and Results: Overall, 50 patients with right-sided HF and severe TR were treated with the transcatheter edge-to-edge repair technique; 14 patients were treated for isolated TR and 36 patients for combined mitral regurgitation (MR) and TR. At 6-month follow-up (available for 98% of patients), a persistent reduction of at least one echocardiographic TR grade was achieved in 90% of patients and New York Heart Association class improved in 79% of patients. The 6-minute walk distance increased by 44% (+84 m, P < 0.001), the median N-terminal pro-B-type natriuretic peptide decreased by 30% (from 3625 to 2526 pg/mL, P = 0.002), and the quality of life score improved by 16% (decrease of 6 points in the Minnesota Living with Heart Failure Questionnaire score, P = 0.056). The improvements were comparable in patients undergoing isolated TR or combined MR and TR treatment. During follow-up, 8 patients died, 14 were hospitalized for worsening of HF, 2 underwent TV surgery, and 2 received a second TV clip procedure., Conclusions: Transcatheter edge-to-edge TV repair for severe TR is safe and effective in reducing TR. It appears to be associated with improved clinical outcome in the majority of patients., (© 2018 The Authors. European Journal of Heart Failure © 2018 European Society of Cardiology.)

Heart-hand syndrome (HHS) is a clinically and genetically heterogeneous disorder characterized by the co-occurrence of a congenital cardiac disease and an upper limb malformation. This study revealed the clinical and epidemiological features of HHS in China. The study was based on patients with congenital upper limb malformation treated in Beijing Ji Shui Tan hospital from October 1 st , 2013 to October 1 st , 2016. We reviewed the patients' medical records and identified patients with abnormal ultrasonic cardiogram and/or electrocardiogram (ECG). A total of 1462 patients (910 male and 552 female) were identified to be treated for congenital upper limb malformation. Among them, 172 (11.8%) had abnormal ultrasonic cardiogram and/or ECG. Abnormal heart structure were discovered in 121 patients and 51 patients had abnormal ECG. The most common type of abnormal heart structure was tricuspid regurgitation (53/121, 43.8%), while the most common abnormal ECG was wave patterns (22/51, 43.1%). This hospital-based study suggests that the rate of congenital heart disease is high in patients treated for congenital upper extremity malformation in China. Surgeons and anesthetists should be aware of the comorbidity and preoperational examination of congenital heart diseases is highly needed to avoid complications during operation.

Objective: This study sought to analyze outcomes in patients with moderate-severe tricuspid regurgitation (TR) undergoing transcatheter aortic valve replacement (TAVR). The consequences of uncorrected significant TR in patients undergoing TAVR remain undefined., Methods: Between 2009 and 2014, 369 patients underwent TAVR at our institution, and 58 of these had baseline moderate-severe TR. Preoperative, 30-day, and 1-year transthoracic echocardiograms were analyzed. Predictors of persistent TR at 30 days and survival were assessed., Results: Fifty-eight patients with baseline moderate-severe TR underwent TAVR. Transcatheter aortic valve replacement resulted in significant reductions in pulmonary artery pressures and TR severity (100% vs 64%; P < 0.001) at 30 days. This was sustained at 1 year and was associated with significant improvements in stroke volume index and New York Heart Association functional class. No changes in right ventricular function or size were noted. The only independent predictor of persistent moderate-severe TR at 30 days was preoperative atrial fibrillation [AF; odds ratio (OR), 4.56; 95% confidence interval, 1.1-18.3; P = 0.033]. Independent predictors of overall long-term survival included AF (OR, 0.41; P = 0.001) and chronic lung disease (OR, 0.47; P = 0.011), but not baseline moderate-severe TR. In patients with baseline moderate-severe TR, persistent moderate-severe TR at 30 days was associated with worsened overall survival (log-rank P = 0.02)., Conclusions: Baseline moderate-severe TR is not uncommon in patients undergoing TAVR, and frequently improves. However, the presence of AF suggests that that TR is likely to persist after TAVR and is also indicative of a poor long-term outcome. Whether redirecting such patients to surgery for concomitant tricuspid valve repair will further improve outcomes requires further study.

Aims: Pulmonary hypertension (PH) is common in severe symptomatic left-sided valvular disease, particularly in aging populations. Inconsistent results have been reported concerning the association between PH and adverse outcomes after aortic valve replacement for aortic stenosis (AS). We therefore retrospectively investigated the prognostic significance of PH using peak tricuspid regurgitation velocity (TRV), as defined by the current European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines, in a large cohort of patients with severe AS., Methods and Results: One thousand and nineteen patients (541 men; mean age 74 ± 11 years) with severe AS (aortic valve area (AVA) <1 cm2 and/or indexed AVA <0.6 cm2/m2 of body surface area) and LV ejection fraction ≥50% were included. Patients were divided into three groups according to the level of their peak TRV at the time of enrolment: Group 1 (n = 695, 68%) when TRV was ≤2.8 m/s; Group 2 (n = 212, 21%) when TRV was between 2.9 m/s and 3.4 m/s and Group 3 (n = 112, 11%) when TRV was > 3.4 m/s. Median overall follow-up was 31 [6-182] months. On univariate analysis, overall mortality during follow-up was globally different between groups (P < 0.001). On multivariate analysis, Group 3 (TRV >3.4 m/s) exhibited significant excess mortality after adjustment for covariates of prognostic importance (P = 0.032) and after further adjustment for surgery (P = 0.012), using Group 1 as the reference group. Dividing the whole population into two groups with a 3.4 m/s TRV threshold, overall mortality during follow-up was higher in the PH group [hazard ratio (HR) 1.87; 95% confidence interval [1.37-2.56]; P < 0.001)]. On multivariate analysis, after covariate adjustment, including surgery, Group 3 exhibited major excess mortality (adjusted HR 1.46 [1.10-1.95], P = 0.009)., Conclusion: This study demonstrates the negative impact of pulmonary pressure, as assessed by current ESC/ERS guidelines, on long-term outcome of patients with severe AS, irrespective of functional status, chronic obstructive pulmonary disease, AS severity and surgery. Baseline TRV should therefore be taken into account in the management of severe AS.

Background: We investigated the prevalence and prognostic significance of functional mitral regurgitation (MR) and tricuspid regurgitation (TR) in patients with atrial fibrillation (AF) and preserved left ventricular ejection fraction (LVEF).Methods and Results:We retrospectively studied the cases of 11,021 consecutive patients who had undergone transthoracic echocardiography. AF appeared in 1,194 patients, and we selected 298 with AF and LVEF ≥50% but without other underlying heart diseases. Moderate or greater (significant) degree of functional MR and of TR was seen in 24 (8.1%) and in 44 (15%) patients, respectively (P=0.0045). In contrast, significant MR and TR were more frequently seen in patients with AF duration >10 years (28% vs. 25%, respectively). During the follow-up period of 24±17 months, 35 patients (12%) met the composite endpoint defined as cardiac death, admission due to heart failure, or mitral and/or tricuspid valve surgery. On Cox proportional hazard ratio analysis, both MR and TR grading predicted the endpoint, independently of other echocardiographic parameters. On Kaplan-Meyer analysis, presence of both significant functional MR and TR was associated with poor prognosis, with an event-free rate of only 21% at the mean follow-up period of 24 months., Conclusions: Significant functional MR and TR are seen in a substantial proportion of patients with longstanding AF, despite preserved LVEF. This MR/TR combination predicts poor outcome for AF patients, who may have to be treated more intensively.

Introduction: Tricuspid valve regurgitation (TR) is a frequent finding in patients with pulmonary arterial hypertension (PAH). However, its prognostic significance and relation to PAH, while suspected, are poorly understood. We assessed 727 consecutive patients with newly diagnosed PAH who underwent transthoracic echocardiographic evaluation of tricuspid valve function., Objectives: The study objective was to determine the association of TR presence and severity with patient characteristics, pulmonary artery hemodynamics and outcome., Methods: Consecutive patients with newly diagnosed PAH (N = 727 with group 1 pulmonary hypertension) underwent transthoracic echocardiographic evaluation of tricuspid valve function at diagnosis. The primary study end point was all-cause mortality or lung transplantation., Results: In this population, 702 patients (96.5%) had TR; in 165 patients (23%), TR was severe. Compared with those with no or mild TR by echocardiography criteria, patients with severe TR had shorter mean (SD) 6-minute walk distances (285 [125] m vs 360 [121] m; P = .02) and higher levels of B-type natriuretic peptide (695 [672] pg/dL vs 328 [300] pg/dL; P < .05). Severe TR was associated with greater right atrial dilatation (91% vs 47%; P = .004) and right ventricular (RV) dilatation (92% vs 51%; P = .008), greater right atrial pressure (mean [SD] 15 [7] mm Hg vs 10 [6] mm Hg; P < .001) and lower cardiac index (mean [SD], 2.2 [0.7] L/min/m2 vs 2.8 [0.9] L/min/m2; P < .001). Severe TR was strongly predictive of greater 5-year mortality risk after adjustment for age, sex, functional class, 6-minute walk distance, diffusing capacity, RV size and pulmonary vascular resistance index (adjusted hazard ratio, 1.83; 95% CI, 1.38-2.41; P < .001)., Conclusions: Severe TR was a significant predictor of long-term mortality rate in PAH, and TR severity correlated with PAH severity., (© 2017 John Wiley & Sons Ltd.)

Evaluation of antiphospholipid antibodies (aPL) and correlation with heart valve abnormalities among patients with systemic lupus erythematosus (SLE). Nested case-control study was conducted with 70 patients with SLE selected from a longitudinal database based on levels of aPL and presence or absence of valve disease by echocardiogram. Valvular abnormalities observed were regurgitation (52), other (14), artificial valves (4), stenosis (2), thickening (2) and no Libman-Sacks endocarditis (0). The mitral valve was the most commonly affected (30 abnormalities), followed by the tricuspid (20 abnormalities). Multivariate logistic regression for those with and without an aPL value ≥20 units/mL, adjusted for disease duration and age, showed significant differences for any valve abnormality (odds ratio [OR] = 3.1; 95% CI: 1.0-8.9; P = 0.041) and individually for the tricuspid valve (OR = 3.3; 95% CI: 1.0-11.1; P = 0.052) but not for the mitral valve (OR = 2.1; 95% CI: 0.68-6.45; P = 0.195). Levels of aPL ≥20 units/mL showed no association with aortic (P = 0.253), pulmonic (P = 1.000), tricuspid (P = 0.127), or mitral (P = 0.249) valve abnormalities. Levels of aPL correlate with certain valvular abnormalities among patients with SLE., (Copyright © 2018 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Objectives: Tricuspid regurgitation (TR) is common in patients referred for cardiac assessment. Nonetheless, current estimates of its prevalence and contributing factors are limited. The aim of the present study was to evaluate the prevalence and demographics of TR in patients referred for echocardiography assessment at two University-affiliated hospitals., Methods: A total of 6711 consecutive Chinese patients were recruited as part of the Chinese Valvular Heart Disease Study (CVATS)., Results: The most common valvular lesion was TR (54.7%), followed by mitral regurgitation (44.7%) and aortic regurgitation (26.5%). Clinically significant (moderate or severe) TR was identified in 8.4% with the proportion increased from 3.9% amongst those aged <51 to 15.9% in those aged ≥81. Multivariable adjustment demonstrated that significant TR was associated with age, congenital heart disease, chronic obstructive pulmonary disease, left-sided valvular heart disease (VHD), impaired left ventricular ejection fraction <50%, atrial fibrillation and pulmonary hypertension., Conclusions: Among all types of VHD, TR was the most common and was identified in over half of the subjects and clinically significant in 8.4%. These unique data provide contemporary clinical and epidemiological characteristics of TR in a large cohort of patients referred for cardiac assessment and confirm the increased burden of TR in the aged population.

Tricuspid regurgitation (TR) is a very frequent manifestation of valvular heart disease. It may be due to the primary involvement of the valve or secondary to pulmonary hypertension or to the left-sided heart valve disease (most commonly rheumatic and involving the mitral valve). The pathophysiology of secondary TR is complex and is intrinsically connected to the anatomy and function of the right ventricle. A systematic multimodality approach to diagnosis and assessment (based not only on the severity of the TR but also on the assessment of annular size, RV function and degree of pulmonary hypertension) is, therefore, essential. Once considered non-important, treatment of secondary TR is currently viewed as an essential concomitant procedure at the time of mitral (and, less frequently, aortic valve) surgery. Although the indications for surgical management of severe TR are now generally accepted (Class I), controversy persists concerning the role of intervention for moderate TR. However, there is a trend for intervention in this setting, especially at the time of surgery for left-sided heart valve disease and/or in patients with significant tricuspid annular dilatation (Class IIa). Currently, surgery remains the best approach for the interventional treatment of TR. Percutaneous tricuspid valve intervention (both repair and replacement) is still in its infancy but may become a reliable option in future, especially for high-risk patients with isolated primary TR or with secondary TR related to advanced left-sided heart valve disease., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: This study aimed to assess the fate of tricuspid regurgitation (TR) after transcatheter atrial septal defect (ASD) closure., Background: Although TR frequently occurs in patients with ASD, the change in TR during long-term follow-up after ASD closure remains unknown., Methods: A total of 419 adult patients who underwent transcatheter ASD closure were enrolled. TR severity was graded by TR jet area on echocardiography., Results: At baseline, 113 patients had severe/moderate TR and 306 patients had mild TR. Among the 113 patients with severe/moderate TR, the TR jet area significantly decreased during a median follow-up of 30 months after the procedure; this decrease was related to the improvement in right ventricular morphology. The severity of TR decreased to mild in 79 (70%) patients. Persistent TR, defined as severe or moderate TR after the procedure, was independently associated with the prevalence of permanent atrial fibrillation. Regarding clinical outcomes, 7 patients with severe/moderate TR and 2 with mild TR were hospitalized because of heart failure. Patients with severe/moderate TR had the worse event-free survival rate than those with mild TR, but more than 90% of them had no cardiovascular events. New York Heart Association functional class and plasma B-type natriuretic peptide levels improved in patients with severe/moderate TR, similar to those with mild TR., Conclusions: Significant TR decreased during the long-term follow-up period after transcatheter ASD closure. Heart failure symptoms improved in patients with severe/moderate TR. Our findings suggest that transcatheter closure alone can be valuable in patients with ASD complicated with TR., (Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Tricuspid regurgitation (TR) is commonly encountered in the management of patients with a variety of cardiovascular diseases. Primary TR is the result of structural abnormalities of the valve or chordal attachments whereas functional TR results from alterations in right ventricular (RV) or right atrial (RA) size, shape or function. The vast majority of TR cases seen in practice are functional in nature and usually results from left-sided heart disease (e.g., mitral valve disease, left ventricular (LV) systolic dysfunction) and/or pulmonary vascular disease, though it also manifests in the presence of isolated chronic atrial fibrillation (AF). The relationships among the tricuspid leaflets, annulus, chordal attachments and papillary muscles are critical to normal valve function. Disruption of these interactions through annular dilation and apical displacement of the papillary muscles underlies the pathophysiology of functional TR. Two-dimensional transthoracic echocardiography (2D-TTE) is the primary modality used to assess TR. In situations where 2D-TEE is limited, 3D-TTE and transesophageal echocardiography (TEE), multidetector computed tomography (CT) and cardiac magnetic resonance imaging (MRI) can provide additional information. Classification schemes have been proposed that focus not only on the severity of TR, but also on annular dilation and the mode of leaflet coaptation. Despite often being referred to as the "forgotten valve," there is increasing evidence that functional TR is prognostically significant and may warrant intervention. Appropriate patient selection for and timing of intervention are important clinical tasks that require a comprehensive understanding of the pathophysiology and natural history of functional TR.

Organ damage in sickle cell disease (SCD) is a crucial determinant for disease severity and prognosis. In a previous study, we analyzed the prevalence of SCD-related organ damage and complications in adult sickle cell patients. We now describe a seven-year follow-up of this cohort.All patients from the primary analysis in 2006 (n = 104), were included for follow-up. Patients were screened for SCD-related organ damage and complications (microalbuminuria, renal failure, elevated tricuspid regurgitation flow velocity (TRV) (≥2.5 m/seconds), retinopathy, iron overload, cholelithiasis, avascular osteonecrosis, leg ulcers, acute chest syndrome (ACS), stroke, priapism and admissions for vaso-occlusive crises (VOC) biannually. Upon 7 years of follow-up, progression in the prevalence of avascular osteonecrosis (from 12.5% to 20.4%), renal failure (from 6.7% to 23.4%), retinopathy (from 39.7% to 53.8%) was observed in the whole group. In HbSS/HbSβ 0 -thal patients also progression in microalbuminuria (from 34% to 45%) and elevated TRV (from 40% to 48%) was observed while hardly any progression in the prevalence of cholelithiasis, priapism, stroke or chronic ulcers was seen. The proportion of patients with at least one episode of ACS increased in the group of HbSS/HbSβ 0 -thal patients from 32% to 49.1%. In conclusion, 62% of the sickle cell patients in this prospective cohort study developed a new SCD-related complication in a comprehensive care setting within 7 years of follow-up. Although the hospital admission rate for VOC remained stable, multiple forms of organ damage increased substantially. These observations underline the need for continued screening for organ damage in all adult patients with SCD., (© 2017 Wiley Periodicals, Inc.)

Background: Little is known on the clinical course of tricuspid regurgitation (TR) in patients with repaired tetralogy of Fallot (rTOF) and which patients are at particular risk. This study aims to determine TR course, characteristics associated with TR progression, and the prognostic relevance of TR in rTOF patients., Methods: In this dualcenter cohort study, rTOF patients from a prospective national registry with ≥1 cardiac magnetic resonance imaging study and ≥2 echocardiograms available were included. Clinical and imaging data were collected. Cox hazards regression analysis was used to assess patient characteristics associated with progression to severe TR and whether severe TR was associated with the combined clinical endpoint of tachyarrhythmia, heart failure, and death, as time-dependent factor., Results: A total of 216 patients were included (57% men, age 34±12years); 11 patients (5%) had severe TR at baseline. During 7.6±3.5years of follow-up, progression to severe TR occurred in 15 patients (7%). NYHA class ≥2 (HR 5.38, 95%-C.I. 1.91-15.16, p=0.001) and moderate baseline TR (HR 13.10, 95%-C.I. 2.95-58.21, p=0.001) were independently associated with progression to severe TR. Adverse events occurred in 47 patients (22%). The occurrence of severe TR was independently associated with adverse events (HR 3.48, 95%-C.I. 1.68-7.21, p=0.001)., Conclusions: In this study, severe TR was present in 12% of adult rTOF patients during 7.6years, and progression to severe TR was most likely in symptomatic patients with moderate baseline TR. In these patients, close surveillance is warranted, because the occurrence of severe TR was associated with worse prognosis., (Copyright © 2017 Elsevier B.V. All rights reserved.)

The tricuspid valve was virtually ignored for a long time in the past. However, significant tricuspid regurgitation (TR) often accompanies left-side heart valve pathology and does not always reverse with its correction. If left untreated, TR can progress and result in progressive right ventricular failure. Current guideline recommendations still hold minor differences. Nevertheless, there is a consensus to operate on patients with severe TR undergoing left-sided valve surgery (class I) or those with mild to moderate TR with a dilated annulus (≥40 or ≥21 mm 2 , Class IIa). However, in case of the primary TR, surgical options is limited by a relatively high risk of mortality and morbidity. For these patients, new percutaneous approaches are becoming available but no long-term data are still available. In this review, we provide a comprehensive overview of the epidemiological and pathophysiological aspects of TR, and the current and future directions of therapy., (© 2017 American Heart Association, Inc.)

Objective: To determine the incidence and effects of tricuspid regurgitation (TR) after surgery for mitral valve (MV) repair for mitral regurgitation (MR) due to degenerative disease., Patients and Methods: We examined 1171 patients who had MV repair and were followed prospectively with periodical clinical and echocardiographic assessments during a mean of 9.1 ± 5.3 years. Patients' mean age was 58.2 ± 12.7 years, and 70.5% were men. Preoperatively, 44.6% were in functional classes III and IV, 20.1% had atrial fibrillation, and 34.2% had ejection fraction <60%. In addition to MV repair, 13.8% had coronary artery bypass, 11.4% had the maze procedure, and 4.7% had tricuspid annuloplasty., Results: Moderate and severe TR was present in 138 patients before surgery and associated with older age, preoperative atrial fibrillation, preoperative congestive heart failure, congenital heart septal defects, lower preoperative left ventricular ejection fraction, and female sex by multivariable analysis. TR resolved postoperatively but recurrent or new isolated TR occurred in 45 patients postoperatively (13.6% at 15 years in all patients). Factors associated with isolated postoperative TR by multivariable analysis included older age at operation, unrepaired preoperative moderate/severe TR, and the development of postoperative MR. Patients with preoperative TR had reduced long-term survival and tricuspid annuloplasty did not restore lifespan., Conclusions: Preoperative TR in patients with MR due to degenerative diseases was associated with longstanding MV disease and adversely affected long-term survival after MV repair. New postoperative TR was uncommon. The findings of this study are compelling reasons to repair the MV before the development of TR., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: In severe right heart obstruction (RHO), redistribution of cardiac output to the left ventricle (LV) is well tolerated by the fetal circulation. Although the same should be true of severely regurgitant tricuspid valve disease (rTVD) with reduced or no output from the right ventricle, affected fetuses more frequently develop hydrops or suffer intrauterine demise. We hypothesized that right atrium (RA) function is altered in rTVD but not in RHO, which could contribute to differences in outcomes., Methods: Multi-institutional retrospective review of fetal echocardiograms performed over a 10-year period on fetuses with rTVD (Ebstein's anomaly, tricuspid valve dysplasia) or RHO (pulmonary atresia/intact ventricular septum, tricuspid atresia) and a healthy fetal control group. Offline velocity vector imaging and Doppler measurements of RA size and function and LV function were made., Results: Thirty-four fetuses with rTVD, 40 with RHO, and 79 controls were compared. The rTVD fetuses had the largest RA size and lowest RA expansion index, fractional area of change, and RA indexed filling and emptying rates compared with fetuses with RHO and controls. The rTVD fetuses had the shortest LV ejection time and increased Tei index with a normal LV ejection fraction. RA dilation (odds ratio, 1.27; 95% CI, 1.05-1.54) and reduced indexed emptying rate (odds ratio, 2.49; 95% CI, 1.07-5.81) were associated with fetal or neonatal demise., Conclusions: Fetal rTVD is characterized by more severe RA dilation and dysfunction compared with fetal RHO and control groups. RA dysfunction may be an important contributor to reduced ventricular filling and output, potentially playing a critical role in the worsened outcomes observed in fetal rTVD., (Copyright © 2017 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Purpose: Although cavotricuspid isthmus-dependent atrial flutter (CTI-AFL) ablation is a highly efficacious treatment, a bidirectional CTI block cannot be achieved in some patients. In this study, we sought to determine the predictors of acute inefficacy of CTI-AFL ablation and the predictors of the radiofrequency (RF) energy time required to achieve a complete bidirectional CTI block., Methods: All consecutive patients who underwent stand-alone CTI-AFL ablation in our institution, except patients with congenital heart disease, were included in this retrospective study. Clinical, echocardiographic, and ablation data were collected from the Arrhythmia Unit and Imaging Unit databases and medical charts., Results: Three hundred and fifty-five patients, with a mean age 63 ± 12 years, were included. The ablation was acutely inefficacious in 30 patients (9%). Tricuspid regurgitation was the only independent predictor of acute inefficacy of CTI-AFL ablation (OR 3.161, 95% CI 1.084-9.220, p = 0.035) and was associated with a longer RF time required to achieve CTI bidirectional block (p = 0.031). Age was inversely correlated with the RF time required to achieve a bidirectional CTI block (r = -0.133, p = 0.025). A previous CTI RF ablation, chronic obstructive pulmonary disease (COPD), the use of an irrigated catheter, and advanced age were the independent predictors for requiring less RF energy time to achieve a bidirectional CTI block., Conclusions: Tricuspid regurgitation is associated with less acute efficacy in CTI-AFL ablation. Prior CTI ablation, COPD, use of an irrigated catheter, and advanced age are independent predictors for needing less RF energy time to achieve a complete bidirectional CTI block.

Objectives: The objective of this study was to examine the effect of laser lead extraction (LLE) on the development of post-procedural tricuspid regurgitation (TR). Some reports have suggested an increase in TR associated with LLE. We present a series of patients who underwent both, LLE and complete echocardiographic evaluation for TR., Methods: A single centre analysis of consecutive patients referred for LLE between January 2012 and August 2015. One hundred and three patients had tricuspid valve function evaluated before the procedure with a transthoracic echocardiography (TTE), during the procedure using transoesophageal echocardiography and postoperatively using a TTE. TR was graded from 0 (none) to 4 (severe)., Results: We treated 235 leads in 103 patients, including 118 ventricular leads. Seventy-seven were male (74.8%) and 26 female (25.2%), with a mean age of 65.6 ± 15.4 years. Mean time from initial lead implantation was 98.0 ± 67.3 months. Twenty-one patients (20.4%) had ejection fraction below 30%. No intra-procedural worsening of tricuspid valve function was seen with TEE in any of the patients. Ten patients (9.7%) were found to have TR before LLE that returned to normal valve function after the procedure. Two patients (1.9%) experienced mild TR after the procedure (both with tricuspid valve endocarditis). Ninety-one patients (88.3%) did not experience any significant change of the tricuspid valve function after LLE., Conclusion: Transthoracic and transoesophageal echocardiography findings showed that laser lead extraction was not associated with a significant increase in the incidence of tricuspid valve regurgitation., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The aims of this study are to evaluate the long-term outcomes of double valve replacement (aortic and mitral valves) and to investigate the determinants of late tricuspid regurgitation (TR). A total of 239 consecutive patients who underwent double valve replacement were enrolled. Valve pathology was rheumatic in 86.6% (207/239) and degenerative in 13.4% (32/239) of patients. Among these patients, 116 patients underwent concomitant tricuspid annuloplasty, and follow-up was completed for all 239 patients (mean = 7.3 ± 4.1, maximum = 15.9 years). We used propensity score matching to match 67 patients without tricuspid annuloplasty to the 114 patients who underwent annuloplasty. There was 1 in-hospital death and 9.7% (23/238) of patients experienced late cardiac-related mortality. Analysis of aortic valves indicated that the transprosthetic mean pressure gradient increased with time (13.4 ± 5.2 vs 15.4 ± 9.0 mm Hg, p = 0.002). Aortic transprosthetic mean pressure gradient increased more notably in woman and was associated with late TR (odds ratio 1.1, p = 0.010). In patients with mild TR, those who underwent tricuspid valve repair were less likely to experience a cardiac-related death within 10 years of surgery (hazards ratio 6.1, p = 0.036)., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Sickle cell anemia (SCA) is the commonest hemoglobinopathy and is associated with high morbidity and mortality. Pulmonary hypertension (PH) is reported to play a significant role in this regard. There is very limited literature on PH in SCA in Nigeria., Objectives: The objectives of this study were to determine the prevalence of Doppler-derived PH in SCA, assess its influence on exercise capacity, and determine the correlates and predictors of measures of estimated pulmonary pressure., Methods: A total of 92 SCA subjects had echocardiography and 6-minute self-paced walking exercise. PH was diagnosed by Doppler echocardiography on finding a tricuspid regurgitant velocity (TRV) of ≥2.5 m/s. The pulmonary flow profile was also assessed to estimate mean pulmonary arterial pressure (MPAP)., Results: Doppler-derived PH was detected in 23.9% of adults with SCA. The 6-minute walking distance (6MWD) was significantly lower in SCA adults with PH than in those without PH (380.33 ± 63.17 m vs 474.28 ± 76.74 m; p = 0.014). TRV and estimated MPAP had a significant inverse correlation with the 6MWD ( r = -0.442; p < 0.001 and r = -0.571; p < 0.001, respectively)., Conclusion: PH as derived by Doppler is common in Nigerian adults with SCA and has a significantly negative influence on exercise capacity. Screening for PH should be encouraged to optimize management and thus improve their quality of life and life expectancy., Competing Interests: Disclosure The authors report no conflicts of interest in this work.