Infective Endocarditis Manifesting as Severe Elevation in Serum Aminotransferases in the Absence of Severe Tricuspid Regurgitation, Heart Failure, or Shock: A Diagnostic Challenge

ObjectivesA substantial number of patients with severe tricuspid regurgitation (TR) and congestive heart failure (CHF) are medically managed without undergoing corrective surgery. We sought to assess the characteristics and outcomes of CHF patients who underwent tricuspid valve surgery (TVS), compared with those who did not.MethodsRetrospective observational study involving 2556 consecutive patients with severe TR from the Cleveland Clinic Echocardiographic Database. Cardiac transplant patients or those without CHF were excluded. Survival difference between patients who were medically managed versus those who underwent TVS was compared using Kaplan-Meier survival curves. Multivariate analysis was performed to identify variables associated with poor outcomes.ResultsAmong a total of 534 patients with severe TR and CHF, only 55 (10.3%) patients underwent TVS. Among the non-surgical patients (n=479), 30% (n=143) had an identifiable indication for TVS. At 38 months, patients who underwent TVS had better survival than those who were medically managed (62% vs 35%; p<0.001). On multivariate analysis, advancing age (HR: 1.23; 95% CI 1.12 to 1.35 per 10-year increase in age), moderate (HR: 1.39; 95% CI 1.01 to 1.90) and severe (HR: 2; 95% CI 1.40 to 2.80) right ventricular dysfunction were associated with higher mortality. TVS was associated with lower mortality (HR: 0.44; 95% CI 0.27 to 0.71).ConclusionAlthough corrective TVS is associated with better outcomes in patients with severe TR and CHF, a substantial number of them continue to be medically managed. However, since the reasons for patients not being referred to surgery could not be ascertained, further randomised studies are needed to validate our findings before clinicians can consider surgical referral for these patients.

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5940Right ventricular reverse remodeling occurs early after transcatheter tricuspid valve repair for isolated severe tricuspid regurgitation and is associated with better outcome

European Heart Journal ◽

10.1093/eurheartj/ehz746.0090 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

M Orban ◽

L Stolz ◽

D Braun ◽

T Stocker ◽

K Stark ◽

...

Keyword(s):

Heart Failure ◽

Clinical Outcome ◽

Tricuspid Valve ◽

Tricuspid Regurgitation ◽

Significant Trend ◽

Tricuspid Valve Repair ◽

Tricuspid Annulus ◽

Valve Repair ◽

Severe Tricuspid Regurgitation

Abstract Background Transcatheter edge-to-edge tricuspid valve repair (TTVR) is a novel treatment option in patients with severe tricuspid regurgitation (TR), right-sided heart failure and prohibitive surgical risk. Purpose We investigated whether RVRR can occur early after TTVR in patients with isolated TR and its potential association with clinical outcome. Method We measured right ventricular parameters by transthoracic echocardiography (TTE) at baseline (BL) in 44 consecutive patients undergoing TTVR for isolated severe TR. We obtained follow-up (FU) TTEs after 1 month. Results At BL, we observed dilated RVs with an RV end-diastolic area (RVEDA) of 28.0±8.3cm2, RV mid diameter of 40.7±7.3mm and tricuspid annulus of 47.5±8.1mm. The majority of patients (63%) showed RV systolic dysfunction with either a tricuspid annular plane excursion (TAPSE) <17mm or fractional area change (FAC) <35%. In 40 Patients (90%), a periprocedural TR reduction by at least 1 degree was achieved (p<0.01). During further clinical FU (272±183 days), 21 patients died (of whom 14 had prior hospitalizations for heart failure before death), 8 patients had hospitalizations for heart failure, 1 patient underwent heart transplantation and 1 patient was lost to clinical FU. We acquired a short-term echocardiographic follow-up (Echo-FU) after 30 days in 36 patients (82%). TR reduction was stable after 1 month with a TR grade ≤2+ in 26 of 36 patients (72%, p<0.01 vs BL). We detected RVRR in the majority of patients with 1-month Echo-FU: RVEDA decreased from 28.8±8.2 to 26.3±7.4cm2 (p<0.01), RV mid diameter from 41.2±7.3 to 38.5±7.7mm (p<0.01) and tricuspid annulus from 48.3±8.3 to 42.8±6.6mm (Figure, p<0.01). We observed a non-significant trend towards reduction of TAPSE (17.5mm to 16.1 mm, p=0.12) and FAC (37.8% to 35.5%, p=0.17), which could represent a normalization of systolic function of a previously hyperactive RV. Next, we evaluated whether RVRR is potentially associated with clinical outcome. We stratified patients into two groups with more or less than median change in RVEDA, RV mid diameter and TV annulus. Fewer combined clinical events (time to death or repeat intervention or first hospitalization for heart failure) were observed in patients with pronounced decrease of RV mid diameter (p=0.03) and TV annulus (Figure, p=0.02) at FU. A decrease of RVEDA showed a non-significant trend towards better outcome (p=0.06). Figure 1 Conclusions Our report demonstrates that RVRR occurs already 1 month after TTVR for isolated TR and is associated with less clinical endpoints.

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TCT-408 Clinical Predictors of Mortality and Heart Failure Hospitalization in Patients With Severe Tricuspid Regurgitation

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2021.09.1261 ◽

2021 ◽

Vol 78 (19) ◽

pp. B167-B168

Author(s):

Kris Kumar ◽

Timothy Byrne ◽

Timothy Simpson ◽

Ashraf Samhan ◽

Raj Shah ◽

...

Keyword(s):

Heart Failure ◽

Tricuspid Regurgitation ◽

Heart Failure Hospitalization ◽

Clinical Predictors ◽

Severe Tricuspid Regurgitation ◽

Predictors Of Mortality

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P288 Prognostic role of hemoglobin levels in patients with severe tricuspid regurgitation

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.142 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

A Garcia Martin ◽

R Hinojar ◽

A Gonzalez Gomez ◽

M Plaza Martin ◽

M Pascual Izco ◽

...

Keyword(s):

Heart Failure ◽

Iron Deficiency ◽

Ejection Fraction ◽

Tricuspid Valve ◽

Tricuspid Regurgitation ◽

Valve Surgery ◽

Therapeutic Options ◽

Severe Tricuspid Regurgitation ◽

End Point ◽

Tricuspid Valve Surgery

Abstract Background Patients with severe tricuspid regurgitation (TR) frequently develop heart failure (HF) and their surgical therapeutic options are limited because of very high or prohibitive risk. According to the 2016 ESC guidelines for HF, anaemia and iron deficiency are associated with worse prognosis and intravenous iron therapy should be considered in symptomatic patients with HF reduced ejection fraction (HFrEF) in order to alleviate symptoms, improve exercise capacity and quality of life. The effect of treating iron deficiency in HF preserved ejection fraction (HFpEF) is unknown. The purpose of this study was to analyze the correlation between levels of hemoglobin (Hb) and the prognosis in patients with severe TR and preserve EF. Methods Consecutive patients with significant TR (moderate to severe or severe by echocardiography) evaluated in the Heart Valve Clinic between 2015-2018 were included. End-point included cardiovascular mortality, tricuspid valve surgery or heart failure. Results A total of 70 patients were included (mean age was 74± 8 years, 71% females). According to aetiology, 94% were functional TR (60% due to left valve disease, 27% due to tricuspid annulus dilatation, 13% others). Mean left ventricular ejection fraction was 56,5% ±6,7%. During a median follow up of 18 months [IQR: 4-28], 35% of the patients reached the combined end-point (n = 16 developed right HF, n = 17 underwent tricuspid valve surgery, and n = 3 died). Patients with events showed lower Hb values (p = 0.04). The level of anaemia was a prognostic factor of the combined endpoint (per gr/dl, HR 0.77 [0-61-0.98], p = 0.036). Conclusion Hemoglobin is predictive of poor outcomes in patients with significant TR. According to these preliminary results, iron deficiency could be a therapeutic target in this subgroup of patients with limited therapeutic options.

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Tachycardia-Induced Right Heart Failure and Severe Tricuspid Regurgitation That Improved with Medication

Chonnam Medical Journal ◽

10.4068/cmj.2015.51.3.135 ◽

2015 ◽

Vol 51 (3) ◽

pp. 135

Author(s):

Young Ae Yang ◽

Dong Heon Yang ◽

Hong Nyun Kim ◽

Sang Hoon Kwon ◽

Se Young Jang ◽

...

Keyword(s):

Heart Failure ◽

Tricuspid Regurgitation ◽

Right Heart Failure ◽

Right Heart ◽

Severe Tricuspid Regurgitation

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Normal myocardial function in severe right ventricular volume overload hypertrophy

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.2001.280.1.h11 ◽

2001 ◽

Vol 280 (1) ◽

pp. H11-H16 ◽

Cited By ~ 10

Author(s):

Yuji Ishibashi ◽

Judith C. Rembert ◽

Blase A. Carabello ◽

Shintaro Nemoto ◽

Masayoshi Hamawaki ◽

...

Keyword(s):

Heart Failure ◽

Right Ventricular ◽

Tricuspid Regurgitation ◽

Contractile Function ◽

Right Heart Failure ◽

Ventricular Volume ◽

Left Ventricular ◽

Right Ventricular Volume ◽

Right Heart ◽

Severe Tricuspid Regurgitation

Severe left ventricular volume overloading causes myocardial and cellular contractile dysfunction. Whether this is also true for severe right ventricular volume overloading was unknown. We therefore created severe tricuspid regurgitation percutaneously in seven dogs and then observed them for 3.5–4.0 yr. All five surviving operated dogs had severe tricuspid regurgitation and right heart failure, including massive ascites, but they did not have left heart failure. Right ventricular cardiocytes were isolated from these and from normal dogs, and sarcomere mechanics were assessed via laser diffraction. Right ventricular cardiocytes from the tricuspid regurgitation dogs were 20% longer than control cells, but neither the extent (0.171 ± 0.005 μm) nor the velocity (2.92 ± 0.12 μm/s) of sarcomere shortening differed from controls (0.179 ± 0.005 μm and 3.09 ± 0.11 μm/s, respectively). Thus, despite massive tricuspid regurgitation causing overt right heart failure, intrinsic right ventricular contractile function was normal. This finding for the severely volume-overloaded right ventricle stands in distinct contrast to our finding for the left ventricle severely volume overloaded by mitral regurgitation, wherein intrinsic contractile function is depressed.

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