309 Upgrading from a dual-chamber pacemaker to a cardiac resynchronization therapy defibrillator in situs inversus totalis with dextrocardia following mitral valve replacement and tricuspid annuloplasty using a left-sided approach

A 71-year-old female patient was referred to our centre to upgrade a dual-chamber pacemaker to a cardiac resynchronization therapy defibrillator (CRT-D) following the detection of worsened systolic function (ejection fraction: 25–30%) via transthoracic echocardiography. The patient had situs inversus totalis with dextrocardia. She had undergone mitral valve replacement and tricuspid annuloplasty in July 2019, with a concomitant left upper pulmonary lobectomy for neoplasm, detected at cardiac tomography incidentally. In January 2020, we performed an upgrade of the preexisting device to a CRT-D system because the patient developed heart failure, reduction in systolic function, and numerous nonsustained ventricular tachycardias. The right ventricular lead that had been previously implanted was extracted. To facilitate the intervention, we decided to flip the fluoroscopic image, obtained with a right-anterior oblique view, by 180 °C (right–left), creating the optical impression of a levocardial position.

Transcatheter Tricuspid Valve Therapy: From Anatomy to Intervention

Nowadays, severe symptomatic tricuspid regurgitation (TR) affects millions of persons worldwide. However, the benefit of surgical correction of isolated secondary TR remains controversial because of the increased risk of periprocedural mortality and morbidity. In recent years, novel transcatheter tricuspid valve interventions (TTVI) were developed to treat TR, so that TTVI is currently considered in symptomatic, inoperable, anatomically eligible patients. TTVI can be divided into these five domains: edge-to-edge leaflet repair, tricuspid annuloplasty, caval implants, spacer, and total valve replacement. Each transcatheter intervention needs specific imaging protocols for assessing the anatomical feasibility and consequentially predicting the procedural success. This review summarizes the available multimodality imaging tools for screening patients with TR, and identifies anatomical characteristics to choose the best option for the patient.

Impact of tricuspid repair on surgical death in patients undergoing mitral valve surgery due to rheumatic disease

Introduction Observational studies differ on the impact of performing tricuspid repair on surgical mortality. Some studies demonstrate increased surgical mortality related to right ventricular failure and circulatory shock, while there are other studies that evidence improvement in quality of life and signs of right heart failure in the long time. Objective To evaluate the impact on surgical mortality of concomitant tricuspid annuloplasty in patients undergoing cardiac surgery for rheumatic mitral valve disease, who have moderate to severe tricuspid regurgitation. Methods This is a prospective cohort from January 1, 2017 to December 30, 2020. All patients over 18 years of age who underwent cardiac surgery to correct rheumatic mitral valve disease with moderate to significant tricuspid regurgitation were included. The primary outcome was 30-days mortality. Results 165 patients were included, 98 (59.4%) underwent tricuspid valve annuloplasty. The mean age was 46, 5 (±12) years, the median of Euroscore II was 2,33%. The 30-days mortality was 17 (10.3%) and there was no difference between the groups submitted or not to tricuspid repair: 12 (12.2%) versus 5 (7.5%); p=0.44, respectively. In the multivariate analysis involving seven variables with a potential prediction of death in 30 days, tricuspid repair had no association with death, RR 2,4 (0,5 – 8,3); p=0.27. Conclusion In patients with rheumatic heart disease undergoing cardiac surgery for rheumatic mitral valve disease, perform tricuspid annuloplasty in individuals who had moderate to severe tricuspid insufficiency was not associated with increased surgical mortality. FUNDunding Acknowledgement Type of funding sources: None.

Effects of a diuretic regimen on body weight and echocardiographic parameters of the tricuspid valve in patients scheduled for transcatheter tricuspid annuloplasty

Background Echocardiographic severity of tricuspid regurgitation is known to be highly variable and strongly related to the volume status of the individual patient. Interventional therapies for tricuspid valve repair or replacement are dependent on reliable measurements in order to select the appropriate device size. Purpose In patients scheduled for transcatheter tricuspid valve annuloplasty, we sought to evaluate the effects of a diuretic regimen started at the screening visit on body weight and tricuspid valve dimensions at the time point of transcatheter intervention. Methods After successful screening for transcatheter tricuspid annuloplasty, an individualized intensified diuretic regimen was initiated in 15 patients. At baseline and at the timepoint of the intervention, body weight and 3D echocardiographic dimensions of the tricuspid valve were documented and compared. Results The cohort comprised 6 males and 9 females (mean age 77±7 years) with severe or higher degree functional tricuspid regurgitation. In all patients not more than mild pulmonary artery hypertension was present (PaP mean 29±5 mmHg). The interval between the screening visit and the timepoint of the procedure was 64±50 days. At baseline mean body weight was 72±12 kg. In 11 patients a reduction of the body weight could be achieved, with a median weight reduction of 2.2 kg (min/max 1.2/6.4 kg). Overall, the average relative reduction of the tricuspid annulur perimeter was 13% (p<0,001), of the tricuspid valve area 2.7% (n.s.), the anterseptal diameter 3.3% (n.s.), while the bicommissural diameter remained almost unchanged (0.4%; n.s.). The average predicted required band length changed by only 1.5% (n.s.). The strongest correlations were found between the absolute change in body weight and the change of the tricuspid valve area (r=0.48), relative change in body weight and relative change of tricuspid valve area (r=0.52), absolute change in body weight and absolute change in predicted band length (r=0.48), and relative changes of the respective variables (r=0.52). More importantly, in 13 out of 15 patients the band size which would have been selected was identical between the screening and the annuloplasty procedure. Only in two patients a smaller device was implanted than predicted at the screening visit. Conclusion Instituting a diuretic therapy in candidates for transcatheter tricuspid annuloplasty prior to the procedure helps to keep tricuspid valve dimensions in a stable range. Changes in body weight in patients with functional tricuspid regurgitation are correlated to changes of tricuspid valve dimensions. FUNDunding Acknowledgement Type of funding sources: None.

Tricuspid Annuloplasty: Transcatheter Approaches

Purpose of Review New transcatheter techniques to perform tricuspid annuloplasty are evolving and are introduced into the clinical routine. Yet, clinical experience is limited. Recent Findings Currently, 3 different techniques for tricuspid annuloplasty have been used in larger clinical cohorts. They can be divided into direct annuloplasty techniques and suture plication techniques. The largest clinical evidence is related to direct annuloplasty techniques. It has been shown that annular dimensions can be effectively reduced. This translates into an improvement of the degree of tricuspid regurgitation and improvement of clinical symptoms. Due to the newness of this type of therapy, long-term data is limited, but for one of the described techniques, published data show that the positive effects persist over a 2-year period. Summary Transcatheter approaches are safe and are able to treat tricuspid regurgitation effectively. There are still differences in the efficacy of the different techniques. Clinical experience varies among the different approaches.

Concomitant Tricuspid Annuloplasty in Patients Undergoing Totally Endoscopic Mitral Valve Surgery: A Propensity-Score Matched Analysis

Background: We aimed to evaluate the clinical outcomes of concomitant tricuspid annuloplasty (TAP) in patients undergoing totally endoscopic mitral valve surgery. Methods: It is a single-center, retrospective study that enrolled a total of 173 patients who underwent mitral valve surgery combined with tricuspid annuloplasty between January 2019 and June 2020 in our institution. Patients who underwent totally endoscopic mitral valve surgery with concomitant tricuspid annuloplasty were categorized into the MIMVS-TAP group (N = 51), and patients who underwent mitral valve surgery with concomitant tricuspid annuloplasty through a median sternotomy were categorized into the MVS-TAP group (N = 122). The data collected included detailed demographic and perioperative data. Each patient in the MIMVS-TAP group was individually matched to a patient in the MVS-TAP group, using the propensity scores, and we obtained a matched sample of 51 patients in each group. Parametric and nonparametric tests were used to analyze outcomes. Results: There were no differences in death rates or related major adverse events between the two groups after propensity score matched analysis. The total operation time was longer in the MIMVS + TAP group versus the MVS+TAP group, as were the mean duration of cardiopulmonary bypass time and the cross-clamp time. The mean duration of intensive care unit stay was longer in the MVS + TAP group compared with that of the MIMVS + TAP group, as was the duration of post-operative hospital stay. Conclusions: Totally endoscopic mitral valve surgery with concomitant tricuspid annuloplasty can improve a patient’s prognosis, with comparable short-term outcomes to those of the open approaches.