757 Cardio-TC role in patients selection for transcatheter edge to edge tricuspid repair

Aims Anatomic knowledge of the tricuspid valve (TV) is the first step in the management of patients with tricuspid regurgitation (TR) who are candidates for transcatheter tricuspid valve intervention (TTVI). Echocardiography is undoubtedly the first approach in assessing the aetiology and severity of TR and the size and function of the right chambers. Computed tomography (CT) provides a detailed morphological visualization of the cardiac structures owing to acquisition of 3D data with high spatial resolution. These findings may undoubtedly help in decision-making progress for novel transcatheter therapies. The purpose of the present study was to assess the geometrical changes of the TV complex using CT images, in patients suffering from functional TR and lead-induced TR. Methods The study population consisted of 21 consecutive patients with symptomatic severe TR referred to Policlinico Universitario Campus Biomedico between November 2020 and October 2021. Patients were prospectively included in the study only if they presented severe TR, diagnosed by echocardiography and underwent cardiac CT study dedicated to the right-chambers. The reconstructions were transferred to an external workstation for off-line image analysis. The following measurements were reported: tricuspid annulus area, perimeter, septal–lateral and antero-posterior diameters. Commissures were identified as antero-septal (AS), postero-septal (PS) and anteroposterior (AP). Were measured the inferior vena cava ostium to tricuspid valve centroid distance, anatomic regurgitant orifice area (AROA) and its position respect to the centroid, and the right chambers. Results All 21 patients underwent CT scan using Siemens SOMATOM Definition AS 128 Slice CT Machine. The measurements were calculated off-line using the 3mensio workstation. In our study population, the annulus resulted enlarged in the annulus area, perimeter, septal-lateral and anterior-posterior dimensions. Measurements did not differ significantly, except for the septal-lateral diameter that was smaller in systole (52.80 ± 7.28 mm vs. 47.83 ± 6.83 mm (P=0.027). Also, distances between the commissures were similar except for the AP-AS distance that was shorter in systole (45.26 ± 3.48 mm vs. 42.13 ± 3.73, P=0.007). The AROA resulted to be central in 7 patients, the IVC ostium to TV centroid distance was 23±3 mm. Right chambers and IVC resulted very enlarged in all patients. Conclusions CT provides a complete morphologic imaging of the heart structures, thanks to a high spatial resolution with excellent capacity to define the endocardial border and allows acquisition of three-dimensional data with high spatial resolution of the TV and provides valuable information about the geometric variations of the tricuspid complex in patients with TR. Image quality for analysis should be optimized with specific CT acquisition protocols that focus on the right ventricles.

181 Impact of leaflet-tethering angle correction on the assessment of tricuspid regurgitation severity using the PISA method

Aims Severe tricuspid regurgitation (TR) is associated with excess mortality and morbidity. Therefore, accurate assessment of TR severity is pivotal. In clinical routine, the calculation of the effective regurgitant orifice area (EROA) and the regurgitant volume (RVol) using flow convergence method (PISA) by echocardiography are among the recommended parameters to define TR severity. However, the distortion of the proximal convergence zone related to the extent of valve leaflet tethering may result in smaller PISA radius and in underestimation of TR severity. Correcting for the angle of the leaflet tethering could reduce errors due to geometric assumption of a flat valvular plane and improve the accuracy of the calculations. The aims of our study were: (1) to evaluate whether taking into account the extent of leaflet tethering by applying the angle correction (AC) in the PISA formula improves the accuracy of the quantitative assessment of TR severity; (2) to assess the potential clinical impact of AC. Methods and results Forty-one patients with functional TR (73.5 ± 11.8 years, 51% men, 36% sinus rhythm, 17% severe), underwent 2D and 3D echocardiography. We compared the RVol obtained by volumetric method (as reference) with the RVol by PISA with and without AC. TR RVol by volumetric method was calculated as: total RV stroke volume (RV SV)–left ventricular forward SV (LV SV), where RV SV was obtained by subtracting the end-systolic from end-diastolic RV volume measured by 3D echocardiography and LV SV was calculated by multiplying LV outflow area by velocity time integral (VTI). TR RVol by PISA was calculated as EROA × VTI TR. Uncorrected EROA was calculated using the formula: 6.28 r2 × Va/PeakV TR (r—PISA radius, Va, aliasing velocity, PeakV TR—TR peak velocity). The corrected EROA accounting for the PISA geometric distortion by leaflet tethering angle (α) was calculated as: 6.28 r2 × Va (α/180)/PeakV TR (PISAAC), where α was measured using a protractor generated by dedicated software. PISA radius and angle were 5.5 ± 1.97 mm and 211.2° ± 13.6°, respectively. Application of AC to PISA method resulted in larger EROA and RVol (0.34 ± 0.38 cm2 vs. 0.24 ± 0.24 cm2 and, 25.2 ± 19.3 ml vs. 18.6 ± 13.1 ml, respectively). The percentage change in EROAAC was over 40%. When compared to the volumetric method, RVol by corrected PISA method was significantly closer and correlated (bias −3.95 ml, LOA ± 6.41 ml, r = 0.987; P < 0.001) than the conventional PISA without AC (bias −10.5 ml, LOA ± 15 ml, r = 0.975). Angle correction resulted in a change of TR severity in 32% of cases and in a greater concordance of TR severity grade with the volumetric method (75%, 31/41 with AC vs. 52%, 22/41 without AC). Conclusions Angle-corrected PISA method that accounts for the extent of the leaflet tethering in TR provided significantly larger TR RVol that were closely correlated with the volumetric RVol by 3D echocardiography. A simple geometric angle correction of the proximal flow with PISA method reclassified up to one-third of patients with functional TR.

47 Quantified mitral regurgitation and left atrial function in HFrEF: intraplay and outcome implications

Aims The debate about the independent prognostic responsibility of functional mitral regurgitation (FMR) is still in turmoil. Growing findings about the predictive role of left atrial (LA) function are emerging in several scenarios. This study aims to define FMR linkage to cardiovascular (CV) outcomes and the interplay with LA function in a prospective cohort of consecutive heart failure patients with reduced ejection fraction (HFrEF). Methods and results 286 consecutive outpatients with chronic HFrEF were enrolled. FMR was quantified by effective regurgitant orifice area (EROA). Global peak atrial longitudinal strain (PALS) was measured by speckle tracking echocardiography (STE). The primary endpoint was defined as a composite of congestive HF hospitalization and CV death. The majority (81%) of patients were men (mean age: 67 ± 11 years, mean LVEF: 32 ± 6%). The median global PALS was 17.7% ranging from 2.7% to 49.2%. FMR was quantifiable in 240 (84%) patients. During a median follow-up period of 6.4 (IQR: 3.9–7.7) years, the primary endpoint occurred in 88 (31%) patients (35 HF admissions, and 53 deaths). EROA showed independent prediction for the primary endpoint [HR: 1.30 (1.05–1.57), P = 0.01]. The spline modelling of the risk by EROA values showed an excess event risk starting at about the EROA value of 0.1 cm2 (Figure 1). There was a remarkable graded association between the EROA strata, even if tested per 0.1 cm2 increase, and the risk of congestive HF hospitalization and CV death (P = 0.0004). Any FMR grade presenting with reduced LA function (PALS < 14%) was associated with dismal outcome (event rate of 63 ± 10% for EROA exceeding 0.3 cm2 and 49 ± 6% for EROA ≥0.1 cm2 at 5 years). Conversely, the presence of EROA ≥0.1 in the context of preserved global PALS showed a better outcome (Figure 2). 47 Figure 1 47 Figure 2 Conclusions Our results refine the independent association between FMR and CV outcome among HFrEF outpatients. The risk of CV events starts at a low EROA value, reaching a severe level above the threshold of 0.3 cm2. Within a moderate EROA range, the LA function mitigates the clinical consequences of the mitral regurgitation, providing measurable proof of the interplay between the regurgitation and the LA compliance.

Multiple and mixed valvular heart disease

Multiple and mixed valvular heart disease are highly prevalent. Multiple valvular heart disease is the combination of stenotic and/or regurgitant lesions occurring on two or more cardiac valves. Mixed valvular heart disease is the combination of stenotic and regurgitant lesions on the same valve. Several haemodynamic interactions may impact their clinical expression and may result in diagnostic pitfalls. Accurate quantification of the valve lesions requires the use of methods that are less dependent on loading conditions, such as planimetry for stenotic lesions, and assessment of the effective regurgitant orifice area and vena contracta for regurgitant lesions. The assessment should address the diagnosis and severity of each single valve lesion as well as the overall consequences resulting from the combination of all lesions. Clinical decision-making should be based on an integrative approach including echocardiography and other imaging modalities.

PASCAL mitral valve repair system versus MitraClip: comparison of transcatheter edge-to-edge strategies in complex primary mitral regurgitation

Background The PASCAL system is a novel device for edge-to-edge treatment of mitral regurgitation (MR). The aim of this study was to compare the safety and efficacy of the PASCAL to the MitraClip system in a highly selected group of patients with complex primary mitral regurgitation (PMR) defined as effective regurgitant orifice area (MR-EROA) ≥ 0.40 cm2, large flail gap (≥ 5 mm) or width (≥ 7 mm) or Barlow’s disease. Methods 38 patients with complex PMR undergoing mitral intervention using PASCAL (n = 22) or MitraClip (n = 16) were enrolled. Primary efficacy endpoints were procedural success and degree of residual MR at discharge. The rate of major adverse events (MAE) according to the Mitral Valve Academic Consortium (MVARC) criteria was chosen as the primary safety endpoint. Results Patient collectives did not differ relevantly regarding pertinent baseline parameters. Patients` median age was 83.0 [77.5–85.3] years (PASCAL) and 82.5 [76.5–86.5] years (MitraClip). MR-EROA at baseline was 0.70 [0.68–0.83] cm2 (PASCAL) and 0.70 [0.50–0.90] cm2 (MitraClip), respectively. 3D-echocardiographic morphometry of the mitral valve apparatus revealed no relevant differences between groups. Procedural success was achieved in 95.5% (PASCAL) and 87.5% (MitraClip), respectively. In 86.4% of the patients a residual MR grade ≤ 1 + was achieved with PASCAL whereas reduction to MR grade ≤ 1 + with MitraClip was achieved in 62.5%. Neither procedure time number of implanted devices, nor transmitral gradient differed significantly. No periprocedural MAE according to MVARC occured. Conclusion In this highly selected patient group with complex PMR both systems exhibited equal procedural safety. MitraClip and PASCAL reduced qualitative and semi-quantitative parameters of MR to an at least comparable extent. Graphic abstract

Impact of effective regurgitant orifice area on outcome of secondary mitral regurgitation transcatheter repair

Objectives To assess the value of effective regurgitant orifice (ERO) in predicting outcome after edge-to-edge transcatheter mitral valve repair (TMVR) for secondary mitral regurgitation (SMR) and identify the optimal cut-off for patients’ selection. Methods Using the EuroSMR (European Registry of Transcatheter Repair for Secondary Mitral Regurgitation) registry, that included patients undergoing edge-to-edge TMVR for SMR between November 2008 and January 2019 in 8 experienced European centres, we assessed the optimal ERO threshold associated with mortality in SMR patients undergoing TMVR, and compared characteristics and outcomes of patients according to baseline ERO. Results Among 1062 patients with severe SMR and ERO quantification by proximal isovelocity surface area method in the registry, ERO was < 0.3 cm2 in 575 patients (54.1%), who were more symptomatic at baseline (NYHA class ≥ III: 91.4% vs. 86.9%, for ERO < vs. ≥ 0.3 cm2; P = 0.004). There was no difference in all-cause mortality at 2-year follow-up according to baseline ERO (28.3% vs. 30.0% for ERO < vs. ≥ 0.3 cm2, P = 0.585). Both patient groups demonstrated significant improvement of at least one NYHA class (61.7% and 73.8%, P = 0.002), resulting in a prevalence of NYHA class ≤ II at 1-year follow-up of 60.0% and 67.4% for ERO < vs. ≥ 0.3 cm2, respectively (P = 0.05). Conclusion All-cause mortality at 2 years after TMVR does not differ if baseline ERO is < or ≥ 0.3 cm2, and both groups exhibit relevant clinical improvements. Accordingly, TMVR should not be withheld from patients with ERO < 0.3 cm2 who remain symptomatic despite optimal medical treatment, if TMVR appropriateness was determined by experienced teams in dedicated valve centres.

Prior Angina Reduces Ischemic Mitral Regurgitation in Patients with ST-Elevation Myocardial Infarction, Role of Ischemic Preconditioning

BackgroundMitral regurgitation may develop due to left ventricular (LV) remodeling within 3 months following acute myocardial infarction (AMI) and is called ischemic mitral regurgitation (IMR). Ischemic preconditioning (IPC) has been reported as the most important mechanism of the association between prior angina and the favorable outcome. The aim of this study was to investigate the effect of prior angina on the development and severity of IMR at 3rd month in patients with ST elevation MI (STEMI).MethodsFourty five (45) patients admitted with STEMI and at least mild IMR, revascularized by PCI were enrolled. According to presence of prior angina within 72 hours before STEMI, patients were then divided into two groups as angina (+) (n:26; 58%) and angina (-) (n:19; 42%). All patients underwent 2D transthoracic echocardiography at 1st, 3rd days and 3rd month. IMR was evaluated by proximal isovelocity surface area (PISA) method: PISA radius (PISA-r), effective regurgitant orifice area (EROA), regurgitant volume (Rvol). LV ejection fraction (EF %) was calculated by Simpson’s method. High sensitive troponin T (hs-TnT), creatine phosphokinase myocardial band (CK-MB) and N-terminal pro-brain natriuretic peptid (NTpro-BNP) levels were compared between two groups.ResultsAlthough PISA-r, EROA and Rvol were similar in both groups at 1st and 3rd days, all were significantly decreased (p=0.012, p=0.007, p=0.011, respectively) and EF was significantly increased (p< 0.001) in angina (+) group at 3rd month. NTpro-BNP and hs-TnT levels at 1st day and 3rd month were similar, however CK-MB level at 3rd month was found to be significantly lower in the angina (+) group (p=0.034).ConclusionAt the end of the 3rd month, it was observed that the severity of IMR evaluated by PISA method was decreased and EF increased significantly in patients who defined angina within 72 hours prior to STEMI, suggesting a relation with IPC.

Vena contracta area size predicts effectiveness of interventional edge-to-edge repair in tricuspid valve regurgitation

Funding Acknowledgements Type of funding sources: None. Background Percutaneous tricuspid valve edge-to-edge repair (pTVR) is a promising interventional technique for patients with tricuspid regurgitation (TR), but guidance regarding patient selection and echocardiographic screening is lacking. The aim of this study was to identify echocardiographic measurements which may predict pTVR success. Methods Before and after pTVR, echocardiographic data, including 3D full-volume datasets, were obtained and quantified. Right ventricular assessments included ejection fraction (RVEF3D) and diastolic (RVVd3D) and systolic (RVVs3D) volumes. Also evaluated were: right atrial (RA) volume, effective regurgitant orifice area by PISA method (EROAPISA), vena contracta area (VCA3D) by multiplanar reconstruction from a 3D colour Doppler loop (Figure 1a), maximal diastolic tricuspid annulus area from a 3D zoom image (Figure 1b), and tricuspid tenting area. TR severity was graded according to EROAPISA and VCA3D as grade 1+ to 5+. Results Patients (n= 44, age 72 ± 9 years, 20 male) with at least moderate to severe TR undergoing pTVR were consecutively included. The patients were divided into groups according to their post-pTVR TR grade. Group 1 had TR grade ≤2+, and group 2 had TR grade ≥3+.Echocardiographic parameters before pTVR for both groups are presented in Table 1. As expected, patients with TVR ≥3+ after pTVR had significantly worse pre-intervention echocardiographic measurements of TR severity, valve dimensions, and chamber volumes. ROC curves for the prediction of TR ≤2+ (mild to moderate) after pTVR (defined as VCA3D &lt;0.75 cm² and EROAPISA &lt;0.4 cm²) were drawn for different echocardiographic features (Figure 2). VCA3D by 3D colour Doppler yielded the highest area under the ROC curve followed by TV anatomy measurements (Annulus area3D, Tenting area) and right atrial volume. Conclusion A thorough evaluation of TR and valve dimensions by 3D echocardiography, particulary the evaluation of VCA3D by 3D colour Doppler, aids in the prediction of the probability of pTVR success. Abstract Figure.