Aims The COAPT randomized trial has shown a huge benefit in the survival of patients with s heart failure and functional mitral regurgitation treated with MitraClip. However, patients in COAPT were highly selected and the clinical course in real-world patients with and without fulfilment of the trial inclusion criteria is unclear. Methods The present study examined the clinical outcome in consecutive patients with symptomatic moderate-to-severe or severe MR of dominant functional aetiology undergoing MitraClip therapy by the presence of the inclusion criteria of the COAPT trial (left ventricular ejection fraction >20%, left ventricular end-systolic dimension <70 mm, non-commissural primary jet, estimated pulmonary artery systolic pressure <70 mmHg, mitral valve orifice area >4 cm2, no prior mitral valve leaflet surgery or any currently implanted prosthetic mitral valve or any prior transcatheter mitral valve procedure). Results The composite endpoint of all-cause mortality or heart failure hospitalization and the endpoint of heart failure hospitalization were analysed. Among 118 patients who underwent MitraClip implantation 61% fulfilled the inclusion criteria of COAPT. The composite endpoint was significantly less frequent (P = 0.05) in patients fulfilling the COAPT selection criteria than in those not fulfilling the criteria, with an estimated 1-year event rate of 25% vs. 49%. Heart failure hospitalization was significantly less frequent (P = 0.04) in patients fulfilling COAPT selection criteria than in those who did not, with an estimated 1-year event rate of 19% vs. 36.8%. Conclusions In this single centre study the outcome of patients with functional mitral regurgitation undergoing MitraClip therapy was significantly worse in patients not fulfilling COAPT inclusion criteria, indicating that these criteria might help identify futility.

Aims Mitral regurgitation is the second-most frequent VHD in Europe. According to the latest ESC Guidelines, transcatheter edge-to-edge repair (TEER) was included as a treatment option in patients with severe symptomatic MR at high risk for surgery (Class IIb recommendation) for primary MR and a Class IIa recommendation for secondary MR. We sought to investigate predictors of clinical outcome in patients with mitral regurgitation undergoing percutaneous valve repair. Methods and Results The MITRA-UMG study, a single-center registry, retrospectively collected consecutive patients with symptomatic moderate-to-severe or severe MR undergoing MitraClip therapy between March 2012 to October 2021 at Magna Graecia University. Clinical, echocardiographic and procedural data were collected and compared with post procedural outcomes. Procedural success was defined as successful implantation of one or more clip(s) with a post-procedure reduction of MR of 2 + or less at discharge. The primary endpoint was the composite of cardiovascular death or rehospitalization for heart failure. The median follow-up was 456 days (IQR 372–1130 days) with a complete 1-year follow- up in 188 of 200 (97%) patients. A functional aetiology was classified in 75% of patients. Procedural success was obtained in 98% of patients. The composite primary endpoint of cardiovascular death or rehospitalization for HF was met in 77 patients (36%) with cumulative incidences of 7% at 30 days and 25% at 1 year. In the Cox multivariate model, NYHA functional class and left ventricular end-diastolic volume index (LVEDVi), independently increased the risk of the primary endpoint at long-term follow-up. At Kaplan–Meier analysis, a LVEDVi > 92 ml/m2 was associated with an increased incidence of the primary endpoint (HR 3.55, 95%CI [2.03, 6.18], P<0.0001) (Figure). Conclusions In this study, patients presenting with dilatated ventricles (LVEDVi > 92 ml/m2) and advanced heart failure symptoms (NYHA IV) carried the worst prognosis after TEER.

Introduction anatomically and functionally different from the left ventricle, the right ventricle (RV) plays an increasingly recognized role in determining symptoms and outcomes in multiple conditions. Due to RV complex anatomy and mechanics, the evaluation of its size and function is challenging. The ideal imaging technique should be capable of comprehensive, accurate and reproducible assessment of RV morphology and contraction. In the absence of a single reliable 2DE measure of the RV systolic function, several surrogate echocardiographic parameters have been proposed for clinical use, from one-dimensional (TAPSE) to 3D techniques. Clinical Case we report a case of an 82-year-old female patient who was admitted to our hospital because of dyspnoea, with a history of atrial fibrillation, hypertension, diabetes mellitus, chronic kidney disease, and a last year hospitalization for heart failure. A transthoracic echocardiography (TTE) was performed, showing a high-grade tricuspid valve regurgitation. Further investigation using transoesophageal echocardiography (TEE) showed, in four chambers view, dilatation of right sections and confirm TR was significant, so screening for TriClip implantation was performed. The exam was diagnostic for massive TR, moderate Mitral Regurgitation, and the estimated PAPs about 50 mmHg, so, in the absence of anatomical exclusion elements, severe pulmonary hypertension and poor RV function, transcatheter treatment with TriClip was offered. We had evaluated RV function, obtaining a FAC about normal limit (which should be corrected by valvular regurgitation), and a reduced Strain value. The patient received an edge-to-edge reparation of the tricuspid valve using the TriClip XTR (Clip) system with 2 clips placed. The post-interventional echocardiographic results were an optimal correction of valvular regurgitation, with, however, a clear right ventricular disfunction. Those finding were confirmed by further echocardiographic follow up exams, even during inotropic treatment by low dobutamine dose. Conclusion estimating RV function remains challenging because of the complex geometry of the RV. In the presence of significant TR, the accurate assessment of RV function becomes even more challenging because of the load and angle dependency of TAPSE, RVFAC and RVEF. Significant TR result in a reduction in RV afterload, which may preserve the markers of TV function even when contractility is impaired. 2d-STE in less angle and load dependent than traditional RV function indices and less confounded by RV geometry and passive motion.

Background echocardiography is a helpful tool in patients with suspected pulmonary hypertension (PH). Data derived from echocardiographic examination allow to assign a level of probability of PH by using multiple parameters. Nevertheless, the gold standard for the diagnosis of PH remains the right heart catheterization. The evaluation of PH is important in patients undergoing transcatheter tricuspid valve repair, in fact, many trials excluded those with “severe” pulmonary hypertension. Aim the aim of this study was to examine, in the evaluation of PH, the parameters derived from echocardiographic estimation and cardiac catheterization in patients undergoing TriClip implantation. Methods a retrospective analysis of 4 patients underwent to TriClip implantation in our department was performed. Echocardiography and right heart catheterization data were collected. In the assessment of pulmonary hypertension, the analyzed echocardiographic parameters were: enlarged right ventricle in parasternal long-axis view (>30 mm), flattened interventricular septum leading to “D-shaped LV”, dilated inferior vena cava (>21 mm) with diminished inspiratory collapsibility (<50%), RVOT acceleration time of pulmonary ejection <105 msec, reduced right ventricular fractional area change (<35%), decreased tricuspid annular plane systolic excursion (TAPSE <18mm), TAPSE/sPAP ratio <0.55 mm/mmHg, enlarged right atrial area (>18 cm2), increased systolic peak tricuspid regurgitation velocity (peak TRV>2.8 m/s), estimated systolic pulmonary artery pressure (sPAP). Echocardiographic probability of pulmonary hypertension was defined as high: peak TRV >3.4 m/s or a peak TRV between 2.9-3.4 m/s and the presence of other echo PH sign; intermediate: peak TRV between 2.9-3.4 or peak TRV ≤2.8 m/sec with other echo PH signs; low: peak TRV ≤2.8 m/sec. Pulmonary hypertension, in accordance with guidelines, was defined by a mean pulmonary arterial pressure (mPAP)>20 mmHg at rest. Results the echocardiographic probability of pulmonary hypertension was high in three patients: 2 patients had a peak TRV>3.4 m/s, one patient had peak TRV 2.95 with RVOT AT 55, flattened interventricular septum, dilated inferior vena cava with diminished inspiratory collapsibility, right atrium area >18cm2. In one patient the probability was intermediate (peak TRV 2.40 m/s, RA area >18 cm2 and TAPSE/sPAP ratio <0.55 mm/mmHg). Right heart catheterization confirmed the diagnosis of pulmonary hypertension in two patients with high echocardiographic probability. In the other two patients (one with high probability and one with intermediate probability) there was no PH diagnosis at right heart catheterization. Conclusion in only two out of four patients with intermediate-high probability of PH the diagnosis was confirmed by right catheterization. Therefore, invasive evaluation of pulmonary pressures should be performed in patients with severe tricuspid regurgitation undergoing Triclip implantation.

Objective transcatheter tricuspid valve repair (TTVR) has recently become available as a treatment option for patients with symptomatic significant tricuspid regurgitation (TR) not eligible for tricuspid valve surgery. In the absence of a single reliable measure of the RV systolic function, a number of surrogate echocardiographic parameters have been proposed for clinical use (tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (FAC), peak S wave velocity of the lateral tricuspid annulus by tissue Doppler imaging (S’ RV-TDI) and RV 2D-FWS. At present, TTVR is not recommended in patients with severe PH and poor RV function, but exact cut-offs when TTVR should be rejected are lacking. Aim of this study was to assess RV function before and after Triclip implantation. Materials and methods from June 2021 to June 2022 clinical and echocardiographic data of 8 patients with TR who underwent TTVR intervention in our division were evaluated for RV function. TAPSE, FAC, S’RV-TDI, RV GS and RV FWS at baseline and 1 month of follow up were assessed. Continuous variables are presented as mean ± standard deviation (SD). Categorical variables were presented as frequencies and percentages. Results the mean values of RV function assessed before and after Triclip implantation were respectively (18,75 mm± 4,04 vs 18,38 mm ± 3,34) for TAPSE, (10,50 cm/sec± 2,33 vs 10,38 cm/sec ± 1,19) for S’ RV-TDI, (38% ± 0,05 vs 37% ± 0,04) for FAC, and (-17% ± 0,03 vs -19% ± 0,02) for RV FWS. The number of patients that show at baseline RV dysfunction, according to the cut-offs indicated from guidelines, were 4 for TAPSE; 3 S’ RV-TDI; 1 for FAC and 7 for RV 2D-FWS. At 1 month of follow-up, patients with ventricular dysfunction were respectively 3,2,2,4. Conclusions in the presence of significant TR, the accurate assessment of RV function becomes even more challenging as a result of the load and angle dependency of TAPSE, RVFAC. Significant TR results in a reduction in RV afterload, which may preserve the aforementioned markers of RV function even when contractility is impaired. Probably RV 2D-STE is less angle and load dependent than traditional RV function indices and less confounded by RV geometry and passive motion.