Functional tricuspid regurgitation: A clustering analysis and prognostic validation of three echocardiographic phenotypes in an external cohort

Vely, Mathilde; L'official, Guillaume; Galli, Elena; Kosmala, Wojciech; Guérin, Anne; Chen, Elisabeth; Sportouch, Catherine; Dreyfus, Julien; Oger, Emmanuel; Donal, Erwan

doi:10.1016/j.ijcard.2022.07.019

Cited by 9 publications

(4 citation statements)

References 32 publications

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“…Finally, a recent study based on a clustering analysis (and no a priori assumption) identified three distinct phenotypes (clusters) of STR based on RV and RA volumes and function: cluster 1 included patients with better right ventricular, left ventricular, and right atrial function; cluster 2 with reduced RV and RA strain despite similar sizes; cluster 3 patients with severely dilated heart chambers associated to RV and RA dysfunctions. These 3 phenotypes were associated with different outcomes and, under non-interventional management, the phenotype corresponding to preserved RV size and preserved RA and RV functions had less incidence of the combined endpoint (death and HF hospitalization) ( 17 ).…”

Section: Discussionmentioning

confidence: 99%

“…Not surprisingly, the most recent guidelines about the management of heart valve diseases suggest that A-STR should be separated from the other forms of STR (12,13) since the mechanisms underlying these two STR phenotypes have been hypothesized to be different (14). Notwithstanding, the recently published studies, including STR patients, do not distinguish between the A-STR and the "ventricular" STR (V-STR) phenotypes (15)(16)(17)(18)(19) and, to the best of our knowledge, only one echocardiographic study examined the differences in geometry of the right heart structures between patients with A-STR and V-STR (20). Furthermore, since A-STR has long been under-recognized as a distinct phenotype of STR, its prognosis and prognostic predictors remain to be clarified, especially in comparison with V-STR, in which the prognosis is also associated with the underlying RV function and/or associated left heart conditions (18,19,21).…”

Section: Introductionmentioning

confidence: 99%

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The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype

Gavazzoni

Heilbron

Badano

et al. 2022

Front. Cardiovasc. Med.

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AimWe sought to evaluate the differences in prognosis between the atrial (A-STR) and the ventricular (V-STR) phenotypes of secondary tricuspid regurgitation.Materials and methodsConsecutive patients with moderate or severe STR referred for echocardiography were enrolled. A-STR and V-STR were defined according to the last ACC/AHA guidelines criteria. The primary endpoint was the composite of all-cause death and heart failure (HF) hospitalizations.ResultsA total of 211 patients were enrolled. The prevalence of A-STR in our cohort was 26%. Patients with A- STR were significantly older and with lower NYHA functional class than V-STR patients. The prevalence of severe STR was similar (28% in A-STR vs. 37% in V-STR, p = 0.291). A-STR patients had smaller tenting height (TH) (10 ± 4 mm vs. 12 ± 7 mm, p = 0.023), larger end-diastolic tricuspid annulus area (9 ± 2 cm2 vs. 7 ± 6 cm2/m2, p = 0.007), smaller right ventricular (RV) end-diastolic volumes (72 ± 27 ml/m2 vs. 92 ± 38 ml/m2; p = 0.001), and better RV longitudinal function (18 ± 7 mm vs. 16 ± 6 mm; p = 0.126 for TAPSE, and −21 ± 5% vs. −18 ± 5%; p = 0.006, for RV free-wall longitudinal strain, RVFWLS) than V-STR patients. Conversely, RV ejection fraction (RVEF, 48 ± 10% vs. 46 ± 11%, p = 0.257) and maximal right atrial volumes (64 ± 38 ml/m2 vs. 55 ± 23 ml/m2, p = 0.327) were similar between the two groups. After a median follow-up of 10 months, patients with V-STR had a 2.7-fold higher risk (HR: 2.7, 95% CI 95% = 1.3–5.7) of experiencing the combined endpoint than A-STR patients. The factors related to outcomes resulted different between the two STR phenotypes: TR-severity (HR: 5.8, CI 95% = 1, 4–25, P = 0.019) in A-STR patients; TR severity (HR 2.9, 95% CI 1.4–6.3, p = 0.005), RVEF (HR: 0.97, 95% CI 0.94–0.99, p = 0.044), and RVFWLS (HR: 0.93, 95% CI 0.85–0.98, p = 0.009) in V-STR.ConclusionAlmost one-third of patients referred to the echocardiography laboratory for significant STR have A-STR. A-STR patients had a lower incidence of the combined endpoint than V-STR patients. Moreover, while TR severity was the only independent factor associated to outcome in A-STR patients, TR severity and RV function were independently associated with outcome in V-STR patients.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype

Gavazzoni

Heilbron

Badano

et al. 2022

Front. Cardiovasc. Med.

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“… 51 Both RV and RA strain may also be prognostically important in patients with significant TR. 52 Although current imaging guidelines do not define grades of severity in RV dysfunction, a proposal for possible cutoffs to be used in clinical trials is shown in Table 7 , and is based on guideline-reported normal mean ± SD, 53 multinational reports of normative data, 15 as well as outcomes studies, 54 and will require validation, particularly given the load dependence of these measurements.…”

Section: Section 1: Disease State Considerationsmentioning

confidence: 99%

Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints

Hahn,

Lawlor,

Davidson

et al. 2023

European Heart Journal

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Interest in the pathophysiology, etiology, management, and outcomes of patients with tricuspid regurgitation (TR) has grown in the wake of multiple natural history studies showing progressively worse outcomes associated with increasing TR severity, even after adjusting for multiple comorbidities. Historically, isolated tricuspid valve surgery has been associated with high in-hospital mortality rates, leading to the development of transcatheter treatment options. The aim of this first Tricuspid Valve Academic Research Consortium document is to standardize definitions of disease etiology and severity, as well as endpoints for trials that aim to address the gaps in our knowledge related to identification and management of patients with TR. Standardizing endpoints for trials should provide consistency and enable meaningful comparisons between clinical trials. A second Tricuspid Valve Academic Research Consortium document will focus on further defining trial endpoints and will discuss trial design options.

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“…Similar findings were published by Hinojan et al, who demonstrated superiority of RV GLS and RV FWLS to predict outcomes compared to conventional RV parameters in a cohort of secondary, at least severe TR patients without indication for intervention, implying that speckle-tracking echocardiography might be best suited to inform regarding intervention [ 35 ]. Downstream RV impairment will affect right atrial function, and subjects with a phenotype of impaired RV and right atrial strain are at higher risk for events [ 36 ].…”

Section: Echocardiographic Assessment Of Right Ventricular Functionmentioning

confidence: 99%

Unmet Needs in the Assessment of Right Ventricular Function for Severe Tricuspid Regurgitation

Anastasiou,

Bazmpani,

Daios

et al. 2023

Diagnostics

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Tricuspid regurgitation (TR) is a highly prevalent valvular heart disease that has been long overlooked, but lately its independent association with adverse cardiovascular outcomes was recognized. The time point to intervene and repair the tricuspid valve is defined by the right ventricular (RV) dilation and dysfunction that comes up at a later stage. While guidelines favor tricuspid valve repair before severe RV dysfunction ensues, the definition of RV dysfunction in a universal manner remains vague. As a result, the candidates for transcatheter or surgical TR procedures are often referred late, when advanced RV dysfunction is established, and any derived procedural survival benefit is attenuated. Thus, it is of paramount importance to establish a universal means of RV function assessment in patients with TR. Conventional echocardiographic indices of RV function routinely applied have fundamental flaws that limit the precise characterization of RV performance. More recently, novel echocardiographic indices such as strain via speckle-tracking have emerged, demonstrating promising results in the identification of early RV damage. Additionally, evidence of the role of alternative imaging modalities such as cardiac computed tomography and cardiac magnetic resonance, for RV functional assessment in TR, has recently arisen. This review provides a systematic appraisal of traditional and novel multimodality indices of RV function in severe TR and aims to refine RV function assessment, designate future directions, and ultimately, to improve the outcome of patients suffering from severe TR.

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Functional tricuspid regurgitation: A clustering analysis and prognostic validation of three echocardiographic phenotypes in an external cohort

Cited by 9 publications

References 32 publications

The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype

The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype

Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints

Unmet Needs in the Assessment of Right Ventricular Function for Severe Tricuspid Regurgitation

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