RACI: A Novel Prognostic Marker in Functional Tricuspid Regurgitation.

Baseline Right Ventricular Assessment and Outcomes After Transcatheter Tricuspid Valve Repair

Tricuspid regurgitation (TR) and right ventricular (RV) remodelling are closely related. Recent ESC/EACTS guidelines on valvular heart disease propose adjusted reference values for RV size and function. To determine the predictive value of the proposed RV dilatation and dysfunction thresholds in a real-world interventional cohort. Echocardiographic thresholds were evaluated retrospectively in 651 patients, who underwent transcatheter tricuspid valve repair (TTVr) at two tertiary centres. The primary endpoint was 2-year survival (Kaplan–Meier estimate: 78.6% [74.9–81.9]). RV strain was the most frequent marker of dysfunction at baseline (FWS <23% in 80.3%, GLS <21% in 88.4%). Proposed cut-offs for RV basal (>24 mm/m2), mid (>21 mm/m2), and tricuspid annular (TA) diameters (>21 mm/m2) were associated with survival (p=0.04, <0.01, and <0.01). TAPSE <17 mm was not (p=0.24), whereas TDI s’ <10 cm/s and FAC ≤35% were associated with survival (p=0.04; 0.01). Severe RV dysfunction (FWS <11% or GLS <9%) was associated with survival (p<0.01; 0.02). In multivariable analysis, TA >21 mm/m2 (HR 2.85 [1.41–5.76]; p<0.01) and FWS <11% (HR 1.91 [1.07–3.38]; p=0.03) independently predicted survival. Mortality risk increased for each additional pathological parameter (HR per parameter 1.33 [1.14–1.57]; p <0.01). After effective TR reduction (residual TR <I; n=341, 52%), no RV cut-off remained associated with survival. TTVr is often performed at an advanced disease stage, and adverse RV remodelling is strongly associated with survival. Nevertheless, effective TR reduction attenuated this prognostic value.

Prognostic Value of Right Ventricular Circumferential Strain in Patients Undergoing Isolated Tricuspid Valve Surgery.

BACKGROUND Right ventricular (RV) function is closely associated with prognosis in isolated tricuspid regurgitation. Beyond conventional longitudinal indexes, nonlongitudinal RV deformation may provide additional prognostic information. OBJECTIVES The authors aimed to evaluate whether 3-dimensional (3D) RV circumferential strain (RV-CS) provides incremental prognostic value in patients undergoing isolated tricuspid valve surgery (ITVS). METHODS Patients scheduled for ITVS were prospectively enrolled and underwent 3D echocardiography 1 day before surgery. 3D RV longitudinal strain, CS, and area strain were derived using commercially available software. The primary endpoint was a composite of all-cause mortality or heart failure hospitalization. RESULTS From April 2018 to December 2024, 251 patients were enrolled; 171/251 (68.1%) were women, and the mean age was 57 ± 14 years. During a median follow-up of 495 days, 48/251 patients (19.1%) reached the primary endpoint. Baseline 3D right ventricular circumferential strain (3D RV-CS) was lower in patients with events than in those without events (P < 0.001) and showed modest but had the highest Harrell's C-index for adverse events discrimination (0.695; 95% CI: 0.618-0.774; P < 0.001) among all tested RV function parameters. Patients with impaired 3D RV-CS, defined as |3D RV-CS| < 14%, had lower 1-year event-free survival than those with preserved 3D RV-CS (54.2% vs 92.5%; log-rank P < 0.001). After multivariable adjustment, impaired 3D RV-CS remained independently associated with adverse events. Adding 3D RV-CS improved risk reclassification beyond European System for Cardiac Operative Risk Evaluation II, TRI-SCORE, and Society of Thoracic Surgeons score models. CONCLUSIONS 3D RV-CS provides complementary prognostic information in patients undergoing ITVS and may improve preoperative risk stratification.

Prognostic implications of echocardiographic and hemodynamic profiles in cirrhosis and high-output heart failure

Introduction Cirrhosis is a recognized cause of high-output heart failure (HOHF), yet the prognostic relevance of paired invasive hemodynamic and echocardiographic remodeling profiles in this population remains incompletely defined. Methods We retrospectively analyzed 41 adults with cirrhosis-associated HOHF who underwent right heart catheterization between 2015 and 2023. HOHF was defined as thermodilution cardiac index (CI) ≥ 4.0 L/min/m2 with elevated filling pressures. The primary outcome was all-cause mortality. Results During a median follow-up of 1.66 years, 18 patients died and 21 underwent liver transplantation. Mean CI was 5.5 ± 1.2 L/min/m2, mean MELD-Na score was 24 ± 9, and echocardiography demonstrated preserved left ventricular ejection fraction (65 ± 11%) with disproportionate left atrial enlargement relative to left ventricular volume, reflected by a mean LA/LV volume ratio of 0.84 ± 0.31. In univariable Cox regression analyses, higher LA/LV volume ratio, CI, and end-systolic elastance (Ees) were associated with increased mortality when modeled per 1-standard deviation increase, with hazard ratios of 2.13 (95% confidence interval, 1.20–3.79; p = 0.010), 1.64 (95% confidence interval, 1.12–2.42; p = 0.012), and 1.93 (95% confidence interval, 1.09–3.44; p = 0.024), respectively. In MELD-Na–adjusted Cox models, LA/LV volume ratio, CI, and Ees remained associated with mortality, with adjusted hazard ratios of 2.02 (95% confidence interval, 1.12–3.65; p = 0.019), 1.66 (95% confidence interval, 1.08–2.56; p = 0.021), and 1.92 (95% confidence interval, 1.09–3.39; p = 0.024), respectively. Similar directionality was observed in Firth penalized Cox models and Fine–Gray competing-risk models treating liver transplantation as a competing event. Discussion In patients with cirrhosis-associated HOHF, disproportionate left atrial remodeling, elevated CI, and higher Ees were associated with mortality. These findings support further evaluation of integrated invasive hemodynamic and quantitative echocardiographic assessment for characterizing risk-related phenotypes in cirrhosis-associated HOHF.

Right atrial functional remodeling for early risk stratification of tricuspid regurgitation progression in atrial fibrillation.

Sex-Specific Left Atrial Strain Thresholds Predict Outcomes in Aortic Stenosis.

BACKGROUND Left atrial (LA) remodeling represents an integral marker of cardiac damage in aortic stenosis (AS). While the LA volume index (LAVi) reflects chronic pressure overload, left atrial reservoir strain (LARS) by speckle-tracking echocardiography detects early LA dysfunction. OBJECTIVES To evaluate the prognostic value of LAVi and LARS in AS, define optimal cut-offs associated with adverse outcomes, and assess whether sex-specific thresholds enhance risk stratification. METHODS Retrospective analysis of 552 outpatients (50.4% men, mean age 81±8 years) with at least moderate AS and in sinus rhythm. The composite endpoint was all-cause mortality or hospitalization for heart failure (HHF). Optimal cut-offs for LAVi and LARS were derived using 2-year time-dependent ROC analysis and validated in an independent external cohort of 192 patients (46% men). Associations with outcomes were examined using multivariable Cox regression adjusted for age, NYHA class, and LVEF. RESULTS Over a median follow-up of 17.4 months, 118 patients (21.1%) experienced the composite endpoint. In univariable analyses, both larger LAVi and lower LARS were associated with adverse outcomes (both p<0.001). However, only LARS retained prognostic significance after multivariable adjustment. Sex-specific analyses identified LARS<13% in women and <19% in men as the optimal thresholds discriminating higher risk. In multivariable Cox models, reduced sex-specific LARS remained independently associated with adverse outcomes in both sexes (women: HR 1.82 [95% CI 1.04-3.18], p=0.03; men: HR 1.90 [95% CI 1.01-3.60], p=0.045), whereas LAVi lost significance (p≥0.19). These results were consistently reproduced in the external validation cohort (p < 0.05). CONCLUSIONS Sex-specific LARS thresholds independently predict mortality and HHF in AS, outperforming LAVi and universal cut-offs. Incorporating LA strain assessment into AS risk stratification may enhance prognostic precision and support personalized management across sexes.

Incremental Diagnostic Value of Right Atrial Strain in Arrhythmogenic Right Ventricular Cardiomyopathy: A Cardiac MRI Study.

RATIONALE AND OBJECTIVES To evaluate the discriminative performance of right atrial (RA) phasic function in arrhythmogenic right ventricular cardiomyopathy (ARVC) patients with preserved right ventricular (RV) function. MATERIALS AND METHODS Right atrial and ventricular strain, together with conventional cardiac MRI (CMR) parameters, were assessed in 38 patients with ARVC and preserved RV function, 38 patients with ARVC and reduced RV function, and 38 healthy controls between January 2012 and May 2021. RESULTS Compared to controls, ARVC patients with preserved RV function showed impaired RA reservoir and conduit strain, as well as reduced RA passive emptying fraction, despite normal RA size. RA conduit strain <17% showed discriminative performance for identifying ARVC with preserved RV function (AUC = 0.79). The combination of RA conduit strain and RV global longitudinal strain (RVGLS) further improved discriminative performance (AUC = 0.89, P < 0.001). Multivariable logistic regression identified RA conduit strain (OR = 0.88, P = 0.005) and RVGLS (OR = 1.37, P < 0.001) as independently associated factors. In addition, RA conduit strain impairment showed modest incremental diagnostic value beyond RVGLS (χ² increased from 31.6 to 41.3, P = 0.002) and correlated with more advanced RV dysfunction and higher N-terminal pro-brain natriuretic peptide (NT-proBNP) levels across the overall ARVC cohort. CONCLUSION RA phasic strain is impaired in ARVC even when RV function is preserved. In combination with RVGLS, RA conduit strain showed improved diagnostic performance and may serve as a potential adjunctive imaging marker, although further evaluation is required.