Tricuspid Annular Geometry as a Marker of Right Ventricular Function and Remodeling.

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.

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.

EXPLORATORY ASSESSMENT OF LEFT VENTRICULAR 1 STRAIN-VOLUME LOOPS IN SEVERE AORTIC VALVE 2 DISEASES

Right Ventricular-Pulmonary Artery Coupling by 3D Echocardiography Predicts Outcomes in Heart Failure with Preserved Ejection Fraction.

BACKGROUND In advanced heart failure with preserved ejection fraction (HFpEF), right ventricular (RV) dysfunction and impaired RV-pulmonary artery (PA) coupling are increasingly recognized as contributors to prognosis. While conventional echocardiography mainly assesses longitudinal RV function, three-dimensional (3D) imaging enables more comprehensive evaluation. We investigated the prognostic value of 3D-derived RV function and RV-PA coupling in patients with HFpEF. METHODS Of 311 prospectively enrolled patients with HFpEF between 2022 and 2023, 229 (age 74.1 ± 10.3 years; 41.5% male) were analyzed. 3D RV ejection fraction (RVEF), pulmonary artery systolic pressure (PASP), tricuspid annular plane systolic excursion (TAPSE), RV free-wall longitudinal strain (RVFWS), and coupling indices (3D RVEF/PASP, TAPSE/PASP, and RVFWS/PASP) were assessed. The primary endpoint was a composite of cardiovascular death or heart failure hospitalization. RESULTS During a median follow-up of 23.5 months, 34 patients (14.8%) experienced the primary endpoint. Reduced 3D RVEF and impaired 3D RVEF/PASP were associated with higher event rates. On time-dependent ROC analysis, 3D RVEF/PASP showed higher discriminatory ability than TAPSE/PASP at 6, 12, and 18 months (P = .009, .032, and .021, respectively). In multivariable Cox analysis, 3D RVEF/PASP remained independently associated with adverse outcomes (adjusted HR 0.86, 95% CI 0.77-0.96; P = .007). The prognostic value of 3D RVEF/PASP persisted in patients with moderate-to-severe TR. CONCLUSIONS 3D RVEF/PASP independently predicted cardiovascular outcomes and showed higher prognostic discrimination than TAPSE/PASP in HFpEF. 3D RV-PA coupling may provide complementary information for noninvasive risk stratification.

Left atrial remodelling and diastolic unloading after transcatheter tricuspid repair

Abstract Background and Aims Severe tricuspid regurgitation (TR) alters ventricular interaction and left-sided filling dynamics. However, the longitudinal effects of transcatheter tricuspid edge-to-edge repair (T-TEER) on left atrial (LA) remodelling and diastolic physiology remain poorly characterized. We aimed to evaluate longitudinal changes in LA structure, function, and diastolic haemodynamics following T-TEER. Methods We studied 125 consecutive patients undergoing T-TEER within the TRI-FR trial and registry (median age 78 [73–81] years; 60.8% women; 73.6% atrial fibrillation). Comprehensive echocardiography was performed at baseline, pre-discharge, and at 6 and 12 months. Longitudinal changes in LA volume index (LAVI), peak atrial longitudinal strain (PALS), E/e′ ratio, LA stiffness index (LASI), and forward flow indices were analysed using linear mixed-effects models. Results Left atrial volume index decreased immediately after T-TEER (estimated change −8.1 ml/m2; 95% CI −14.6 to −1.6; adjusted P = .033), but this reverse remodelling was not sustained at 12 months. In contrast, LA reservoir function deteriorated early and remained impaired throughout follow-up [PALS −1.2%; 95% confidence interval (CI) −2.0 to −0.3; adjusted P = .029]. Estimated LV filling pressure increased acutely (E/e′ + 3.26; 95% CI 2.34–4.18; adjusted P < .001), while LASI remained elevated at 12 months (ratio 1.22; 95% CI 1.05–1.42; adjusted P = .016). Stroke volume index and cardiac index did not change significantly over time (P = .969 and P = .562, respectively). Early mitral regurgitation worsening occurred in 20% of patients but was transient and unrelated to changes in diastolic or forward-flow parameters. Conclusions Transcatheter tricuspid edge-to-edge repair induces immediate anatomical LA unloading but does not restore LA mechanical function. Despite early reductions in LA volume, filling pressure surrogates increased, LA stiffness remained elevated, and forward flow did not improve. These findings demonstrate a dissociation between structural and functional remodelling after TR correction and highlight the importance of serial assessment of LA mechanics and diastolic physiology following T-TEER.

RACI: A Novel Prognostic Marker in Functional Tricuspid Regurgitation.

RACI is a novel parameter that effectively integrates RA and RV remodeling, and independently predicts all-cause mortality in functional TR, and incorporating RACI into clinical assessment may help with improving risk stratification and guiding the timing of intervention in patients with functional TR.