Tricuspid Regurgitation: From Pathophysiology to New Therapeutic Approaches

Dear Colleagues,

Following the surge of new catheter-based therapies, the tricuspid valve is no longer considered the forgotten valve. An in-depth review of the tricuspid valve anatomy was conducted to implement these new treatments and there is already initial data from clinical trials about their prognostic relevance. However, several aspects regarding tricuspid regurgitation mechanisms and evolution need to be clarified. We already know that tricuspid regurgitation is not as benign as previously believed. Nevertheless, surgical repair has been classically associated with high in-hospital mortality. Therefore, new criteria are needed to optimize the patient selection and timing for intervention. Moreover, due to the growing number of percutaneous treatment options and the increasing interest in surgical repair improvements, selection of the best therapeutic approach for each patient is required. Cardiac imaging may shed light on these aspects, incluing attaining a better understanding of the right ventricular volume overload management, refining key anatomic features for intervention timing and personalization, and predicting posprocedural functional and clinical response, among others. Thus, this Special Issue will encompass all recent advances in tricuspid regurgitation management, with a specific focus on imaging diagnosis.

Dr. Eduardo Pozo Osinalde
Guest Editor

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• tricuspid regurgitation
• right ventricular function
• heart failure
• cardiac imaging
• surgical repair and replacement
• percutaneous intervention
• prognosis

Title: New therapeutic advances in the management of tricuspid valve regurgitation
Authors: Andreas Synetos; Nikolaos Ktenopoulos; Odysseas Katsaros; Konstantina Vlasopoulou; Theofanis Korovesis; Maria Drakopoulou; Anastasios Apostolos; Leonidas Koliastasis; Konstantinos Toutouzas; Constantinos Tsioufis
Affiliation: Hippocration General Hospital
Abstract: For original research articles, systematic reviews and meta-analyses, the abstract should be an objective representation of the article and consist of about 250 words. It must not contain results that have not been substantiated in the main text and should not exaggerate the main conclusion. The abstract should be structured to contain the following headings. Background/Objectives: highlight the purpose of the study, introduce your research question(s), and the context surrounding them. Methods: describe the main methods or treatments applied, highlighting any unique characteristics of the participant/patient samples. Include any relevant preregistration numbers. Clinical trials should include details that CONSORT has identified as essential. Results: summarize the article's main findings. Conclusions: describe the main takeaways and interpretations of the study. For other article type, such as Reviews, a 200 word unstructured abstract should be included.

Title: Assessment of tricuspid regurgitation by cardiac magnetic resonance imaging: current role and future applications
Authors: C. M. Van De Heyning
Affiliation: Antwerp University Hospital, BE Hospital Clinic de Barcelona, ES
Abstract: Tricuspid regurgitation (TR) is a prevalent valvular disease with a significant mortality rate. Evaluation of TR severity and associated right heart remodeling and dysfunction is crucial to determine the optimal therapeutic strategy and to improve prognosis. While echocardiography remains the first-line imaging technique to evaluate TR, it has many limitations, both operator- and patient-related. Cardiac magnetic resonance imaging (CMR) has emerged as an innovative and comprehensive non-invasive cardiac imaging technique, with additional value beyond routine echocardiographic assessment. Besides its established role as the gold standard for evaluation of cardiac volumes, CMR can add important insights with regard to valvular anatomy and function. Accurate quantification of TR severity, including calculation of regurgitant volume and fraction, can be performed using either the well-known indirect volumetric method or novel 4D Flow imaging. In addition, CMR can be used to assess the impact on the right heart, including right heart remodeling, function and tissue characterization. Several CMR derived parameters have been associated with outcome, highlighting the importance of multi-modality imaging in patients with TR. The aim of this review is to provide an overview of the current role of CMR in assessment and management of patients with TR, and of its future applications.

Title: Impact of Leaflet-to-Annulus Index on Residual Regurgitation Following Transcatheter Edge-to-Edge Repair of the Tricuspid Valve
Authors: Fausto Pizzino; Giancarlo Trimarchi; Andreina D’Agostino; Michela Bonanni; Giovanni Benedetti; Umberto Paradossi; Rachele Manzo; Rosangela Capasso; Gianluca Di Bella; Concetta Zito; Scipione Carerj; Sergio Berti; Massimiliano Mariani
Affiliation: Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
Abstract: Background: The mismatch between tricuspid valve (TV) leaflet length and annulus dilation, assessed with the septal-lateral leaflet-to-annulus index (SL-LAI), predicts residual tricuspid regurgitation (TR) following tricuspid transcatheter edge-to-edge-repair (T-TEER). When posterior leaflet grasping is required, the anterior-posterior leaflet-to-annulus index (AP-LAI) may offer additional information. Methods: This single-center retrospective cohort study included all patients referred for T-TEER with severe and symptomatic TR with high surgical risk, from April 2021 to March 2024. Patients were categorized into 'optimal result' (<moderate TR) or 'suboptimal result' (≥moderate TR) groups. SL-LAI and AP-LAI were calculated using pre-procedural transesophageal echocardiography (TEE) measurements. Results: Of the 25 patients, 12 had suboptimal post-procedural results, while 13 showed optimal outcomes. Optimal result group showed higher prevalence of type IIIA-IIIB TV morphology (85% vs 45%, P<0.05), wider SL-annulus diameter (42.5± vs 37±5 mm, P<0.05), and longer posterior leaflet length (28±4 vs 22±5 mm, P<0.01). SL-LAI was lower in the optimal group (1±0.2 vs 1.2±0.32, P<0.05), while AP-LAI was higher (0.7±0.1 vs 0.5±0.2, P<0.05). ROC curve analysis showed that AUC for AP-LAI was 0.769 (95% CI 0.51 – 0.93, P<0.05) and Youden test identified the best cut-off value <0.5 (sensitivity 50%, specificity 100%) for a suboptimal result. SL-LAI showed very low AUC in predicting suboptimal result (0.245, 95% CIO 0.08 – 0.47). Comparing the 2 ROC curves we showed that AUC difference is significant with AP-LAI showing the best association to the outcome (p=0.01). Conclusions: AP-LAI and SL-LAI can help in predicting post T-TEER result, ameliorating patients’ outcomes and avoiding futile procedures.