2026-04-01
Jagdip Kang, Antonio Mutarelli, Svitlana Bielichenko, Abdellaziz Dahou, Jacob P. Dal-Bianco, Michael A. Borger, Nathaniel B. Langer, David D’Alessandro, Judy Hung, Thoralf M. Sundt, Evin Yucel, Serguei Melnitchouk
Background: The accurate evaluation of right ventricular function and its response to correction of tricuspid valve pathology are challenging. This retrospective study evaluated the predictive value of right ventricular-pulmonary arterial (RV-PA) coupling in patients undergoing isolated or combined tricuspid and mitral valve surgery. Methods: Patients at Massachusetts General Hospital who underwent isolated tricuspid or combined tricuspid and mitral valve surgery between January 2013 and June 2024 with available preoperative transthoracic echocardiography images were included. The RV-PA coupling ratio was calculated by dividing the tricuspid annular plane systolic excursion (TAPSE) by PA systolic pressure. The optimal cut-off value for this ratio was determined using the maximal log-rank test. The primary outcome was mid-term survival, while secondary outcomes included in-hospital mortality, intensive care unit (ICU) stay duration, hospital stay, and prolonged postoperative inotrope use. Results: A total of 264 patients were followed for a median of 23 months (interquartile range, 7.0–48.0 months). The optimal RV-PA coupling ratio linked to mortality was 0.339 mm/mmHg. Patients with an RV-PA coupling ratio of ≤0.339 mm/mmHg had significantly higher all-cause mortality (25.5% vs. 10.0%; P<0.002), longer median ICU stay (4.0 vs. 3.0 days; P<0.001), longer median hospital stay (11.5 vs. 9.0 days; P=0.002), increased need for inotropic support (45.7% vs. 21.8%; P<0.001), and higher in-hospital mortality (10.6% vs. 2.9%). In multivariable Cox regression analysis, an RV-PA coupling ratio >0.339 mm/mmHg was linked to a reduced risk of all-cause mortality (hazard ratio 0.09, P=0.003). TAPSE and RV free-wall strain showed no association with mortality. Conclusions: Echocardiography-derived RV-PA coupling is a robust, independent predictor of adverse outcomes in patients undergoing tricuspid valve surgery, particularly in those undergoing combined procedures. It captures a critical dimension of RV physiology not fully appreciated by standard measures and may serve as a powerful tool in surgical risk stratification and patient selection.
2026-04-01
Vandan Upadhyaya, Perry Wengrofsky, Sung-Han Yoon, Craig Basman, Ryan Kaple
Cardiac implantable electronic devices (CIEDs) are frequently encountered in patients undergoing transcatheter edge-to-edge repair (TEER) for severe tricuspid regurgitation (TR), with a prevalence exceeding 30%. Transvalvular leads introduce unique anatomic and procedural challenges, including imaging shadowing, leaflet tethering, device-lead interaction, and risk of entanglement during repair. Successful intervention requires careful preprocedural assessment of tricuspid valve anatomy, mechanism of TR, inferior vena cava (IVC) alignment, and the spatial relationship of right atrial, coronary sinus, right ventricular, or leadless systems to the tricuspid apparatus. This manuscript describes a structured intraoperative approach to managing CIED leads during tricuspid TEER (tTEER). The strategy incorporates multi-site femoral venous access, stiff-wire straightening techniques to correct IVC offset, and the use of a steerable sheath to achieve controlled intracardiac lead manipulation. Step-by-step technical considerations are detailed, including lead tethering, commissural repositioning, and controlled release following device deployment. This approach aims to standardize management of CIED-related challenges and provide a reproducible technique for safe and effective tTEER in this complex cohort.
2026-03-31
Laura Lupi, Alessandra Ricci, Elisa Pezzola, Marianna Adamo
2026-03-30
Rajni Singh, Massimiliano Meineri, Waseem Zakhary, Sophia Sgouropoulou, Joerg Ender, Anna Flo Forner
Background: Tricuspid regurgitation (TR) is often incidentally detected at intraoperative transesophageal echocardiography (TEE), resulting in possible changes in the surgical plan. The aim of this study was to compare 2D and 3D measurements of TR vena contracta width (VCW) and the degree of TR severity using TEE from the three standard mid-esophageal (ME) views. Methods: In a prospective observational study, we analyzed 3D and 2D TEE datasets from 30 adult patients undergoing elective tricuspid valve (TV) repair. 2D and 3D TEE color flow Doppler (CFD) loops of the TV in the three standard ME views (4Chamber, RV inflow-outflow (inflow) and modified bicaval) were recorded immediately after induction of anesthesia. VCW from single views and the average of the measurement of biplane VCW (2D biplane VCW) from each standard view were compared with the maximum and minimum diameters of the 3D vena contracta area (VCA) and their average (3D average VCW). TR severity classification was compared between 2D biplane VCW and 3D average VCW and VCA. Correlation between measurements was analyzed using Pearson coefficient and agreement assessed using the Bland-Altman method. Cohen’s Kappa correlation was used to assess TR severity concordance. Results: Biplane VCW in all three ME views underestimated 3D average VCW measurement, with VCW from ME inflow view showing the best agreement. VCW measurements in single standard views systematically underestimated the maximum 3D VCA diameter. We detected very good agreement in TR grading between 3D average VCW and 3D VCA, and an underestimation by 2D biplane VCW (moderate agreement for inflow and fair for the other views). Intra- and inter-observer correlation when repeating 2D measurements was more reliable than that for 3D measurements. Conclusions: Our study shows that 2D biplane VCW from the ME inflow view best agrees with 3D average VCW and allows the most accurate classification of TR severity compared to 3D average VCW.
2026-03-27
Suzanne de Waha, Thilo Noack, Tobias Kister, Steffen Desch, Mateo Marín-Cuartas, Philipp Kiefer, Michael A. Borger
Tricuspid valve disease (TVD) has long been underrecognized compared with left-sided valvular disorders, yet it represents a major determinant of cardiovascular morbidity and mortality. Tricuspid regurgitation (TR), the predominant manifestation of TVD, is being recognized with increasing frequency as populations age and the burden of left-sided heart disease rises. While mild TR is often physiological, moderate and severe TR are associated with adverse outcomes, independent of left ventricular function or pulmonary pressures. Secondary TR, driven by right atrial or right ventricular remodeling, constitutes the majority of cases, whereas primary TR due to intrinsic valvular pathology is less frequent. Cardiac implantable electronic device (CIED)-related TR represents a distinct and increasingly prevalent mechanism that often requires dedicated management considerations. Historically, management of TVD has often been delayed until the onset of advanced right heart failure or end-organ dysfunction, resulting in poor outcomes. Contemporary evidence emphasizes the importance of early recognition, precise etiologic characterization, and timely intervention within a multidisciplinary framework. Surgical repair, particularly annuloplasty, remains the reference standard in suitable candidates, offering durable results when performed before irreversible right ventricular remodeling develops. Transcatheter tricuspid valve interventions have expanded therapeutic options for high-risk or inoperable patients, demonstrating symptomatic and hemodynamic improvement in early studies. Optimal management of TVD follows a lifetime approach, integrating multimodality imaging, risk stratification, and individualized treatment strategies. General physicians and cardiologists play a key role in early detection, while coordinated collaboration among imaging specialists, electrophysiologists, heart failure experts, interventional cardiologists, cardiac surgeons, and anesthesiologists is essential for comprehensive care. Ultimately, a patient-centered lifetime management strategy initiated early and adapted to disease progression offers the best opportunity to preserve right heart function, improve survival, and maintain quality of life in patients with TVD.
2025-12-16
Marc Gillinov, Tarek Malas, Per Wierup, Lars G. Svensson