Ciobanu, A.

Background Tricuspid regurgitation (TR) is a common valvular disorder that can affect patients’ quality of life and survival. The impact of TR etiology on overall survival and the associated risk factors in each subgroup are not well studied. Methods Multisite, retrospective study evaluating survival based on TR etiology using Kaplan–Meier and Cox regression models. Stepwise approach was used to define TR etiology (≥moderate): primary (PTR; presence of a primary valvular pathology), lead associated (LTR; lead interfering with closure), and secondary TR (STR) in the setting of left‐sided valvular disease, left ventricular disease, other causes of pulmonary hypertension, right ventricular disease, and atrial secondary TR. Results A total of 12 899 patients were included (3% PTR, 90% STR, 7% LTR). The mean age was 68±14, 73±13, and 71±13 years, respectively (44%–55% female patients). Adjusting for age, sex, and TR severity, patients with PTR had better overall survival (PTR: reference; STR hazard ratio [HR], 1.4 [1.2–1.6], LTR HR, 1.5 [1.1–1.7]). On multivariable Cox regression, the Tricuspid Regurgitation Impact on Outcomes score was associated with mortality across all groups ( P <0.05 for all). In addition, other risk factors associated with worse outcomes included pulmonary hypertension and ≥moderate right ventricular enlargement in PTR; left‐sided valvular disease, pulmonary hypertension, and ≥moderate right ventricular dysfunction in STR; and left ventricular disease and ≥moderate right ventricular dysfunction in LTR. Conclusions Patients with PTR have better survival than STR and LTR. Tricuspid Regurgitation Impact on Outcomes score was associated with mortality across etiologies, whereas other risk factors are etiology specific. Improved risk profiling may enhance patient selection, treatment decisions, and outcomes.

Background: Tricuspid regurgitation (TR) is associated with significant morbidity, but individualized treatment and timing of intervention are yet to be defined. We previously proposed and validated artificial intelligence electrocardiography (AI-ECG) scores for various diseases. Whether incorporating AI-ECG information adds to risk stratification above and beyond classical clinical parameters is unknown. Objectives: To identify AI-ECG scores independently associated with all-cause mortality in chronic TR and to create a composite AI-ECG risk score. Methods: Patients with a first echocardiographic diagnosis of ≥moderate TR between 2005-2016 and an ECG within ±15 days were included. The Tricuspid Regurgitation Impact on Outcome (TRIO) score was calculated as previously described based on 8 simple parameters (age, sex, severe TR, heart failure, lung disease, heart rate, creatinine and AST). AI-ECG probabilities of low ejection fraction, aortic stenosis, amyloid, cirrhosis, atrial fibrillation and hypertrophic cardiomyopathy were estimated by existing algorithms; the first 4 were associated with all-cause mortality and a composite AI-ECG risk score was calculated (0-4; 1 point for each AI-ECG above specific threshold). Results: A total of 12,377 pts were included (age 72±13 yrs, 55% women). Over a median follow-up of 1.3 yrs (IQR 0.1 to 4.4), 7,121 pts (58%) died. Mortality risk increased significantly with higher composite AI-ECG risk score (Fig. 1A). On multivariable analysis (proportional hazards method), the composite AI-ECG risk score remained independently associated with death, even after adjusting for age, sex, high NT-proBNP levels (>2,500 pg/mL), right ventricular systolic pressure (RVSP), diuretic use and TRIO risk score category (Fig. 1B). Conclusions: Patients with ≥moderate TR show progressively worse survival with increasing composite AI-ECG risk score. Incorporating AI-derived information from a simple and inexpensive ECG may identify patients with the highest risk of mortality beyond clinical risk scores as TRIO or classical clinical, laboratory and echocardiographic parameters. Prospective validation of this approach needs to be tested in future trials.

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) is known to cause dilation in both the mitral (MA) and the tricuspid (TA) annuli. Few studies have investigated MA dynamics and function in AF compared to sinus rhythm (SR). However, no study addressed this issue in TA. Hence, we set forth to describe TA dynamics in AF and SR and its relationship with severity of tricuspid regurgitation (TR). Methods 3D echocardiographic imaging data were acquired from adult patients in AF or SR with varying degrees of TR between 2018 and 2020. TA was automatically tracked throughout the cardiac cycle using a commercially available software (TomTec 4MV software; Figure 1) over 4-6 cardiac cycles per patient. Time to minimal area as percentage of the R-R interval was recorded in each of the cycles. Absolute change in TA area was calculated as the difference between maximal and minimal TA area in each cardiac cycle and was averaged over 4-6 cycles per patient. This measurement was used to reflect the dynamic range of TA deformation during the cardiac cycle. Right atrial (RA) and right ventricular (RV) volumes and longitudinal strain were also measured (speckle tracking, 4-ch view). Results A total of 70 patients were studied (35 AF; 35 SR; 54% males in each group). Patients with AF were older [median (IQR) of 81 (72-86) years vs. 69 (59-78) years in SR, p &lt; 0.001], had larger maximal TA area and circumference (p &lt; 0.001 for both), larger RA size (p &lt; 0.001), lower RA reservoir strain (p &lt; 0.001) and RV free-wall strain (p &lt; 0.001). Absolute change in TA area was significantly decreased in AF [2.3 (1.7-2.7) cm2] vs. 3.1 (2.3-3.5) cm2 in SR, p = 0.002. Patients with ≥ moderate TR (n = 41, 59%) had lower absolute change in TA area [2.4 (1.7-3.1) cm2 vs. 2.8 (2.2-3.5) cm2 in &lt; moderate TR, p = 0.05]. Female sex was associated with lower absolute change in TA area [2.3 (1.7-3.2) cm2 vs. 2.7 (2.2-3.6) cm2 in males, p = 0.02] on univariate analysis. AF patients had more frequently ≥ moderate TR [28 AF vs. 13 SR, p &lt; 0.001]. On multivariate analysis including sex, rhythm, TR severity, RA and RV strains, and averaged maximal TA area, independent factors associated with lower absolute change in TA area were AF, ≥ moderate TR, and larger maximal TA area (p &lt; 0.05 for all). Time to minimal TA size was achieved in (0-40%) of the R-R interval in 70% of patients in SR compared to only 41% of patients in AF (Figure 2) and in 73% in patients with &lt; moderate TR compared to 43% in patients with ≥ moderate TR. Conclusion AF is associated with blunted TA dynamics resulting in lower decrease in TA size and with a heterogenous timing of minimal TA size throughout the cardiac cycle. The blunted and discoordinated annular contraction may reduce systolic tricuspid valve competence and be involved in the pathophysiology of functional TR. Future studies are needed to confirm this hypothesis and evaluate the effect of restoration of SR on TA dynamics and time to minimal TA size. Abstract Figure 1Abstract Figure 2

Abstract Aims Beat-to-beat variability in cycle length is well-known in atrial fibrillation (Afib); whether this also translates to variability in annulus size remains unknown. Defining annulus maximal size in Afib is critical for accurate selection of percutaneous devices given the frequent association with mitral and tricuspid valve diseases. Methods and results Images were obtained from 170 patients undergoing 3D echocardiography [100 (50 sinus rhythm (SR) and 50 Afib) for mitral annulus (MA) and 70 (35 SR and 35 Afib) for tricuspid annulus (TA)]. Images were analysed for differences in annular dynamics with a commercially available software. Number of cardiac cycles analysed was 567 in mitral valve and 346 in tricuspid valve. Median absolute difference in maximal MA area over four to six cycles was 1.8 cm2 (range 0.5–5.2 cm2) in Afib vs. 0.8 cm2 (range 0.1–2.9 cm2) in SR, P &lt; 0.001. Maximal MA area was observed within 30–70% of the R-R interval in 81% of cardiac cycles in SR and in 73% of cycles in Afib. Median absolute difference in maximal TA area over four to six cycles was 1.4 cm2 (range 0.5–3.6 cm2) in Afib vs. 0.7 cm2 (range 0.3–1.7 cm2) in SR, P &lt; 0.001. Maximal TA area was observed within 60–100% of the R-R interval in 81% of cardiac cycles in SR, but only in 49% of cycles in Afib. Conclusion MA and TA reach maximal size within a broad time interval centred around end-systole and end-diastole, respectively, with significant beat-to-beat variability. Afib leads to a larger beat-to-beat variability in both timing of occurrence and values of annulus size than in SR.

Abstract Background Atrial fibrillation (Afib) leads to beat-to-beat variability in cycle length; however, whether there is associated beat-to-beat variability in the tricuspid annulus (TA) dimensions or variability in the time in cardiac cycle when TA reaches maximal size is unknown. Purpose We aim to assess the beat-to-beat variability in the TA dimensions in Afib compared with sinus rhythm (SR). Methods Images were obtained from 58 patients (29 in Afib, 29 in SR) undergoing either 3D TTE or TEE examination. We measured TA in 3–6 cardiac cycles per patient using commercially available software (TomTec 4MV). Results Median absolute difference in maximal TA area over 3–6 cardiac cycles was 1.60 cm2 (range 0.35 cm2 to 4.08 cm2) in Afib vs. 1.17 cm2 (range 0.32 cm2 to 2.19 cm2) in SR, p=0.0063. Median absolute difference in the maximal circumference was 0.79 cm (range 0.09 cm to 2.2 cm) in Afib vs 0.54 cm (range 0.12 cm to 1.43 cm) in SR, p=0.0175. A total of 118 cardiac cycles were analyzed in patients in SR and 147 in Afib. Timing of maximal TA area was most commonly recorded at end-diastole (80–100% of the R-R interval) in 62% of cycles in SR; however, it was distributed over a broad range in Afib, p&lt;0.0001, [Figure]. Conclusion Afib leads to significant beat-to-beat variability in the maximal TA area, minimal TA area, maximal TA circumference, and in the time of maximal TA area. These findings suggest that accurate assessment of TA dimensions should be based on continuous tracking of the TA over several cardiac cycles, especially in patients with Afib. These observations have significant implications for device sizing in percutaneous tricuspid valve interventions. Timing of Maximal TA Area Funding Acknowledgement Type of funding source: None