RESUMO
INTRODUÇÃO: Métodos de imagem tradicionais são limitados na avaliação precoce da disfunção do ventrículo direito, particularmente em casos de insuficiência tricúspide (IT). O strain longitudinal de parede livre de ventrículo direito (SL-PLVD) emergiu como uma ferramenta promissora para aprimorar essa avaliação. OBJETIVO: Nosso objetivo foi conduzir uma revisão sistemática e metanálise para investigar se a redução do SL-PLVD em pacientes com IT moderada a importante está associada a um risco aumentado de mortalidade por todas as causas e hospitalização por insuficiência cardíaca (IC). MÉTODOS: Pesquisamos PubMed, Embase e Cochrane por estudos que examinaram essa questão. Dois revisores realizaram de forma independente a seleção dos estudos, extração de dados e avaliação do risco de viés. O SL-PLVD foi avaliada como uma variável binária: normal/quase normal vs. reduzido, sendo o último definido como SL-PLVD > 17% (foram utilizados valores absolutos para melhor comunicação dos dados). A análise estatística foi realizada usando o Review Manager 5.4.1. Calculamos hazard ratios (HR) com intervalos de confiança (IC) de 95% sob um modelo de efeitos aleatórios. Também realizamos uma análise de subgrupo de análises multivariadas para minimizar o efeito de variáveis de confusão. RESULTADOS: Incluímos 2.176 pacientes de 6 estudos de coorte, cujo seguimento médio variou de 1,18 a 3,9 anos e a faixa etária de 62 a 85 anos; 2.121 (97,4%) tinham IT funcional. A mortalidade por todas as causas (HR 1,09; IC 95% 1,03-1,15; p=0,002) e o composto de mortalidade por todas as causas ou hospitalizações por IC (HR 1,12; IC 95% 1,06-1,18; p<0,001;) foram significativamente maiores em pacientes com SL-PLVD reduzidos em comparação com SL-PLVD normal ou quase normal. Considerando apenas dados ajustados por multivariáveis, pacientes com SL-PLVD reduzido também apresentaram risco mais elevado de mortalidade por todas as causas s (HR 1,08; IC 95% 1,02-1,14; p = 0,007). CONCLUSÕES: Nossos achados indicam que a SL-PLVD é um fator prognóstico independente para mortalidade por todas as causas entre pacientes com IT moderada a importante. O uso da SL-PLVD para orientar o manejo dessa população requer investigações adicionais.
Assuntos
Insuficiência da Valva TricúspideRESUMO
AIMS: Renal and liver congestion are associated with adverse outcomes in patients with tricuspid regurgitation (TR). Currently, there are no valid sonographic indicators of fluid status in this population. Intra-renal venous Doppler (IRVD) is a novel method for quantifying renal congestion but its interpretation can be challenging in severe TR due to altered haemodynamics. This study explores the potential of portal vein Doppler (PVD) as an alternative marker for decongestion during volume removal in patients with severe TR. METHODS AND RESULTS: Forty-two patients with severe TR undergoing decongestive therapy were prospectively enrolled. Inferior vena cava diameter, PVD, and IRVD were sequentially assessed during volume removal. Improvement criteria were portal vein pulsatility fraction (PVPF) < 70% and renal venous stasis index (RVSI) < 0.5 for partial improvement, and PVPF < 30% and RVSI < 0.2 for complete improvement. After volume removal, PVPF significantly improved from 130 ± 39% to 47 ± 44% (P < 0.001), while IRVD improved from 0.72 ± 0.08 to 0.54 ± 0.22 (P < 0.001). A higher proportion of patients displayed improvement in PVD compared to IRVD (partial: 38% vs. 29%, complete: 41% vs. 7%) (P < 0.001). Intra-renal venous Doppler only improved in patients with concomitant improvement in severe TR. Portal vein Doppler was the only predictor of achieving ≥5â L of negative fluid balance [area under the ROC curve (AUC) 0.83 P = 0.001]. CONCLUSION: This proof-of-concept study suggests that PVD is the only sonographic marker that can track volume removal in severe TR, offering a potential indicator for decongestion in this population. Further intervention trials are warranted to determine if PVD-guided decongestion improves patient outcomes in severe TR.
Assuntos
Veia Porta , Estudo de Prova de Conceito , Insuficiência da Valva Tricúspide , Humanos , Veia Porta/diagnóstico por imagem , Masculino , Feminino , Insuficiência da Valva Tricúspide/fisiopatologia , Insuficiência da Valva Tricúspide/diagnóstico , Estudos Prospectivos , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Idoso , Ultrassonografia Doppler/métodos , Hemodinâmica/fisiologia , Veia Cava Inferior/diagnóstico por imagemRESUMO
OBJECTIVE: A substantial proportion of patients with rheumatic heart disease (RHD) have tricuspid regurgitation (TR). This study aimed to identify the impact of functional TR on clinical outcomes and predictors of progression in a large population of patients with RHD. METHODS: A total of 645 patients with RHD were enrolled, mean age of 47±12 years, 85% female. Functional TR was graded as absent, mild, moderate or severe. TR progression was defined either as worsening of TR degree from baseline to the last follow-up echocardiogram or severe TR at baseline that required surgery or died. Incidence of TR progression was estimated accounting for competing risks. RESULTS: Functional TR was absent in 3.4%, mild in 83.7%, moderate in 8.5% and severe in 4.3%. Moderate and severe functional TR was associated with adverse outcome (HR 1.91 (95% CI 1.15 to 3.2) for moderate, and 2.30 (95% CI 1.28 to 4.13) for severe TR, after adjustment for other prognostic variables. Event-free survival rate at 3-year follow-up was 91%, 72% and 62% in patients with no or mild, moderate and severe TR, respectively. During mean follow-up of 4.1 years, TR progression occurred in 83 patients (13%) with an overall incidence of 3.7 events (95% CI 2.9 to 4.5) per 100 patient-years. In the Cox model, age (HR 1.71, 95% CI 1.34 to 2.17), New York Heart Association functional class III/IV (HR 2.57, 95% CI 1.54 to 4.30), right atrial area (HR 1.52, 95% CI 1.10 to 2.10) and right ventricular (RV) dysfunction (HR 2.02, 95% CI 1.07 to 3.84) were predictors of TR progression. By considering competing risk, the effect of RV dysfunction on TR progression risk was attenuated. CONCLUSIONS: In patients with RHD, functional TR was frequent and associated with adverse outcomes. TR may progress over time, mainly related to right-sided cardiac chambers remodelling.
Assuntos
Apêndice Atrial , Doenças das Valvas Cardíacas , Cardiopatia Reumática , Insuficiência da Valva Tricúspide , Disfunção Ventricular Direita , Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Masculino , Cardiopatia Reumática/diagnóstico , Cardiopatia Reumática/diagnóstico por imagem , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Insuficiência da Valva Tricúspide/diagnóstico por imagem , Insuficiência da Valva Tricúspide/epidemiologiaAssuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Substituição da Valva Aórtica Transcateter , Insuficiência da Valva Tricúspide , Humanos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Insuficiência da Valva Tricúspide/cirurgia , Estenose da Valva Aórtica/cirurgia , Resultado do Tratamento , Cateterismo Cardíaco , Valva Aórtica/cirurgiaRESUMO
BACKGROUND: The extent of cardiac damage associated with aortic stenosis has important prognostic implications after transcatheter aortic valve replacement (TAVR). However, the role of tricuspid regurgitation (TR) in this clinical setting is still unclear. OBJECTIVES: To explore the association between TR and mortality in patients undergoing TAVR and assess changes in TR severity post TAVR and its relationship with short and mid-term mortality. METHODS: Relevant databases were searched for articles published from inception until August 2020. Out of 414 screened studies, we selected 24 that reported the degree of TR pre or post TAVR. The primary outcome was all-cause mortality, and random effects meta-analysis models were conducted (at a significance level of 5%). RESULTS: Seventeen studies reported associations between pre-TAVR TR and all-cause mortality (> 45,000 participants) and thirteen accessed TR severity post TAVR (709 participants). Moderate/severe baseline TR was associated to higher all-cause mortality both at 30 days (HR 1.65; 95% CI, 1.20-2.29) and 1.2 years (HR 1.56; 95% CI, 1.31-1.84). After TAVR, 43% of patients presented a decrease of at least one grade in TR (30 days, 95% CI, 30-56%), sustained at 12.5 months in 44% of participants (95% CI, 35-52%). Persistence of significant TR was associated with a two-fold increase in all-cause mortality (HR 2.12; 95% CI, 1.53-2.92). CONCLUSIONS: Significant TR pre TAVR is associated with higher mortality. Although TR severity may improve, the persistence of significant TR post TAVR is strongly associated with increased mortality. Our findings highlight the importance of a detailed assessment of TR pre and post TAVR and might help identify patients who may benefit from more careful surveillance in this scenario.
FUNDAMENTO: A extensão do dano cardíaco associada à estenose aórtica tem importantes implicações prognósticas após a substituição da valva aórtica transcateter (TAVR). Contudo, ainda não está claro qual é o papel da insuficiência tricúspide (IT) nesse cenário clínico. OBJETIVOS: Explorar a associação entre IT e mortalidade em pacientes submetidos a TAVR e avaliar as alterações na gravidade da IT após a TAVR e sua relação com mortalidade de curto e médio prazo. MÉTODOS: Foram feitas pesquisas em bases de dados relevantes de artigos publicados do início até agosto de 2020. Dos 414 estudos triados, selecionamos 24 que relataram o grau de IT pré- ou pós-TAVR. O desfecho primário foi mortalidade por todas as causas, e foram conduzidos modelos de metanálise de efeitos aleatórios (a um nível de significância de 5%). RESULTADOS: Dezessete estudos relataram associações entre IT pré-TAVR e mortalidade por todas as causas (> 45.000 participantes), e 13 avaliaram a gravidade da IT pós-TAVR (709 participantes). A IT basal moderada/grave foi associada a maior mortalidade por todas as causas em 30 dias [razão de risco (RR) 1,65; intervalo de confiança (IC) 95% 1,20-2,29] e 1,2 ano (RR 1,56; IC95% 1,31-1,84). Após a TAVR, 43% dos pacientes apresentaram redução de pelo menos um grau na IT (30 dias, IC95% 30-56%), que se sustentou em 12,5 meses em 44% dos participantes (IC95% 35-52%).A persistência de IT significativa foi associada a um aumento de duas vezes na mortalidade por todas as causas (RR 2,12; IC95% 1,53-2,92). CONCLUSÕES: A IT significativa pré-TAVR está associada a maior mortalidade. Ainda que a gravidade da IT possa melhorar, a persistência de IT significativa após a TAVR está fortemente associada ao aumento da mortalidade. Nossos achados destacam a importância de uma avaliação detalhada da IT pré- e pós-TAVR e podem ajudar a identificar pacientes que possam se beneficiar de uma vigilância mais cuidadosa nesse cenário.
Assuntos
Estenose da Valva Aórtica , Substituição da Valva Aórtica Transcateter , Insuficiência da Valva Tricúspide , Humanos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Insuficiência da Valva Tricúspide/complicações , Resultado do Tratamento , Fatores de Risco , Prognóstico , Valva Aórtica/cirurgia , Índice de Gravidade de DoençaRESUMO
INTRODUCTION: We studied the effect of tricuspid valve (TV) surgery combined with surgical ventricular restoration (SVR) on operative outcomes, rehospitalization, recurrent tricuspid regurgitation, and survival of patients with ischemic cardiomyopathy. Additionally, surgery was compared to conservative management in patients with mild or moderate tricuspid regurgitation. To the best of our knowledge, the advantage of combining TV surgery with SVR in patients with ischemic cardiomyopathy had not been investigated before. METHODS: This retrospective cohort study included 137 SVR patients who were recruited from 2009 to 2020. Patients were divided into two groups - those with no concomitant TV surgery (n=74) and those with concomitant TV repair or replacement (n=63). RESULTS: Extracorporeal membrane oxygenation use was higher in SVR patients without TV surgery (P=0.015). Re-exploration and blood transfusion were significantly higher in those with TV surgery (P=0.048 and P=0.037, respectively). Hospital mortality occurred in eight (10.81%) patients with no TV surgery vs. five (7.94%) in the TV surgery group (P=0.771). Neither rehospitalization (log-rank P=0.749) nor survival (log-rank P=0.515) differed in patients with mild and moderate tricuspid regurgitation in both groups. Freedom from recurrent tricuspid regurgitation was non-significantly higher in mild and moderate tricuspid regurgitation patients with no TV surgery (P=0.059). Conservative management predicted the recurrence of tricuspid regurgitation. CONCLUSION: TV surgery concomitant with SVR could reduce the recurrence of tricuspid regurgitation; however, its effect on the clinical outcomes of rehospitalization and survival was not evident. The same effects were observed in patients with mild and moderate tricuspid regurgitation.
Assuntos
Cardiomiopatias , Implante de Prótese de Valva Cardíaca , Isquemia Miocárdica , Insuficiência da Valva Tricúspide , Humanos , Insuficiência da Valva Tricúspide/cirurgia , Resultado do Tratamento , Estudos Retrospectivos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Fatores de Risco , Fatores de Tempo , Isquemia Miocárdica/complicações , Isquemia Miocárdica/cirurgia , Cardiomiopatias/cirurgiaRESUMO
Tricuspid regurgitation (TR) in children may be secondary to congenital anomalies of the tricuspid valve complex which is composed by annulus, leaflets, commissures, chordae tendineae, and papillary muscles. The most common congenital cause is Ebstein's anomaly; however, there are less frequent causes such as abnormal number of tricuspid leaflets, tricuspid cleft, leaflet prolapse, double orifice tricuspid valve, and congenital tricuspid valve dysplasia. Identifying the precise cause is important to plan an appropriate repair surgery. In this article, the case of a 4-year-old patient with a tetracuspid valve with significant tricuspid regurgitation is presented and the morphological analysis was made by two-dimensional (2D) and three-dimensional (3D) transthoracic echocardiography. The morphological differences between a tetracuspid valve and a cleft of the anterior leaflet tricuspid valve are exposed. 3D echocardiographic evaluation of the tricuspid valve allowed a better understanding of the tricuspid valve anatomy, which includes evaluation of the tricuspid annulus, leaflets, commissures, and subvalvular apparatus. Recognizing the accurate cause of isolated tricuspid regurgitation allows better planning of the surgical technique.
Assuntos
Anomalia de Ebstein , Pediatria , Insuficiência da Valva Tricúspide , Humanos , Criança , Pré-Escolar , Insuficiência da Valva Tricúspide/diagnóstico por imagem , Insuficiência da Valva Tricúspide/etiologia , Ecocardiografia , Valva Tricúspide/cirurgia , Anomalia de Ebstein/complicações , Anomalia de Ebstein/cirurgiaRESUMO
OBJECTIVE: Device lead-induced tricuspid regurgitation (LITR) mechanisms are well-defined by 3D transthoracic echocardiography (3D-TTE). There is a lack of data on the Latin-American population. The objective of this study was to describe the prevalence of several mechanisms and insights in patients with permanent right ventricular (RV) implanted devices by 3D-TTE examination. METHODS: We performed a cross-sectional analysis of 101 patients with permanent cardiac devices such as pacemakers or defibrillators. 3D-TTE was obtained on all patients in RV-focused apical views to perform a complete tricuspid valve (TV) evaluation: leaflets, subvalvular apparatus, precise lead location, and functional assessment to evaluate possible mechanisms of tricuspid regurgitation (TR). RESULTS: In a total of 101 patients, the leads did not interfere with TV function in 53 p. (59%), while LITR was observed in 38 (41%) patients. Adherent, impinging, entangled, and mixed lead-induced mechanisms were observed. Time in years since device implantation was significantly higher in patients with LITR. CONCLUSIONS: LITR was present in a high proportion of our population. LITR is the result of damage to the TV as well as its subvalvular apparatus due to the fibrotic and inflammatory response over time when leads are situated in unfavorable locations.
Assuntos
Ecocardiografia Tridimensional , Insuficiência da Valva Tricúspide , Humanos , Insuficiência da Valva Tricúspide/diagnóstico por imagem , Estudos Transversais , Valva Tricúspide/diagnóstico por imagem , Ecocardiografia Tridimensional/métodos , Ventrículos do Coração/diagnóstico por imagemRESUMO
INTRODUCTION: Tricuspid regurgitation has been increasingly recognized as a clinically relevant entity with a long-term prognostic impact on quality of life and survival. Despite this, there are still some unmet clinical needs regarding the management of tricuspid regurgitation that require further investigation. AREAS COVERED: This review addresses current evidence for the treatment of tricuspid regurgitation, focusing primarily on new catheter-based technologies. In addition, we discuss recent registries and clinical trial outcomes. EXPERT OPINION: A multimodality and multiparametric integrative approach has been preconized to assess tricuspid regurgitation mechanism and severity, and new technologies have been developed to address the main causative factors of tricuspid regurgitation. Matching the right device to the right patient and deciding when is the best time for intervention are major challenges in the management of tricuspid regurgitation.
Assuntos
Insuficiência da Valva Tricúspide , Humanos , Cateterismo Cardíaco/efeitos adversos , Prognóstico , Qualidade de Vida , Resultado do Tratamento , Valva Tricúspide/cirurgia , Insuficiência da Valva Tricúspide/cirurgiaRESUMO
A regurgitação tricúspide (RT) importante está associada à alta morbidade e mortalidade. Como o tratamento cirúrgico da RT isolada tem sido associado à alta mortalidade, as intervenções transcateter na valva tricúspide (VT) têm sido utilizadas para o seu tratamento, com risco relativamente mais baixo. Há um atraso na intervenção da RT e provavelmente está relacionado a uma compreensão limitada da anatomia da VT e do ventrículo direito, além da subestimação da gravidade da RT. Nesse cenário, faz-se necessário o conhecimento anatômico abrangente da VT, a fisiopatologia envolvida no mecanismo de regurgitação, assim como a sua graduação mais precisa. A VT tem peculiaridades anatômica, histológica e espacial que fazem a sua avalição ser mais complexa, quando comparado à valva mitral, sendo necessário o conhecimento e treinamento nas diversas técnicas ecocardiográficas que serão utilizadas frequentemente em combinação para uma avaliação precisa. Esta revisão descreverá a anatomia da VT, o papel do ecocardiograma no diagnóstico, graduação e fisiopatologia envolvida na RT, as principais opções atuais de tratamento transcateter da RT e a avaliação do resultado após intervenção transcateter por meio de múltiplas modalidades ecocardiográficas.(AU)
Severe tricuspid regurgitation (TR) is associated with high morbidity and mortality. Given that surgical treatment of TR alone has been associated with high mortality, transcatheter interventions in the tricuspid valve (TV) have been used for its treatment, with relatively lower risk. There is a delay in intervention for TR, and this is probably related to a limited understanding of the anatomy of the TV and the right ventricle, in addition to an underestimation of the severity of TR. In this scenario, it is necessary to have comprehensive anatomical knowledge of the TV, the pathophysiology involved in the mechanism of regurgitation, and more accurate grading. The TV has anatomical, histological, and spatial peculiarities that make its assessment more complex when compared to the mitral valve, requiring knowledge and training in the various echocardiographic techniques that will often be used in combination for accurate assessment. This review will describe the anatomy of the TV, the role of echocardiography in the diagnosis, grading, and pathophysiology involved in TR; the main transcatheter treatment options currently available for TR; and the assessment of outcomes after transcatheter intervention by means of multiple echocardiographic modalities.(AU)