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Comparison of Residual Tricuspid Regurgitation Severity Assessed by Intraprocedural and Postprocedural Echocardiography in Patients Undergoing Transcatheter Tricuspid Valve Repair

Published:August 27, 2022DOI:https://doi.org/10.1053/j.jvca.2022.08.020
      To the Editor:TRANSCATHETER TRICUSPID valve repair (TTVr) using edge-to-edge clipping devices has emerged recently to treat high-risk symptomatic patients with severe tricuspid regurgitation (TR).
      • Bocchino PP
      • Angelini F
      • Vairo A
      • et al.
      Clinical outcomes following isolated transcatheter tricuspid valve repair: A meta-analysis and meta-regression study.
      Inaccurate grading of TR severity during the procedure may result in suboptimal results, leading to significant residual TR. Thus, an accurate estimation of intraprocedural TR is essential. Because systemic venous return and cardiac output are frequently decreased during anesthesia,
      • Alwardt CM
      • Redford D
      • Larson DF.
      General anesthesia in cardiac surgery: A review of drugs and practices.
      we hypothesized that residual TR during the procedure would be underestimated. This study compared the severity grades and color jet area (CJA) of residual TR, as assessed by the intraprocedural transesophageal echocardiography (TEE) and postprocedural transthoracic echocardiography (TTE), in patients undergoing TTVr. Patients who underwent isolated TTVr using the MitraClip system (Abbott Vascular) in our institution between January 2017 and November 2021 were included. Although baseline and postprocedural TTE were performed under conscious conditions, intraprocedural TEE was conducted under general anesthesia during mechanical ventilation. The baseline, intraprocedural, and postprocedural TR grades were collected from the echocardiography reports. The TR grades were classified by experienced cardiologists based on a multiparametric integrative approach in accordance with current guidelines,
      • Zoghbi WA
      • Adams D
      • Bonow RO
      • et al.
      Recommendations for noninvasive evaluation of native valvular regurgitation: A report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance.
      • Hahn RT
      • Thomas JD
      • Khalique OK
      • et al.
      Imaging assessment of tricuspid regurgitation severity.
      • Hoffmeister KJ
      • Henderson ZT
      • Hussey PT
      • et al.
      Guidelines for the evaluation of valvular regurgitation after percutaneous valve repair or replacement: A focused review for the cardiac anesthesiologist.
      as none/trace, mild, mild-to-moderate, moderate, moderate-to-severe, severe, and massive/torrential. The CJA of TR was measured by tracing the largest jet area in midsystole on color Doppler images, with an aliasing velocity of 50-to- 60 cm/s from the apical 4-chamber or right ventricle (RV) inflow view on TTE and the midesophageal four-chamber or RV inflow-outflow view on TEE.
      Ninety-two patients were reviewed retrospectively. The etiology of TR was functional (n = 70), pacemaker lead-related (n = 16), and degenerative (n = 6). The number of implanted clips was 2.2 ± 0.8. The median time interval between baseline TTE and TEE was 21 days (IQR: 7-59). All postprocedural TTE tests were performed within 2 days after TTVr. Figure 1A shows the distributions of TR grades at 3 time points. Moderate or greater TR on baseline TTE was observed in 91 patients. Both TEE and postprocedural TTE showed improvements in TR (p < 0.001 for both comparisons) compared to the baseline TTE. Moreover, the median grades of TR severity were “mild-to-moderate” and “moderate” on intraprocedural TEE and postprocedural TTE, respectively, and the grade distribution on intraprocedural TEE was less severe than that on postprocedural TTE (p = 0.025). Similarly, the CJA of TR significantly improved after the implantation of clips, and the CJA on intraprocedural TEE was smaller compared to postprocedural TTE (4.7 ± 3.2 v 8.4 ± 5.8 cm2, p < 0.001), as shown in Figure 1B. The results demonstrated that intraprocedural TEE showed lower residual TR grades and smaller CJA than postprocedural TTE. Although there is a lack of evidence regarding the influence of anesthesia and mechanical ventilation on TR severity, previous studies demonstrated that intraoperative or intraprocedural mitral regurgitation severity can be underestimated during general anesthesia.
      • Sanfilippo F
      • Johnson C
      • Bellavia D
      • et al.
      Mitral regurgitation grading in the operating room: A systematic review and meta-analysis comparing preoperative and intraoperative assessments during cardiac surgery.
      ,
      • Alachkar MN
      • Kirschfink A
      • Grebe J
      • et al.
      General anesthesia leads to underestimation of regurgitation severity in patients with secondary mitral regurgitation undergoing transcatheter mitral valve repair.
      Positive-pressure ventilation may increase RV afterload, but anesthesia and mechanical ventilation can reduce systemic venous return, RV preload, and cardiac output.
      • Alwardt CM
      • Redford D
      • Larson DF.
      General anesthesia in cardiac surgery: A review of drugs and practices.
      ,
      • Berger D
      • Takala J.
      Determinants of systemic venous return and the impact of positive pressure ventilation.
      A previous experimental study also described the impaired RV contractility and tricuspid annular dynamics during anesthesia.
      • Jazwiec T
      • Malinowski M
      • Proudfoot AG
      • et al.
      Tricuspid valvular dynamics and 3-dimensional geometry in awake and anesthetized sheep.
      Therefore, we speculated that the emergence from anesthesia is associated with RV preload and potentially worsening TR, as assessed by postprocedural TTE.
      Fig 1
      Fig 1Comparison of tricuspid regurgitation (TR) severity assessed by the baseline, intraprocedural, and postprocedural echocardiography in patients who underwent transcatheter tricuspid valve repair. (A) Severity grades of TR and (B) the color jet area of TR. TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.

      Acknowledgments

      Dr Kuwajima is supported by UTokyo Global Activity Support Program for Young Researchers.

      Conflict of Interest

      Dr Makkar has received grant support from Edwards Lifesciences and St. Jude Medical and is a consultant for Abbott Vascular, Cordis, and Medtronic. All other authors have no conflict of interests to disclose.

      Author Contributions

      Dr Kuwajima: Conceptualization, methodology, data curation, formal analysis, and writing of the original draft. Dr Kagawa: Data curation and writing, review, and editing. Dr Yamane: Data curation and writing, review, and editing. Dr Hasegawa: Data curation and writing, review, and editing. Dr Makar: Data curation and writing, review, and editing. Dr Makkar: Data curation and writing, review, and editing. Dr Shiota: Conceptualization, methodology, supervision, and writing of the original draft.

      References

        • Bocchino PP
        • Angelini F
        • Vairo A
        • et al.
        Clinical outcomes following isolated transcatheter tricuspid valve repair: A meta-analysis and meta-regression study.
        JACC Cardiovasc Interv. 2021; 14: 2285-2295
        • Alwardt CM
        • Redford D
        • Larson DF.
        General anesthesia in cardiac surgery: A review of drugs and practices.
        J Extra Corpor Technol. 2005; 37: 227-235
        • Zoghbi WA
        • Adams D
        • Bonow RO
        • et al.
        Recommendations for noninvasive evaluation of native valvular regurgitation: A report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance.
        J Am Soc Echocardiogr. 2017; 30: 303-371
        • Hahn RT
        • Thomas JD
        • Khalique OK
        • et al.
        Imaging assessment of tricuspid regurgitation severity.
        JACC Cardiovasc Imaging. 2019; 12: 469-490
        • Hoffmeister KJ
        • Henderson ZT
        • Hussey PT
        • et al.
        Guidelines for the evaluation of valvular regurgitation after percutaneous valve repair or replacement: A focused review for the cardiac anesthesiologist.
        J Cardiothorac Vasc Anesth. 2020; 34: 2740-2753
        • Sanfilippo F
        • Johnson C
        • Bellavia D
        • et al.
        Mitral regurgitation grading in the operating room: A systematic review and meta-analysis comparing preoperative and intraoperative assessments during cardiac surgery.
        J Cardiothorac Vasc Anesth. 2017; 31: 1681-1691
        • Alachkar MN
        • Kirschfink A
        • Grebe J
        • et al.
        General anesthesia leads to underestimation of regurgitation severity in patients with secondary mitral regurgitation undergoing transcatheter mitral valve repair.
        J Cardiothorac Vasc Anesth. 2022; 36: 974-982
        • Berger D
        • Takala J.
        Determinants of systemic venous return and the impact of positive pressure ventilation.
        Ann Transl Med. 2018; 6: 350
        • Jazwiec T
        • Malinowski M
        • Proudfoot AG
        • et al.
        Tricuspid valvular dynamics and 3-dimensional geometry in awake and anesthetized sheep.
        J Thorac Cardiovasc Surg. 2018; 156: 1503-1511