BACKGROUND Anatomic regurgitant orifice area (AROA) can be measured by 4-dimensional (4D)-computed tomography angiography (CTA) to define tricuspid regurgitation (TR) severity, but its association with outcomes has not been established. OBJECTIVES This study aims to assess the independent prognostic value of TR quantification by 4D-CTA AROA measurement. METHODS Comprehensive clinical, echocardiographic and 4D-CTA data were collected from patients with clinically significant TR evaluated at 4 Allina Health centers between 2019 and 2023 for TR intervention. The outcome of interest was all-cause mortality under medical management after diagnosis. RESULTS AROA measurement was obtained in 174 patients (median age 83 years [Q1-Q3: 77-97 years], left ventricular ejection fraction 58% [Q1-Q3: 51%-60%], right ventricular [RV] ejection fraction 46% [Q1-Q3: 41%-51%] and tricuspid AROA 0.74 cm(2) [Q1-Q3: 0.55-1.42 cm(2)]). During a median follow-up of 2.3 years [Q1-Q3: 1.1-3.2 years], 49 (28%) patients died under medical management with 3-year survival rate of 55% [Q1-Q3: 45%-67%]. Spline curve analysis showed that AROA 1.1 cm(2) was the threshold associated with increased mortality within the cohort. Patients with AROA >1.1 cm(2) had higher TRI-SCOREs, larger tricuspid annulus dimension, tricuspid maximum coaptation gap, RV and right atrial volumes (all P < 0.001). Despite similar RV ejection fraction, patients with AROA >1.1 cm(2) had worse RV function denoted by lower RV free-wall longitudinal strain (P < 0.001) compared to those with AROA <1.1 cm(2). In multivariable analysis, AROA >1.1 cm(2) remained independently associated with excess mortality (adjusted HR 2.23 [95% CI: 1.02-4.85]; P = 0.040) and worse 3-year survival under medical management (68% [Q1-Q3: 56%-82%] vs 36% [Q1-Q3: 28%-52%]; P = 0.013). CONCLUSIONS This first outcome study of patients with clinically significant TR examined by 4D-CTA shows that higher AROA measurement strongly associates with worse right heart remodeling and independently associates with excess mortality. Therefore, 4D-CTA, beyond anatomical assessment, provides prognostically relevant assessment of TR severity. Thus, AROA measurement should be considered in patients with TR evaluated by 4D-CTA. (JACC Cardiovasc Imaging. 2026;19:197-207) (c) 2026 by the American College of Cardiology Foundation.

Tricuspid regurgitation (TR) is increasingly recognized as a major contributor to cardiovascular morbidity and mortality, with growing attention to its development and progression in patients with cardiac implantable electronic devices (CIEDs). While leadless pacemakers (LPMs) were introduced to eliminate transvalvular leads-long considered the primary driver of CIED-related TR-emerging evidence suggests that LPMs do not completely eliminate the risk of developing new or worsening TR. Instead, TR in this population appears to arise from a broader set of mechanical, anatomical, and electrophysiologic mechanisms, many of which extend beyond the historical lead-impingement paradigm. This review consolidates the current knowledge on epidemiology, mechanisms, and diagnostic challenges, while outlining a multidisciplinary framework for diagnosis and management strategies of LPM-related TR. In addition, we aim to highlight current gaps in evidence and areas for future investigation.

BACKGROUND:Right ventricular-pulmonary arterial coupling is a known prognostic marker in patients with tricuspid regurgitation (TR). However, its assessment by cardiac magnetic resonance and its clinical implications have not been evaluated. We aimed to assess the prognostic role of a cardiac magnetic resonance surrogate of right ventricular-pulmonary arterial coupling in a large cohort of patients with a spectrum of TR severity. METHODS:Comprehensive data were collected from patients referred for cardiac magnetic resonance from 2019 to 2024 who had TR quantification. Right ventricular-pulmonary arterial coupling was calculated by dividing the forward right ventricular stroke volume (f-RVSV) by the right ventricular end-systolic volume (ESV). The outcome of interest was the composite of all-cause death and heart failure hospitalization, under medical management. RESULTS:In the 631 patients included, median age was 66 (interquartile range [IQR], 54-75) years, median tricuspid regurgitant volume was 18 (IQR, 12-30 mL), median left ventricular ejection fraction was 53 (IQR, 41-61)%, median RV ejection fraction was 53 (IQR, 45-58)%, and median f-RVSV/ESV ratio was 0.82 (IQR, 0.58-1.11). In restricted spline curve analysis, the f-RVSV/ESV ratio cutoff associated with a hazard >1 for the composite outcome was ≤0.57. At baseline, a low f-RVSV/ESV ratio was strongly associated with subjective and objective signs of right heart failure, higher TRI-SCORE, and worse right-sided chamber remodeling (all P<0.001). After a median follow-up of 1.8 years (IQR, 1.5-2.0), patients with a low f-RVSV/ESV ratio showed worse survival (P<0.001). After comprehensive adjustment for clinical and imaging confounders, f-RVSV/ESV ≤0.57 remained a powerful predictor of outcome (adjusted hazard ratio, 2.36 [95% CI, 1.27-4.37]; P=0.004). Finally, patients with low f-RVSV/ESV displayed a worse long-term prognosis across mild, moderate, and severe TR groups (P<0.001, P<0.001, and P=0.018, respectively). CONCLUSIONS:In this large cohort of patients with a wide spectrum of TR severity, right ventricular-pulmonary arterial coupling assessed by cardiac magnetic resonance was strongly associated with right-sided heart failure and worse long-term prognosis, even after comprehensive adjustment.

AIMS:Quantitative methods for tricuspid regurgitation (TR) severity assessment are insufficiently validated. This study aims to assess cardiac magnetic resonance (CMR) quantitation of TR severity and its association with clinical and physiological consequences. METHODS AND RESULTS:Patients with prospective comprehensive CMR with TR assessment including regurgitant volume and fraction (TRF) were retrospectively identified. Comprehensive clinical, echocardiographic, and laboratory data were collected to assess other markers of TR severity and of TR-related heart-failure (HF), right-sided volumetric characteristics, and prognostic markers. A total of 335 patients were included presenting with a wide range of TR severity [median TRF 21% (13-33%)]. The number of guideline-based echocardiographic signs of severe TR was strongly associated with TRF (P < 0.001). TRF was significantly associated with subjective/objective signs of right-sided HF, including biomarkers of liver dysfunction and CMR-based liver extracellular volume [L-ECV, 36% (32-39%) for TRF > 40%, 31% (28-34%) for TRF 21-40% and 27% (26-30%) for TRF ≤ 20%, P < 0.001]. TRF was associated with maladaptive right-sided remodelling, including right ventricular end-diastolic volume-indexed [RV-EDVi, 117 mL/m2 (99-135 mL/m2) for T-RF > 40%, 98 mL/m2 (79-118 mL/m2)] for TRF 21-40% and 85 mL/m2 (73-103 mL/m2) for TRF ≤ 20%, P < 0.001]. TRF was also strongly associated with prognostic markers of outcomes in TR including TAPSE/PASP ratio [0.38 (0.32-0.46) for TRF > 40%, 0.53 (0.34-0.68) for TRF 21-40% and 0.69 (0.52-0.87) for TRF ≤ 20%, P < 0.001) and the TRISCORE [5 (3-7) for TRF > 40%, 2 (1-3) for TRF 21-40% and 1 (0-2) for TRF ≤ 20%, P < 0.001). CONCLUSION:In this all-comers TR cohort, CMR quantification of TR using TRF associated with guideline-based criteria for echocardiographic diagnosis of severe TR. RV remodelling objective right-sided HF signs/symptoms already occurred at TRF thresholds ≥20%, supporting the physiological consequences.

In recent years, the landscape for the diagnosis and management of patients with aortic stenosis (AS) has rapidly changed, with a dramatic increase in therapeutic options and substantial advances in different imaging modalities. Multidetector CT (MDCT) has become an essential imaging tool for evaluating the feasibility of both surgical and interventional treatments for patients with severe AS. Novel MDCT imaging acquisition protocols, postprocessing tools, and technological advances offer not only detailed anatomic information for adequate procedural planning but also comprehensive quantitative evaluation of the myocardium for assessment of remodeling and function, both of which have prognostic and therapeutic implications. This review provides a comprehensive update on the role of novel MDCT quantitative techniques in the assessment of patients with severe AS. Keywords: CT, Cardiac, Valves, Aortic Stenosis © RSNA, 2025.

BACKGROUND:Tricuspid regurgitation (TR) progression following left-sided valvular heart disease (VHD) correction is a critical clinical concern. This study aimed to determine the incidence, predictors and outcomes of TR progression in a contemporary cohort. METHODS:We analysed 1644 patients (mean age 73 years, 62% men) without severe TR who underwent surgical or transcatheter treatment for aortic or mitral disease between 2014 and 2018. TR progression was defined as an increase in TR grade to moderate or severe on follow-up echocardiography. RESULTS:At 5 years, TR progression incidence was 12.0% (95% CI 10.5% to 13.7%). Baseline factors associated with TR progression included older age, female sex, atrial fibrillation, prior pacemaker implantation and larger tricuspid annular diameter (TAD). The relationship between TAD and TR progression was linear (HR 1.08; 95% CI 1.04 to 1.11; p<0.001), with sex differences mitigated by indexing TAD to body surface area. TR progression was associated with increased all-cause mortality (adjusted HR 2.77; 95% CI 2.16 to 3.56; p<0.001) and a combined endpoint of death or heart failure hospitalisation (adjusted HR 2.91; 95% CI 2.21 to 3.82; p<0.001). CONCLUSIONS:TR progression is common after left-sided VHD correction and is associated with adverse outcomes. Indexing TAD to body surface area mitigates sex differences in risk assessment. These findings suggest that lower thresholds for prophylactic tricuspid intervention may be warranted in high-risk patients.

Background: Bioprosthetic valves are widely used in patients aged ≥65 years, but their durability is limited by structural valve deterioration (SVD). Data on repeat bioprosthetic aortic valve replacement (AVR) for early SVD (≤5 years) are scarce. Objectives: The purpose of this study was to evaluate 3-year hemodynamic outcomes and the incidence of recurrent SVD following repeat AVR. Methods: The authors retrospectively studied patients with surgical aortic valve replacement (SAVR) and early SVD requiring reintervention at Abbott Northwestern Hospital from January 2012 to December 2022. All patients had echocardiographic follow-up ≥30 days after repeat AVR. The primary endpoint was early SVD of the second bioprosthesis as per Valve Academic Research Consortium 3 criteria within 5 years after repeat SAVR or valve-in-valve transcatheter aortic valve replacement (TAVR). Secondary outcomes were mortality, congestive heart failure admission, and acute stroke. Results: Among 92 patients requiring reintervention for early SVD after SAVR, 76 had TAVR upon reintervention, and 16 had repeat SAVR. Recurrent early SVD occurred in 20 patients (21.7%); 13 (65.0%) occurred in the first year. Recurrent early SVD rates were higher, but not statistically different among patients receiving TAVR-after-SAVR (23.7%) vs SAVR-after-SAVR (12.5%) (adjusted HR: 3.31; 95% CI: 0.43-25.5; P = 0.23). Mean gradient ≥20 mm Hg, aortic valve area <1.0 cm2, and moderate/severe aortic regurgitation at discharge or 30 days were independent predictors of recurrent early SVD. At 3 years, mortality was 18.5%, stroke was 5.4%, and congestive heart failure was 26.1%. Conclusions: Early failure of the second bioprosthesis after reintervention, especially following valve-in-valve TAVR, mostly occurred within the first year. Residual hemodynamic abnormalities at discharge strongly predict early SVD.

IntroductionClinical evidence highlighting the efficacy and safety of transcatheter aortic valve replacement (TAVR) and the 2019 Food and Drug Administration (FDA) approval for TAVR in low-risk (younger) patients has created a demand for durable and long-lasting bioprosthetic heart valve (BHV) leaflet materials. Over the life of an implanted BHV mechanical stress, immunogenicity, calcification, and hemodynamic dysfunction lead to failure via structural valve deterioration (SVD). Consequently, the durability of the bioprosthetic materials selected for valve manufacture is of utmost importance.TechnologyThe ADAPT™ tissue engineering process, an anti-calcification preparation that transforms xenograft tissue (bovine pericardium) into a durable valve bioscaffold, shows significant clinical benefits in mitigating the interrelated mechanisms leading to SVD. The novel acellular, biostable and non-calcifying biomaterial has recently been molded into a single-piece 3D biomimetic valve (DurAVR™) with excellent early clinical results and the potential to meet the growing demand of durable BHVs for the treatment of aortic stenosis.DiscussionThe unique design of the DurAVR biomimetic valve in combination with the superior biostability of ADAPT tissue could advance the BHV space by providing superior performance and durability to aortic stenosis patients in need of TAVR.