Impact of severe secondary tricuspid regurgitation on rest and exercise hemodynamics of patients with heart failure and a preserved left ventricular ejection fraction Claudia Baratto, Sergio Caravita, Giorgia Corbetta, Davide Soranna, Antonella Zambon, et al. Frontiers in Cardiovascular Medicine, 2023 BackgroundBoth secondary tricuspid regurgitation (STR) and heart failure with preserved ejection fraction (HFpEF) are relevant public health problems in the elderly population, presenting with potential overlaps and sharing similar risk factors. However, the impact of severe STR on hemodynamics and cardiorespiratory adaptation to exercise in HFpEF remains to be clarified.AimTo explore the impact of STR on exercise hemodynamics and cardiorespiratory adaptation in HFpEF.MethodsWe analyzed invasive hemodynamics and gas-exchange data obtained at rest and during exercise from HFpEF patients with severe STR (HFpEF-STR), compared with 1:1 age-, sex-, and body mass index (BMI)- matched HFpEF patients with mild or no STR (HFpEF-controls).ResultsTwelve HFpEF with atrial-STR (mean age 72 years, 92% females, BMI 28 Kg/m2) and 12 HFpEF-controls patients were analyzed. HFpEF-STR had higher (p < 0.01) right atrial pressure than HFpEF-controls both at rest (10 ± 1 vs. 5 ± 1 mmHg) and during exercise (23 ± 2 vs. 14 ± 2 mmHg). Despite higher pulmonary artery wedge pressure (PAWP) at rest in HFpEF-STR than in HFpEF-controls (17 ± 2 vs. 11 ± 2, p = 0.04), PAWP at peak exercise was no more different (28 ± 2 vs. 29 ± 2). Left ventricular transmural pressure and cardiac output (CO) increased less in HFpEF-STR than in HFpEF-controls (interaction p-value < 0.05). This latter was due to lower stroke volume (SV) values both at rest (48 ± 9 vs. 77 ± 9 mL, p < 0.05) and at peak exercise (54 ± 10 vs. 93 ± 10 mL, p < 0.05). Despite these differences, the two groups of patients laid on the same oxygen consumption isophlets because of the increased peripheral oxygen extraction in HFpEF-STR (p < 0.01). We found an inverse relationship between pulmonary vascular resistance and SV, both at rest and at peak exercise (R2 = 0.12 and 0.19, respectively).ConclusionsSevere STR complicating HFpEF impairs SV and CO reserve, leading to pulmonary vascular de-recruitment and relative left heart underfilling, undermining the typical HFpEF pathophysiology.
Association of outcome with left ventricular volumes and ejection fraction measured with two- and three-dimensional echocardiography in patients referred for routine, clinically indicated studies Denisa Muraru, Sorina Mihaila Baldea, Davide Genovese, Michele Tomaselli, Francesca Heilbron, et al. Frontiers in Cardiovascular Medicine, 2022 ObjectivesWe sought to analyze if left ventricular (LV) volumes and ejection fraction (EF) measured by three-dimensional echocardiography (3DE) have incremental prognostic value over measurements obtained from two-dimensional echocardiography (2DE) in patients referred to a high-volume echocardiography laboratory for routine, clinically-indicated studies.MethodsWe measured LV volumes and EF using both 2DE and 3DE in 725 consecutive patients (67% men; 59 ± 18 years) with various clinical indications referred for a routine clinical study.ResultsLV volumes were significantly larger, and EF was lower when measured by 3DE than 2DE. During follow-up (3.6 ± 1.2 years), 111 (15.3%) all-cause deaths and 248 (34.2%) cardiac hospitalizations occurred. Larger LV volumes and lower EF were associated with worse outcome independent of age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart diseases). In stepwise Cox regression analyses, the associations of both death and cardiac hospitalization with clinical data (CD: age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart disease) whose Harrel’s C-index (HC) was 0.775, were augmented more by the LV volumes and EF obtained by 3DE than by 2DE parameters. The association of CD with death was not affected by LV end-diastolic volume (EDV) either measured by 2DE or 3DE. Conversely, it was incremented by 3DE LVEF (HC = 0.84, p < 0.001) more than 2DE LVEF (HC = 0.814, p < 0.001). The association of CD with the composite endpoint (HC = 0.64, p = 0.002) was augmented more by 3DE LV EDV (HC = 0.786, p < 0.001), end-systolic volume (HC = 0.801, p < 0.001), and EF (HC = 0.84, p < 0.001) than by the correspondent 2DE parameters (HC = 0.786, HC = 0.796, and 0.84, all p < 0.001) In addition, partition values for mild, moderate and severe reduction of the LVEF measured by 3DE showed a higher discriminative power than those measured by 2DE for cardiac death (Log-Rank: χ2 = 98.3 vs. χ2 = 77.1; p < 0.001). Finally, LV dilation defined according to the 3DE threshold values showed higher discriminatory power and prognostic value for death than when using 2DE reference values (3DE LVEDV: χ2 = 15.9, p < 0.001 vs. χ2 = 10.8, p = 0.001; 3DE LVESV: χ2 = 24.4, p < 0.001 vs. χ2 = 17.4, p = 0.001).ConclusionIn patients who underwent routine, clinically-indicated echocardiography, 3DE LVEF and ESV showed stronger association with outcome than the corresponding 2DE parameters.
The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype Mara Gavazzoni, Francesca Heilbron, Luigi P. Badano, Noela Radu, Andrea Cascella, et al. Frontiers in Cardiovascular Medicine, 2022 AimWe sought to evaluate the differences in prognosis between the atrial (A-STR) and the ventricular (V-STR) phenotypes of secondary tricuspid regurgitation.Materials and methodsConsecutive patients with moderate or severe STR referred for echocardiography were enrolled. A-STR and V-STR were defined according to the last ACC/AHA guidelines criteria. The primary endpoint was the composite of all-cause death and heart failure (HF) hospitalizations.ResultsA total of 211 patients were enrolled. The prevalence of A-STR in our cohort was 26%. Patients with A- STR were significantly older and with lower NYHA functional class than V-STR patients. The prevalence of severe STR was similar (28% in A-STR vs. 37% in V-STR, p = 0.291). A-STR patients had smaller tenting height (TH) (10 ± 4 mm vs. 12 ± 7 mm, p = 0.023), larger end-diastolic tricuspid annulus area (9 ± 2 cm2 vs. 7 ± 6 cm2/m2, p = 0.007), smaller right ventricular (RV) end-diastolic volumes (72 ± 27 ml/m2 vs. 92 ± 38 ml/m2; p = 0.001), and better RV longitudinal function (18 ± 7 mm vs. 16 ± 6 mm; p = 0.126 for TAPSE, and −21 ± 5% vs. −18 ± 5%; p = 0.006, for RV free-wall longitudinal strain, RVFWLS) than V-STR patients. Conversely, RV ejection fraction (RVEF, 48 ± 10% vs. 46 ± 11%, p = 0.257) and maximal right atrial volumes (64 ± 38 ml/m2 vs. 55 ± 23 ml/m2, p = 0.327) were similar between the two groups. After a median follow-up of 10 months, patients with V-STR had a 2.7-fold higher risk (HR: 2.7, 95% CI 95% = 1.3–5.7) of experiencing the combined endpoint than A-STR patients. The factors related to outcomes resulted different between the two STR phenotypes: TR-severity (HR: 5.8, CI 95% = 1, 4–25, P = 0.019) in A-STR patients; TR severity (HR 2.9, 95% CI 1.4–6.3, p = 0.005), RVEF (HR: 0.97, 95% CI 0.94–0.99, p = 0.044), and RVFWLS (HR: 0.93, 95% CI 0.85–0.98, p = 0.009) in V-STR.ConclusionAlmost one-third of patients referred to the echocardiography laboratory for significant STR have A-STR. A-STR patients had a lower incidence of the combined endpoint than V-STR patients. Moreover, while TR severity was the only independent factor associated to outcome in A-STR patients, TR severity and RV function were independently associated with outcome in V-STR patients.
RECENT SCHOLAR PUBLICATIONS
Discordant severity grading in right ventricular dysfunction: prognostic implications of conventional parameters versus 3D echocardiography-derived ejection fraction M Tolvaj, E Surkova, D Muraru, N Radu, AS Buta, A Clement, B Lakatos, ... European Heart Journal-Cardiovascular Imaging 27 (Supplement_1), jeaf367. 141 , 2026 2026
AN UNUSUSPECTED CASE OF MYOPERICARDITIS T Rinforzi, F Perelli, C Torlasco, R Brambilla European Heart Journal Supplements 27 (Supplement_5), suaf076. 352 , 2025 2025
INCIDENTAL CARDIAC AMYLOIDOSIS WITH AN ARRHYTHMIC PRESENTATION IN AN ASYMPTOMATIC ATHLETE T Rinforzi, F Perelli, R Brambilla, N Radu, C Torlasco, L Badano, L Crotti, ... European Heart Journal Supplements 27 (Supplement_5), suaf076. 213 , 2025 2025
Left atrial function and left atrioventricular coupling indices for atrial fibrillation prediction in hypertrophic cardiomyopathy V Rella, C Delcea, A Clement, S Fisicaro, F Perelli, M Tomaselli, M Penso, ... European Heart Journal-Cardiovascular Imaging 26 (Supplement_1), jeae333. 372 , 2025 2025 Citations: 1
Left ventricular mass by three-dimensional echocardiography is associated with myocardial replacement fibrosis and ventricular arrhythmias in hypertrophic cardiomyopathy V Rella, C Delcea, A Clement, F Perelli, M Tomaselli, M Penso, A Buta, ... European Heart Journal-Cardiovascular Imaging 26 (Supplement_1), jeae333. 355 , 2025 2025
Significant disagreement between conventional parameters and 3D echocardiography-derived ejection fraction in the detection of right ventricular systolic dysfunction and its … M Tolvaj, A Kovács, N Radu, A Cascella, D Muraru, B Lakatos, A Fábián, ... Journal of the American Society of Echocardiography 37 (7), 677-686 , 2024 2024 Citations: 29
Right atrial remodeling and outcome in patients with secondary tricuspid regurgitation M Tomaselli, DN Radu, LP Badano, FP Perelli, F Heilbron, A Cascella, ... Journal of the American Society of Echocardiography 37 (5), 495-505 , 2024 2024 Citations: 37
OLD BUT NOT GOLD: DISAGREEMENT BETWEEN CONVENTIONAL PARAMETERS AND 3D ECHOCARDIOGRAPHY-DERIVED EJECTION FRACTION IN THE EVALUATION OF RIGHT VENTRICULAR SYSTOLIC DYSFUNCTION M Tolvaj, DN Radu, A Cascella, D Muraru, BK Lakatos, A Fabian, ... Journal of the American College of Cardiology 83 (13_Supplement), 1374-1374 , 2024 2024
WAITING FOR A CONCERT IN SUMMER HEAT: A TRANSIENT ST ELEVATION IN A YOUNG MAN G Benzoni, F Perelli, B Bilo, A Giuliano, G Parati, R Brambilla European Heart Journal Supplements 26 (Supplement_2), ii184-ii185 , 2024 2024
Significant disagreements between conventional functional metrics and 3D echocardiography-derived ejection fraction in the detection of right ventricular systolic dysfunction M Tolvaj, N Radu, A Cascella, N Muraru, B Lakatos, A Fabian, M Tokodi, ... European Heart Journal 44 (Supplement_2), ehad655. 021 , 2023 2023
Clinical Value of a Novel Three-Dimensional Echocardiography–Derived Index of Right Ventricle–Pulmonary Artery Coupling in Tricuspid Regurgitation M Gavazzoni, LP Badano, A Cascella, F Heilbron, M Tomaselli, ... Journal of the American Society of Echocardiography 36 (11), 1154-1166. e3 , 2023 2023 Citations: 79
Incremental value of right atrial strain analysis to predict atrial fibrillation recurrence after electrical cardioversion M Tomaselli, LP Badano, V Cannone, N Radu, E Curti, F Perelli, ... Journal of the American Society of Echocardiography 36 (9), 945-955 , 2023 2023 Citations: 35
Discordance between conventional functional parameters and 3D echocardiography-derived ejection fraction in the detection of right ventricular systolic dysfunction M Tolvaj, N Radu, A Cascella, D Muraru, B Lakatos, A Fabian, M Tokodi, ... European Heart Journal-Cardiovascular Imaging 24 (Supplement_1), jead119. 265 , 2023 2023 Citations: 1
Mechanical adaptation of the right ventricle to increased volume overload associated with secondary tricuspid regurgitation DN Radu, E Surkova, A Cascella, A Fabian, D Muraru, B Merkely, ... European Heart Journal-Cardiovascular Imaging 24 (Supplement_1), jead119. 136 , 2023 2023 Citations: 1
Prognostic impact of disproportionate secondary tricuspid regurgitation A Cascella, M Gavazzoni, D Muraru, F Perelli, M Tomaselli, N Radu, ... European Heart Journal-Cardiovascular Imaging 24 (Supplement_1), jead119. 087 , 2023 2023
The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype (vol 9, 1022755, 2022) M Gavazzoni, F Heilbron, LP Badano, N Radu, A Cascella, M Tomaselli, ... FRONTIERS IN CARDIOVASCULAR MEDICINE 10 , 2023 2023
Corrigendum: The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype M Gavazzoni, F Heilbron, LP Badano, N Radu, A Cascella, M Tomaselli, ... Frontiers in Cardiovascular Medicine 10, 1169907 , 2023 2023 Citations: 1
Impact of severe secondary tricuspid regurgitation on rest and exercise hemodynamics of patients with heart failure and a preserved left ventricular ejection fraction C Baratto, S Caravita, G Corbetta, D Soranna, A Zambon, C Dewachter, ... Frontiers in Cardiovascular Medicine 10, 1061118 , 2023 2023 Citations: 28
An accurate and time-efficient deep learning-based system for automated segmentation and reporting of cardiac magnetic resonance-detected ischemic scar DM Papetti, K Van Abeelen, R Davies, R Menè, F Heilbron, FP Perelli, ... Computer Methods and Programs in Biomedicine 229, 107321 , 2023 2023 Citations: 20
Corrigendum: The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype (Front. Cardiovasc. Med.,(2022), 9, 1022755, 10 … M Gavazzoni, F Heilbron, L Badano, N Radu, A Cascella, M Tomaselli, ... Frontiers Media SA , 2023 2023
MOST CITED SCHOLAR PUBLICATIONS
Clinical Value of a Novel Three-Dimensional Echocardiography–Derived Index of Right Ventricle–Pulmonary Artery Coupling in Tricuspid Regurgitation M Gavazzoni, LP Badano, A Cascella, F Heilbron, M Tomaselli, ... Journal of the American Society of Echocardiography 36 (11), 1154-1166. e3 , 2023 2023 Citations: 79
The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype M Gavazzoni, F Heilbron, LP Badano, N Radu, A Cascella, M Tomaselli, ... Frontiers in Cardiovascular Medicine 9, 1022755 , 2022 2022 Citations: 74
Right atrial remodeling and outcome in patients with secondary tricuspid regurgitation M Tomaselli, DN Radu, LP Badano, FP Perelli, F Heilbron, A Cascella, ... Journal of the American Society of Echocardiography 37 (5), 495-505 , 2024 2024 Citations: 37
Incremental value of right atrial strain analysis to predict atrial fibrillation recurrence after electrical cardioversion M Tomaselli, LP Badano, V Cannone, N Radu, E Curti, F Perelli, ... Journal of the American Society of Echocardiography 36 (9), 945-955 , 2023 2023 Citations: 35
Significant disagreement between conventional parameters and 3D echocardiography-derived ejection fraction in the detection of right ventricular systolic dysfunction and its … M Tolvaj, A Kovács, N Radu, A Cascella, D Muraru, B Lakatos, A Fábián, ... Journal of the American Society of Echocardiography 37 (7), 677-686 , 2024 2024 Citations: 29
Impact of severe secondary tricuspid regurgitation on rest and exercise hemodynamics of patients with heart failure and a preserved left ventricular ejection fraction C Baratto, S Caravita, G Corbetta, D Soranna, A Zambon, C Dewachter, ... Frontiers in Cardiovascular Medicine 10, 1061118 , 2023 2023 Citations: 28
An accurate and time-efficient deep learning-based system for automated segmentation and reporting of cardiac magnetic resonance-detected ischemic scar DM Papetti, K Van Abeelen, R Davies, R Menè, F Heilbron, FP Perelli, ... Computer Methods and Programs in Biomedicine 229, 107321 , 2023 2023 Citations: 20
The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype. Front Cardiovasc Med 2022; 9: 1022755 M Gavazzoni, F Heilbron, LP Badano, N Radu, A Cascella, M Tomaselli, ... 2022 Citations: 8
Association of outcome with left ventricular volumes and ejection fraction measured with two-and three-dimensional echocardiography in patients referred for routine, clinically … D Muraru, SM Baldea, D Genovese, M Tomaselli, F Heilbron, ... Frontiers in Cardiovascular Medicine 9, 1065131 , 2022 2022 Citations: 5
Left atrial function and left atrioventricular coupling indices for atrial fibrillation prediction in hypertrophic cardiomyopathy V Rella, C Delcea, A Clement, S Fisicaro, F Perelli, M Tomaselli, M Penso, ... European Heart Journal-Cardiovascular Imaging 26 (Supplement_1), jeae333. 372 , 2025 2025 Citations: 1
Discordance between conventional functional parameters and 3D echocardiography-derived ejection fraction in the detection of right ventricular systolic dysfunction M Tolvaj, N Radu, A Cascella, D Muraru, B Lakatos, A Fabian, M Tokodi, ... European Heart Journal-Cardiovascular Imaging 24 (Supplement_1), jead119. 265 , 2023 2023 Citations: 1
Mechanical adaptation of the right ventricle to increased volume overload associated with secondary tricuspid regurgitation DN Radu, E Surkova, A Cascella, A Fabian, D Muraru, B Merkely, ... European Heart Journal-Cardiovascular Imaging 24 (Supplement_1), jead119. 136 , 2023 2023 Citations: 1
Corrigendum: The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype M Gavazzoni, F Heilbron, LP Badano, N Radu, A Cascella, M Tomaselli, ... Frontiers in Cardiovascular Medicine 10, 1169907 , 2023 2023 Citations: 1
Discordant severity grading in right ventricular dysfunction: prognostic implications of conventional parameters versus 3D echocardiography-derived ejection fraction M Tolvaj, E Surkova, D Muraru, N Radu, AS Buta, A Clement, B Lakatos, ... European Heart Journal-Cardiovascular Imaging 27 (Supplement_1), jeaf367. 141 , 2026 2026
AN UNUSUSPECTED CASE OF MYOPERICARDITIS T Rinforzi, F Perelli, C Torlasco, R Brambilla European Heart Journal Supplements 27 (Supplement_5), suaf076. 352 , 2025 2025
INCIDENTAL CARDIAC AMYLOIDOSIS WITH AN ARRHYTHMIC PRESENTATION IN AN ASYMPTOMATIC ATHLETE T Rinforzi, F Perelli, R Brambilla, N Radu, C Torlasco, L Badano, L Crotti, ... European Heart Journal Supplements 27 (Supplement_5), suaf076. 213 , 2025 2025
Left ventricular mass by three-dimensional echocardiography is associated with myocardial replacement fibrosis and ventricular arrhythmias in hypertrophic cardiomyopathy V Rella, C Delcea, A Clement, F Perelli, M Tomaselli, M Penso, A Buta, ... European Heart Journal-Cardiovascular Imaging 26 (Supplement_1), jeae333. 355 , 2025 2025
OLD BUT NOT GOLD: DISAGREEMENT BETWEEN CONVENTIONAL PARAMETERS AND 3D ECHOCARDIOGRAPHY-DERIVED EJECTION FRACTION IN THE EVALUATION OF RIGHT VENTRICULAR SYSTOLIC DYSFUNCTION M Tolvaj, DN Radu, A Cascella, D Muraru, BK Lakatos, A Fabian, ... Journal of the American College of Cardiology 83 (13_Supplement), 1374-1374 , 2024 2024
WAITING FOR A CONCERT IN SUMMER HEAT: A TRANSIENT ST ELEVATION IN A YOUNG MAN G Benzoni, F Perelli, B Bilo, A Giuliano, G Parati, R Brambilla European Heart Journal Supplements 26 (Supplement_2), ii184-ii185 , 2024 2024
Significant disagreements between conventional functional metrics and 3D echocardiography-derived ejection fraction in the detection of right ventricular systolic dysfunction M Tolvaj, N Radu, A Cascella, N Muraru, B Lakatos, A Fabian, M Tokodi, ... European Heart Journal 44 (Supplement_2), ehad655. 021 , 2023 2023
