Predictors of mid-term functional tricuspid regurgitation after device closure of atrial septal defect in adults: Impact of pre-operative tricuspid valve remodeling

- Residual functional tricuspid regurgitation (TR) is common after device closure.
- It was related to excessive structural changes in tricuspid valve anatomy.
- Tricuspid valve changes include annular dilation & increased septal leaflet tenting.
- It was not related to changes in RV or pulmonary vasculature.
- The natural course and clinical impact of TR should be further explored.

BackgroundFunctional TR occurs in adults with congenital atrial septal defect (ASD) due to left-to-right inter-atrial shunting and enlarged right heart. The prevalence and the predictors of TR following ASD closure in adults remain unknown. Moreover, whether preoperative anatomical parameters of tricuspid valve related to TR after ASD closure is understudied.MethodsComprehensive transthoracic echocardiography was performed in 64 consecutive secundum ASD patients before and at 3 months after device closure. Tricuspid valve parameters [annulus diameter (TAD), tenting area, tenting height, distal tricuspid septal leaflet angle (TSLA)], right ventricular (RV) function, pulmonary arterial pressures and severity of TR were recorded. Post-closure TR was defined as PISA radius ≥ 6 mm at 3 months.ResultsThe TR severity was reduced after ASD closure with post-closure TR in 31 patients (48%) at follow-up. TR patients had larger ventricles, more TR, greater TAD, and larger tenting area/height and TSLA but similar RV long-axis function and pulmonary pressures at baseline. Pre-closure TAD [odds ratio (OR): 6.076, p = 0.032] and TSLA (OR: 1.218, p = 0.001) were the independent predictors for TR. A TAD > 3.5 cm and a TSLA > 30° had sensitivity, specificity, and area under the curve of 97%, 76%, and 0.82 and 100%, 78%, and 0.84, respectively. Assessment of TSLA showed an incremental value over TAD for predicting TR after closure (χ2 = 21.3 vs. 9.9, p < 0.001).ConclusionNearly half of adults had TR following device closure of ASD. It was related to the excessive pre-operative structural remodeling in tricuspid valve rather than changes in RV.