Chordae Rupture Alters Tricuspid Valve Leaflet Biomechanics.

Surgical Management of Three Dogs with an Interatrial Communication and Atrioventricular Valve Abnormalities

PurposeChordae rupture is one of the main lesions observed in traumatic heart events that might lead to severe tricuspid valve (TV) regurgitation. TV regurgitation following chordae rupture is often well tolerated with few or no symptoms for most patients. However, early repair of the TV is of great importance, as it might prevent further exacerbation of the regurgitation due to remodeling responses. To understand how TV regurgitation develops following this acute event, we investigated the changes on TV geometry, mechanics, and function of ex-vivo porcine hearts following chordae rupture.MethodsSonomicrometry techniques were employed in an ex-vivo heart apparatus to identify how the annulus geometry alters throughout the cardiac cycle after chordae rupture, leading to the development of TV regurgitation.ResultsWe observed that the TV annulus significantly dilated (~9% in area) immediately after chordae rupture. The annulus area and circumference ranged from 11.4 ± 2.8 to 13.3 ± 2.9 cm2 and from 12.5 ± 1.5 to 13.5 ± 1.3 cm, respectively, during the cardiac cycle for the intact heart. After chordae rupture, the annulus area and circumference were larger and ranged from 12.3 ± 3.0 to 14.4 ± 2.9 cm2 and from 13.0 ± 1.5 to 14.0 ± 1.2 cm, respectively.ConclusionsIn our ex-vivo study, we showed for the first time that the TV annulus dilates immediately after chordae rupture. Consequently, secondary TV regurgitation may be developed because of such changes in the annulus geometry. In addition, the TV leaflet and the right ventricle myocardium are subjected to a different mechanical environment, potentially causing further negative remodeling responses and exacerbating the detrimental outcomes of chordae rupture.

Repair of Ebstein's Anomaly: Reply

Tricuspid valve leaflet remodeling in sheep with biventricular heart failure: A comparison between leaflets.

Historically, right-sided valvular disease has received less attention from clinicians and researchers than left-sided valve disease, in part because of a protracted latent asymptomatic period. Moreover, because tricuspid regurgitation (TR) is often due to left-sided valve disease and pulmonary regurgitation (PR) is often secondary to congenital cardiac disease, the underlying disorder rather than the valve lesion tends to dominate the clinical picture. It is increasingly recognized that right-sided valve disease is not benign and has a significant and independent impact on morbidity and mortality. Today, diagnostic techniques and appropriate management strategies for patients with right-sided valve disease are established and continually refined. In this era of increasing awareness and improved treatment options for patients with valve disease, it is important that clinicians consider the diagnosis of right-sided valve disease, understand its pathophysiology, choose appropriate confirmatory testing, and refer patients for timely intervention to prevent clinical deterioration with associated adverse consequences. This review examines the causes of right-sided valve disease and the latest diagnostic advances and treatment options for these often-neglected valve lesions. Patients with native right-sided valve disease are rarely affected by endocarditis, and indications for prophylaxis have recently changed.1 ### Tricuspid Regurgitation TR that is at least moderate in severity is most frequently “functional” in nature and by definition not related to primary tricuspid valve (TV) leaflet pathology but rather secondary to another disease process causing right ventricular (RV) dilatation, distortion of the subvalvular apparatus, tricuspid annular dilatation, or a combination of these. Furthermore, a moderate or greater degree of TR, regardless of primary origin, usually engenders additional TR as a result of the adverse hemodynamic consequence of RV volume overload. Causes of clinically significant TR are outlined in Table 1; 2 classic examples of primary tricuspid leaflet pathology are demonstrated in Figure 1. View this table: Table 1. Causes of TV …

The degree of systolic movement of the tricuspid valve (TV) leaflets was measured in 100 consecutive apparently healthy men 18-20 years old at the time of maximum posterosuperior motion toward or into the right atrium. Backward bowing of greater than 0.20 mm2 of the anterior leaflet, and greater than 0.15 mm2 of either the posterior or septal leaflets beyond the plane of the tricuspid annulus was found in 5% or less of the cohort irrespective of the echocardiographic view in which it was recorded. The upper 5% of these young men had greater than 0.80 mm2 of backward bowing when the leaflet motion was summed from all three views. The anterior leaflet demonstrated more bowing than either the septal or posterior leaflets. The systolic TV prolapse area correlated highly with the degree of mitral leaflet prolapse (r = 0.654, p less than 0.001). We conclude that there is a wide continuous spectrum of tricuspid valve leaflet prolapse area in healthy young men. This quantitative approach may help standardize the echocardiographic evaluation of tricuspid leaflet motion.

Role of intracardiac echocardiography for guiding ablation of tricuspid valve arrhythmias

Surgical approach to repair of ruptured chordae tendineae causing tricuspid regurgitation

Role of the septal leaflet in tricuspid valve closure: Consideration for treatment of complete atrioventricular canal

Supravalvar ablation has now been well documented to be the ideal mode for ablating specific forms of ventricular tachycardia, atrial tachycardia, and accessory pathways. A studied appreciation of the anatomy of the supravalvar region is a prerequisite for electrophysiologists to safely and effectively approach these arrhythmias. In addition, the consistent ability to correlate the recorded electrograms with fluoroscopic anatomy and intracardiac ultrasound images enhances the chance of successful elimination of supravalvar arrhythmias.

Abnormal Echoes in the Left Ventricular Outflow Tract Caused by Ruptured Chordae Tendineae of the Mitral Valve

Cardiologia CROATICA We present an echocardiographic evaluation of a 27-yearold young male patient who was referred to our institution after a loud systolic murmur was found during his occupational health check-up.. Besides the murmur, his physical exam, and results of his laboratory tests were normal. He has no significant complaints. His first 2D transthoracic echocardiogram (TTE) revealed severely dilated right ventricle (RV area greater than left ventricular area), volume overloaded and excentrically hypertrophied (wall thickness >6 mm), with severe tricuspid regurgitation (vena contracta 12 mm), large abundant sail-like anterior leaflet of the tricuspid valve (TV), apically displaced short septal leaflet (17 mm), and in the same time normal left ventricular systolic function and dimensions. These findings, especially apical displacement of septal leaflet indicate Ebstein’s anomaly. Ebstein’s anomaly is a rare congenital heart defect that occurs in only about <1% of congenital heart disease. In normal human hearts the apical displacement of the septal and posterior TV leaflets is <8 mm/m body surface area from the level of anterior mitral valve insertion. Differential diagnosis includes TV dysplasia, TV prolapse, TV endocarditis, and arrhythmogenic right ventricular cardiomyopathy, to name a few. With 2D TTE we were positive that this patient had some form of Ebstein’s anomaly, however we could not generate important information about valvular apparatus, such as morphology of the leaflets, the true origin of septal and posterior leaflets as well as precise coaptation. Those information are necessary in order to complete classification of TV pathology. Therefore we obtained 3D TTE and 3D TEE, and with multiplanar review mode and 3D reconstruction revealed complete agenesis of the posterior leaflet leaving almost unguarded tricuspid orifice with a large zone of lack of coaptation as the origin of severe tricuspid regurgitation. Subsequent 3D analysis also verified absence of complete posterior leaflet subvalvular apparatus, or in the context of embryological development, complete absence of posterior leaflet delamination. We used 2D echocardiography to study morphology and function of right ventricle, but 3D echocardiography provided additional important information regarding the morphology and orientation of TV and its apparatus. Only 3D TEE obtained agenesis of the posterior leaflet. According to parameters derived by 2D TTE and 3D TEE this patient was classified as type I Ebstein’s anomaly.

Over the past few decades, it has become apparent that mitral valve repair is preferable to mitral valve replacement for the majority of patients undergoing surgery for mitral regurgitation (MR). The advantages of mitral valve repair include low rates of thromboembolism, resistance to endocarditis, excellent late durability reported for as long as 25 years, and no need for anticoagulation in the majority of patients.1–5 Because of these advantages of repair over replacement, the threshold for performing mitral valve repair has been lowered to include patients with MR who have early symptoms or even those who are asymptomatic, assuming that the chance of successful repair is ≥90% according to the latest American College of Cardiology/American Heart Association guidelines.6,7 Recently, surgeons have evaluated new techniques to further improve mitral valve repair, and cardiologists and surgeons are increasingly interested in the potential for percutaneous approaches to mitral valve repair.8 Myxomatous MR affects 1% to 2% of the population and therefore is a common pathology for mitral valve surgery, but the complexity of the operation may be difficult, which leads to generally low rates of repair. In a recent review, only 44.3% of patients in the United States who required mitral valve surgery for MR received a mitral valve repair,9 and in the Euro Heart Survey, repair rates were similarly low (46.5%).10 The goals of mitral repair are to maintain leaflet mobility, remodel the annulus, and allow normal coaptation of the anterior and posterior leaflets. Recent advances in techniques and new concepts for mitral repair are important to cardiologists and other clinicians interested in the management of patients with mitral valve disease. Accordingly, an improved understanding of these concepts will aid in the development of innovative techniques to create safe, durable, reliable, and reproducible mitral valve repair techniques, both …

The first known use of the double-orifice valve technique for Ebstein anomaly, performed 30 years ago

Pressure-induced microstructural changes in porcine tricuspid valve leaflets.