Competent Tricuspid Valve Research Articles

Tricuspid Valve Reconstruction in Patients with Right Heart Decompensation Due to Severe Tricuspid Regurgitation on LVAD Support

Background/Objectives: Right ventricular (RV) dysfunction after left ventricular assist device (LVAD) implantation is associated with reduced survival and affects duration of hospitalization. Some patients with RV dysfunction on LVAD have significant tricuspid valve regurgitation (TR) with concomitant signs of RV failure. In these cases, tricuspid valve repair (TVR) may minimize clinical signs of RV failure. Methods: We report on two patients (one female, one male) developing significant TR receiving TVR through a right thoracotomy on LVAD support. Results: The time between LVAD implantation and TVR was 4 months and 50 months, respectively. The female patient could be discharged from hospital without TR and any signs of RV dysfunction. The male patient died 13 days later due to septic shock following mesenteric ischemia. At this time, echocardiography showed a competent tricuspid valve. Conclusions: In conclusion, these results provide insight into the clinical judgment of when TVR should be attempted. They suggest whether TVR may be a strategy to avoid hospitalization, minimize the clinical signs of RV insufficiency and improve quality of life in patients on LVAD support with severe TR and clinical signs of right heart dysfunction.

Abstract 15467: Bi-Leaflet Tricuspid Valve in Children With Hypoplastic Left Heart Syndrome is Rarely Incompetent, While Bi-Leaflet With a Cleft Results in Tricuspid Valve Regurgitation

Introduction: Tricuspid valve (TV) regurgitation in Hypoplastic Left Heart Syndrome (HLHS) increases the risk of death/transplantation by 2 to 3 times. Abnormalities in TV annular shape, leaflets expansion and subvalve apparatus position, have been associated in HLHS with subsequent tricuspid regurgitation (TR). As TV morphological variation is increasingly recognized, its role on tricuspid valve function remains unknown. This study aims to describe and examine the relationship between the TV leaflet morphologies in HLHS and its association with TV repair. Methods: Cross sectional study of selected 38 “classic” HLHS patients from a prospective longitudinal 3DE study of HLHS TV. TV leaflet morphology from 3DE datasets were reviewed (S.Z and N.S.K) blinded to TR grade. We adapted a previously proposed nomenclature to describe the TV leaflets (Figure 1). Using the Chi-squared test, we compared the frequencies of TV morphological types of HLHS with mild or less TR (n = 23) vs. HLHS who had TV repair (n = 15) at latest follow up. Results: Incidence of TV morphological type is summarized in Figure 2. Bi-leaflet TV was the second most common, followed by bi-leaflet with a cleft. When comparing HLHS with mild or less TR vs. HLHS with TVR, only 1 of 9 bi-leaflet TV had subsequent TVR, while all bi-leaflet TV with a cleft, underwent TVR (p<0.05). Conclusion: HLHS has considerable TV leaflet variations with bi-leaflet TV being the second most common variation. While bi-leaflet TV is more likely to be found in a competent TV, those with a bi-leaflet TV with a cleft, all required TVR. Bi-leaflet TV with a cleft, warrants further study to assess its relationship and relative role with TVR.

Tricuspid annulus dynamics in atrial fibrillation compared to sinus rhythm using 3-D echocardiography: relation with tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) is known to cause dilation in both the mitral (MA) and the tricuspid (TA) annuli. Few studies have investigated MA dynamics and function in AF compared to sinus rhythm (SR). However, no study addressed this issue in TA. Hence, we set forth to describe TA dynamics in AF and SR and its relationship with severity of tricuspid regurgitation (TR). Methods 3D echocardiographic imaging data were acquired from adult patients in AF or SR with varying degrees of TR between 2018 and 2020. TA was automatically tracked throughout the cardiac cycle using a commercially available software (TomTec 4MV software; Figure 1) over 4-6 cardiac cycles per patient. Time to minimal area as percentage of the R-R interval was recorded in each of the cycles. Absolute change in TA area was calculated as the difference between maximal and minimal TA area in each cardiac cycle and was averaged over 4-6 cycles per patient. This measurement was used to reflect the dynamic range of TA deformation during the cardiac cycle. Right atrial (RA) and right ventricular (RV) volumes and longitudinal strain were also measured (speckle tracking, 4-ch view). Results A total of 70 patients were studied (35 AF; 35 SR; 54% males in each group). Patients with AF were older [median (IQR) of 81 (72-86) years vs. 69 (59-78) years in SR, p < 0.001], had larger maximal TA area and circumference (p < 0.001 for both), larger RA size (p < 0.001), lower RA reservoir strain (p < 0.001) and RV free-wall strain (p < 0.001). Absolute change in TA area was significantly decreased in AF [2.3 (1.7-2.7) cm2] vs. 3.1 (2.3-3.5) cm2 in SR, p = 0.002. Patients with ≥ moderate TR (n = 41, 59%) had lower absolute change in TA area [2.4 (1.7-3.1) cm2 vs. 2.8 (2.2-3.5) cm2 in < moderate TR, p = 0.05]. Female sex was associated with lower absolute change in TA area [2.3 (1.7-3.2) cm2 vs. 2.7 (2.2-3.6) cm2 in males, p = 0.02] on univariate analysis. AF patients had more frequently ≥ moderate TR [28 AF vs. 13 SR, p < 0.001]. On multivariate analysis including sex, rhythm, TR severity, RA and RV strains, and averaged maximal TA area, independent factors associated with lower absolute change in TA area were AF, ≥ moderate TR, and larger maximal TA area (p < 0.05 for all). Time to minimal TA size was achieved in (0-40%) of the R-R interval in 70% of patients in SR compared to only 41% of patients in AF (Figure 2) and in 73% in patients with < moderate TR compared to 43% in patients with ≥ moderate TR. Conclusion AF is associated with blunted TA dynamics resulting in lower decrease in TA size and with a heterogenous timing of minimal TA size throughout the cardiac cycle. The blunted and discoordinated annular contraction may reduce systolic tricuspid valve competence and be involved in the pathophysiology of functional TR. Future studies are needed to confirm this hypothesis and evaluate the effect of restoration of SR on TA dynamics and time to minimal TA size. Abstract Figure 1Abstract Figure 2

Cone reconstruction for Ebstein anomaly: Late biventricular function and possible remodeling

ObjectivesTo evaluate late-term tricuspid valve competence and biventricular function following cone reconstruction for Ebstein anomaly, and to explore biventricular remodeling. MethodsConsecutive adult and pediatric patients who underwent cone reconstruction from 2009 to 2019 were reviewed for inclusion in this retrospective cardiac magnetic resonance imaging study. Tricuspid valve competence was assessed with tricuspid regurgitation fraction. Biventricular systolic function was assessed by ejection fraction, cardiac index, indexed stroke volume, and indexed aortic and pulmonary artery beat volume. Biventricular remodeling was assessed by planimetered areas (right atrium, functional right ventricle, left heart), and indexed end-diastolic and end-systolic ventricular volumes. Paired t tests or Wilcoxon signed-rank tests were used for analyses. ResultsOf 58 included patients, 50 underwent cardiac magnetic resonance imaging. Twelve patients had both preoperative and late postoperative cardiac magnetic resonance imaging with a median follow-up of 5.11 years (interquartile range, 3.12-6.07 years). Focusing on these, tricuspid regurgitation fraction decreased (from 69% to 10%; P = .014), right ventricle ejection fraction remained stable, and antegrade pulmonary artery beat volume increased (from 26.7 to 41.6 mL/beat/m2; P = .037). The left ventricle stroke volume (from 30.4 to 44.1 mL/m2; P = .015) and antegrade aortic beat volume (from 28.5 to 41.1 mL/beat/m2; P = .014) also increased, and the left ventricle stroke volume improved progressively with time since surgery (P = .048). Whereas the right atrium area decreased (P = .004), the functional right ventricle and left heart area increased (cm2, P = .021 and P = .004). Right ventricle volumes showed a tendency to normalize and left ventricle indexed end-diastolic volume increased (from 50 to 69 mL/m2; P = .03) over time. ConclusionsCone valve integrity was sustained. Biventricular function improved progressively during follow-up, and there are positive signs of biventricular remodeling late after cone reconstruction.

Association of spectral Doppler cardiac activity in the lower limb veins and echocardiographic findings in patients with tricuspid regurgitation.

ObjectiveTo determine the association between spectral Doppler cardiac activity in the lower limb veins and echocardiographic findings in patients with tricuspid regurgitation.Material and methodsA cross-sectional analysis was performed in the Gilani Ultrasound Center over a period of 13 months. The total study sample comprised 400 subjects. All individuals referred for abdominal ultrasound having cardiac activities in external iliac vein, popliteal and posterior tibial vein, individuals having normal venous Doppler ultrasound, both genders and all ages, were included, and unwilling and non-cooperative patients were excluded from the study.ResultsOut of 400 individuals, 200 showed cardiac activity in the lower limb veins on Doppler vascular ultrasound, while 200 did not show cardiac activity. On echocardiography, 204 individuals were diagnosed with tricuspid regurgitation, and 196 individuals had a competent tricuspid valve. According to the independent sample t-test the mean difference in the posterior tibial vein was 25.54 (95% CI: 24.09; 26.98), while the mean difference in the iliac vein was 2.34 (95% CI: 0.64; 4.03) among normal and tricuspid regurgitation.ConclusionA correlation was found between the cardiac activities in the lower limb veins and tricuspid regurgitation.

Does addition of bi-directional cavo-pulmonary shunt to tricuspid repair in advanced cases of Ebstein anomaly result in better outcomes?

Ebstein anomaly can be managed by single ventricular, bi-ventricular and one and a half ventricular repairs. We present midterm results of Comprehensive Tricuspid Valve repair (CTVR) with bi-directional cavo-pulmonary shunt (BCPS). In this prospective observational study (Jan2012-July2018), 69 patients underwent surgery for Ebstein anomaly. In Group I (n = 48; 69.6%), all patients got CTVR and a BCPS (one and a half ventricle repair). Group II (n = 15; 21.8%) consisted of a similar repair without BCPS (bi-ventricle repair). All patients were echocardiographed at six monthly intervals. Median age of the cohort was 17years (range 1-68). 12 (17.4%) patients were Carpentier type B, 51 (73.9%) were type C and 6 (8.7%) were type D. There were two early mortalities (2.89%). At a mean follow up of 3.2 ± 1.2years, there were no late deaths and one delayed repair-failure in each group. Group I had significantly lower mean TR grade (1.2 ± 0.4vs1.6 ± 0.5, p = 0.03) as compared to Group II without a significant difference in the mean gradients (1.5 ± 0.5vs1.6 ± 0.6, p = 0.4). Mean indexed TAPSE (15.0 ± 6.7vs.16.6 ± 5.6mm/m2, p = 0.21), NYHA class (1.2 ± 0.4vs1.3 ± 0.4) and six-minute walk distance (506 vs 507m, p = 0.7) was similar in both groups. One and a half ventricle repair of Ebstein anomaly gives a more functionally competent, non-stenotic and durable tricuspid valve as compared to a two-ventricle repair. BCPS doesn't result in facial swelling or AV malformations. Preload reduction by BCPS may allow the myopathic ventricle to remodel.

Tricuspid Intervention Following Pulmonary Valve Replacement in Adults With Congenital Heart Disease

BackgroundTricuspid regurgitation (TR) is common among adults with corrected tetralogy of Fallot (TOF) or pulmonary stenosis (PS) referred for pulmonary valve replacement (PVR). Yet, combined valve surgery remains controversial. ObjectivesThis study sought to evaluate the impact of concomitant tricuspid valve intervention (TVI) on post-operative TR, length of hospital stay, and on a composite endpoint consisting of 7 early adverse events (death, reintervention, cardiac electronic device implantation, infection, thromboembolic event, hemodialysis, and readmission). MethodsThe national Canadian cohort enrolled 542 patients with TOF or PS and mild to severe TR who underwent isolated PVR (66.8%) or PVR+TVI (33.2%). Outcomes were abstracted from charts and compared between groups using multivariable logistic and negative binomial regression. ResultsMedian age at reintervention was 35.3 years. Regardless of surgery type, TR decreased by at least 1 echocardiographic grade in 35.4%, 66.9%, and 92.8% of patients with pre-operative mild, moderate, and severe insufficiency. In multivariable analyses, PVR+TVI was associated with an additional 2.3-fold reduction in TR grade (odds ratio [OR]: 0.44; 95% confidence interval [CI]: 0.25 to 0.77) without an increase in early adverse events (OR: 0.85; 95% CI: 0.46 to 1.57) or hospitalization time (incidence rate ratio: 1.17; 95% CI: 0.93 to 1.46). Pre-operative TR severity and presence of transvalvular leads independently predicted post-operative TR. In contrast, early adverse events were strongly associated with atrial tachyarrhythmia, extracardiac arteriopathy, and a high body mass index. ConclusionsIn patients with TOF or PS and significant TR, concomitant TVI is safe and results in better early tricuspid valve competence than isolated PVR.

TRICUSPID VALVE PROLAPSE IN CHILDREN WITH HYPOPLASTIC LEFT HEART SYNDROME PATIENTS REQUIRING TRICUSPID VALVE REPAIR IS DUE TO LEAFLET MALADAPTATION, NOT SUB-VALVE CHANGES - A QUANTITATIVE THREE-DIMENSIONAL ECHOCARDIOGRAPHY STUDY

Tricuspid valve regurgitation (TR) is associated with morbidity and mortality in hypoplastic left heart syndrome (HLHS). Over 25% of HLHS patients require tricuspid valve (TV) repair within 10 years, while the mechanism of TR remains poorly understood. This study explores TV remodeling in HLHS requiring surgical repair, using novel quantitative three-dimensional echocardiography (3DE) to further understand the mechanisms of TV failure in HLHS. This case-control study with prospectively acquired 3DE in 72 children with HLHS, 36 children prior to TV repair (group 1) and 36 age- and stage-matched controls with no TV repair and mild or less TR (group 2). All 3DE were analyzed using a specific custom TV software (MATLAB) to quantitate TV annulus and leaflet area (Figure), prolapse and tethering volumes, and bending angle. TV leaflets were segmented into the anterior (AL), septal (SL) and posterior (PL) to measure regional areas and volumes. We also measured position of papillary muscle (PM) and chord length. Variables were indexed by body surface area (BSA), and comparison was performed using t-test with significance at p < 0.05. Group 1 and 2 had similar age and BSA (mean: 2.3 years; 0.47 m2) at assessment. Group 1 had larger total annulus (10.3 vs 8.4 cm2/m2, P< 0.001) and leaflet (11.7 vs 9.3 cm2/m2, P= 0.002) area. SL area (2.66 vs. 2.00 cm2/m2, p= 0.009) was larger and AL trended to being larger (5.2 vs 4.2 cm2/m2, P= 0.05). Group 1 had larger total prolapse volume and for each leaflets (Total leaflet 140 vs 5.8 μl/m2, p=<0.002; AL: 39.4 vs 2.2 μl/m2, p= 0.004; SL: 2.2 vs 0.16 μl/m2, p= 0.017; PL: 2.7 vs 0.12 μl/m2, p= 0.032). No difference in tethering volume for total or each leaflet. Group 1 had greater bending angle (156.6 vs 151.8 degree, p= 0.034), hence a flatter annulus. No difference in PM angle and length, nor chord length between the groups. Failing TV in children with HLHS had larger annulus and leaflet size, specifically in SL and AL, and greater prolapse of all the leaflets compared to HLHS with competent TV. Despite increased leaflet prolapse, there is no difference in chord or PM length, suggesting that failing TV prolapse is due to leaflet mal-adaptation, rather than chord or PM changes. This novel insight suggests future research into TV leaflet mal/adaptation in HLHS maybe important.

Air Bubbles Introduced From Peripheral Intravenous Lines Into the Cerebral Venous System: Response.

We wish to thank Dr. Horton for his interest and clinical insights regarding our report of embolism in the superior ophthalmic vein after intravenous fluid injection using a peripheral intravenous cannula (1). As Dr Horton notes, passage from the subclavian to the internal jugular vein would present the most direct pathway for an air bubble ascending from the upper limb to the head. Our choice of wording was intended to connote, however, that retrograde passage from more proximally in the venous system remains possible, as established by the work of Schlimp et al (2), where they demonstrated retrograde flow of an air bubble against a column of venous blood. In addition, reflux from the right atrium is commonly identified on dynamic imaging and tends to be increased in atrial fibrillation (3) and apnea (4). We would thus submit that an air embolus in the superior vena cava—perhaps, even one that has not yet traversed a competent tricuspid valve (5)—may still be prone to retrograde embolization, provided the head and neck are elevated at the time of injection, and the embolus is buoyant. In any event, we share Dr. Horton's concern regarding the ease with which air emboli can be introduced during peripheral injections. This risk is vividly illustrated during echocardiographic bubble studies and intraoperative transesophageal echocardiography during cardiac surgery, where cavitations and bubbles can be visualized in the right heart after peripheral injection. The ophthalmic corollary is peripheral injection during fluorescein angiography—which is often conducted under time pressure and in conditions of poor lighting. Our case and Dr. Horton's patient illustrate how air bubbles contained in peripherally injected fluids can embolize to the head and neck, and agree that these are an avoidable risk.

Surgical Algorithm for Rheumatic Tricuspid Disease

Rheumatic involvement of the tricuspid valve frequently occurs in patients with mitral and aortic valve disease. Inadequate attention to tricuspid valve function can lead to increased morbidity and may necessitate reoperation. A surgical algorithm is developed and presented for treatment of rheumatic heart disease. Seventy-four patients underwent tricuspid valve repair. Competent tricuspid valve (not more than mild tricuspid regurgitation) could be achieved in all of these patients.

Outcomes and risk factors associated with tricuspid valve repair in children with hypoplastic left heart syndrome.

Tricuspid valve (TV) competence is important for successful palliation of hypoplastic left heart syndrome (HLHS). We report our experience with TV repair in HLHS patients with a focus on TV and right ventricular (RV) function and associated clinical outcomes. From 2002 to 2012, 219 neonates with HLHS underwent the Norwood operation. Thirty patients who underwent TV repair at various stages comprised our current series cohort. Echocardiographic and clinical data were reviewed to determine the effectiveness of TV repair and outcomes of the patients. Thirty patients received TV repair during Norwood (n = 4), Glenn (n = 17) and Fontan (n = 9) operations. Median age at TV repair was 188 days (range 3-1498). Preoperatively, all patients had ≥moderate TV regurgitation and 4 (13%) patients had ≥moderate RV dysfunction. After repair, TV regurgitation was none or trivial (n = 12, 40%), mild (n = 8, 27%), ≥moderate (n = 10, 33%), whereas 10 (33%) had ≥moderate regurgitation at last follow-up; ≥moderate RV dysfunction was present in 5 (17%) patients following TV repair and 10 (33%) patients at last follow-up. Competing risk analysis showed that 10 years following TV repair, 21% of patients had TV reoperation, 18% died or underwent transplantation and 61% were alive without subsequent reoperation. Overall, 10-year survival, transplant-free survival and freedom from second TV reoperation were 89%, 71% and 78%, respectively; ≥moderate RV dysfunction following TV repair was associated with diminished transplant-free survival (P = 0.0277). Although TV repair is successful in reducing regurgitation in the majority of HLHS patients, outcomes are restricted by limited repair durability with recurrent significant regurgitation in one-third of the patients. RV dysfunction in these patients is progressive and a major determinant of transplant-free survival.

Regional Changes in Leaflet Coaptation Dynamics After Total Tricuspid Reconstruction

Stentless porcine extracellular matrix tricuspid tube grafts were developed for tricuspid valve reconstruction. The purpose of this study was to conduct an echocardiographic assessment of the performance of native and tube graft leaflets in an acute porcine model. Fourteen 65-kg pigs were randomly assigned to tube graft (n= 7) or control with native valve preservation (n= 7). Epicardial echocardiography was performed at baseline after sternotomy, after valve operation, and after hemodynamic stabilization. No baseline differences were found (p > 0.05). All valves were competent with only a mild central regurgitant jet in two tube grafts and two native valves. Tube graft valves were compared with native valves. Anterior-septal leaflet coaptation length (18 ± 6 mm versus 6 ± 1 mm, p < 0.0005), coaptation height (20 ± 9 mm versus 9 ± 4 mm, p < 0.005), and anterior leaflet length (31± 1 mm versus 22 ± 2 mm, p < 0.00005) were all significantly larger in the tube graft valves. The billowing index (0.8 ± 0.1 versus 0.9 ± 0.1, p > 0.05) and tenting height (5 ± 1 mm versus 4 ± 2 mm, p > 0.1) were not significantly different. Leaflet excursion angles for both leaflets were not significantly different between the native and tube graft valves (p > 0.1). In a porcine experimental model, a competent tricuspid valve was constructed using extracellular matrix tube graft material. Coaptation geometry was significantly different from native valves with an increased coaptation zone because of excessive leaflet tissue in the tube graft valves. The tube graft tended to prolapse into the atrium, but it did not compromise the motion and competence of the leaflets.

Single-stage, three-fold repair for Ebstein's anomaly.

Favourable outcomes in the repair of Ebstein's anomaly are predicated on tricuspid valve competence, right ventricular function and presence of arrhythmia. We report our experience with a single-stage, three-fold repair of Ebstein's anomaly, namely, cone reconstruction of the tricuspid valve supplemented by bidirectional cavopulmonary anastomosis and right atrial electrocautery maze. From 2010 to 2014, 37 consecutive patients with Ebstein's anomaly, median age 17.3 (9.1-56.2) years, underwent this single-stage, three-fold surgical procedure. The principal elements of the procedure include (i) cone reconstruction of the tricuspid valve, limited plication at the level of the displaced valve, insertion of a homemade annuloplasty ring, defect repair and reduction atrioplasty supplemented by (ii) right atrial electrocautery maze and (iii) bidirectional cavopulmonary anastomosis. Postoperatively, all patients were followed up regularly for a mean period of 2.3 (1-4) years by clinical, electrocardiographic and echocardiographic examinations. The in-hospital mortality rate was 2.7% (1 patient) with no late deaths. Mean cardiopulmonary bypass time was 110 ± 18.3 min and aortic cross-clamp time was 48.5 ± 7.4 min. Echocardiographic examination showed significant improvement of valve regurgitation (P < 0.0001). NYHA functional class was I in 77.8% of the survivors and II in 22.2%. The cardiothoracic ratio decreased significantly (P < 0.05). No deleterious effects of the Glenn shunts have been reported. Sinus rhythm has remained stable in 31 patients (86.1%) during the follow-up period. Single-stage, three-fold repair for the management of Ebstein's anomaly offers good outcome in terms of low mortality and morbidity rates. It can achieve a durable valve-sparing repair, good functional mid-term outcomes and good quality of life among survivors.

Cardiac output monitoring: a contemporary assessment and review.

An increasing number of minimally or noninvasive devices are available to measure cardiac output in the critical care setting. This article reviews the underlying physical principles of these devices in addition to examining both animal and human comparative studies in an effort to allow clinicians to make informed decisions when selecting a device to measure cardiac output. Peer-reviewed manuscripts indexed in PubMed. A systematic search of the PubMed database for articles describing the use of cardiac output monitors yielded 1,526 sources that were included in the analysis. From all published cardiac output monitoring studies reviewed, the animal model, number of independent measurements, and correlation between techniques was extracted. Comparative studies in animals and humans between devices designed for measurement of cardiac output and experimental reference standards indicate thermodilution and Doppler-based techniques to have acceptable accuracy across a wide range of hemodynamic conditions, with bioimpedance techniques being less accurate. Thermodilution devices are marginally more accurate than Doppler-based devices but suffer from slower response time, increased invasiveness, and require stable core temperatures, good operator technique, and a competent tricuspid valve. Doppler-based techniques are less invasive and offer beat-to-beat measurements and excellent trending ability, but are dependent on accurate beam alignment and knowledge of aortic cross-sectional area. Studies of newer devices, such as pulse contour analysis, partial rebreathing, and pulse wave velocity, are far less in number and are primarily based on comparisons with thermodilution-based cardiac output measurements. Studies show widely ranging results. Thermodilution is relatively accurate for cardiac output measurements in both animals and humans when compared to experimental reference standards. Doppler-based techniques appear to have similar accuracy as thermodilution pulmonary artery catheters. Bioimpedance, pulse contour, partial rebreathing, and pulse wave velocity-based devices have not been studied as rigorously; however, the majority of studies included in this analysis point towards decreased accuracy.

Continuous Flow Left Ventricular Assist Device Implant Significantly Improves Pulmonary Hypertension, Right Ventricular Contractility, and Tricuspid Valve Competence

Continuous flow left ventricular assist devices (CF LVAD) are being implanted with increasing frequency for end-stage heart failure. At the time of LVAD implant, a large proportion of patients have pulmonary hypertension, right ventricular (RV) dysfunction, and tricuspid regurgitation (TR). RV dysfunction and TR can exacerbate renal dysfunction, hepatic dysfunction, coagulopathy, edema, and even prohibit isolated LVAD implant. Repairing TR mandates increased cardiopulmonary bypass time and bicaval cannulation, which should be reserved for the time of orthotopic heart transplantation. We hypothesized that CF LVAD implant would improve pulmonary artery pressures, enhance RV function, and minimize TR, obviating need for surgical tricuspid repair. One hundred fourteen continuous flow LVADs implanted from 2005 through 2011 at a single center, with medical management of functional TR, were retrospectively analyzed. Pulmonary artery pressures were measured immediately prior to and following LVAD implant. RV function and TR were graded according to standard echocardiographic criteria, prior to, immediately following, and long-term following LVAD. There was a significant improvement in post-VAD mean pulmonary arterial pressures (26.6 ± 4.9 vs. 30.2 ± 7.4 mmHg, p = 0.008) with equivalent loading pressures (CVP = 12.0 ± 4.0 vs. 12.1 ± 5.1 p = NS). RV function significantly improved, as noted by right ventricular stroke work index (7.04 ± 2.60 vs. 6.05 ± 2.54, p = 0.02). There was an immediate improvement in TR grade and RV function following LVAD implant, which was sustained long term. Continuous flow LVAD implant improves pulmonary hypertension, RV function, and tricuspid regurgitation. TR may be managed nonoperatively during CF LVAD implant.

Management and midterm outcomes of post-infarction ventricular septal defect

We assessed midterm outcomes, predictors of mortality, and residual defects after repair of post-infarction ventricular septal defect in 10 patients (mean age, 65.3 years; range, 50-78 years) who were operated on between 2000 and 2008. Mean time from onset of symptoms of myocardial infarction to diagnosis of ventricular septal defect was 3.5 days. Time from diagnosis to surgery ranged from 6 h to 84 days. The defects were located anteriorly in 4 patients and posteriorly in 6. Patch reconstruction of the septum was used in 6 patients and the infarct exclusion technique in 4. Hospital mortality was 60%. The only predictor of mortality was tricuspid valve competence (p = 0.048). There was no correlation between location of the defect or type of repair and operative mortality. Residual or recurrent ventricular septal defect was noted in 6 patients. Location of the defect and type of repair were not predictors of residual or recurrent defects. Residual ventricular septal defect was not associated with increased short-term mortality or reduction of functional status. Early mortality associated with post-infarction ventricular septal defect repair is significant. Discharged patients continue to have good functional capacity and quality of life, as well as favorable midterm survival.

Continuous flow left ventricular assist device implant significantly improves pulmonary hypertension, right ventricular contractility and tricuspid valve competence

Fairman, Alexander S. BA; Atluri, Pavan MD; MacArthur, John W. MD; Yang, Elaine BSc(Hons); Shudo, Yashuhiro MD; Hiesinger, William MD; Acker, Michael A. MD; Woo, Joseph Y. MD, FACS Author Information

Editorial Comment: Corrected transposition of the great arteries: the continuing quest for the optimal surgical management

Hiramatsu et al. [1] have reported their experience with an anatomic repair of congenitally corrected transposition of the great arteries (ccTGA). This included 90 patients operated on between 1983 and 2010. Seventy-two patients with ccTGA, ventricular septal defect (VSD) and pulmonary stenosis underwent atrial switch plus intraventricular rerouting. Eighteen patients without pulmonary stenosis had atrial switch plus arterial switch. The long-term results were carefully evaluated. Differences between the two groups were noted. Patients without pulmonary stenosis (the double-switch group) had a better outcome at 20 years regarding survival (83% vs 76%, NS), freedom from reoperation (94% vs 78%, P < 0.05) or arrhythmia (79% vs 57%, P < 0.05). The total freedom from all cardiac events (death, reintervention or reoperation, arrhythmia) was significantly different (60% in the double-switch group vs 40% in the group with pulmonary stenosis). The functional outcome was similar in both groups and, overall, satisfactory. These results should, however, be taken with caution, because of the small number of patients in the double-switch group. Interestingly, the Birmingham group (another institution with a large experience in this field) has recently reported its own experience between 1991 and 2011 [2]. This included 45 patients with Rastelli-Senning repair and 68 patients with double-switch operation. The results at 10 years were somewhat different. Survival (84% in the double-switch group vs 77% in the Rastelli-Senning group) and freedom from reintervention (50% vs 49%) were similar in both groups. However, freedom from death, transplantation or heart failure was better in the Rastelli-Senning group. These results may seem contradictory. Actually, I think that they show only how difficult it is to draw out firm conclusions when so many factors are involved. ccTGA is a rare malformation; it is therefore difficult (actually impossible for any individual institution) to collect large cohorts of patients who undergo homogeneous surgical approaches. Very different patients are involved; patients with right ventricular dysfunction and severe tricuspid regurgitation because of Ebstein-like malformation are different from patients with a well-functioning right ventricle and a competent tricuspid valve; patients with an intact ventricular septum who need left ventricular retraining before undergoing a double-switch operation are different from patients with a large VSD and a left ventricle ready to sustain the systemic output. Different surgical options are available and may yield different results; regarding atrial switch, the Senning and Mustard operations or hemi-Mustard procedure with cavo-pulmonary anastomosis may influence the incidence of postoperative arrhythmias; reconstructing the right ventricular outflow tract with or without an extracardiac conduit may greatly modify the need for reoperation. Well-designed large multicentre cohort studies are necessary to address all these issues. Before such information is available, some considerations must be kept in mind:

Persistent embryonic right venous valve giving a cor triatriatum dexter appearance in a cyanotic neonate

Embryonic right venous valve may persist after birth as a membrane seen inside the right atrium and give a cor triatriatum dexter appearance in echographic imaging. The finding is usually asymptomatic, but may rarely cause cyanosis when flow from the inferior vena cava is redirected into the left atrium and be misdiagnosed with a tricuspid valve anomaly. We report the case of a cyanotic newborn who underwent a successful resection of a cor triatriatum dexter membrane.

Tricuspid Endocarditis with Indirect Gerbode: Septal Translocation of Posterior Leaflet

Tricuspid valve endocarditis with acquired Gerbode defect is rare and can be quiet challenging to the surgeon, often requiring complex repair procedures. We present a technique for Gerbode shunt closure using pericardial patch and reconstruction of the tricuspid valve by septal translocation of posterior tricuspid leaflet, which resulted in a good and competent tricuspid valve with no residual shunt.