Degrees Of Tricuspid Regurgitation Research Articles

Echocardiographic assessment of right ventricular function and right ventriculoarterial coupling in tricuspid regurgitation.

Echocardiographic evaluation of the cardiopulmonary unit is difficult in case of tricuspid regurgitation (TR) and combined echocardiographic parameters could be useful. This study aimed to assess the variation of simple and combined echocardiographic parameters analysing the cardiopulmonary unit according to the severity of TR. TR was graded according to Hahn's classification in 179 patients. Classical morphological, function and load parameters analysing right ventricle were assessed. Combined parameters of function and load; morphology and load; and morphology-load-function index were calculated. We used ROC curve analysis to analyze the diagnostic value of echocardiographic parameters to predict potential high or low surgical risk of mortality according to TRISCORE in 82 patients. Simple parameters were significatively different among groups with a nonlinear progression between the 5 levels of severity of TR. Combined parameters were also significatively different among groups. Among them, myomechanical index (MMI = RV-RA mean pressure gradient x RVFWS/indexed RAED area × 10-2) and morphology-load-function index (MLF = RVED length/area x TR TVI x RVFWS) had a linear progression between the 5 groups and had the best predictive value for TRISCORE high and low risk. Combined parameters are relevant to evaluate cardiopulmonary unit in patients with various degrees of TR, especially when combining morphology, function, and load parameters, and are potentially interesting in their prognostic assessment, as shown by the good predictive value for TRISCORE risk.

Association of tricuspid regurgitation with clinical events and quality of life after surgery for severe ischemic mitral regurgitation

BackgroundThe clinical consequences of coexistent tricuspid regurgitation (TR) in patients with severe ischemic mitral regurgitation (IMR) remain unclear. We examined the association of baseline TR severity with outcomes after mitral valve (MV) surgery for IMR. MethodsWe conducted a secondary analysis of a randomized trial evaluating the effectiveness and safety of MV replacement versus repair for severe IMR. Patients were stratified by baseline TR (none/trace/mild vs moderate/severe). The primary endpoint was all-cause mortality. Secondary endpoints included major adverse cardiac and cerebrovascular events (MACCE) and quality of life (QoL) using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Cox proportional hazards and logistic models were used in the analysis. ResultsOf 251 randomized patients with severe IMR, 246 undergoing MV repair or replacement (123 each) were included in this secondary analysis. Sixty-one patients (25%) had ≥ severe TR, of whom 43% underwent MV repair and 57% underwent MV replacement. The 2-year all-cause mortality was significantly higher for those with moderate/severe TR compared to those with none/trace/mild TR (38% vs 16%; adjusted hazard ratio [aHR], 2.93; 95% confidence interval [CI], 1.59-5.38). MACCE rates were higher in patients with moderate/severe TR (53%) compared to those with none/trace/mild TR (39%) (aHR, 1.91; 95% CI, 1.21-3.03). No significant difference in 1-year QoL, measured as being alive with a 5-point improvement in the MLHFQ, was observed (odds ratio, 0.61; 95% CI, 0.28-1.33). ConclusionsIn patients undergoing surgery for severe IMR, preoperative moderate/severe TR was significantly associated with increased all-cause mortality and MACCE. Whether concomitant TV surgery would improve postoperative outcomes in patients with severe IMR and different degrees of TR should be evaluated in a randomized trial.

Right Atrial Function Role in Tricuspid Regurgitation-Related Systemic Venous Congestion

Tricuspid regurgitation (TR) is a frequent valvular pathology and when significant, may cause systemic venous congestion (SC). The right atrium (RA) is an intermediate structure between the tricuspid valve and the venous system and its role in SC is not yet defined. A total of 116 patients with a measurable TR effective regurgitant orifice area (EROA) and regurgitant volume (RVol) were selected from 2020 to 2022. SC was estimated by echocardiography using inferior vena cava diameter and estimated right atrial pressure (eRAP) and by clinical congestive features. TR grade was mild in 23 patients (20%), moderate in 53 patients (46%), and severe in 40 patients (34%). There was a significant decrease in RA function measured by strain with increasing TR severity (p<0.001). There was a marked difference in RA strain between the groups with eRAP >10 and ≤10mmHg (25±11% vs 11±7%, p<0.0001). Variables independently associated with inferior vena cava diameter were RA strain (β -0.532, p<0.001), RA volume indexed (β 0.249, p=0.002), RVol (β 0.229, p=0.005) and EROA (β 0.185, p=0.016), and independently associated with eRAP >10mmHg were EROA (odds ratio [OR] 1.024, 95% confidence interval [CI] 1.002 to 1.046), RVol (OR 1.039, 95% CI 1.007 to 1.072) and RA strain (OR 0.863, 95% CI 0.794 to 0.940). The addition of RA strain to models containing EROA or RVol significantly improved the power of the model. RA strain was independently associated with the presence of 3 or more congestive features. In conclusion, echocardiographic and clinical signs of SC are frequent in higher degrees of TR, and RA function seems to play a key role in modulating the downstream effect of TR.

Successful Radiofrequency Ablation of the Right Lateral Accessory Pathway with Modified Carpentier Reconstruction Surgery in a Patient with Ebstein Anomaly Concomitant of Secundum Atrial Septal Defect, Atrial Fibrillation, and Wolff–Parkinson–White Syndrome

Ebstein anomaly (EA) results from the failure of proper delamination of the tricuspid valve leaflets from the right ventricle (RV) myocardium. The severity of EA occurs on a spectrum that results in varying degrees of tricuspid regurgitation, atrial dilation, RV dilation, and dysfunction. These effects have the potential to create substrates that can give rise to atrial arrhythmia, ventricular arrhythmia, and a greater incidence of Wolff–Parkinson–White (WPW) syndrome Wackel et al. (2018) accounting for 0.5% of all congenital heart diseases (Oh et al. 1985). In the case of atrial fibrillation and WPW, it is very dangerous for the patient because of hemodynamic compromise, syncope, and sudden death. In this case report, we share our experience in using radiofrequency ablation to ablate right lateral accessory pathway, with modified Carpentier technique in operation to treat an adult patient diagnosed with Ebstein anomaly, atrial septal defect, atrial fibrillation, and WPW syndrome.

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 &amp;lt; 0.001], had larger maximal TA area and circumference (p &amp;lt; 0.001 for both), larger RA size (p &amp;lt; 0.001), lower RA reservoir strain (p &amp;lt; 0.001) and RV free-wall strain (p &amp;lt; 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 &amp;lt; 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 &amp;lt; 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 &amp;lt; 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 &amp;lt; 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

Распространенность трикуспидальной регургитации среди пациентов многопрофильного стационара

Tricuspid regurgitation (TR) is a widespread valvular heart disease. Most times life expectancy doesn’t depend on trace to mild degrees of TR. Tricuspid valve surgery is probably recommended for patients with moderate to severe TR because of their poor long-term outcomes. It is necessary to study TR in different patients. The aim of this work was to study the incidence of TR in general hospital and to investigate moderate to severe TR incidence rate. We analyzed 50.647 transthoracic echocardiograms (TTE) done in Federal State Governmental Establishment «Burdenko Main Military Clinical Hospital» of Russian Federation Defense Ministry in 2004–2019. The median age of patients was 56 years (age 54.23±17.95 years). We discovered 44.854 cases of TR. Moderate to severe TR was detected in 5.735 (11.3%) patients (age 68.11±14.42 years, M=71 years). In general hospitals TR can be found in 88% of patients. Patients with moderate to severe TR are older patients with progressive TR. Male patient with severe TR is often older than a female patient.

Evaluation of Surgical Effect of Atrial Septal Defect with Tricuspid Regurgitation by Transesophageal 3D Echocardiography Based on MC Image Reconstruction Algorithm

This study was to explore the application and effect of three-dimensional (3D) images of the esophagus in the treatment of atrial septal defect (ASD) combined with tricuspid regurgitation (TR) surgery under the processing of marching cubes (MC) image reconstruction algorithm. The MC image reconstruction algorithm was improved as the optimized MC image reconstruction algorithm. 100 patients who had successfully undergone the ASD combined with TR surgery in the hospital from January 2017 to December 2019 were selected as the research objects and grouped based on size of the defect. The preoperative and postoperative conditions of the patients were analyzed with the MC image reconstruction algorithm. Compared with the traditional MC image algorithm, the optimized MC was advanced with less running time and fewer fixed points ( P &lt; 0.05 ). There were significant differences in TR of all ASD patients after the surgery ( P &lt; 0.05 ), and the TR of all patients showed obvious declines from the 1st day to 30th day after surgery and gradually stabilized from the 3rd month to the 6th month after surgery. Compared with patients with normal pulmonary artery pressure, the amount of TR in patients with elevated pulmonary artery pressure increased significantly, and the difference was statistically significant ( P &lt; 0.05 ). In addition, the improvement of TR after occlusion was correlated with the preoperative ASD of the patient. The optimized MC algorithm had been improved greatly in the number of fixed points and running time. The analysis using the optimized MC algorithm showed that ASD patients generally suffered different degrees of TR, TR increased with the increase of the defect, and good effect could be achieved in surgery of all kinds of ASD patients.

Clinical impact of concomitant tricuspid valve procedures during left ventricular assist device implantation

Tricuspid regurgitation (TR) is common in patients with end-stage heart failure receiving left ventricular assist devices (LVADs), but the benefit of concomitant tricuspid valve procedures (TVPs) remains uncertain. This study examined the impact of TVP at the time of LVAD implantation on clinical outcomes and quality of life (QOL) metrics. We included adult patients in the Interagency Registry for Mechanical Circulatory Support database with various degrees of TR who received continuous-flow LVADs from 2008 to 2017. Patients undergoing concomitant TVP were compared with those without the intervention in a stratified analysis. Descriptive analyses, survival analyses, and Andersen‒Gill hazard models were used as appropriate to examine associations with clinical and patient-centered QOL outcomes. Our analysis included 8,263 (53.1%) mild, 4,252 (33.3%) moderate, and 2,100 (13.5%) severe TR cases. TVP rate increased with severity: 8.6% of mild, 18.0% of moderate, and 43.9% of severe cases. TVP was not associated with survival benefit in cases of mild (adjusted hazard ratio [aHR]: 0.97, 95% CI: 0.79-1.19, p = 0.75), moderate (aHR: 1.03, 95% CI: 0.88-1.20, p = 0.72), or severe (aHR: 1.20, 95% CI: 0.98-1.48, p = 0.08) TR. For patients with combined moderate or severe TR, TVP was associated with increased mortality (log-rank p < 0.01, aHR: 1.13, 95% CI: 1.00-1.27, p = 0.04). After adjusting for TR severity, TVP was associated with increased risk of bleeding, arrhythmia, and stroke (p < 0.01 each) and no improvements in QOL (p > 0.05). TVP at the time of LVAD implantation was not associated with either improved survival or QOL, and there were associations with increased risk of adverse events among patients with moderate and severe TR.

Three-dimensional echocardiography investigation of the mechanisms of tricuspid annular dilatation.

Tricuspid annular (TA) size, assessed by 2D transthoracic echocardiography (TTE), has a well-established prognostic value in patients undergoing mitral valve surgery, with TA dilatation triggering simultaneous tricuspid annuloplasty. While TA dilatation is common in patients with dilated atria secondary to atrial fibrillation, little is known about the mechanisms of TA dilatation in patients with sinus rhythm (SR). This study aimed to identify echocardiographic parameters most closely related to the TA size as a potential tool for identification of patients prone to developing TA enlargement. 120 patients with SR underwent clinically indicated TTE, including 30 patients with normal hearts and 90 patients diagnosed with at least one right heart abnormality, defined as: right ventricular (RV) or right atrial (RA) dilatation, ≥ moderate tricuspid regurgitation (TR) and elevated systolic pulmonary artery pressure (sPAP). RA and RV end-diastolic and end-systolic volumes (EDV, ESV) and function were measured using commercial 3D software (TomTec). 3D RV long and short axes were used as surrogate indices of RV shape. Degrees of TR and sPAP were estimated by 2D TTE. 3D TA sizing was performed at end-diastole using 3D custom software. Linear regression analysis was used to identify variables best correlated with TA size, followed by multivariate analysis to identify independent associations. The highest correlations were found between TA area and: RA ESV (r = 0.73; p < 0.01), RV EDV (r = 0.58; p < 0.01), RV end-diastolic long and short axes (r = 0.53, 0.42; both p < 0.01), TR degree (r = 0.40; p < 0.01) and sPAP (r = 0.32; p < 0.01). Multivariate analysis revealed that RA ESV was the only parameter independently associated with TA area (p < 0.05, r = 0.85). In conclusion,RA volume plays an important role in TA dilatation even in patients with normal SR. Understanding of annular remodeling mechanisms could aid in identifying patients at higher risk for TA dilatation, especially those scheduled for mitral valve surgery.

Ebstein&amp;#39;s Anomaly—An Overview

Aim: To present the various echocardiographic spectrum of Ebstein’s mal-formation in adolescence and adults. Introduction: Ebstein’s anomaly has different anatomic and hemodynamic variables with clinical manifestations of cyanosis, right-sided heart failure and arrhythmias. The leaflet tethering and dysplasia, together with dilatation of the tricuspid valve ring, constitute the anatomic cause of tricuspid regurgitation observed in this condition. Case Reports: The spectrum of leaflet tethering from mild to extreme with varying degrees of tricuspid regurgitation were documented by echocardiography in a 16-year-old cyanotic male with Ebstein’s anomaly associated with an atrial septal defect and mild low tricuspid regurgitation (TR), 22-year-old acyanotic male with right-sided heart failure due to severe tricuspid regurgitation and an intact atrial septum, 55-year-old asymptomatic female with moderate high tricuspid regurgitation. The extreme form was described as an “atretic” mem-brane in a 28-year-old cyanotic male and as a “blanket” of leaflet tissue in a 30-year-old cyanotic male. Conclusion: Ebstein’s anomaly has to be sus-pected clinically in presence of cyanosis with a WPW (Wolf-Parkinson-White) or atrioventricular (AV) block pattern of ECG and its management is complex and must be individualized. RV (right ventricular) exclusion procedures are preferred in advanced cases.

Tricuspid Regurgitation Associated With Ischemic Mitral Regurgitation: Characterization, Evolution After Mitral Surgery, and Value of Tricuspid Repair

Tricuspid regurgitation (TR) often accompanies ischemic mitral regurgitation and is generally assumed to be a secondary consequence of altered hemodynamics of the left-sided regurgitation. We hypothesized that it may also be a direct consequence of right-sided ischemic disease. Therefore, our objectives were to (1) characterize the nature of this TR and (2) describe its time course after mitral valve surgery for ischemic mitral regurgitation, with or without concomitant tricuspid valve repair. From 2001 to 2011, 568 patients with ischemic mitral regurgitation underwent mitral valve surgery. They had varying degrees of TR and altered right-side heart morphology and function; 131 had concomitant tricuspid valve repair. Postoperatively, 1,395 echocardiograms were available to assess residual and recurrent TR. Greater severity of preoperative TR was accompanied by larger tricuspid valve diameter, greater leaflet tethering, worse right ventricular function, and higher right ventricular pressure (all p [trend] ≤ 0.002). Without tricuspid valve repair, 31% of patients with no preoperative TR had moderate or greater TR by 5 years, as did 62% with moderate TR. With tricuspid valve repair, 25% with moderate preoperative TR remained in that grade at 5 years, but 11% had severe TR. Tricuspid regurgitation accompanying ischemic mitral regurgitation is associated with right-side heart remodeling and dysfunction often mirroring that occurring in the left side of the heart-ischemic TR. Tricuspid valve repair is effective initially, but as with mitral valve repair, TR progressively returns. Therefore, when the severity of TR and right-sided remodeling reaches the point of irreversibility, it may be an indication to eliminate the TR by replacing the tricuspid valve.

Multi-parametric quantification of tricuspid regurgitation using cardiovascular magnetic resonance: A comparison to echocardiography

BackgroundVelocity-encoding is used to quantify tricuspid regurgitation (TR) by cardiovascular magnetic resonance (CMR), but requires additional dedicated imaging. We hypothesized that size and signal intensity (SI) of the cross-sectional TR jet area in the right atrium in short-axis steady-state free-precession images could be used to assess TR severity. MethodsWe studied 61 patients with TR, who underwent CMR and echocardiography within 24h. TR severity was determined by vena contracta: severe (N=20), moderate or mild (N=41). CMR TR jet area and normalized SI were measured in the plane and frame that depicted maximum area. ROC analysis was performed in 21/61 patients to determine diagnostic accuracy of differentiating degrees of TR. Optimal cutoffs were independently tested in the remaining 40 patients. ResultsMeasurable regions of signal loss depicting TR jets were noted in 51/61 patients, while 9/10 remaining patients had mild TR by echocardiography. With increasing TR severity, jet area significantly increased (15±14 to 38±20mm2), while normalized SI decreased (57±27 to 23±11). ROC analysis showed high AUC values in the derivation group and good accuracy in the test group. ConclusionTR can be quantified from short-axis CMR images in agreement with echocardiography, while circumventing additional image acquisition.

Surgical indication for functional tricuspid regurgitation at initial operation: judging from long term outcomes.

The assessment and management of tricuspid valve disease have evolved substantially during the past several years. Whereas tricuspid stenosis is uncommon, tricuspid regurgitation is frequently encountered and it is most often secondary due to annular dilatation and leaflet tethering from right ventricular remodelling. The indications for tricuspid valve surgery to treat tricuspid regurgitation are several and mainly related to the underlying disease, to the severity of insufficiency and to the right ventricular function. Surgical tricuspid repair has been avoided for years, because of the misleading concept that tricuspid regurgitation should disappear once the primary left-sided problem has been eliminated. Instead, during the last decade, many investigators have reported evidence in favor of a more aggressive surgical approach to functional tricuspid regurgitation, recognising the risk of progressive tricuspid insufficiency in patients with moderate or lesser degrees of tricuspid regurgitation and tricuspid annular dilatation. This concept, along with the long-term outcomes of principal surgical repair techniques are reported and discussed. Last, novel transcatheter therapies have begun to emerge for the treatment of severe tricuspid regurgitation in high-risk patients. Hence, very preliminary pre-clinical and clinical experiences are illustrated. The scope of this review is to explore the anatomic basis, the pathophysiology, the outcomes and the new insights in the management of functional tricuspid regurgitation.

Is systemic right ventricular function by cardiac MRI related to the degree of tricuspid regurgitation in congenitally corrected transposition of the great arteries?

Background and MethodsSystemic right ventricular dysfunction and tricuspid regurgitation (TR) are frequently encountered in patients with congenitally corrected transposition of the great arteries (CCTGA). Studies using echocardiography have suggested a relationship between the degree of TR and systemic right ventricular dysfunction; however, assessment of systemic right ventricular function by echocardiography is limited. Cardiac MRI (CMR) is the gold standard for volumetric assessment of the systemic right ventricle. We performed a retrospective cohort study at our center evaluating all adult patients with CCTGA who underwent a CMR between 1/1999 and 1/2013 to determine the relationship between the degree of TR and systemic right ventricular function. ResultsOf the 33 patients identified, 12 had ≤mild TR (37%), 13 had moderate TR (40%), and 8 had severe TR (24%). Mean age at CMR was 38years (23–64). Mean right ventricular ejection fraction (45% vs. 41% vs. 42%, p=0.68) and mean indexed right ventricular end diastolic volume (122ml/m2 vs. 136ml/m2 vs. 138ml/m2p=0.36) were not significantly different for patients with ≤mild TR, moderate TR or severe TR. The degree of TR was not associated with additional congenital lesions, prior procedures, presence of an intraventricular conduction delay, or decreased left ventricular function. ConclusionNo association between the degree of TR and right ventricular volume or ejection fraction by CMR was identified. Failure to show worsening function or increased volume with greater degrees of TR suggests that the degree of regurgitation alone may not fully explain the heterogeneity in right ventricular size and function.

IS SYSTEMIC RIGHT VENTRICULAR FUNCTION BY CARDIAC MRI RELATED TO THE DEGREE OF TRICUSPID REGURGITATION IN CONGENITALLY CORRECTED TRANSPOSITION OF THE GREAT ARTERIES?

Abstract Background and Methods Systemic right ventricular dysfunction and tricuspid regurgitation (TR) are frequently encountered in patients with congenitally corrected transposition of the great arteries (CCTGA). Studies using echocardiography have suggested a relationship between the degree of TR and systemic right ventricular dysfunction; however, assessment of systemic right ventricular function by echocardiography is limited. Cardiac MRI (CMR) is the gold standard for volumetric assessment of the systemic right ventricle. We performed a retrospective cohort study at our center evaluating all adult patients with CCTGA who underwent a CMR between 1/1999 and 1/2013 to determine the relationship between the degree of TR and systemic right ventricular function. Results Of the 33 patients identified, 12 had ≤mild TR (37%), 13 had moderate TR (40%), and 8 had severe TR (24%). Mean age at CMR was 38years (23–64). Mean right ventricular ejection fraction (45% vs. 41% vs. 42%, p =0.68) and mean indexed right ventricular end diastolic volume (122ml/m 2 vs. 136ml/m 2 vs. 138ml/m 2 p =0.36) were not significantly different for patients with ≤mild TR, moderate TR or severe TR. The degree of TR was not associated with additional congenital lesions, prior procedures, presence of an intraventricular conduction delay, or decreased left ventricular function. Conclusion No association between the degree of TR and right ventricular volume or ejection fraction by CMR was identified. Failure to show worsening function or increased volume with greater degrees of TR suggests that the degree of regurgitation alone may not fully explain the heterogeneity in right ventricular size and function.

Replacement of tricuspid valve with homovital mitral homograft in infective endocarditis: a case report

We have read with great interest the case description by Dasarathan et al. that just appeared in the latest issue of the Journal [1]. The authors have addressed an important but uncommon problem which is the need for replacement of the tricuspid valve in the setting of infective endocarditis. They have been clever enough to use a homovital homograft as part of the donation process for heart transplantation. The follow-up at 6 months yields a competent transplanted valve. Transplantation of the mitral valve into the tricuspid position is an old story as the authors have appropriately pointed out. We were able to deal with the problem some time ago and so far our own experience [2] and that of the others [3] confirms this as a valid alternative when the tricuspid valve has to be replaced. In their discussion Dasarathan et al. state that “... Although the long-term outlook of this operation remains uncertain, an element of tricuspid regurgitation is well tolerated...”. We agree with the authors, however we have been able to produce midand some long-term follow-up. At 6 years with a median follow-up of five, neither calcification nor rupture of the homograft was detected and different degrees of tricuspid regurgitation with no clinical impact were seen on echocardiography [4]. Furthermore, we were able to perform homograft ring annuloplasty in a patient 13 years after the original operation [5] with good result. This confirms that this is a better alternative than the option of tricuspid valvulectomy without valve replacement as advocated many years ago by Arbulu et al. [5]. In any case, this latter option did save a number of lives in critically ill patients.

Improvement of Tricuspid Regurgitation after Pulmonary Thromboendarterectomy

Chronic thromboembolic pulmonary hypertension causes right ventricular dilation with various degrees of tricuspid regurgitation, leading to right heart failure. Pulmonary thromboendarterectomy can substantially improve pulmonary hemodynamics and right ventricular dilation. The aim of this study was to determine whether the reduction of tricuspid regurgitation persists during follow-up. We studied 26 patients undergoing pulmonary thromboendarterectomy without repair of tricuspid regurgitation; 24 were followed up for 7 to 59 months after surgery (mean, 33 months). Echocardiographic and right heart catheterization data were obtained before and early after surgery. Severity of tricuspid regurgitation and tricuspid pressure gradient were evaluated at follow-up. Two patients died early after surgery, but none died during follow-up. Pulmonary thromboendarterectomy substantially improved pulmonary hemodynamics and right ventricular dilation. Tricuspid regurgitation graded severe in 5 patients and moderate in another 5, improved to trivial or mild postoperatively. The decreases in tricuspid pressure gradient and regurgitation early after surgery persisted during follow-up.

Functional Tricuspid Regurgitation in Patients With Pulmonary Hypertension: Is Pulmonary Artery Pressure the Only Determinant of Regurgitation Severity?

Pulmonary hypertension is a common cause of functional tricuspid regurgitation (TR), but other factors play a role in determining TR severity. The objectives of our study were to determine the distribution of TR severity in relation to pulmonary artery systolic pressure (PASP) and to define the determinants of TR severity. The echocardiographic reports and selected echocardiographic studies of patients with echocardiographic estimation of PASP were reviewed. Patients with organic tricuspid valve (TV) disease were excluded from the analysis. Among 2,139 patients, the frequency of moderate or severe TR was progressively greater in patients with higher PASP. Nevertheless, TR was only mild in a substantial proportion of patients with high PASP (mild TR in 65.4% of patients with PASP 50-69 mm Hg and in 45.6% of patients with PASP >or= 70 mm Hg). By multivariate analysis, age, female gender, PASP (odds ratio, 2.26 per 10-mm Hg increase; 95% confidence interval, 1.95 to 2.61), pacemaker lead, right atrial (RA) and right ventricular enlargement, left atrial enlargement, and organic mitral valve disease were independently associated with greater degrees of TR. In patients with PASP >or= 70 mm Hg, RA size, tricuspid annular diameter, and TV tethering area were greater in patients with greater degrees of TR. PASP is a strong determinant of TR severity, but many patients with pulmonary hypertension do not exhibit significant TR. In addition to PASP, demographic characteristics, mechanical factors, remodeling of the right heart cavities, and other factors (possibly reflecting the presence of atrial fibrillation or occult organic TV disease) are predictive of TR severity.

Abstract 2586: Tricuspid Valve Repair During Left Ventricular Assist Device Insertion

Purpose Right ventricular (RV) failure is associated with significant post-operative morbidity and mortality after left ventricular assist device (LVAD) insertion. Concomitant tricuspid valve repair (TVR) in the setting of tricuspid regurgitation (TR) is frequently performed to improve RV function after LVAD insertion. This study compared outcomes of patients with TR after LVAD insertion with and without TVR. Methods This was a retrospective case control study of 70 patients with matched degrees of TR undergoing LVAD implantation from 2000 to 2006 (Heartmate1, Heartmate2, DeBakey MicroMed). The TVR group consisted of patients undergoing LVAD insertion with TVR (n=24). The control group consisted of patients undergoing LVAD insertion without TVR (n=46). TR was quantified as 0 (none) to 4+ (severe) on echocardiography preoperatively and postoperatively. RV dysfunction score was defined as 0 (none), 1 (mild), 2 (moderate), or 3 (severe) on echocardiography. Postoperative clinical parameters, complications, and outcomes were evaluated. Results The TVR group and control group were similar in age (55y±15 vs 53y±12 respectively), gender distribution (18/24 male vs 42/46 male), ejection fraction (16%±5 vs 16%±6), LVAD score (preoperative measure of risk assessment 0–10), TR, mean PAP, CVP, and peak RV systolic pressure. In the TVR group, TR decreased from 2.0±0.8 to 0.7±0.5 post-operatively (p&lt;0.001). In the control group, TR also decreased from 2.2±0.7 to 1.3±0.8 (p&lt;0.001). In the TVR group, RV dysfunction score fell from 2.1±0.6 to 1.4±1.0 (p=0.01). In the control group, RV dysfunction score fell from 2.1±0.8 to 0.8±1.1 (p=0.049). Bypass time was higher in the TVR group (124±33min vs 66±46min). Incidence of acute renal failure (ARF) was lower in the TVR group (OR 0.2, p=0.02). There were no differences between the two groups regarding need for post-operative RVAD, early extubation, ICU LOS, bridge to transplant rate, or 30 day mortality. Conclusion Patients with TR requiring LVAD insertion had no improved survival when TVR was performed simultaneously. Bypass time was prolonged when TVR was performed. Patient groups with and without TVR had similar decreases in TR and improvement in RV dysfunction. Incidence of ARF was lower in the TVR group.

INVITED COMMENTARY

Anderson and colleagues have provided us with a thoughtful retrospective study describing the significance of tricuspid regurgitation (TR) detected by intraoperative transesophageal echocardiography at the time of orthotopic heart transplantation in 130 patients over a 10-year period. The authors have demonstrated that mild or greater (≥2+) degrees of TR were associated with poor posttransplant survival. Obviously there are significant limitations in any retrospective study, and the authors have clearly recognized and acknowledged the areas of greatest concern. In particular, it is well known that the use of transesophageal echocardiography has limitations in accurately assessing the degree of TR and degree of right ventricular (RV) dysfunction. The ability to quantify TR is albeit, better than the ability to quantify RV dysfunction. The method of quantification of TR utilized by Anderson and colleagues is somewhat simplistic. Using the instantaneous appearance of the area of the regurgitant tricuspid valve (TV) jet can sometimes overestimate the degree of TR when the jet is not holosystolic. Conversely, when the TV jet impinges on the wall of the right atrium, a smaller jet area may be visualized, underestimating the degree of the regurgitant jet. Also, it is important to take into consideration the size of the convergence zone when quantifying TR. These limitations become most important in the group of patients with mild (2+) or moderate (3+) degrees of TR and with no evidence of RV dysfunction. Intuitively for this group, it is difficult to imagine that TR of only a mild degree (2+) in the absence of RV dysfunction would have such a profound impact on early survival. Unfortunately the number of patients in this study with isolated significant TR and no RV dysfunction was small (n = 7); therefore it is difficult to draw major assumptions from these data for this subgroup. One must speculate whether significant underestimation of the degree of TR or RV dysfunction may have occurred with this group. Thus the overall inability to accurately assess the degree of RV dysfunction may have been the reason for both TR and RV dysfunction being observed as independent predictors of mortality in the proportional hazards model, and not just RV dysfunction alone. The second, somewhat puzzling observation is the absence of an effect of mild to moderate TR on late survival (> 6 months). If this degree of TR had such a profound adverse effect on early survival, why would this adverse effect not continue into late follow-up? Again, the numbers remain small, but if this observation is accurate, one can postulate that the cause of early mortality may not have been entirely attributable to TR alone, or alternatively, the dynamics of favorable pulmonary remodeling and reduction in pulmonary resistance occurred differently in the group of survivors making the continued presence of TR less significant. Doctor Anderson and colleagues have thoughtfully raised issues to debate regarding the importance of managing RV dysfunction and TR. That concomitant TV repair at the time of orthotopic heart transplantation may benefit and improve posttransplant RV dysfunction and survival is both intriguing and intuitive, but remains speculative on the basis of the data presented in this article. Importantly, because the overall incidence of significant TR is low in this setting, I would hope that the surgical community waits for additional future studies to determine whether the use of TV repair is appropriate to affect the natural history of TR, nicely brought to light by Anderson and colleagues.