Flail Tricuspid Leaflet Research Articles

Management of severe tricuspid valve regurgitation due to ruptured papillary muscle in a patient with mediastinitis early after heart transplant.

Even though severe tricuspid regurgitation is not uncommon after cardiac transplantation, primary severe tricuspid regurgitation is rare. We present such a case with additional complexities. The patient was 44-year-old man with a HeartWare durable left ventricular assist device (Heartware Inc) who received a temporary right ventricular assist device (RVAD) with a ProtekDuo cannula (LivaNova Inc USA) for refractory ventricular fibrillation and underwent a heart transplant as United Network for Organ Sharing Status 1, in the presence of partially compensated cardiogenic shock, renal failure. Given complex re-operative surgery in a volume-overloaded patient with unknown pulmonary vascular resistance, an RVAD cannula was preserved and re- inserted during cardiac transplant. Postoperatively he required hemodialysis, had severe primary tricuspid regurgitation discovered after RVAD removal and developed Enterobacter mediastinitis. He underwent complex tricuspid valve repair for flail tricuspid leaflet due to ruptured papillary muscle likely due to RVAD cannula injury, after multiple mediastinal washouts and was followed by delayed chest reconstruction. The patient is doing well, 6 months after discharge to home, asymptomatic, without re-admissions, on renal recovery path, with no tricuspid regurgitation and good biventricular function. Replacing the tricuspid valve in presence of hemodialysis catheter, immunosuppression and mediastinitis could be high risk for endocarditis. Even though we have short-term follow-up, tricuspid valve repair can be an effective way of managing primary severe regurgitation especially when there is a desire or need to avoid valve replacement.

Ruptured Tricuspid Valve Papillary Muscle in a Neonate with Intractable Persistent Fetal Circulation.

Unguarded tricuspid regurgitation (TR) due to a flail tricuspid leaflet is a rare condition of newborn cyanosis. A high perinatal mortality has been associated with this fatal condition. But, there are feasible surgical repairs to improve survival. We report the case of a male full-term neonate with intractable hypoxia. He had profound tricuspid insufficiency and leaflet prolapse caused by a ruptured papillary muscle supporting the anterior leaflet of the tricuspid valve. He presented with severe cyanosis and respiratory distress immediately after birth. Despite medical management, the pulmonary vascular resistance was not decreased and a low cardiac output persisted. Initial stabilization was accomplished with nitric oxide and extracorporeal membrane oxygenation. The tricuspid valve repair surgery was successfully performed subsequently. TR resulting from papillary muscle rupture is a potentially lethal condition. Timely diagnosis and proper surgical treatment can be lifesaving.

Chiari’s Network: An Unusual but not Uncommon Finding

A 23-year-old male patient with the diagnosis of rheumatic heart disease with severe mitral stenosis and mitral regurgitation was scheduled to undergo mitral valve replacement. After induction of anaesthesia, transoesophageal echocardiography (TEE) confirmed mitral valve disease. In addition, echocardiography revealed thin, filamentous, and freely mobile structure showing whiplike motion in the right atrium (Figs 1 and 2). The diagnosis of Chiari’s network was made based on the fine fibres originating near the inferior vena cava (Eustachian valve). The Chiari’s network was first described in 1897 in an autopsy series by Dr Chiari.1 This is a reticulated web-like network of fibres originating from the eustachian and thebesian valves at the orifice of the inferior vena cava and the coronary sinus and show attachments to different parts of the right atrium. The network results from incomplete reabsorption of the right valve of the sinus venosus during embryonic development1 and is present in approximately 2% of the population.2 According to definition1 Chiari’s network is considered, if coarse or fine fibres originating from a eustachian or thebesian valve at the orifice of the inferior vena cava or the coronary sinus are seen and they demonstrate attachments to the upper wall of the right atrium or the interatrial septum. Chiari’s network should be carefully differentiated from a large eustachian valve by looking for attachments to other parts of the right atrium as seen in the present patient (Fig. 2). Chiari’s network is often considered clinically insignificant. However, association has been made with the persistence of patent foramen ovale,2 formation of atrial septal aneurysm,2 thromboembolic events,2 intra-atrial thrombus,3 catheter entrapment,4 infective endocarditis5,6 and atrial tachyarrhythmias.7 It also poses diagnostic difficulties during echocardiography where it could be confused with right atrial thrombi, tumours, right heart vegetation’s, flail tricuspid leaflet, or a ruptured chordae tendineae. Chiari’s network can also cause difficult cannulation of the coronary sinus for retrograde coronary perfusion.8 Because of its proximity to atrial structures, TEE provides a high resolution imaging technique for atrial pathology. In summary, echocardiographic features of a rare case of Chiari’s network are presented.

Unusually Prominent Chiari’s Network Prolapsing Into the Right Ventricle in an Asymptomatic Newborn

Chiari's network (CN) is an embryologic remnant of eustachian valve located in the right atrium (RA). Incomplete involution of the fetal sinus venosus valves results in ''redundant'' CN. CN has been found in 1.3-4 % of autopsy studies and is believed to be of little clinical consequence. However, a redundant CN may favor persistence of a patent foramen ovale, formation of an atrial septal aneurysm, atrial thrombus, or paradoxic embolism, or cause intense right-to-left shunting. It may also cause arrythmias or compromise cardiovascular functions. We report an asymptomatic newborn with a prominent CN prolapsing into the right ventricle and discuss the clinical consequences of a CN. Although the patient herein presented is asymptomatic, CN may cause persistent cyanosis in the newborns mimicking congenital heart disease. It can also be confused with other curvilinear, highly mobile pathologic structures in the RA, such as vegetation, flail tricuspid leaflet, ruptured chordae tendinae, thrombus, or tumor. CN is not always a benign structure; therefore, identification and accurate diagnosis by echocardiography is important.

The forgotten valve: lessons to be learned in tricuspid regurgitation

This editorial refers to ‘Geometric changes after tricuspid annuloplasty and predictors of residual tricuspid regurgitation: a real-time three-dimensional echocardiography study’, by S.-Y. Min et al. doi:10.1093/eurheartj/ehq227 Only limited information is currently available about the prognostic significance of tricuspid regurgitation (TR). The few existing studies, however, suggest a strong impact of TR on clinical outcome. Significant TR is associated with poor prognosis in patients with mitral stenosis after percutaneous balloon valvuloplasty1 and with a reduction in exercise capacity after mitral valve surgery.2 A significant increase in mortality among patients with moderate and severe TR has been reported, which was independent of left ventricular ejection fraction or pulmonary artery pressure.3 In 60 patients with flail tricuspid leaflet due to trauma, significant increases in atrial fibrillation, heart failure, and death were observed.4 TR was also an independent predictor of increased mortality in 1400 patients with left ventricular systolic dysfunction.5 TR is only rarely caused by primary abnormalities of the tricuspid leaflets. In most instances it is ‘functional’ in nature and is the consequence of geometric alterations caused by right ventricular dilatation,6,7 distortion of the subvalvular apparatus, tricuspid annular dilatation, or a combination … *Corresponding athor. Tel: +43 1 40 400 4614, Fax: +43 1 40400 4216, E-mail: gerald.maurer{at}meduniwien.ac.at

Surgical approach to repair of ruptured chordae tendineae causing tricuspid regurgitation

Surgical approach to repair of ruptured chordae tendineae causing tricuspid regurgitation

Three-dimensional Imaging of Redundant Chiari’s Network Prolapsing into Right Ventricle

An asymptomatic 1-month-old girl was studied in another institution because of the presence of a cardiac murmur, and referred to our center for further evaluation as a result of tricuspid valve abnormalities detected in the echocardiographic study. Echocardiography revealed a very redundant, thin, freely mobile structure in the right atrium, moving rapidly in (systole) and out (diastole) of the right ventricle through the tricuspid orifice. It arose from near the border of the inferior vena cava and attached to the atrial wall close to the coronary sinus ostium, suggesting an unusually prominent Chiari's network. Three-dimensional imaging allowed definition of the structure in all the planes and dimensions, and the relationship of the structure with right atrium and ventricle. Chiari's network is an embryonic remnant present in 2% to 3% of the population. The identification of a Chiari's network is important because the widely mobile structure within the right atrium can be confused with other entities, such as right heart vegetation, flail tricuspid leaflet, ruptured chordae tendinae, or a thrombus.

Complications of endomyocardial biopsy in children

OBJECTIVESTo evaluate the incidence of, and risk factors for, complications of endomyocardial biopsy in children.BACKGROUNDEndomyocardial biopsy (EMB) is a low risk procedure in adults, but there is a paucity of data with regard to performing this procedure in children.METHODSRetrospective review of the morbidity and mortality of 1,000 consecutive EMB procedures.RESULTSOne thousand EMB procedures (right ventricle 986, left ventricle 14) were performed on 194 patients from July 1987 through March 1996. Indications for EMB included heart transplant rejection surveillance (846) and the evaluation of cardiomyopathy or arrhythmia for possible myocarditis (154). Thirty-seven (4%) procedures were performed on patients receiving intravenous inotropic support. There was one biopsy related death, secondary to cardiac perforation, in a two-week-old infant with dilated cardiomyopathy. There were nine perforations of the right ventricle, eight occurring in patients with dilated cardiomyopathy and one in a transplant recipient. The transplant patient did not require immediate intervention; two patients required pericardiocentesis alone, and six underwent pericardiocentesis and surgical intervention. All nine perforations were from the femoral venous approach (p < 0.01). Multivariate analysis demonstrated that the greatest risk of perforation occurred in children being evaluated for possible myocarditis (p = 0.01) and in those requiring inotropic support (p < 0.01). Other complications included arrhythmia (5) and single cases of coronary-cardiac fistula, flail tricuspid leaflet, pneumothorax, hemothorax, endocardial stripping and seizure.CONCLUSIONSRisk of endomyocardial biopsy is highest in sick children with suspected myocarditis on inotropic support. However, EMB can be performed safely with very low morbidity in pediatric heart transplant recipients.

Biopsy-induced flail tricuspid leaflet and tricuspid regurgitation following orthotopic cardiac transplantation

Damage to the tricuspid valve apparatus has been described after endomyocardial biopsy and may be associated with hemodynamically significant tricuspid regurgitation (TR). This study was performed to determine the prevalence of TR and flail tricuspid leaflet in cardiac transplant recipients and to evaluate the use of a 45 cm sheath placed directly in the right ventricle during endomyocardial biopsy to reduce the incidence of these complications. Echocardiograms and right heart catheterization data of 72 orthotopic cardiac transplant recipients were assessed for the presence of flail tricuspid leaflet, TR, and right-sided cardiac dysfunction 29 ± 20 months (mean ± SD) after transplantation. Moderate or severe TR was present in 23 patients (32%). Ten patients (14%) had flail tricuspid leaflet, with 7 of these having severe TR. Right atrial pressure (10 ± 5 vs 6 ± 5 mm Hg, p < 0.05) was higher, cardiac index (2.0 ± 0.2 vs 2.5 ± 0.7 L/min/m 2, p < 0.05) was lower, and right-sided cardiac dimensions were greater in patients with flail leaflets than in those without flail leaflets. Both the prevalence of flail tricuspid leaflet (41% to 6%, p < 0.0001) and mean grade of TR (2 to 1, p < 0.0001) were reduced after the use of a 45 cm sheath. We conclude that TR secondary to biopsy-induced damage to the valve apparatus occurs in cardiac transplant recipients and is associated with signs of early right-sided heart failure. Use of a 45 cm sheath during endomyocardial biopsy reduces the prevalence of flail tricuspid leaflet and the severity of TR.

Flail tricuspid leaflet, not persistent right-sided dysfunction or overload, is the most important determinant of the severity of tricuspid regurgitation at late follow-up after orthotopic cardiac transplantation

Flail tricuspid leaflet, not persistent right-sided dysfunction or overload, is the most important determinant of the severity of tricuspid regurgitation at late follow-up after orthotopic cardiac transplantation

Sushi Syncope Schusser Gets Wedeler's Valve at Vail

To the Editor. — A 68-year-old man was involved in a severe frontal impact with another skier while wedeling at a high rate of speed in Vail, Colo. Medical history was unremarkable, other than having developed sushi syncope at 63 years of age. 1 While prior to the accident he had experienced no difficulty skiing expert trails at an elevation of over 3600 m (10000 ft), afterward he became dyspneic while walking at the base of the mountain. On returning to sea level, he noted continued dyspnea on exertion; examination revealed V waves in the jugulars evident at 30° and a prominent murmur of tricuspid insufficiency. Transesophageal echocardiography demonstrated a flail tricuspid leaflet, and angiography revealed wide-open tricuspid regurgitation. Fortunately, his dyspnea gradually resolved, and by 3 months after the event he had returned to playing tennis without difficulty. Serial echocardiograms reveal that his right ventricular size has remained stable,

An Unusual Echocardiographic Finding in a Ruptured Sinus of Valsalva Aneurysm

A patient with a ruptured sinus of Valsalva aneurysm (RSVA) demonstrated an unusual two-dimensional echocardiographic manifestation of this entity. A discrete mass of echoes, appearing attached to a posterior leaflet of the tricuspid valve, moved to and fro into the right ventricle during diastole and into the right atrium in systole. This echocardiographic appearance mimics a vegetation of the tricuspid valve, a flail tricuspid leaflet, a right atrial myxoma or a pedunculated right atrial thrombus. Therefore, the differential diagnosis of this echocardiographic finding should include RSVA in addition to the above mentioned disorders.