Functional Tricuspid Valve Regurgitation Research Articles

Tricuspid valve replacement after cardiac transplantation

Tricuspid valve regurgitation is the most frequent valvular complication following orthotopic cardiac transplantation. It leads to diminished quality of life and predicts shortened long-term survival. The optimal surgical management of refractory tricuspid valve regurgitation in this setting is unclear. Tricuspid valve regurgitation following cardiac transplantation is likely related to accumulated injury from repeated endomyocardial biopsies. Durability of repair in this setting was shown to be suboptimal. Replacement with a bioprosthesis was found to be durable and relieves symptoms of heart failure associated with tricuspid valve regurgitation in the majority of patients. Prophylactic tricuspid valve annuloplasty at transplantation was found to significantly decrease the incidence of early and late tricuspid valve regurgitation; long-term benefits remain unclear. Results of tricuspid valve repair in the post-cardiac transplant setting are not ideal, and this strategy is better suited to treating functional tricuspid valve regurgitation resulting from annular dilatation. Tricuspid valve replacement with a bioprosthesis is a safe, durable, and effective method of treating tricuspid valve regurgitation following transplantation and allows for future endomyocardial biopsies to be performed. Mechanical valves should be avoided. A randomized controlled trial examining the long-term outcomes of prophylactic tricuspid annuloplasty is warranted.

Tricuspid valve surgery for functional tricuspid valve regurgitation associated with left-sided valvular disease.

We have reviewed 260 patients who underwent initial tricuspid valve surgery for functional tricuspid valve regurgitation (TR) and analyzed independent predictors for early and late unfavorable results. Between 1981 and 1998, 260 tricuspid valve operations were performed for functional TR. There were 94 males and 166 females with a mean age of 55 years. The tricuspid valve surgery procedures consisted of De Vega tricuspid annuloplasty in 240 patients, ring annuloplasty in four patients, and tricuspid valve replacement in 16 patients. The mean duration of follow-up was 7.8 years. Hospital mortality was 8.9% (23 patients). Late deaths occurred in 34 patients including cardiac-related late deaths in 26 patients. The survival rates were 83+/-2% at 5 years and 78+/-3% at 10 years. Late tricuspid valve reoperation was performed on 13 patients due to residual or recurrent TR in 12 patients and thrombosed tricuspid bileaflet mechanical valve in one patient. The tricuspid valve reoperation-free survival rate was 90+/-2% at 5 years and 84+/-3% at 10 years. The only predictor of hospital mortality was preoperative highly elevated right atrial pressure (P=0.01). Variables predictive of cardiac-related late death were preoperative New York Heart Association (NYHA) class IV (P=0.01) and poor left ventricular ejection fraction (LVEF) (P=0.02). Residual TR of more than grade 2+ early after tricuspid annuloplasty was a significant risk factor for late tricuspid valve reoperation (P=0.01). Preoperative TR of grade 4+ was predictive of early residual TR (P=0.04). Tricuspid valve surgery for functional TR can be performed with acceptable levels of early mortality. Cardiac-related late mortality after tricuspid surgery may be improved by earlier surgical treatment before NYHA class IV or deterioration of LVEF occurs. To prevent late tricuspid reoperation, it is important not to leave residual TR of grade 2+ or more after tricuspid annuloplasty.

Surgical repair for atrial septal defect in patients over 70 years of age.

Atrial septal defect (ASD) is the most common congenital heart anomaly encountered in adults. For patients over 60 years old, acceptable operative mortality and symptomatic improvement following surgery have been reported. We reviewed patients with ASD aged over 70 years and studied their preoperative hemodynamics, the surgical procedures used and the results. Between January 1994 and December 1996, 18 patients over the age of 40 years underwent surgical repair of ASD. Four patients were over 70 years of age (Group A). The other 14 patients were studied as a control group (Group B). We compared the preoperative clinical status, hemodynamic data, and surgical results between the two groups. The postoperative clinical status of Group A was studied during the follow-up period. The NYHA functional class of the elderly patients was greater than that of the middle-aged patients. None of the elderly patients had pulmonary hypertension. Moderate or severe tricuspid valve regurgitation (TR) due to annular dilatation was found, and tricuspid annuloplasty was performed in all four elderly patients. There were no operative or hospital deaths in either group. The NYHA functional class and TR improved in all the aged patients after surgery. In order to prevent progressive tricuspid annular dilatation due to an intraatrial left to right shunt, surgical closure of ASD should be performed for physically active adult patients.

MITRAL VALVE DISEASE COMPLICATED BY LEFT-TO-RIGHT SHUNT AT ATRIAL LEVEL.

The clinical features and the changes in hemodynamics are described before and after operation in two patients with mitral valve disease associated with left-to-right shunt at atrial level. The first patient had severe rheumatic mitral stenosis, which masked the associated moderate shunt. Since the interatrial communication was small, there was a moderate gradient in pressure between the two atria. Thus, the finding of an elevated left atrial or pulmonary artery wedge pressure in a patient with mitral stenosis and an increase in the saturation of blood at atrial level does not eliminate the possibility of a small interatrial communication. The second patient had severe mitral regurgitation due to a structurally abnormal valve with ruptured chordae tendineae, and had also functional pulmonary and tricuspid valve regurgitation. These lesions also masked the associated large left-to-right shunt. Electrocardiographic and angiocardiographic criteria were used to exclude the possibilities of persistent atrioventricular canal defect and of left ventricle-right atrium shunt. After operation, cardiac catheterization demonstrated a return of the hemodynamic changes toward normal in both patients. There was also a striking clinical improvement. In both, the interatrial communication was situated in the fossa ovalis. It appeared to be a foramen ovale that had become patent due to stretching of the walls of the left atrium, rather than a true atrial septal defect. Although left-to-right shunting may occur through a patent foramen ovale in infants with mitral or aortic valve atresia, we are unaware of previous hemodynamic or surgical evidence of a similar phenomenon developing as a consequence of severe mitral valve disease in adults.