Left Heart Valve Surgery Research Articles

Trans-catheter repair of tricuspid regurgitation following left heart valve surgery: Expansion of the interventionist portfolio.

Key points Tricuspid regurgitation (TR) is highly prevalent and leads to poor outcomes if left untreated. Surgical treatment of TR, if indicated, is generally recommended at the time of left heart valve surgery. Patients with only mild TR not meeting indications for concomitant tricuspid repair/replacement may develop progressive TR requiring treatment. A strategy of trans‐catheter tricuspid valve replacement in select patients with prior left heart valve surgery is feasible

Isolated tricuspid regurgitation: a new entity to face. Prevalence, prognosis and treatment of isolated tricuspid regurgitation.

In recent years the tricuspid is no longer considered the "forgotten valve," but nowadays, specialists focused the treatment of tricuspid regurgitation (TR) especially at the time of left heart valve (LHV) surgery, overlooking the emerging entity of isolated TR. Its incidence appears to be rising along with the higher prevalence of atrial fibrillation (AF), intracardiac devices and intravenous drug users. Hence, the aim of the present review is to summarize the available evidences in terms of natural history, clinical presentation and treatment of isolated TR. Tricuspid regurgitation is commonly classified into primary and secondary etiology. Primary or organic TR is relatively uncommon (10%) and may be due to either acquired or congenital diseases. Conversely, secondary or functional TR, caused by dilatation and flattening of the tricuspid annulus along with increase of leaflet tethering due to the remodeling of the right ventricle (RV) has become in last decade an emerging entity. Secondary TR may be due grade progression after left heart valve surgery, to previous TV surgery failure, RV remodeling or permanent AF. Primary TR causes pure volume overload on initially normal right-sided cardiac chambers. Conversely, RV enlargement is the major finding of secondary TR; RV systolic area, RV spherical index and right atrial area were identified as independent factors correlated with TV tethering height. The RV has less muscle mass than the left ventricle, and RV systolic function is therefore more load sensitive. Thus, pulmonary hypertension results in an early fall in RV ejection fraction and associated RV enlargement. An interesting entity is isolated TR related to AF, whose prevalence is estimated to be 14% in recent studies. It is known to cause dilation of the mitral and tricuspid annulus, together with changes in the dynamic mechanisms that govern the variation in area size during the cardiac cycle; as a matter of fact the relative change in TA area was significantly lower in AF (13.5%) than in sinus rhythm (SR) (33.1%). In isolated TR, medical therapy (MT) is indicated only in patients with secondary TR having also severe RV/LV dysfunction or severe pulmonary hypertension. Diuretics are the main MT in case of isolated TR in the presence of right HF in carefully selected candidates, surgery can be performed safely with good long-term survival and it should be considered early at first stages. In the treatment of isolated TR we had two diametrically opposed approaches so far, such as medical therapy, based almost exclusively on diuretics, and surgical therapy. In this scenario, trans-catheter approach is gaining momentum, including repair or replacement treatment. The former sees the use of devices for direct or indirect annuloplasty, or leaflet approximation. The second consists of orthotopic or heterotopic replacement devices (transcatheter tricuspid valve replacement devices). Evidences from randomized studies and longer follow-up will help clarify the best patient selection and treatment strategies.

Which is the best prosthesis in an isolated or combined tricuspid valve replacement?

The debate concerning the optimal choice of tricuspid position continues. We compared the long-term results of mechanical and biological prostheses in patients who underwent isolated or combined tricuspid valve replacement, at 2 major cardiac surgical centres in central China. From January 1999 to December 2018, 338 patients underwent tricuspid valve replacement. Patients were divided into an isolated group or a combined group according to whether their surgery was combined with a left heart valve surgery. Mechanical tricuspid valve replacement was performed in 142 patients (isolated group: 41 vs combined group: 101), and 196 patients underwent bioprosthetic tricuspid valve replacement (isolated group: 145 vs combined group: 51). Operative results, long-term survival and tricuspid valve-related events were compared. Early mortality in the combined group was higher (n = 6, 4%) than that in the isolated group (n = 3, 2%), but no significant difference was observed between the mechanical and biological subgroups. In the isolated group, there was a higher event-free rate in the biological subgroup than in the mechanical subgroup (P = 0.042) and a similar result was also observed for patients without Ebstein's anomaly (P = 0.039). In the combined group, no significant difference was observed (P = 0.98). Survival rates were similar between the mechanical and biological subgroups in both the isolated (P = 0.54) and combined (P = 0.81) groups. Mechanical valves in isolated tricuspid valve replacement were more prone to valve thrombosis and bleeding. Every decision regarding tricuspid valve prostheses should be individualized, but biological prostheses may be an optimal choice for patients, especially for patients without Ebstein's anomaly, in isolated tricuspid valve replacement.

Tricuspid Regurgitation in Ostium Secundum Atrial Septal Defects: Repair or Not?

Longstanding ostium secundum atrial septal defects lead to functional tricuspid regurgitation. Significant functional tricuspid regurgitation associated with left heart valve disease is addressed at the time of primary left heart valve surgery. In contrast, there is no global recommendation for tricuspid regurgitation associated with atrial septal defects. This study assesses changes in tricuspid regurgitation after isolated atrial septal defect closure. Retrospectively, records were examined of 100 patients who underwent isolated ostium secundum atrial septal defect closure without tricuspid valve repair. Echocardiograms were done preoperatively and 3 days, 3 months, and 1 year after surgery. Data on tricuspid regurgitation status, right ventricle dimensions, and pulmonary artery hypertension status were collected and analyzed. After surgical closure, echocardiography showed a regression of tricuspid regurgitation to mild or less in 76% of patients at 3 days, 89% at 3 months, and 93% at 1 year. Severe pulmonary artery hypertension (32% patients preoperatively) showed statistically significant regression: 14% at 3 days, 10% at 3 months, and 2% at 1 year. Preoperatively, the mean right ventricular internal diameter was 37.9 mm, which decreased to 34 ± 5.5 mm (mean ± standard deviation) at 3 days, 32.3 ± 5.3 mm at 3 months, and 31.3 ± 5.4 mm at 1 year. It was also noted that regression favored patients who were <25 years old. Tricuspid valve repair may not be required in patients with ostium secundum atrial septal defect with functional tricuspid regurgitation.

P303 Characteristics and prognosis of patients with significant tricuspid regurgitation

Abstract Funding Acknowledgements none Background Severe tricuspid regurgitation (TR) usually remains asymptomatic for a long period, and the diagnosis is often delayed, at an advanced stage of right heart failure (RHF). Only a minority of patients are referred to surgery. Purpose To describe the characteristics and prognosis according to aetiologies of patients with significant TR. Methods Two hundred and eight consecutive patients with moderate-to-severe (grade III) or severe (grade IV) TR were included from echocardiography reports between 2013 and 2017. Median follow-up was 18(6-38) months. Results Patients (mean age 75 years, 46.6% males) were divided into 4 groups according to TR aetiology, group 1: primary TR (15%), group 2: TR secondary to left heart or pulmonary disease with a history of left heart valve surgery (24.5%), group 3: TR secondary to left heart disease with no history of left valvular surgery (26.4%) and group 4: idiopathic TR (34.1%). During follow-up, 61 patients (29%) experienced at least one decompensation of RHF requiring hospitalization. Only 11 patients (5.3%) underwent tricuspid valve surgery during follow-up. The 4 years survival was much lower than the expected survival of age- and sex-matched individuals of the general population (56 ± 4%vs74%). After adjustment for outcome predictors, patients with idiopathic TR had a higher risk of mortality (adjusted HR = 1.83[1.05-3.21]; p = 0.034) compared to other groups. Conclusions Moderate-to-severe and severe TR is associated with a high risk of hospitalization for RHF and death at 4 years and a low rate of surgery. Idiopathic TR is associated with worse outcome than other etiologies Abstract P303 Figure. SURVIVAL CURVES

Characteristics and prognosis of patients with significant tricuspid regurgitation

Severe tricuspid regurgitation (TR) usually remains asymptomatic for a long period, and the diagnosis is often delayed, at an advanced stage of right heart failure (RHF). Only a minority of patients are referred to surgery. To describe the characteristics and prognosis according to aetiologies of patients with significant TR. Two hundred and eight consecutive patients with moderate-to-severe (grade III) or severe (grade IV) TR were included from echocardiography reports between 2013 and 2017. Median follow-up was 18(6-38) months. Patients (mean age 75 years, 46.6% males) were divided into 4 groups according to TR aetiology, group 1: primary TR (15%), group 2: TR secondary to left heart or pulmonary disease with a history of left heart valve surgery (24.5%), group 3: TR secondary to left heart disease with no history of left valvular surgery (26.4%) and group 4: idiopathic TR (34.1%). During follow-up, 61 patients (29%) experienced at least one decompensation of RHF requiring hospitalization. Only 11 patients (5.3%) underwent tricuspid valve surgery during follow-up with a perioperative mortality of 36%. The 4 years survival was much lower than the expected survival of age- and sex-matched individuals of the general population (56 ± 4% vs. 74%). After adjustment for outcome predictors, patients with idiopathic TR had a higher risk of mortality (adjusted HR = 1.83 [1.05–3.21]; P = 0.034) compared to other groups ( Fig. 1 ). Moderate-to-severe and severe TR is associated with a high risk of hospitalization for RHF and death at 4 years and a low rate of surgery. Idiopathic TR is associated with worse outcome than other etiologies.

The procedure choice for the reoperation of tricuspid valve lesion after left heart valve surgery

Tricuspid insufficiency late after left-sided heart valve surgery is not uncommon. These patients usually suffer from severe right heart insufficiency and poor general condition due to untimely surgical intervention, and are often complicated with hepatic and renal insufficiency and hemopoietic dysfunction. The choice of strategy for reoperation and perioperative management are still the major challenges for contemporary cardiac surgeons. This article introduces the clinical characteristics and operation timing of patients with severe tricuspid insufficiency after previous left-sided heart valve surgery, and focuses on the selection of operation approach and operation methods.

Characteristics and prognosis of patients with significant tricuspid regurgitation

Severe tricuspid regurgitation (TR) usually remains asymptomatic for a long period, and the diagnosis is often delayed until an advanced stage of right heart failure (RHF). Only a minority of patients are referred for surgery. To describe the characteristics and prognosis of patients with significant TR, according to aetiology. Two-hundred and eight consecutive patients with moderate-to-severe (grade III) or severe (grade IV) TR were included from echocardiography reports between 2013 and 2017. Median follow-up was 18 (6-38) months. Patients (mean age 75 years; 46.6% men) were divided into four groups according to TR aetiology: group 1, primary TR (14.9%); group 2, TR secondary to left heart disease with a history of left heart valve surgery (24.5%); group 3, TR secondary to left heart or pulmonary disease with no history of left valvular surgery (26.5%); and group 4, idiopathic TR (34.1%). During follow-up, 61 patients (29.3%) experienced at least one episode of RHF decompensation requiring hospitalization. Only 11 patients (5.3%) underwent tricuspid valve surgery during follow-up. The 4-year survival was much lower than the expected survival of age- and sex-matched individuals in the general population (56±4% vs. 74%). After adjustment for outcome predictors, patients with idiopathic TR had a higher risk of mortality (adjusted hazard ratio 1.83, 95% confidence interval 1.05-3.21; P=0.034) compared with other groups. Moderate-to-severe or severe TR is associated with a high risk of hospitalization for RHF and death at 4 years, and a low rate of surgery. Idiopathic TR is associated with worse outcome than other aetiologies.

Characteristics and prognosis of patients with significant tricuspid regurgitation

Severe tricuspid regurgitation (TR) usually remains asymptomatic for a long period, and the diagnosis is often delayed, at an advanced stage of right heart failure (RHF). Only a minority of patients are referred to surgery. We aim to describe the characteristics and prognosis according to aetiologies of patients with significant TR. Two hundred and eight consecutive patients with moderate-to-severe (grade III) or severe (grade IV) TR were included from echocardiography reports between 2013 and 2017. Median follow-up was 18(6–38) months. Patients (mean age 75 years, 46.6% males) were divided into 4 groups according to TR aetiology, group 1: primary TR (15.4%), group 2: TR secondary to left heart disease with a history of left heart valve surgery (24.5%), group 3: TR secondary to left heart disease with no history of left valvular surgery (26%) and group 4: idiopathic TR (34.1%). During follow-up, 61 patients (29%) experienced at least one decompensation of RHF requiring hospitalization. Only 11 patients (5.3%) underwent tricuspid valve surgery during follow-up with a perioperative mortality of 36%. The 4 years survival was much lower than the expected survival of age- and sex-matched individuals of the general population (56 ± 4% vs. 74%). After adjustment for outcome predictors, patients with idiopathic TR had a higher risk of mortality (adjusted HR = 1.83[1.05–3.21]; P = 0.034) compared to other groups. Moderate-to-severe and severe TR is associated with a high-risk of hospitalization for RHF and death at 4 years and a low rate of surgery. ( Fig. 1 Idiopathic TR is associated with worse outcome than other etiologies)

Valoración a medio plazo de la insuficiencia tricuspídea funcional tras anuloplastia con anillo rígido tridimensional

Introduction and objectivesSignificant functional tricuspid regurgitation is associated with a high morbidity and mortality if not repaired during left heart-valve surgery, or if it recurs during the follow-up.Classic tricuspid annuloplasty with suture techniques has a high rate of tricuspid regurgitation recurrence. Annuloplasty techniques with prosthetic rings are currently preferred for this condition, since they have longer-lasting results during the follow-up.The objectives of this study are to assess the medium-term echocardiographic outcomes of tricuspid annuloplasty using a three-dimensional rigid ring, and to determinate the predictive factors for recurrence of significant tricuspid regurgitation after annuloplasty. MethodsVariables were collected from a total 260 tricuspid annuloplasties with a three-dimensional rigid ring performed in our centre, along with the clinical and echocardiographic follow-up data. A multivariate regression analysis was carried out in order to establish the risk factors predisposing to significant tricuspid regurgitation during the follow-up. ResultsAfter a median follow-up time 16 months (3.9-34.5), 220 patients (84.62%) had a control echocardiogram. Persistent/recurrent severe tricuspid regurgitation occurred in 5.0%. Risk factors for significant tricuspid regurgitation after annuloplasty were: Severe pulmonary hypertension at follow-up (OR 337.91; 95% CI: 34.60-3300.07; P<.001) and post-operative right heart failure (OR 1.02; 95% CI: 1.003-1.037; P=.021). Preserved left ventricle function (OR 0.96; 95% CI: 0.927-0.993; P=.018) and concomitant mitral surgery (OR 0.97; 95% CI: 0.960-0.990; P=.001) emerged as protector factors. ConclusionsTricuspid annuloplasty using a three-dimensional rigid ring is an effective procedure for correcting secondary tricuspid regurgitation, with a low rate of persistent or recurrent significant tricuspid regurgitation during the follow-up.

The failing right heart: implications and evolution in high-risk patients undergoing transcatheter aortic valve implantation.

Right ventricular dysfunction (RVdy) is negatively associated with survival after left heart valve surgery. It is unclear whether RVdy has the same impact in patients undergoing transcatheter aortic valve implantation (TAVI). We sought to evaluate the prognostic impact of different grades of RVdy on TAVI, with and without concomitant left ventricular dysfunction (LVdy), and the possible impact of TAVI on RVdy. Among 870 consecutive patients with severe symptomatic aortic stenosis undergoing TAVI, 226 patients (26%) presented with a concomitant diagnosis of RVdy. Patients were divided into three groups, Group 1: normal RV systolic function, i.e., tricuspid annular plane systolic excursion (TAPSE) >16 mm (n=644, 74%); Group 2: mild-to-moderate RVdy, i.e., TAPSE 10-16 mm (n=180, 20.6%); Group 3: severe RVdy, i.e., TAPSE <10 mm (n=46, 5.2%). Patients in Groups 1 and 2 showed a similar overall mortality rate at one month (5% vs. 8%, OR 1.1 [0.7-1.55], p=0.2) and at one-year follow-up (15% vs. 19%, HR 1.5 [0.84-2.2], p=0.09), respectively. Compared to Groups 1 and 2, patients in Group 3 showed a significantly higher overall mortality at one month (22%, OR 3.3 [1.8-4.1], p<0.001, and OR 2.1 [1.7-3.1], p=0.02, respectively) as well as at one-year follow-up (45%, HR 2.6 [2.1-3.45], p<0.001, and HR 1.9 [1.5-2.7], p=0.02), respectively. Pulmonary hypertension >60 mmHg (HR 1.5 [1.1-2.2], p=0.03), AF (HR 1.6 [1.1-2.4], p=0.01), creatinine clearance <30 mL/min (HR 1.92 [1.3-2.5], p=0.003), LVEF <30% (HR 1.5 [1.1-2.9], p=0.03), severe RVdy (HR 2.9 [2.7-3.3], p=0.002), severe RV dilation (HR 1.7 [1.2-2.2], p=0.005) and severe biventricular dysfunction (HR 3.9 [2.7-4.1], p=0.002) were independent predictors of one-year mortality. Among survivors, the majority of patients in Groups 2 and 3 experienced a significant improvement in NYHA class. Severe RVdy limits the expected benefit of TAVI. In current risk scores right heart failure is not considered. The present study advocates the evaluation of this strong predictor in a more complete pre-procedural work-up.

Tricuspid valve repair by DeVega technique versus ring annuloplasty in patients with functional severe tricuspid regurge

BackgroundRepairing the tricuspid valve in patients undergoing left heart valve surgery is still controversial. Severe Tricuspid regurge is repaired by most surgeons, while moderate regurge is frequently unaddressed. Another controversy is the technique of repair. DeVega technique is widely used; still, the longevity of this repair is still questioned. The risk of its early failure and subsequent recurrence of significant regurge requiring redo surgery has led many surgeons to adopt the use of annuloplasty rings. The aim of our study was to assess the short term results (1 year) of tricuspid repair with or without ring annuloplasty. Patients and methods80 patients who had tricuspid repair concomitantly with mitral valve surgery at Cairo University Hospitals over 5 years were studied by echocardiography at discharge and at 1 year after surgery. Results62 patients had repair using the DeVega annuloplasty (group A) while 18 had ring annuloplasty (group B). The mean age was 33 ± 6 years and 37 ± 8 years for group A and B respectively. The cardiopulmonary bypass (CPB) time was relatively longer in group B. There was only one mortality in group A. Echocardiography done for all patients of both groups at discharge and at 1 year postoperatively showed no significant difference between both groups. ConclusionTricuspid repair using ring annuloplasty has good results but with no significant benefits over DeVega annuloplasty at one year.

Prevalence, Predictors and Clinical Outcome of Residual Pulmonary Hypertension Following Tricuspid Annuloplasty.

BackgroundTricuspid annuloplasty is increasingly performed during left heart valve surgery, but the long‐term clinical outcome postoperatively is not satisfactory. The aim of this study was to determine whether residual pulmonary hypertension (PHT) contributes to the adverse outcome.Methods and ResultsOne‐hundred thirty‐seven patients (age 61±11 years; men, 30%) who underwent tricuspid annuloplasty during left‐side valve surgery were enrolled. The mean pulmonary artery systolic pressure before surgery was 49±13 mm Hg and 32±15 mm Hg following surgery. Patients were divided into 3 groups according to postoperative pulmonary artery systolic pressure: no residual PHT (n=78, 57%), mild residual PHT (n=43, 31%), or significant residual PHT (n=16, 12%). A preoperative larger right ventricular (RV) geometry and tricuspid valve tethering area were associated with mild or significant residual PHT. A total of 24 adverse events (20 heart failures and 4 cardiovascular deaths) occurred during a median follow‐up of 25 months. Kaplan–Meier survival curve demonstrated that patients with significant residual PHT had the highest percentage of adverse events followed by those with mild residual PHT. Patients with no residual PHT had a very low risk of adverse events. Multivariable Cox regression analysis revealed that both mild (hazard ratio=4.94; 95% CI =1.34–18.16; P=0.02) and significant residual PHT (hazard ratio=8.67; 95% CI =2.43–30.98; P<0.01) were independent factors associated with adverse events.ConclusionsThe present study demonstrated that 43% of patients who underwent tricuspid annuloplasty had residual PHT. The presence of mild or significant residual PHT was associated with adverse events in these patients.

Right atrial contractile dynamics are impaired in patients with postcapillary pulmonary hypertension.

Left ventricular (LV) dysfunction in conjunction with postcapillary pulmonary hypertension (PH) is frequently associated with right ventricular (RV) dysfunction, determining the patient prognosis. Compensatory mechanisms for RV dysfunction have not been previously evaluated in detail. Since calcium dependent right atrial (RA) dynamics are a surrogate for RA contractile properties, the present study examined the calcium dependency of RA tissue obtained from patients with or without postcapillary PH. In total, 15 patients with PH (PH group; mean age, 70.7±7.2 years) and 10 patients without postcapillary PH (non-PH group; mean age, 55.7±11.8 years) who were scheduled to undergo elective left heart valve surgery were included in the current study. Calcium concentration (pCa; shown as the negative log10) against force curves were generated, while LV and RV function was evaluated by echocardiography. Echocardiography data revealed a significantly reduced LV function in the PH group, while the RV function was preserved in the two groups, precluding overt RV dysfunction. In the PH group, significantly reduced force values were detected at high pCa values when compared with the non-PH group force, indicating impaired RA function. Furthermore, reduced calcium sensitivity was observed (which was determined as the pCa at half maximal activation) in the PH group, and the presence of a compensatory mechanism for reduced force capacity was hypothesized. In conclusion, the preliminary results of the current study showed impaired RA contractile properties in postcapillary hypertension with preserved RV function. The diminished RA compensatory mechanisms may lead to accelerated RV dysfunction in the clinical course of postcapillary PH.

Tricuspid Regurgitation, the Forgotten Valvular Lesion-A Contemporary Review of Etiology, Prevalence, and Management Options.

Tricuspid regurgitation (TR) is a common finding. Pathologic TR is an independent risk factor for mortality. TR can be classified by etiology into functional versus organic. Organic TR is caused by structural damage to the tricuspid valve (TV) by a spectrum of etiologies, including pacemaker leads and right heart biopsies, whereas functional TR is predominantly due to elevated pulmonary pressures. Atrial fibrillation and chamber enlargement, among other risk factors, are strong predictors of functional TR. Correction of elevated pulmonary pressures improves TR, and concurrent repair of severe TR at the time of left heart valve surgery improves postoperative heart failure symptoms but does not improve survival. TR repair is associated with less operative and long-term mortality than TV replacement, and demonstrates similar improvements in heart failure symptoms. Substantial residual TR remains after repair, and reoperative mortality for residual TR is considerable. Percutaneous TV replacement may offer a rescue strategy.

0407: Evaluation of the tricuspid annulus size: clinical implications from comparison between 2D-transthoracic and 3D-transesophageal echocardiography

Tricuspid annuloplasty is recommended during left-heart valve surgery when tricuspid annulus (TA) is dilated, independently of the degree of tricuspid regurgitation, but the methodology to measure TA and thresholds are not clearly defined. We aimed to compare TA diameter (TAD) measurements performed using bi-dimensional transthoracic echocardiography (2D-TTE) in the 4 different views to three-dimensional measurements performed during transesophageal echocardiography (3D-TEE) and to define thresholds of TA enlargement for routine practice. 2D-TTE measurement of the TAD was performed in parasternal long-axis view of the right ventricle inflow, parasternal short-axis, apical 4-chamber (A4C) and sub-costal views in 195 prospectively enrolled patients and 66 healthy volunteers. 3D dynamic volumetric datas of the TA were also acquired by TEE using a matrix array transducer (X7-2t, Philips) in the 195 patients. Multiplanar reconstructions were performed offline using dedicated software (QLab7, Philips) to measure the long-axis (LA) of the TA. In the 195 patients, TAD measurements were not different between the 4 TTE views (P=0.13), but A4C was the most feasible and the most reproducible method (Table). TAD measurement in A4C view by TTE (3.90±0.62cm) was well correlated (r=0.84, p<0.0001) to LA by 3D-TEE (4.33±0.63cm), but with a systematic 4mm underestimation. In the healthy volunteers, mean value of TAD in A4C was 3.2±0.4cm or 1.8±0.23cm/m² and the upper limit of 95% confidence interval was 4.2cm or 2.3cm/m². TAD measurement in A4C view by 2D-TTE was highly feasible, reproducible and accurately reflected TA size, even if it was systematically underestimating its maximal diameter. Based on measurements in healthy volunteers, we suggest to consider tricuspid annuloplasty during left-heart valve surgery when TA is more than 2.3cm/m² or 4.2cm in A4C.

0402: Assessment of tricuspid annulus shape and orientation using three-dimensional transesophageal echocardiography

The tricuspid annulus (TA) is a complex structure that has been rarely evaluated. Three-dimensional transesophageal echocardiography (3D-TEE) gives us the unique opportunity to evaluate TA shape and dimensions. 3D dynamic volumetric datas of the TA were acquired by TEE using a matrix array transducer (X7-2t, Philips) in 184 patients. Multiplanar reconstructions were performed offline using a dedicated software (QLab7, Philips). Long-axis (LA) diameter, short-axis (SA) diameter and the area of the TA at the time of its maximal opening were measured. The eccentricity index (EI) of the TA was defined as LA/SA and TA orientation as the angle between the interatrial septum axis (aortic valve on the top at 0°) and the LA in the surgical view. Morphology of TA was more often oval (EI=1.35±0.22) but shapes were significantly different among indivuals, from circular to oval (EI values from 1 to 2.15). TA dilatation occurred homogeneously in all the directions of the right ventricle free wall as attested by the very good correlation between the TA area and both LA (r=0.89, p<0.0001) and SA (r=0.88, p<0.0001). TA dilatation, as shown by increase in TA area, was associated with a small decrease of EI (r=-0.21, p<0.0001), thus a trend to a more circular TA. All orientations of TA were observed, from 5 to 175° (mean=87°±57°) with a bimodal distribution (most frequently at 40° and 150°). 3D-TEE allowed a good assessment of the TA shape and orientation, which is significantly different among individuals. This method could be interesting to improve assessment of TA dilatation before left-heart valve surgery. Abstract 0402 – Figure

Presence of tricuspid regurgitation after left-heart valve surgery independently predicts mortality

Background: Significant tricuspid regurgitation (TR) occurring late after left-heart valve surgery is frequent and associated with decreased exercise tolerance and quality of life. Re-operative tricuspid valve (TV) surgery has been reported to result in early mortality rates as high as 10% to 25%. The aim of the study was to evaluate whether significant TR late after left-heart valve surgery impacts on prognosis. Methods: 602 consecutive patients after successful surgery of the aortic or/and the mitral valve (49±29 months post-surgery) were prospectively followed for 5 years. The severity of TR was assessed by echocardiography. Significant TR was defined as TR ≥ moderate. The primary endpoint was defined as cardiovascular death. Cox-Regression was used to determine the impact of TR on survival. Results: Significant TR was present in 122 (20.3%) patients, who were predominantly female (66% vs. 49%, p<0.001), had a higher EuroSCORE (9.8±2.5 vs. 8.9±2.3, p<0.001) and had more previous cardiac surgeries (1.2±0.5 vs. 1.1±0.3, p=0.010). They more often had atrial fibrillation (48% vs. 19%, p<0.001) and were more symptomatic (NYHA≥II 55% vs. 31% p<0.001). Patients with significant TR had larger right ventricles (36.9±7.9mm vs. 32.7±5.0mm, p<0.001), more dilated left and right atria (66.7±13.0mm vs. 57.9±8.3mm and 65.0±13.1mm vs. 55.3±7.5mm; both p<0.001) and presented with worse left ventricular function (LVEF<50%: 19% vs. 11%; p=0.020). In total, 132 (21.9%) patients died during follow up (36.1% with significant TR vs. 18.3% without; p<0.001). 76 (12.6%) patients died of cardiovascular causes (26.2% vs. 9.2%, p<0.001). By Kaplan-Meier analysis, overall survival was significantly worse in patients with significant TR (1-,3- and 5-year survival 91.8%, 81.2% and 63.9% vs. 96.0%, 89.0% and 81.7%; log rank p<0.001). By multivariable Cox regression analysis, age (p<0.001), left atrial enlargement (p<0.001), coronary artery disease (p=0.001) and significant TR (p=0.008) were found to independently predict cardiovascular mortality. Conclusion: Significant TR late after left-sided valve surgery is frequent and independently predicts mortality.

Current Readings: Status of Tricuspid Valve Repair

The surgical management of mitral and aortic valvular heart disease has changed significantly over the last decade. Meanwhile, tricuspid valve (TV) surgery has remained less commonly performed than left-sided valve surgeries, and there is a relative paucity of reports in the literature. There are ongoing controversies as to the optimal surgical management of TV disease, including repair versus replacement, the type of prosthesis preferred, optimal repair techniques, appropriate management of functional tricuspid regurgitation (TR) with concomitant left heart valve surgery, and others. In this article, we review what we believe are five important and contemporary papers that cover important aspects of TV surgery and provide recommendations for the surgical management of TV disease.

Role of concomitant tricuspid surgery in moderate functional tricuspid regurgitation in patients undergoing left heart valve surgery

Functional tricuspid regurgitation (FTR) is frequently present in patients undergoing aortic, and particularly mitral valve, surgery. Untreated FTR may lead to right heart failure. Reoperative cardiac surgery for late FTR is associated with high morbidity and mortality. Therefore, severe FTR has emerged as a Class I indication for concomitant tricuspid valve surgery in patients undergoing left valve surgery. Concomitant tricuspid valve surgery during left heart valve surgery to address moderate and mild FTR is controversial. This review addresses this issue and proposes an algorithm for the treatment of FTR in patients undergoing left heart valve surgery.