Mild Tricuspid Valve Regurgitation Research Articles

Valve repair for tricuspid valve regurgitation in pediatric patients: Midterm outcomes

BackgroundTricuspid valve regurgitation in pediatric patients has heterogeneous lesions, and surgical intervention is sometimes necessary. Tricuspid valve repair is the preferred treatment for tricuspid valve regurgitation. ObjectivesThis study aimed to review the midterm outcomes of tricuspid valve repair for tricuspid valve regurgitation in pediatric patients. MethodsA total of 26 patients aged < 18 years who underwent tricuspid valve repair for tricuspid valve regurgitation at our institute between January 2005 and September 2022 were retrospectively reviewed. Their median age was 3.7 years (range, 1 month–16.2 years), and 15 were males. 23 had congenital heart diseases. Among them, 35 % of patients had tetralogy of Fallot or pulmonary atresia with ventricular septal defect (9/26), followed by ventricular septal defect (23 %, 6/26). ResultsSeveral reparative techniques were used according to valve lesions. Commissural edge-to-edge suture was the most frequently used technique. There were two cases of hospital death, and no late death occurred. During the median follow-up period of 7.8 years (range, 5 months–17.5 years), reoperation was performed in one patient with pulmonary atresia with intact ventricular septum. At the last follow-up, all survivors had mild or less tricuspid valve regurgitation. No patient had tricuspid valve stenosis. Postoperative tricuspid annular diameter increased within the normal range in all patients. Survival and reoperation-free rates at both 5 and 10 years were 92.3 % and 95.8 %, respectively. ConclusionTricuspid valve repair for tricuspid valve regurgitation in pediatric patients is safe and feasible with satisfactory midterm outcomes.

Triple repeated fetal congenital heart disease linked to PLD1 mutation: a case report

BackgroundCongenital heart disease occurs in approximately 1 in 100 cases. Although sibling occurrence is high (3–9%), the causative genes for this disease are still being elucidated. PLD1 (Phospholipase D1) is a recently discovered gene; however, few case reports have been published on it. In this report, we describe a case of triplicate fetal congenital heart disease that was diagnosed as a PDL1 mutation. Our objective is to explore the clinical manifestations of PLD1 mutations in this particular case.Case presentationA 32-year-old Japanese woman (gravida, para 0) was introduced since fetus four chamber view was not clear and was diagnosed with ductus arteriosus-dependent left ventricular single ventricle and pulmonary atresia at 21 weeks and 1 day of gestation during her first pregnancy. Artificial abortion using Gemeprost was performed at 21 weeks and 5 days of gestation. The second pregnancy was diagnosed as pulmonary atresia with intact ventricular septum with cardiomegaly, a cardiothoracic area ratio of more than 35%, and a circulatory shunt at 13 weeks and 3 days of gestation. Subsequently, intrauterine fetal death was confirmed at 14 weeks and 3 days of gestation. Regarding the third pregnancy, fetal ultrasonography at 11 weeks and 5 days of gestation showed mild fetal hydrops and moderate tricuspid valve regurgitation. At 16 weeks and 5 days of gestation, the fetus was suspected to have a left ventricular-type single ventricle, trace right ventricle, pulmonary atresia with intact ventricular septum, or cardiomyopathy. Cardiac function gradually declined at 26 weeks of gestation, and intrauterine fetal death was confirmed at 27 weeks and 5 days of gestation. The fourth pregnancy resulted in a normal heart with good progression and no abnormal baby. We submitted the first and second fetuses’ umbilical cord, third fetus’ placenta, and the fourth fetus’ blood to genetic testing using whole exome analysis with next generation sequencing. Genetic analysis identified hemizygous PLD1 mutations in the first, second, and third fetuses. The fourth fetus was heterozygous. In addition, the parents were heterozygous for PLD1. This case is based on three consecutive cases of homozygosity for the PLD1 gene in the sibling cases and the fetuses with recurrent right ventricular valve dysplasia. This will elucidate the cause of recurrent congenital heart disease and intrauterine fetal death and may serve as an indicator for screening the next fetus. To date, homozygous mutations in PLD1 that repeat three times in a row are not reported, only up to two times. The novelty of this report is that it was repeated three times, followed by a heterozygous live birth.ConclusionsThis report is consistent with previous reports that mutations in PLD1 cause right ventricular valve dysplasia. However, there have been few case reports of PLD1 mutations, and we hope that this report will contribute to elucidate the causes of congenital heart disease, especially right ventricular valve dysplasia, and that the accumulation of such information will provide more detailed information on PLD1 mutations in heart disease.

Tricuspid valve detachment for ventricular septal defect closure: A meta-analysis of existing evidence.

Ventricular septal defect (VSD) is one of the most common congenital cardiac defects. However, in some cases, VSD sites are difficult to expose due to obstruction from chordal attachments and leaflets of the tricuspid valve (TV). To systematically review the efficacy and safety of tricuspid valve detachment, (TVD) versus conventional surgical repair (non-TVD) in the treatment of ventricular septal defect (VSD). This article is aimed to compare the many outcomes from existing studies and provide evidence regarding the necessity of performing TVD. We searched the following databases: PubMed via NCBI, the Cochrane Central Register of Controlled Trials (no date restriction), Medline via Ovid (from 1966 to May 2020); Embase via Ovid (no date restriction), and China National Knowledge Infrastructure for studies comparing the efficacy of TVD and other surgical techniques in VSD repair. Cardiopulmonary bypass time, Cross-clamp time; postoperative complications including residual defect, postoperative atrioventricular block, implantation of pacemakers, tricuspid regurgitation; length of stay (LOS), length of intensive care unit (ICU) stay were analyzed. Only nine studies were included after selection, including seven retrospective cohort studies, one respective cohort study, and one prospective observational study, a patient pool of 1404 patients with 374 underwent TVD and 1030 underwent non-TVD procedures, met the inclusion criteria. Meta analysis has drawn to the following conclusions. First, TVD prolongs CPB time (MD = 7.75, 95% confidence interval [CI] = 2.60-12.89, p = .003) and cross-clamp time (MD = 7.77, 95% CI = 4.76-10.78, p < .001) compared with non-TVD techniques in VSD repair surgeries. Second, no significant difference exists in LOS, length of ICU stay, postoperative atrioventricular block, implantation of pacemakers, incidence of ≥mild tricuspid valve regurgitation (TR) postoperatively and at discharge, as well as the incidence of ≥small residual VSD after surgery and during follow-up (all p ＞ .05). Third, application of TVD increases the risk of TR during follow-up (odds ratio [OR] = 2.42, 95% CI = 1.55-3.76, p < .001). VSD closure using TVD technique results in longer CPB and cross-clamp time, and increases risk of TR during follow-up. TVD provides equally viable and safe alternative in treating VSD.

Abstract 14248: The Impact of Trastuzumab on the Pulmonary Artery Systolic Pressure in Patients With HER-2 Positive Breast Cancer

Introduction: Despite that trastuzumab (TZB) improves life expectancy and prognosis in patients with HER-2 positive breast cancer (BC), cardiotoxicity is a well-established complication. However, other potential cardiac complications of TZB such as pulmonary hypertension (PHTN) are poorly investigated. Aim: Evaluate the effect of TZB on pulmonary artery systolic pressure (PASP) and measure the predictors of developing elevated PASP. Methods: The medical records for all females who received TZB treatment for confirmed HER-2 positive BC at King Hussein Cancer Centre in Jordan between 2014 - 2019 who had a documented normal PASP of ≤35 mmHg before treatment were evaluated. Results: A total of 436 patients with a mean age of 53±11 years were included. The leading comorbidities were hypertension and diabetes mellitus affecting 26.2% and 15.4% of the patients, respectively. 15.6% of the study’s population were active smokers. Prior to initiating TZB, 22.3% had left ventricular hypertrophy (LVH), 14.3% had mild tricuspid valve regurgitation (TR), 11.5% had pericardial effusion, and 4.8% had mild aortic valve regurgitation (AR).Of alarming significance, 24.8% of the patients had their PASP increased after one year. Patients who developed elevated PASP tend to be older (56.9 vs 51.3, P&lt;0.001), had baseline mild TR (26.3% vs 10.3%, P&lt;0.001), LVH (39.4% vs 17.6%, P&lt;0.001), and mild AR (9.1% vs 3.7%, P=0.031).Multivariate analysis showed that the only predictors of elevated PASP are TR at baseline (OR 3.9; 95% CI 1.58-6.17, P=0.001), and age (OR 1.04; 95% CI 1.01-1.06, P=0.005). However, baseline LVH (OR 1.79; 95% CI 0.98-3.26, P=0.057), number of the TZB cycles (OR 0.93; 95% 0.85-1.02, P=0.152), and the total dose of TZB (OR 1; 95% CI 1-1, P=0.284) were non-significant predictors. At 1 year follow up, the mean total cumulative dose of TZB was 6.8±1.8 grams that were given at a mean of 15±3 cycles. Moreover, major events (heart failure exacerbation, pulmonary embolism, and acute coronary syndrome) were recorded in 3.9% of the patients and death occurred in 4.1%. Conclusions: Trastuzumab demonstrated an increase in the PASP in a considerable portion of the patients at 1-year interval with this elevation being substantially concerning due to being highly indicative of PHTN.

68 The confounder in time of confusion: a case report on Multisystem Inflammatory Syndrome in Children (MIS-C)

68 The confounder in time of confusion: a case report on Multisystem Inflammatory Syndrome in Children (MIS-C)

Ventricular septal defect closure using radial incision of the tricuspid valve for exposure: is it really necessary?

To evaluate the effects of radial incision of the tricuspid valve in patients who had undergone ventricular septal defect (VSD) closure. Overall 173 patients were included in this study between 2012 and 2019. In 44 individuals, a tricuspid valve radial incision (TVRI) was included in the surgical process. There were no mortalities. The demographic data did not differ between the groups. The mean ages of the TVRI and non-TVRI groups were 2.92 ± 3.88 and 2.69 ± 2.80 years, respectively. There were no significant differences between the groups in terms of mean duration of cardiopulmonary bypass aortic cross-clamp, postoperative intubation time and intensive care unit stay. Mild tricuspid valve regurgitation was detected in only two patients in the TVRI and six patients in the non-TVRI groups. There was no tricuspid valve stenosis and all patients were in New York Heart Association functional class 1. This technique, which can facilitate exposure and closure of VSDs, did not compromise the tricuspid valve function at mid-term, therefore proving to be safe.

Tricuspid valve repair concomitant with the Norwood operation among babies with hypoplastic left heart syndrome.

Among patients with hypoplastic left heart syndrome (HLHS), tricuspid valve regurgitation (TR) portends a poor prognosis. Our goal was to describe the outcomes of tricuspid valve reconstruction (TVR) concomitant with the Norwood operation and using two-dimensional echocardiography and evaluate the structural factors associated with successful functional correction. We performed a retrospective, single-centre study of patients with HLHS undergoing TVR at the time of the Norwood operation. Structural echocardiographic parameters were compared between patients with successful correction (≤ mild TR) and those with ≥ moderate regurgitation at discharge. Preoperative dimensions of matched HLHS controls with ≤ trivial TR were used as a reference. Of 205 patients with HLHS undergoing the Norwood operation, 18 patients had a concomitant TVR. Ten (56%) patients had an improved TR grade postoperatively, 8 (44%) of whom had ≤ mild TR at discharge. Improvement in TR grade (P = 0.001) and having ≤ mild TR at discharge (P = 0.011) were associated with an improved reintervention and TR-free survival. Patients with successful functional correction had smaller preoperative tricuspid annulus lateral dimensions (P = 0.023), tricuspid valve area (P = 0.007) and right ventricle mid-width (P = 0.064). Preoperatively, the successful TVR cases tended to have had higher anterior leaflet excursion (80 ± 20 vs 55 ± 11, P = 0.010), and a higher proportion of anterior leaflet prolapse (63% vs 10%, P = 0.043) compared to cases where TVR was not successful. Patients with HLHS with significant tricuspid regurgitation undergoing the stage 1 operation were more likely to have successful concomitant tricuspid valve repair if they had less tricuspid annular dilation, less-severe RV enlargement and predominantly anterior leaflet prolapse. Successful tricuspid valve repair was associated with improved mid- and long-term outcomes.

Pre-Procedural Right Ventricular Longitudinal Strain and Post-Procedural Tricuspid Regurgitation Predict Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI).

Background: Right ventricular (RV) dysfunction has been linked to worse outcomes in patients undergoing TAVI. Assessment of RV function is challenging due to its complex morphology. RV longitudinal strain (LS) assessed by speckle-tracking echocardiography (STE) is a novel measure that may overcome most of the limitations of conventional echocardiographic parameters of RV function. The aim of current study was to assess the prognostic value of RV LS in patients undergoing TAVI and to assess echocardiographic predictors of long-term mortality. Methods and results: A retrospective analysis of all consecutive patients who underwent TAVI at our hospital between 1 January 2015 and 1 June 2016. Indication for TAVI was approved by a local heart-team. Echocardiographic data at baseline and after TAVI were re-analyzed and RV LS was measured in all patients with adequate image quality. A total of 229 patients were included in our study (mean age 83.8 ± 5 years, 62% women, mean EuroSCORE II 5.7 ± 5%). All-cause mortality occurred in 17.3% over a mean follow-up of 929 ± 373 days. In multivariate analysis, only baseline average RV free-wall LS (HR 1.05, 95% CI (1.01 to 1.10), p = 0.049) and more than mild tricuspid valve regurgitation (TR) after TAVI (HR 4.39, 95% CI (2.22 to 8.70), p < 0.001) independently increased the risk of all-cause mortality at long- term follow-up (2.5 years), while conventional echocardiographic parameters of RV function did not predict mortality. Conclusion: Pre-procedural RV LS and post-procedural tricuspid regurgitation significantly predicted long-term all-cause mortality in patients undergoing TAVI while conventional echocardiographic parameters of RV function failed in predicting long-term outcome. RV longitudinal strain by STE should be considered in the routine echocardiographic assessments of patients with severe AS.

Rheumatic Heart Disease Down but Not Elimnated - A Case Study for Community Action

Acute rheumatic fever, a multisystem inflammatory disease beginning in childhood with manifestations of episodes of fleeting joint pains, skin, and central nerve system. Such episodes if not treated well or preventive steps not taken will pave way for rheumatic heart disease, after many years. RHD involves immune inflammatory injury to cardiac values. Here I present one such case I witnessed in March 2020. A 40-year-old female with known history of RHD since 2013 sought treatment in KMC super specialty hospital. Patient was under medication for RHD. In the current episode she Reported with the complaints of chest pain, sore throat, fever, and fatigue on 27th March 2020. Based on echocardiogram, cardiologist confirmed that she has Rheumatic heart disease with mild mitral valve and tricuspid valve regurgitation. She was asked to continue Pentids 400 mg and metoclopramide that she was already taking and added Tab. Paracetamol 500 mg, Domperidone, Omeprazole, table B complex 400 mg. She was advised for routine check-up and follow up care. There was an improvement in patient condition within 2 days. Patient is under routine follow and under medications as of 31 May 2021 and doing well. Public Health Professional opine that RHD control program by the national health authorities is the need of the time.

Tricuspid valve repair with echocardiographic guiding.

In this study we discuss the conditions of four patients with severe tricuspid valve (TV) regurgitation, in which a differentiated intraoperative transesophageal echocardiographic (TEE) analysis - as performed in TV-clipping procedures - provided major guidance for refined TV repair. Between January 2019 and March 2020, four patients with central tricuspid regurgitation and an intercommisural jet underwent annuloplasty with an echo-guided plication stitch on the affected leaflet basis, especially anteroseptal. All patients underwent complex multiple valve (aortic- and/or mitral valve) surgery with concomitant TV-repair. No or mild TV regurgitation after TV repair was confirmed in the predischarge echocardiography in all patients. We conclude, that differentiated intraoperative TEE is essential for the surgical TV repair strategy. Plication of the anteroseptal commissure additionally performed to TV annuloplasty, is an easy and effective add-on in selected patients.

The analysis of left ventricular ejection fraction after minimally invasive surgery for primary mitral valve regurgitation.

Although minimally invasive mitral valve surgery (MIMVS) has become the first choice for primary mitral regurgitation (MR) in recent years, clinical evidence in this field is yet limited. The main focus of this study was the analysis of preoperative (Pre), postoperative (Post), and 1-year follow-up (Fu) data in our series of MIMVS to identify factors that have an impact on the left ventricular ejection fraction (LVEF) evolution after MIMVS. We reviewed the perioperative and 1-year follow-up data from 436 patients with primary MR (338 isolated MIMVS und 98 MIMVS combined with tricuspid valve repair) to analyzepatients' baseline characteristics, the change of LV size, the postoperative evolution of LVEF and its factors, and the clinical outcomes. The overall mean value of ejection fraction (EF) slightly decreased at 1-year follow-up (mean change of LVEF: -2.63 ± 9.00%). A significant correlation was observed for preoperative EF (PreEF) und EF evolution, the higher PreEF the more pronounced decreased EF evolution (in all 436 patients; r = -.54, p < .001, in isolated MIMVS; r = -.54, p < .001, in combined MIMVS; r = -.53, p < .001). Statistically significant differences for negative EF evolution were evident in patients with mild or greater tricuspid valve regurgitation (TR) (in all patients; p < .05, odds ratio [OR] = 1.64, in isolated MIMVS; p < .01, OR = 1.93, respectively). Overall clinical outcome in New York Heart Association classification at 1 year was remarkably improved. Our results suggest an excellent clinical outcome at 1 year, although mean LVEF slightly declined over time. TR could be a predictor of worsened follow-up LVEF in patients undergoing MIMVS.

Cardiomyopathy and echocardiographic abnormalities in Indian patients with psoriasis: Results of a pilot study

The relationship between psoriasis and cardiomyopathy is understudied in Indian patients. We evaluated psoriasis patients for cardiomyopathy and other echocardiographic abnormalities. About 98 (M:F=67:31) patients with mild to moderate psoriasis aged 18-75years (mean±SD=42.12±12.79years) having no pre-existing metabolic syndrome and cardiovascular disorders were studied. X-ray chest, electrocardiogram and echocardiography were performed and interpreted by cardiologist for size of the left and right ventricles, left ventricle ejection fraction, diastolic function, pulmonary artery pressure and valve abnormality/regurgitation and their severity as per current guidelines/recommendations. The cardiomyopathies were defined according to standard diagnostic guidelines. Echocardiographic abnormalities were noted in 13 (13.3%) patients aged 19-75years (mean±SD=43.30±15.71years). The left ventricular diastolic dysfunction (grade 1) was observed in nine patients (moderate severe psoriasis in four patients) and one of them also had concentric left ventricular hypertrophy; a precursor of restrictive cardiomyopathy. Mild tricuspid valve regurgitation was present in other four patients. There was no statistically significant difference in age, gender, duration and the severity of psoriasis when compared with patients having normal echocardiography. The mitral or aortic valves, pulmonary artery pressure, mid-right-ventricular diameter and the left atrial volume showed no abnormality. Psoriasis perhaps plays a role in left ventricular dysfunction and possibly cardiomyopathy even with moderately severe disease and in the absence of clinical symptoms. However, these observations need to be interpreted with caution in the absence of any statistically significant difference between age, gender, duration and severity of psoriasis in the patients having normal and abnormal echocardiography.

Impact of tricuspid regurgitation and its postprocedural reduction on long term outcome in patients undergoing percutaneous mitral valve edge to edge repair

Abstract Background Prevalence of functional tricuspid valve regurgitation (TR) in the adult population is high and mostly considered as a consequence of left-sided heart failure. In patients with moderate-to-severe and severe mitral regurgitation (MR), relevant concomitant TR is found in about 30–50%. For many years the concept of a reduction of secondary TR after mitral valve surgery has been widely accepted. However, more recently, compelling data have shown that surgically untreated functional TR can persist or even worsen despite the correction of the associated left-sided lesion. In line with previous research, studies have indicated that preexisting concomitant TR is an independent predictor for adverse outcome in patients undergoing percutaneous mitral valve Edge-to-Edge Repair (pMVR). Purpose This study intends to determine the extent to which the severity of tricuspid regurgitation, measured six months after pMVR, impacts the outcome. Methods Between September 2008 and July 2018, 805 consecutive patients with moderate-to-severe or severe MR underwent pVMR therapy with the MitraClip device at our center. We exclude patients with missing date of follow-up (n=54) and patients with missing values for baseline tricuspid regurgitation (n=93). We analyze, therefore, data of 658 patients with a median follow-up time of 4.93 (4.2, 4.99) years. Severity of TR was evaluated at baseline and six months after pMVR. Results Among 658 high-risk patients (mean age 75.4±8.7 years, 59.7% male, median STS Score 3.9 [2.4, 6.1]), 248 patients were suffering from no/mild (37.6%), 213 from moderate (32.6%) and 197 patients from severe (29.9%) TR. Functional MR was present in 429 (65.5%) patients. Procedural success was achieved in the majority of patients (no/mild TR 90.3%, moderate TR 91.1%, severe TR 90.4%). Overall, mortality rates up to two-year follow-up were highest for patients with severe TR (no/mild TR 30.2%, moderate TR 37.6%, severe TR 42.6%, p=0.023). The risk for overall mortality (Kaplan-Meier analysis, p=0.0027, Figure 1) was related to increasing TR severity. However, Kaplan-Meier analysis showed no relevant differences for the combined endpoint of death and rehospitalization (p=0.058). Interestingly, in a pairwise comparison, the risk for patients with pre-existing severe TR and postprocedural reduction to mild or moderate TR (n=17) was reduced for the combined endpoint (p=0.021) compared to patients with persistent severe TR (n=28). Conclusion Moderate and severe TR in high-risk patients undergoing pMVR is associated with an increased risk for overall mortality. While preliminary, the presented data suggest a favorable outcome in patients with a postprocedural reduction in the severity of TR. The results of this study indicate the importance of developing new therapeutic strategies in high-risk patients with combined MR and TR, probably leading to concomitant tricuspid valve interventions. Figure 1 Funding Acknowledgement Type of funding source: None

Outcomes of Tricuspid Valve Operation at the Time of Pericardiectomy for Constrictive Pericarditis

This study sought to determine the outcome effect of concomitant tricuspid valve operation for regurgitation during pericardiectomy for constrictive pericarditis. This cohort study included 310 patients with mild or greater tricuspid valve regurgitation who underwent pericardiectomy for constrictive pericarditis from 2000 to 2016 at the Mayo Clinic in Rochester, Minnesota. Patients were divided into 2 treatment groups: tricuspid valve operation (n= 68) and no tricuspid operation (n= 242). Survival analysis, proportional odds models, and landmark analysis were carried out to estimate the treatment effects of tricuspid valve operation. Tricuspid valve regurgitation was graded mild in 203 (65%) patients, moderate in 69 (22%), and severe in 38 (12%). Tricuspid valve operation included repair in 54 patients (17%) and replacement in 14 (5%). Mechanical circulatory support was used more commonly in the intervention group (15% vs 5%; P= .009), but rates of stroke (3% vs 2%; P= .210) and mortality (9% vs 6%; P= .422) were similar. Tricuspid valve intervention resulted in a reduced risk of long-term mortality (hazard ratio, 0.68; 95% confidence interval [CI], 0.38 to 1.21; P= .192), less than moderate tricuspid valve regurgitation at follow-up (odds ratio vs moderate or severe, 0.093; 95% CI, 0.04 to 0.19), and less than moderate right ventricular enlargement at follow-up (odds ratio vs moderate or severe, 0.67; 95% CI, 0.35 to 1.24). Remnant severe right ventricular dysfunction resulted in increased risk of mortality (hazard ratio vs none or trivial, 4.87; 95% CI, 1.10 to 21.65; P= .037). Concomitant tricuspid valve operation for regurgitation can be performed without increased operative mortality during pericardiectomy for constrictive pericarditis. Operation appears protective against long-term mortality, residual tricuspid regurgitation, and right ventricular enlargement.

Preoperative Right Heart Dysfunction and Gastrointestinal Bleeding in Patients with Left Ventricular Assist Devices.

Gastrointestinal bleeding (GIB) is a common cause of morbidity among patients supported by left ventricular assist devices (LVADs). The aim of this study was to identify if pre-LVAD right ventricular (RV) dysfunction is associated with risk of GIB after LVAD implantation. Of 398 patients implanted with LVADs between July 2008 and July 2016, 130 (33%) developed GIB at a median of 2.6 months following LVAD implantation. Arteriovenous malformations (AVMs) were found in 42 (34%) GIB patients. Patients with GIB were older and more likely to have hypertension, diabetes, and ischemic cardiomyopathy. On pre-LVAD echocardiography, GIB patients had increased RV diastolic dimension (4.7 ± 0.8 vs. 4.4 ± 0.9 cm, p = 0.02), a higher rate of greater than mild tricuspid valve (TV) regurgitation (73 [60%] vs. 120 [47%], p = 0.006), and underwent TV repair more often (38 [30%] vs. 43 [16%], p = 0.0006) during LVAD implantation. After multivariable adjustment, preoperative greater than mild RV enlargement (hazard ratio [HR] 2.32, 95% CI 1.12-5.03; p = 0.03), TV regurgitation (HR 1.83, CI 1.02-3.44; p = 0.01), and TV repair (HR 3.76, confidence interval [CI] 1.02-4.44; p = 0.01) remained associated with risk of GIB. This finding was driven by the AVM-GIB subgroup. Preoperative RV enlargement and TV regurgitation are associated with post-LVAD AVM-related GIB.

Tricuspid Valve Regurgitation in Patients Undergoing Pericardiectomy for Constrictive Pericarditis

We hypothesized that tricuspid valve regurgitation was associated with increased risk of mortality after pericardiectomy for constrictive pericarditis. We reviewed the records of 518 patients who received pericardiectomy for constrictive pericarditis between January 2000 and December 2016. We excluded cases of radiation induced constrictive pericarditis, tuberculous-related constrictive pericarditis, and concomitant tricuspid valve intervention. Patients were classified according to preoperative transthoracic echocardiography tricuspid regurgitation grade: none/trivial in 276 (53%) patients, mild in 191 (37%), and moderate/severe in 51 (10%). A multivariable Cox proportional hazards regression model was used to determine an association between tricuspid valve regurgitation grade and mortality. Primary endpoint of this study was mortality. Median patient age was 62 years (interquartile range 51-69), sex was male in 409 (79%) patients, and left ventricular ejection fraction was 60% (54-65). Clinical follow-up was obtained in all patients at a median of 7.6 years (3.6-11.3). Kaplan-Meier estimates of mortality were 10.6% at 1 year, 23.5% at 5 years, and 39.0% at 10 years. Multivariable analysis demonstrated increased mortality risk with mild tricuspid valve regurgitation vs none/trivial (hazard ratio 1.64; 95% confidence interval 1.11-2.43; P = 0.012) and moderate/severe tricuspid valve regurgitation vs none/trivial (hazard ratio 2.27; 95% confidence interval 1.39-3.69; P = 0.001). These findings were independent of right ventricular function. Tricuspid valve regurgitation is a common and clinically important comorbidity in patients operated with pericardiectomy for constrictive pericarditis. Mild or greater tricuspid valve regurgitation is associated with an increased risk of mortality following operation.

The experience of surgical treatment for Ebstein anomaly in 141 children

Objective: To explore the surgical strategy for Ebstein anomaly in children. Methods: From January 2003 to December 2015, a total of 141 cases of Ebstein anomaly were treated at Department of Pediatric Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University. There were 65 male and 76 female patients, with age of (6.9±1.6) years (ranging from 10 months to 15 years), weight of (19.6±4.7) kg (ranging from 6.5 to 59.0 kg). All patients were diagnosed by 2 dimensional Doppler echocardiography and the septal leaflet and posterior leaflet displaced downward from 1.0 to 5.0 cm. The tricuspid valve regurgitation (TR) were mild in 26 cases, moderate in 46 cases and severe in 69 cases. Tricuspid valvuloplasty were performed in 131 cases (94 cone reconstruction, 37 valve hoist), tricuspid valve replacement in 2 cases and tricuspid valve closed in 8 cases. Surgical strategy were divided into biventricular heart function in 77 cases, one and a half ventricular heart function in 56 cases, and single ventricular heart function in 8 cases. Results: Three patients were changed to one and a half ventricular repair from biventricular repair due to unstable hemodynamics in the early postoperative period. One case died in biventricular group. The complete atrioventricular block were occurred in 3 patients and pacemaker were applied. One hundred and forty cases discharged from hospital. There were mild TR in 118 cases, moderate in 14 cases and closed in 8 cases. One hundred and thirty-seven cases were followed up regularly in 18 to 172 months. Ninety-one cases were treated by cone reconstruction (mild TR in 75 cases, moderate in 15 cases and severe in 1 case). Thirty-six cases were operated by tricuspid valve hoist (mild TR in 21 cases, moderate in 12 cases and severe in 3 cases). In the patients with severe TR (4 cases), 3 cases were reoperated by cone reconstruction. One case's valve was closed because of the dysplasia of the anterior valve and then from one and a half ventricular heart function to single ventricular function, the oxygen saturation was increased. Two patients underwent tricuspid valve replacement, 1 died and the other's mechanical valve was removed, and changed to single ventricular function repair. Conclusions: Although tricuspid cone reconstruction can achieve good results, the stable hemodynamic of early postoperative can be effectively maintained by using the surgical strategy of one and a half ventricular repair. To the patients with severe tricuspid regurgitation and hypoxemia due to severe tricuspid valve dysplasia, transforming to a functional single ventricle may be the only choice when there comes to the unstable hemodynamic.

The prognostic significance of tricuspid valve regurgitation in pulmonary arterial hypertension.

Tricuspid valve regurgitation (TR) is a frequent finding in patients with pulmonary arterial hypertension (PAH). However, its prognostic significance and relation to PAH, while suspected, are poorly understood. We assessed 727 consecutive patients with newly diagnosed PAH who underwent transthoracic echocardiographic evaluation of tricuspid valve function. The study objective was to determine the association of TR presence and severity with patient characteristics, pulmonary artery hemodynamics and outcome. Consecutive patients with newly diagnosed PAH (N = 727 with group 1 pulmonary hypertension) underwent transthoracic echocardiographic evaluation of tricuspid valve function at diagnosis. The primary study end point was all-cause mortality or lung transplantation. In this population, 702 patients (96.5%) had TR; in 165 patients (23%), TR was severe. Compared with those with no or mild TR by echocardiography criteria, patients with severe TR had shorter mean (SD) 6-minute walk distances (285 [125] m vs 360 [121] m; P = .02) and higher levels of B-type natriuretic peptide (695 [672] pg/dL vs 328 [300] pg/dL; P < .05). Severe TR was associated with greater right atrial dilatation (91% vs 47%; P = .004) and right ventricular (RV) dilatation (92% vs 51%; P = .008), greater right atrial pressure (mean [SD] 15 [7] mm Hg vs 10 [6] mm Hg; P < .001) and lower cardiac index (mean [SD], 2.2 [0.7] L/min/m2 vs 2.8 [0.9] L/min/m2; P < .001). Severe TR was strongly predictive of greater 5-year mortality risk after adjustment for age, sex, functional class, 6-minute walk distance, diffusing capacity, RV size and pulmonary vascular resistance index (adjusted hazard ratio, 1.83; 95% CI, 1.38-2.41; P < .001). Severe TR was a significant predictor of long-term mortality rate in PAH, and TR severity correlated with PAH severity.

Congenital Giant Left Atrium with Severe Mitral Valve Regurgitation.

A three-month-old male infant presented to the Royal Hospital, Muscat, Oman in April 2014 following two episodes of pneumonia. On presentation, the patient was not dysmorphic; however, he was tachycardic and tachypnoeic with severe respiratory distress. A pansystolic murmur was heard in his apex, radiating to the axilla. A chest examination showed bilateral wheezing and scattered crepitations. An abdominal examination revealed a soft abdomen with hepatomegaly (liver span of 12 cm), situated 4 cm below the right costal margin. Echocardiography and an angiographic volume-rendered reconstructed computed tomograph showed a giant left atrium measuring 7.4 × 4.7 cm [Figure 1]. The atrium had severe mitral valve regurgitation from poor coaptation of the mitral valve leaflets due to annulus dilation of 22 mm. The mitral valve apparatus and left atrial appendage were normal, excluding the associated left atrial appendage aneurysm. There was mild tricuspid valve regurgitation with a peak gradient of 90 mmHg (systemic blood pressure: 80/55 mmHg), indicating severe pulmonary hypertension. The left ventricle was moderately dilated—the left ventricular posterior wall dimension in diastole was 4 mm; the interventricular septum dimension in diastole was 4 mm; the left ventricular end diastolic dimension was 40 mm; and the left ventricular end systolic dimension was 18 mm. Normal ventricular systolic function was noted (ejection fraction: 62%). The right ventricle was compressed by the dilated left ventricle, with severe compression of the right atrium secondary to the dilated left atrium. The inferior vena cava and hepatic veins were dilated; however, the superior vena cava was compressed by the dilated left atrium with a mean gradient of 8 mmHg at its midportion. The dilated pulmonary veins drained normally to the left atrium. No intracardiac vegetation or thrombi were seen. These findings were confirmed by cardiac computed tomography (CT) angiography; severe compression of the left main bronchus was also observed [Figure 2]. The CT angiography also revealed a left atrial volume of 84 mL compared to a left ventricular volume of 10 mL. A chest radiograph of the infant revealed a persistent left-sided lung opacity [Figure 3]. Further abdominal ultrasonography and CT findings indicated eventration of the left hemidiaphragm with a raised spleen position corresponding to the opaque shadow seen on the chest radiograph. A diagnosis of a congenital giant left atrium (CGLA) was made. Figure 1A & B: A: Four chamber echocardiograph showing a giant congenital left atrium (white arrow) severely compressing the right atrium (red arrow) in a three-month-old male infant. B: Volume-rendered reconstructed computed tomography angiograph showing the giant ... Figure 2A & B: A: Axial computed tomography (CT) angiograph showing a giant congenital left atrium (black arrow) with left upper lobe and segmental right lower lobe atelectasis (red arrows) in a three-month-old male infant. B: Maximum-intensity CT angiograph projection ... Figure 3: Frontal chest radiograph of a three-month-old male infant with congenital giant left atrium showing a persistent left-sided lung opacity (arrow). This was determined by ultrasonography and computed tomography to be a raised spleen caused by eventration ... Despite cardiac anti-failure medications and inotropic support, a high-risk operation was performed to repair the mitral valve due to the cardiac findings and prolonged intubation. A posterior annuloplasty and a posterior left atrial wall excision were also carried out concurrently. The diagnosis of CGLA was confirmed during the course of the surgery. Following the operation, the left atrial dilation improved and the right ventricular systolic pressure decreased to 30 mmHg (estimated from the tricuspid valve regurgitation jet). Unfortunately, the moderate mitral valve regurgitation continued postoperatively and the infant died two weeks later due to severe cardiorespiratory compromise.

Relationship between isolated mild tricuspid valve regurgitation in second-trimester fetuses and postnatal congenital cardiac disorders.

In most cases, the clinical importance of fetal isolated mild tricuspid valve regurgitation is not known. This study evaluated the relationship between fetal isolated mild tricuspid regurgitation in the general obstetric population and postnatal congenital cardiac disorders. Detailed fetal echocardiography was done between 18 and 24 weeks' gestation to detect tricuspid regurgitation and to exclude complicated cardiac defects. Routine second-trimester targeted organ scans were also performed to exclude extracardiac defects. Follow-up was done until birth. After birth, the cardiac anatomy of the neonates was examined by echocardiography. The association between fetal isolated mild tricuspid regurgitation and postnatal congenital cardiac disorders was assessed by logistic regression analysis. No major cardiac disorders were found postnatally. Some minor disorders were found, including a patent foramen ovale, atrial septal defects, a patent ductus arteriosus, and small ventricular septal defects. Fetuses with isolated mild tricuspid regurgitation had a significantly higher likelihood of having ventricular septal defects (odds ratio, 5.80; P = .027) or a patent foramen ovale with atrial septal defects and a patent ductus arteriosus (odds ratio, 11.61; P = .007). There was no significant association between tricuspid regurgitation and an isolated patent foramen ovale or a patent foramen ovale with atrial septal defects in neonates. Fetuses with isolated mild tricuspid regurgitation in the second trimester did not have a higher incidence of major cardiac disorders after birth. The presence of isolated mild tricuspid regurgitation may be an indication of minor postnatal congenital cardiac disorders.