Native Tricuspid Valve Research Articles

An Integrated Pericardial Valved Stent Special for Percutaneous Tricuspid Implantation: An Animal Feasibility Study

Various percutaneous valve replacement approaches have been reported in animals to replace the aortic and pulmonary valve. To broaden the indications of percutaneous approach to atrioventricular valves replacement, we developed a novel valved stent and evaluated the feasibility and safety of percutaneous implantation of the device in the tricuspid position. A unidirectional semilunar valve of porcine pericardium was sutured to a valvular ring. Then the ring with pericardial valve was mounted on a double-edge nitinol stent to construct the tricuspid valved stent. Transcatheter tricuspid valved stent implantation was performed on 10 healthy sheep. These sheep were followed up shortly after procedure with echocardiography evaluation and 64-slice CT imaging examination during the periodical follow-up at 1 mo and at 6 mo post-implantation. Additionally, two sheep were sacrificed after the procedure for anatomic and histological evaluation one at 1 h and the other at 1 mo, respectively. Percutaneous valve implantation was successful in eight of 10 sheep. Two sheep died during the procedure due to migration of stent and fatal arrhythmia. The pressure of right heart did not significantly change after the procedure. Further echocardiography and imaging confirmed the stents were in desired position during the follow-up. The remaining six sheep with normal valvular and cardiac functionality survived for 6 mo after implantation. The tricuspid stent with a valvular ring and pericardial valve can be implanted in tricuspid annulus percutaneous. The double-edge stent could substitute the native tricuspid valve chronically.

Isolated tricuspid valve endocarditis

We present two non-HIV-infected patients with isolated native non-rheumatic tricuspid valve endocarditis who were not intravenous drug abusers. The patients presented with fever and chills. Plain radiography or high-resolution computed tomography of the chest revealed consolidation or infiltrate of the left parenchyma in both patients. Large vegetation located on the tricuspid leaflets was detected by transesophageal echocardiography. Staphylococcus aureus grew in two out of three blood cultures for one patient. Tricuspid valve endocarditis imitates illnesses with fever and pulmonary symptoms or signs of acute or chronic onset, and might be present even without abnormal chest X-rays or intravenous drug addiction.

Live 3-Dimensional Transesophageal Echocardiography: Initial Experience Using the Fully-Sampled Matrix Array Probe

Our study goals were to evaluate the 3-dimensional matrix array transesophageal echocardiographic (3D-MTEE) probe by assessing the image quality of native valves and other intracardiac structures. Because 3-dimensional transesophageal echocardiography with gated rotational acquisition is not used routinely as the result of artifacts, lengthy acquisition, and processing, a 3D-MTEE probe was developed (Philips Medical Systems, Andover, Massachusetts). In 211 patients, 3D-MTEE zoom images of the mitral valve (MV), aortic valve, tricuspid valve, interatrial septum, and left atrial appendage were obtained, followed by a left ventricular wide-angled acquisition. Images were reviewed and graded off-line (Xcelera with QLAB software, Philips Medical Systems). Excellent visualization of the MV (85% to 91% for all scallops of both MV leaflets), interatrial septum (84%), left atrial appendage (86%), and left ventricle (77%) was observed. Native aortic and tricuspid valves were optimally visualized only in 18% and 11% of patients, respectively. The use of 3D-MTEE imaging, which is feasible in most patients, provides superb imaging of native MVs, which makes this modality an excellent choice for MV surgical planning and guidance of percutaneous interventions. Optimal aortic and tricuspid valve imaging will depend on further technological developments. Fast acquisition and immediate online display will facilitate wider acceptance and routine use in clinical practice.

Endocarditis por Peptostreptococcus: presentación de dos casos y revisión de la literatura

We describe two new cases of Peptostreptococcus endocarditis, one case of Peptostreptococcus micros prosthetic valve endocarditis and the other of Peptostreptococcus assaccharolyticus tricuspid native valve endocarditis in an intravenous drug user (IDU) patient and review nine cases previously reported.

Candida parapsilosis tricuspid native valve endocarditis: 3-year follow-up after surgical treatment

In non-addicted patients, several states such as alcoholism, previous valvular heart disease or prosthetic valve replacement, immunodeficiency states, prolonged intravenous hyperalimentation, permanent pacemakers, and some congenital heart diseases can provide the predisposing factors for tricuspid valve endocarditis. It is an extremely rare occurrence in patients with normal native cardiac valves. In this report, we present a case of a 67-year-old woman with tricuspid native valve endocarditis related to Candida parapsilosis which is a very rare cause of infective endocarditis and carries a high mortality risk. An operation was indicated for the patient due to persistent enlarging vegetation on tricuspid valve, severe tricuspid regurgitation, septic pulmonary emboli and finally uncompensated respiratory and heart failure. She underwent tricuspid valve replacement with bioprothesis three years ago and now she is in a satisfactory condition without any medical treatment.

Fatal right-sided endocarditis due toAspergillusin a kidney transplant recipient

Invasive aspergillosis (IA) is an emerging infectious disease in different groups of immunocompromised patients. In transplant recipients, intensification of immunosuppressive therapy to treat allograft rejection poses a major risk factor for IA. We present the clinical features, diagnostic findings and outcome of a kidney transplant recipient who developed pulmonary aspergillosis complicated by endocarditis of his native tricuspid valve. Despite replacement of the valve and treatment with combined antifungal therapy, the patient died of an acute pulmonary bleeding.

Aspergillus fumigatus tricuspid native valve endocarditis in a non-intravenous drug user

Invasive aspergillosis is an emerging infection mainly affecting immunocompromised patients. This report details a case of Aspergillus fumigatus tricuspid native valve endocarditis complicated by recurrent septic pulmonary emboli in a young, non-intravenous drug user. He was treated by surgical resection of the posterior leaflet of the tricuspid valve and the vegetations, as well as by valvuloplasty, which was followed by a combination of liposomal amphotericin B and voriconazole as acute-phase therapy and voriconazole alone as suppression therapy.

Intracardiac Echo Guided Valvuloplasty of a Stenotic Tricuspid Prosthetic Valve in a Patient with Idiopathic Hypereosinophilic Syndrome

A 52-year-old male with idiopathic hypereosinophilic syndrome (HES) was transferred to our institution following the development of acute respiratory failure and shock. He had previously undergone tricuspid valve replacement with bioprosthetic valves on two occasions: the initial surgery for severe native tricuspid valve stenosis and the redo surgery for severe prosthetic valve stenosis and regurgitation. Conventional imaging assessment using transoesophageal echocardiography was suboptimal and comprehensive assessment of prosthetic valve function was aided by the use of intracardiac echocardiography (ICE). ICE provided high quality 2D imaging of the prosthesis demonstrating thrombus-like material coating the inner surfaces of the prosthetic valve stents effectively forming a tunnel-like obstruction. Unusual hemodynamics secondary to severe tricuspid stenosis were demonstrated by CW Doppler with intermittent "signal fusion" resulting from blunted respiratory variation in the markedly elevated right atrial pressure relative to right ventricular pressure. Successful balloon valvuloplasty was performed with ICE proving highly valuable in guiding balloon position as well as monitoring the efficacy of the subsequent inflations.

Papillary Fibroelastoma and Lambl's Excrescences: Echocardiographic Diagnosis and Differential Diagnosis

A previously healthy 44-year-old male was admitted with a history of two transient ischemic attacks (TIA) during the previous month. Transthoracic echocardiography (TTE) revealed normal cardiac dimensions and left ventricular function, however, a 1-cm mobile mass was noted attached to the tip of the posterior mitral valve leaflet (Fig. 1). This mass was also noted by transesophageal echocardiography (TEE), but another smaller immobile mass was also found attached to the atrial surface of the anterior leaflet of the mitral valve (Fig. 2). Mitral valve replacement was then performed. Histopathology revealed both masses to be that of papillary fibroelastoma (Fig. 3). Diastolic parasternal long-axis image demonstrates a 1-cm rounded mass (horizontal arrow) attached to the tip of the posterior leaflet of the mitral valve. AML = anterior leaflet mitral valve; LA = left atrium; LV = left ventricle. Systolic TEE frame at 72° in the mid-esophagus demonstrates the mass shown in Figure 1 attached to the posterior mitral leaflet (horizontal arrow), but also another mass attached to the atrial side of the anterior mitral leaflet (vertical arrow). LA = left atrium; LV = left ventricle. Hematoxylin-eosin stain of one of the masses removed from the mitral valve at the time of surgery. A. Low power (1×) demonstrates the tumor is composed of a dense base (horizontal arrows) of fibroelastic tissue with papillary fronds (vertical arrows). B. Magnified power (10×) of the papillary fronds composed of fibroelastic tissue covered by endothelium. Papillary fibroelastomas are the most common primary tumors of the cardiac valves. This benign tumor is covered by endothelium surrounding loose connective tissue made up of an acid mucopolysaccharide matrix, smooth muscles, collagen, and elastic fibers.1 These tumors have been found on all four cardiac valves, but in adults are most often found on the aortic valve (usually ventricular surface) and also the mitral valve (atrial surface). Rarely they are attached to the subvalvular apparatus of the mitral or tricuspid valve, and very rarely to the free wall of a ventricular chamber.2 In children, the tumor is most often noted on the tricuspid valve.1 A papillary fibroelastoma may serve as a nidus for platelet and fibrin aggregation, leading to arterial embolism, but most are found at autopsy as an incidental finding. Some investigators have recommended anticoagulation once a papillary fibroelastoma is noted by echocardiography. There appear to be no firm data to support or refute surgical removal of a papillary fibroelastoma in an asymptomatic patient.3 Echocardiographic characteristics of a papillary fibroelastoma include: most often the tumor is solitary usually <1 cm in diameter, but may become 3–4 cm in size the tumor usually arises from the midportion of valve leaflets (a fibrous strand usually arises from the line of closure) often pedunculated (occasionally sessile) with high-frequency oscillations during the cardiac cycle characteristic “frond-like” appearance3 In contrast to papillary fibroelastoma, Lambl's excrescences (fibrous strands) are best identified by TEE as fine thread-like strands arising on the line of closure (contact surface) of heart valves. Most commonly, they occur on the mitral, followed by aortic valve (Fig. 4). These strands have been described on prosthetic valves, and rarely on native tricuspid or pulmonic valves.4, 5 They are acellular strands covered by a single layer of endothelium. Found in 70–80% of adults, they are multiple in >90% of affected hearts.6 Most often these strands are not associated with cardioembolic events.7 A. TEE in the mid-esophagus (157°) of a patient with an aortic valve Lambl's excrescence (horizontal marker). B. Systolic TEE frame (105°) in the mid-esophagus of a patient with a St. Jude mechanical mitral prosthesis. Using tissue Doppler imaging (TDI), a mobile valve strand is noted (arrow—red color strand) in the left atrium (LA). (Fig. 4A modified with permission from 5).

Carpentier-Edwards Perimount valve and intraoperative structural failure

We read with great interest the article by Saunders and associates.1Saunders P.C. Grossi E.A. Esposito R.A. Bizekis C.S. Strong M.D. Colvin S.B. Failure of four bovine pericardial mitral prostheses.J Thorac Cardiovasc Surg. 2004; 127: 267-268Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar The authors described a post–cardiopulmonary bypass (post-CPB) structural valve failure, leading to an intraoperative replacement of 4 Carpentier-Edwards Perimount valves. The negative experience has been lived in 2 different institutions. Two Perimount valves were replaced because of a severe central insufficiency at the weaning-off phase from CPB, another valve was replaced soon after its insertion because of being judged not continent as a result of the impossibility of leaflet coaptation before atrial closure, and the last as a result of incompetence at hydraulic testing.The pericardial tissue valves were replaced with either a new Carpentier-Edwards porcine valve or a Medtronic Mosaic porcine valve. The authors speculated that the Perimount valves were distorted by the mitral valve annulus, leading to an unacceptable incompetence, and that the tolerance to this mechanical distortion is lower for pericardial tissue valves when compared with porcine valves. The Carpentier-Edwards tissue valves, both porcine and pericardial, have the same support.2Jamieson W.R.E. Marchand M.A. Pelletier C.R. Norton R. Pellerin M. Dubiel T.W et al.Structural valve deterioration in mitral replacement surgery: comparison of Carpentier-Edwards supra-annular porcine and Perimount pericardial.J Thorac Cardiovasc Surg. 1999; 118: 297-305Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar The stent is an Elgiloy wire support, which allows a specific area flexibility, namely at the post area, with the aim to reduce the leaflet stress at the commissures. The bovine pericardium is glutaraldehyde fixed at zero pressure to enhance tissue durability. One of the limits related to the no-pressure fixation method is the reduced leaflet coaptation when the valve is packaged. Nevertheless, when the valve is exposed to normal physiologic pressure, namely left ventricular pressure during systole or diastolic aortic pressure according to the insertion position, the leaflets coapt, and the valves function well. The first valve has been replaced before left atrial closure. Therefore its performance was not physiologically tested. The second Carpentier-Edwards Perimount valve has been replaced after a long period of CPB. In the second patient the Perimount valve showed incompetence after hydraulic testing, and therefore it has been removed. The last patient experienced massive native mitral and tricuspid valve incompetence, and he was referred with a normal left ventricular ejection fraction. Immediately after weaning from CPB, the valve showed severe central incompetence at transesophageal echocardiography, and this valve was replaced. Our hypothesis is that in all these cases the tissue valves were not exposed to enough physiologic pressure to allow normal leaflet coaptation, provoking a misleading incompetence that convinced the surgeons to replace the valves and to retain the cause of failure related to a structural failure. The early primary structural failure of a tissue valve is a well-defined entity, and it is believed to occur when part of the elements of a prosthesis are not well functioning because of wear and tear. We think that if these replaced prostheses were tested at physiologic pressure in vitro or in vivo, they would show a normal function. ReplyThe Journal of Thoracic and Cardiovascular SurgeryVol. 128Issue 5PreviewWe appreciate the comments of Bottio and colleagues on our recent report of intraoperative failure involving 4 bovine pericardial mitral prostheses.1 The correspondents point out that Carpentier-Edwards Perimount bioprostheses require physiologic pressure to overcome the inherent limited leaflet coaptation that results from no-pressure fixation. They further comment that had the valves in our report been subjected to more physiologic hemodynamics, they might have demonstrated normal function. Full-Text PDF

An unusual native tricuspid valve endocarditis caused by Candida colliculosa

Candida colliculosa, which grew in blood cultures of a 71-year-old retired man with fever of unknown origin that had lasted for 7 months, in conjunction with transthoracic echocardiography, demonstrating a 20-mm vegetation, superior to the tricuspid valve, herniating into the right atrial cavity. The finding led to the diagnosis of fungal endocarditis. Fluconazole, 600 mg daily, was commenced for 8 days; followed by amphotericin B, 1 mg/kg daily. On the fourth day of the amphotericin B treatment, the patient underwent replacement of the infected tricuspid valve. Even though the initial postoperative period was relatively uncomplicated, the patient died after a gross aspiration on the 67th day of his hospital stay, despite aggressive cardiovascular support and antimicrobial therapy. This is the first report of a native tricuspid valve fungal endocarditis due to C. colliculosa or Torulaspora delbrueckii, which is not known to be a human pathogen.

Tricuspid valve supra-annular implantation in adult patients with Ebstein’s anomaly

Background. Tricuspid valve supra-annular implantation (TVSI) has been performed for adult patients with Ebstein’s anomaly at our hospital for several decades. TVSI is characterized by reliable reduction of tricuspid annulus size without affecting the conduction system; by prevention of residual tricuspid regurgitation (RTR) through preservation of the native tricuspid valve; and by implantation of the bioprosthesis at a supra-annular site. Methods. Ten adult patients with Ebstein’s anomaly underwent TVSI. The right ventricular diameter and residual tricuspid regurgitation were evaluated by echocardiography preoperatively, at discharge, 1 year after the operation, and over the long term (12.4 ± 5.5 years). Actuarial survival rate, actuarial freedom from structural valve deterioration rate, and postoperative occurrence of arrhythmia were also evaluated. Results. The actuarial survival rate at 19 years was 76 ± 15%. Tricuspid regurgitation disappeared in 8 patients just after operation. Right ventricular diameter was significantly smaller at discharge than preoperatively (63 ± 11 vs 37 ± 9, p < 0.01), and there were no significant differences between values at discharge and at follow-up. The actuarial freedom from structural valve deterioration rate and the reoperation rate were both 100%. There were no fatal complications related to arrhythmia or thromboembolism. Conclusions. TVSI is useful for adult patients with Ebstein’s anomaly. The absence of complications related to fatal arrhythmia and thromboembolism, good durability of the bioprosthesis, and a simple operative procedure are merits of this therapy.

Isolated Native Tricuspid Valve Endocarditis Caused by Viridans Streptococcus

The present report describes a case of native tricuspid valve endocarditis caused by viridans group streptococcus in a 43-year-old man who had recently undergone dental extraction. The patient had no history of intravenous drug use, heart disease or right heart catheterization. Although there have been scattered reports of unusual organisms, to the authors' knowledge, this is the first case of viridans group streptococcal endocarditis involving only the tricuspid valve after dental manipulation.

Surgical strategy for severe tricuspid valve regurgitation complicated by advanced mitral valve disease: Long-term outcome of tricuspid valve supra-annular implantation in eighty-eight cases

Objective: Although annuloplasty has been the most commonly performed surgical modality for severe tricuspid regurgitation, tricuspid valve supra-annular implantation has been performed in our hospital for more than a decade. The aim of this study was to assess the long-term outcome of tricuspid valve supra-annular implantation in a subgroup of patients with severe tricuspid regurgitation, those who also had advanced mitral valve disease. Methods: Mitral valve replacement in conjunction with tricuspid valve supra-annular implantation was performed on 88 patients at our hospital between 1984 and 1998. The patients (mean age 57 ± 11 years) were followed up for an average of 7.2 ± 4.5 years after the operation (range 0-14 years); total follow-up was 643.1 patient-years. All patients except 2 (97.6%) were included in the follow-up. We evaluated the mortality, the cause of death, survival, the freedom from structural valve deterioration and reoperation, postoperative complications, and long-term echocardiographic findings. Results: Overall survival at 14 years was 69% ± 7.7%. Freedom from structural valve deterioration at 14 years was 100% and from reoperation, 88% ± 9.4%. There were no instances of pulmonary thromboembolism or of complications associated with fatal arrhythmias. Echocardiography showed little residual tricuspid regurgitation, no atrophic and stenotic change in the native tricuspid valve, and no thrombus formation between native valve and the implanted bioprosthesis. Conclusions: The procedure’s simplicity, the good long-term durability of the bioprosthesis, and the absence of fatal arrhythmias and pulmonary thromboembolism indicate that tricuspid valve supra-annular implantation is a useful procedure for patients with severe tricuspid regurgitation complicated by advanced mitral valve disease. (J Thorac Cardiovasc Surg 2000;120:280-3)

Native tricuspid valve endocarditis in a young woman.

Accepted 23 April 1998 A 30-year-old woman was admitted having suffered from fever and malaise for about a month. During this period no drugs were taken, except antipyretics. On examination...

Isolated tricuspid valve endocarditis in nonaddicted patients: a diagnostic challenge.

Isolated native nonrheumatic tricuspid valve endocarditis rarely is described in the absence of intravenous drug use, intracardiac catheters, or cardiac anomalies. We diagnosed tricuspid valve endocarditis in two elderly nonaddicted patients with recurrent pulmonary infiltrates, anemia, and microscopic hematuria that occurred during several months and was caused by Gemella morbillorum and Candida glabrata, respectively. We have reviewed 27 other cases of nonaddicted patients with tricuspid valve endocarditis from the literature and discussed etiology, clinical characteristics, and outcome. Mean age was 53.5 years (range, 22 to 74 years old), and 72% had underlying medical conditions. Staphylococcus oureus, Streptococcus bovis, and candida species were the causative organisms in 70% of the cases. Average duration of infection before diagnosis was 9.3 months. We conclude that isolated tricuspid valve endocarditis in nonaddicted patients occurs mainly in the middle-aged and older persons, mimicking chronic illness and community-acquired pneumonia. In the absence of a history of intravenous drug use, diagnostic delays are common. We suggest that right-sided endocarditis must be considered in any patient with the "Tricuspid Syndrome," consisting of recurrent pulmonary events, anemia, and microscopic hematuria. Careful evaluation of prior medical records and clinical course can be very helpful. Echocardiography and serial blood cultures provide the key to diagnosis.

Nocardial Endocarditis of the Native Mitral and Tricuspid Valves

Nocardial Endocarditis of the Native Mitral and Tricuspid Valves

Tricuspid valve surgery revisited.

Contrary to general opinion, the tricuspid valve remains a challenge in terms of its precise diagnosis, indications, and appropriate surgical treatment. This is due to: (1) its relatively low incidence, (2) its functions in a low pressure system, (3) its close relation to right ventricular function, and (4) it following the dictates of the left-side lesions. In an attempt to elucidate its present status, we reviewed our experience under several categories: (I) Incidence: Among the 1298 valvular patients operated in a period of 5 years (July 1988 to August 1993), 306 (23.6%) native tricuspid valves required surgery. Among the 899 patients with rheumatic etiology, tricuspid involvement was present in 249 (27.7%). (II) Pathology: Excluding other pathologies, organic rheumatic disease was present in 126 (50.6%) and functional regurgitation in 123 (49.4%). However, 45.3% of the organic tricuspids had a dilated annulus, suggesting the existence of organofunctional lesions. (III) Diagnosis: Although two-dimensional echo-Doppler is a reliable diagnostic method, only 41.7% of the organic lesions were diagnosed preoperatively and the remaining at surgery. (IV) Influence of left-side lesions: In a previous study we showed that the postoperative functional status and cardiac output were primarily related to the results of surgery on the mitral valve, irrespective of whether the tricuspid valve had been correctly or incorrectly repaired or even ignored. (V) Surgical techniques: Because of these reasons, evaluation of the individual superiority is difficult, but all annuloplasties result in a degree of residual stenosis (30% to 70% of patients) that is more pronounced in those with organic lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

Right-Sided Native-Valve Endocarditis Caused By Actlnobaclllus actinomycetemcomitans

The clinical and echocardiographic features of a case of endocarditis due to Actinobacillus actinomycetemcomitans uniquely involving the native tricuspid valve are presented. The importance of two-dimensional echocardiographic studies in the evaluation of patients with suspected endocarditis is emphasized.

Persistence of the Third Heart Sound after Resection of the Native Mitral and Tricuspid Valves: Evidence Against the Valvular Theory of Third Sound Origin

A patient is described with severe rheumatic mitral and tricuspid insufficiency in whom both atrioventricular valves with their chordae tendineae and papillary muscles were resected and replaced with Hancock porcine grafts. This would appear to be the second such patient reported and the first described in detail in whom the third heart sound persisted postoperation. This occurrence documents the fact that a third heart sound can occur in the absence of native atrioventricular valve leaflets and the major portions of the subvalvular supporting apparatus, and argues against the theory that the third heart sound is generated by either the valvular leaflets of the subvalvular apparatus.