Patients Undergoing Tricuspid Annuloplasty Research Articles

Morphological and functional types of tricuspid regurgitation: prognostic value in patients undergoing tricuspid annuloplasty during left-sided valvular surgery.

The nonuniform benefit of tricuspid annuloplasty may be explained by the proportionality of tricuspid regurgitation (TR) severity to right ventricular (RV) area. The purpose of this study was to delineate distinct morphological phenotypes of functional TR and investigate their prognostic implications in patients undergoing tricuspid annuloplasty during left-sided valvular surgery. The ratios of pre-procedural effective regurgitant orifice area (EROA) with right ventricular end-diastolic area (RVDA) were retrospectively assessed in 290 patients undergoing tricuspid annuloplasty. Based on optimal thresholds derived from penalized splines and maximally selected rank statistics, patients were stratified into proportionate (EROA/RVDA ratio ≤ 1.74) and disproportionate TR (EROA/RVDA ratio > 1.74). Overall, 59 (20%) and 231 (80%) patients had proportionate and disproportionate TR, respectively. Compared to those with proportionate TR, patients with disproportionate TR were older, had a higher prevalence of atrial fibrillation, lower pulmonary pressures, more impaired RV function, and larger tricuspid leaflet tenting area. Over a median follow-up of 4.1years, 79 adverse events (47 heart failure hospitalizations and 32 deaths) occurred. Patients with disproportionate TR had higher rates of adverse events than those with proportionate TR (32% vs 10%; P = 0.001) and were independently associated with poor outcomes on multivariate analysis. TR proportionality outperformed guideline-based classification of TR severity in outcome prediction and provided incremental prognostic value to both the EuroSCORE II and STS score (incremental χ2 = 6.757 and 9.094 respectively; both P < 0.05). Disproportionate TR is strongly associated with adverse prognosis and may aid patient selection and risk stratification for tricuspid annuloplasty with left-sided valvular surgery.

Impact of proportionality of tricuspid regurgitation on outcome after tricuspid annuloplasty

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Sanming Project of Medicine in Shenzhen, China [No. SZSM201911020]; HKU-SZH Fund for Shenzhen Key Medical Discipline [No. SZXK2020081] Background Patients with secondary tricuspid regurgitation (TR) benefit differentially from tricuspid annuloplasty. We hypothesized that TR severity may be proportional or disproportional to right ventricular (RV) remodeling and investigated the prognostic implication of this novel framework. Methods The ratios of pre-procedural effective regurgitant orifice area (EROA) with right ventricular end-diastolic area (RVDA) and tricuspid annular plane systolic excursion (TAPSE) were retrospectively assessed in 307 patients undergoing tricuspid annuloplasty. Based on optimal thresholds derived from cubic splines and maximally selected rank statistics, patients were stratified into 3 groups: proportionate TR (Group 1: EROA/RVDA ≤1.70 and EROA/TAPSE ≤3.42), disproportionate TR to RV size (Group 2: EROA/RVDA &amp;gt;1.70 and EROA/TAPSE ≤3.42), and disproportionate TR to RV size and function (Group 3: EROA/RVDA &amp;gt;1.70 and EROA/TAPSE &amp;gt;3.42). Results Overall, 77 (25%), 126 (41%), and 104 (34%) patients were classified into Group 1, 2, and 3, respectively. Compared with those with proportionate TR (Group 1), patients with disproportionate TR (Group 2 and 3) had a higher prevalence of atrial fibrillation and smaller left ventricular end-diastolic and end-systolic volumes. During a median (interquartile range) follow-up of 4.1 (2.5-6.2) years, 81 adverse events (49 HF hospitalizations and 32 deaths) occurred. Patients with disproportionate TR (Group 2 and 3) had higher rates of adverse events than those with proportionate TR (22% and 44% versus 9%; P = 0.018 and P &amp;lt; 0.001, respectively) and were independently associated with poor outcomes on multivariate analysis. TR proportionality outperformed guideline-based prediction algorithm comprising EROA and RV assessment in outcome prediction (C-statistic 0.70 versus 0.62, p = 0.015; likelihood ratio test &amp;lt;0.001). Conclusion Disproportionate TR is independently associated with poor prognosis in patients undergoing tricuspid annuloplasty. Characterization of TR severity to RV size and function may aid patient selection and risk stratification for tricuspid annuloplasty. Abstract Figure.

Prognostic implications of the proportionality of tricuspid regurgitation in tricuspid annuloplasty

Abstract Funding Acknowledgements Type of funding sources: None. Background Patients with secondary tricuspid regurgitation (TR) represent a heterogeneous group that benefits differentially from tricuspid annuloplasty. We hypothesized that TR severity may be proportional or disproportional to right ventricular (RV) remodeling and investigated the prognostic implications of this novel paradigm. Methods The ratios of pre-procedural effective regurgitant orifice area (EROA) with right ventricular end-diastolic area (RVDA) and tricuspid annular plane systolic excursion (TAPSE) were retrospectively assessed in 307 patients undergoing tricuspid annuloplasty. Based on optimal thresholds derived from cubic splines and maximally selected rank statistics, patients were stratified into 3 groups: proportionate TR (Group 1: EROA/RVDA ≤1.68 and EROA/TAPSE ≤3.42), disproportionate TR to RV size (Group 2: EROA/RVDA &amp;gt;1.68 and EROA/TAPSE ≤3.42), and disproportionate TR to RV size and function (Group 3: EROA/RVDA &amp;gt;1.68 and EROA/TAPSE &amp;gt;3.42). Results Overall, 72 (23%), 127 (41%), and 108 (35%) patients were classified into Group 1, 2, and 3, respectively. Compared with those with proportionate TR (Group 1), patients with disproportionate TR (Group 2 and 3) had a higher prevalence of atrial fibrillation, moderate to severe aortic stenosis, and smaller left ventricular end-diastolic and end-systolic volumes. During a median (interquartile range) follow-up of 4.3 (2.6-6.3) years, 74 adverse events (42 HF hospitalizations and 32 deaths) occurred. Patients with disproportionate TR (Group 2 and 3) had higher rates of adverse events than those with proportionate TR (21% and 38% versus 8%; P = 0.010 and P &amp;lt; 0.001, respectively; Figure) and were independently associated with poor outcomes on multivariate analysis. Importantly, this novel framework outperformed the TR grading system recommended by current guidelines, which was unable to effectively stratify prognosis in this population (Hazard Ratio for severe versus moderate TR 1.42; 95% CI 0.84-2.38; P = 0.194). Conclusion Disproportionate TR is independently associated with poor prognosis in patients undergoing tricuspid annuloplasty. Characterization of TR severity to RV size and function may aid patient selection and risk stratification for tricuspid annuloplasty. Abstract Figure.

Prevalence and Prognostic Importance of Massive Tricuspid Regurgitation in Patients Undergoing Tricuspid Annuloplasty With Concomitant Left-Sided Valve Surgery: A Study on Rheumatic Valvular Heart Disease.

BackgroundThe presence of tricuspid regurgitation (TR) is very common in patients with concomitant left-sided valve disease. Recent studies have advocated an additional grading of massive TR that is beyond severe. The present study sought to characterize the spectrum of TR in patients undergoing tricuspid annuloplasty (TA) and to evaluate the prognostic value of TR severity for post-operative outcome following TA.MethodsA total of 176 patients who underwent TA with combined left-sided valve surgery, secondary to rheumatic valvular heart disease, were prospectively evaluated. The severity of TR was quantified by effective regurgitant orifice area (EROA) using the proximal isovelocity surface area method. Patients were categorized as having non-massive TR (EROA < 0.6 cm2) or massive TR (EROA ≥ 0.6 cm2). Adverse outcome was defined as all-cause mortality or heart failure requiring hospital admission following TA.ResultsA total of 55 (31%) patients were considered to have massive TR. Patients with massive TR had a greater right ventricular dimension but a smaller left ventricular dimension compared with those with non-massive TR. After a median follow-up of 39 months, 35 adverse events occurred. Cox-regression analysis showed that both continuous EROA and dichotomized EROA (massive vs. non-massive TR) were independently associated with adverse events even after multivariable adjustment. Further, Harrell C index demonstrated that the addition of massive TR provided better discrimination ability of a prediction model to known prognosticators following TA.ConclusionsMassive TR is common and up to 31% of study population had massive TR. Massive TR was associated with adverse outcome in patients undergoing TA. Classification of the severity of TR by quantitative measures and identification of massive TR in patients with concomitant left-sided valve disease are essential when considering the optimal timing of corrective surgery.

Abstract 11994: Proteomic Evaluation And Biomarker Identification In Tricuspid Regurgitation

Introduction: Not only are mechanisms involved in tricuspid regurgitation (TR) incompletely understood, there is no established means of risk stratification for patients undergoing tricuspid valve interventions. A better understanding of underlying biological mechanisms allows for identification of therapeutic targets as well as biomarkers for disease staging, monitoring, and prediction following intervention. Methods: Preoperatively, 276 patients undergoing tricuspid annuloplasty, divided into training and validation cohorts, were assessed and followed-up for adverse events defined as death or heart failure requiring hospitalisation. Preoperative plasma samples were analysed for levels of cardiac troponin-T, NTproBNP, as well as 91 other markers (Olink multiplex assay). Correlated network analysis was used for clustering plasma markers. The relations of clusters to echocardiographic parameters and adverse outcomes were assessed by linear and Cox regression respectively. Pathway overrepresentation analysis was conducted to ascertain biological mechanisms overrepresented in relevant clusters by enrichment with reference to existing knowledge. Results: Over a median follow-up period of 3.7 years, 83 adverse events occurred. Two clusters of biomarkers in the training cohort significantly correlate with right chamber and tricuspid annular dilatation, regurgitant jet area, effective regurgitant orifice area and/or adverse outcomes following tricuspid annuloplasty (P&lt;0.05). The two clusters are represented by hub proteins TNF Receptor Superfamily Member 10A and TRAIL receptor 2. Overrepresented biological pathways in the two clusters include immunological responses, cytokine production regulation, and responses to lipids. Both clusters are conserved in the validation cohort. Conclusion: Immunoinflammatory pathways may be implicated in tricuspid regurgitation, and markers related to such pathways show prognostic significance.

Prognostic value and reversibility of liver stiffness in patients undergoing tricuspid annuloplasty.

Liver stiffness (LS) assessed by transient elastography is associated with adverse events in patients with heart failure. However, the predictive value of LS for adverse outcome is uncertain in patients undergoing tricuspid annuloplasty (TA). This study sought to evaluate the prognostic value and reversibility of LS in patients undergoing TA during left-sided valve surgery. A total of 158 patients who underwent TA were prospectively evaluated. Patients were divided into three groups according to tertile of LS. Adverse outcome was defined as heart failure that required hospital admission or all-cause mortality following TA. The median LS was 13.9 (inter-quartile range 8.1-22.3) kPa and independently correlated positively with tricuspid regurgitation (TR) severity, inferior vena cava diameter and negatively with tricuspid annular plane systolic excursion. During a median follow-up of 31 months, 49 adverse events occurred. Multivariable Cox regression analysis revealed that LS was an independent predictor of adverse events. Significant improvement in LS at 1-year post-TA (13.1-7.8 kPa, P < 0.01) was noted only in patients who had no adverse events, not in those who experienced heart failure (17.1-14.2 kPa, P = 0.87) and seems to be linked to an absence of TR recurrence. This study demonstrated that LS is predictive of adverse outcome and is reversible in patients undergoing TA without TR recurrence at 1 year. These findings suggest that assessing LS, an integrative correlate of right heart condition, may aid the pre-operative risk assessment of candidate for heart surgery including TA.

Prognostic value and reversibility of liver stiffness in patients undergoing tricuspid annuloplasty

Abstract Background Hepatic dysfunction was previously suggested to be related to poor outcome in patients undergoing tricuspid annuloplasty (TA), the predictive value of liver stiffness (LS) for adverse events is nonetheless uncertain. Purpose The aim of this study was to evaluate the prognostic value and reversibility of LS in patients undergoing TA. Methods A total of 158 patients (age 63, male 35%) who underwent TA during left-sided valve surgery were prospectively evaluated. Transient elastography was used to assess LS. Patients were divided into three groups according to tertiles of LS. Adverse outcome was defined as heart failure requiring hospital admission or mortality. Results The median LS was 13.9 (8.1–22.3) kPa which independently correlates with tricuspid regurgitation severity (assessed by effective regurgitant orifice area), inferior vena cava diameter and tricuspid annular plane systolic excursion. During a median follow-up of 31 months, 49 adverse events occurred. Multivariable Cox regression analysis demonstrated that LS was an independent predictor of adverse events. Furthermore, a higher LS tertile was predictive for adverse events (Hazard Ratio 4.19, P&amp;lt;0.01) even after adjusting for the other prognosticators. Kaplan-Meier curve showed that patients in the third tertile LS group had the highest percentage of adverse events followed by patients in the second tertile. Significant improvement of LS at 1-year post-TA was noted only in patients who had no adverse events but not in those who experienced heart failure. Conclusions The present study demonstrates that LS is predictive of adverse outcome in patients undergoing TA. These findings suggested that assessing LS, an integrative assessment of right heart condition, may aid the management of patients undergoing TA. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): The Health and Medical Research Fund from the Food and Health Bureau, the Government of Hong Kong Special Administrative Region.

Right ventricular morphology and function undergo complex changes after cardiac surgery

Abstract Background An impairment of certain echocardiographic parameters of right ventricular (RV) function, such as tricuspid annular peak systolic excursion (TAPSE), is a known phenomenon in patients undergoing cardiac surgery. However, little is known about significance of these alterations with regard to other aspects of RV function. The aim of our study was to clarify this issue using parameters based on 3D echocardiography and speckle tracking technique. Methods The study population comprised 122 patients (92 men, mean age 65±11 years), referred for coronary artery bypass grafting and/or replacement of mitral or aortic valve. Patients undergoing tricuspid annuloplasty and with baseline suboptimal image quality were excluded from the study group. Transthoracic echocardiographic examination was performed on average 2±2 days prior to surgery (TTE1), and 7±4 days after surgery (TTE2), whereas follow-up TTE (TTE3) was performed on average 12±2months after the surgery. Parameters measured during these examinations included both standard and advanced indices of RV size and function (such as TAPSE, systolic velocity of tricuspid annulus (S'), fractional area change (FAC), RV ejection fraction (EF) and RV global longitudinal systolic strain (GLS), as well as a new parameter introduced by our team - RV shortening fraction (RV SF), calculated as the change in mid RV transverse diameter. Results Echocardiographic measurements were completed for TTE1, TTE2 and TTE3 in 95% of patients. We noticed a significant postoperative (TTE2) impairment of parameters of RV longitudinal function (TAPSE, S' and GLS; p&amp;lt;0,0001). However, neither RV size assessed by both 2D and 3D technique changed, nor the global RV function measured with the use of FAC and EF. Additionally during the postoperative period an increase in the value of a RV SF by 12.85% was observed. After 12 months (TTE3) we observed an improvement in the parameters of the longitudinal RV function. Conclusion Cardiac surgery results in an impairment of the longitudinal systolic RV function, with no influence on the global RV function. The preservation of global function results from increased RV SF. After 12 months, an improvement of the longitudinal function can be observed. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Grant Polish Cardiac Society

P1413 Complexity of changes in right ventricular function in patients undergoing cardiac surgery

Abstract Background An impairment of certain echocardiographic parameters of right ventricular (RV) function, such as tricuspid annular peak systolic excursion (TAPSE), is a known phenomenon in patients undergoing cardiac surgery. However, little is known about significance of these alterations with regard to other aspects of RV function. The aim of our study was to clarify this issue using parameters based on 3D echocardiography and speckle tracking technique. Methods The study population comprised 105 patients (76 men, mean age 65 ± 16 years), referred for coronary artery bypass grafting and/or replacement of mitral or aortic valve. Patients undergoing tricuspid annuloplasty and with baseline suboptimal image quality were excluded from the study group. Transthoracic echocardiographic examination was performed on average 2 ± 2 days prior to surgery (TTE1) , and 7 ± 4 days after surgery (TTE2), whereas follow-up TTE (TTE3) was performed on average 12 ± 2months after the surgery. Parameters measured during these examinations included both standard and advanced indices of RV size and function, such as TAPSE, systolic velocity of tricuspid annulus (S"), fractional area change (FAC), RV ejection fraction (EF) and RV global longitudinal systolic strain (GLS). Results Echocardiographic measurements were completed for TTE1, TTE2 and TTE3 in 95% of patients. We noticed a significant postoperative (TTE2) impairment of parameters of RV longitudinal function (TAPSE, S’ and GLS; p &amp;lt; 0,0001). However, neither RV size assessed by both 2D and 3D technique changed, nor the global RV function measured with the use of FAC and EF. After 12 months (TTE3) we observed an improvement in the parameters of the longitudinal RV function. Conclusion Cardiac surgery results in an impairment of the longitudinal systolic RV function, with no influence on the global RV function. After 12 months, an improvement of the longitudinal function can be observed.

Kay annuloplasty of the tricuspid valve versus ring annuloplasty for repair of functional tricuspid regurgitation

Objective Ideal management of functional tricuspid regurgitation (TR) has been a matter of debate for a long time. We try to discuss the midterm results with tricuspid Kay annuloplasty versus ring tricuspid annuloplasty for the treatment of functional TR. Patients and methods From January 2015 to January 2019, 82 patients underwent tricuspid annuloplasty for functional TR as part of their cardiac surgical procedure. Kay annuloplasty was performed in 55 patients and ring annuloplasty in 27 patients. Preoperatively, patients had moderate or greater TR with a median regurgitation of +3. Follow-up information was obtained for the patients with a mean follow-up time of 3 years. Postoperative transthoracic echocardiograms were assessed for severity of TR. Moderate or greater TR was considered significant. Survival and development of recurrent TR were evaluated by transthoracic echocardiograms analysis. TR and risk factors for recurrent regurgitation were identified and analyzed. Results At 3 years postoperatively, TR in patients treated by Kay annuloplasty was zero to mild in 75%, moderate in 11%, moderate to severe in 6%, and severe in 8% of patients. In those undergoing ring annuloplasty, TR was zero to mild in 69%, moderate in 14%, moderate to severe in 7%, and severe in 10%. There was no significant difference between the two groups. Risk factors for recurrent TR included higher preoperative regurgitation grade, preoperative TR without concomitant mitral regurgitation, and higher pulmonary artery systolic pressure. Conclusion Kay annuloplasty and ring annuloplasty were effective in eliminating TR at 3 years postoperatively. Kay annuloplasty is a simple, inexpensive option for addressing functional TR. All patients with moderate-to-severe functional TR should undergo tricuspid annuloplasty regardless of the technique used.

Prognostic Value of Tricuspid Valve Geometry and Leaflet Coaptation Status in Patients Undergoing Tricuspid Annuloplasty: A Three-Dimensional Echocardiography Study

The advent of three-dimensional echocardiography (3DE) enables detailed evaluation of the tricuspid valve (TV) apparatus; nonetheless, the clinical value of preoperative 3DE is unknown in patients undergoing tricuspid annuloplasty (TA). The aim of this study was to evaluate the prognostic value of TV geometric parameters and leaflet coaptation status evaluated by 3DE in patients undergoing TA. A total of 122 patients who underwent TA during left-sided heart valve surgery were prospectively evaluated. Detailed 3DE was performed before surgery. Adverse outcome was defined as the occurrence of heart failure requiring hospital admission or all-cause mortality following TA. A total of 33 adverse events (17 heart failures and 16 deaths) occurred during a median follow-up of 36months. Tethering volume (hazard ratio=1.32; 95% CI=1.05-1.66; P=.01) and ratio of total leaflet length to closure length (hazard ratio=1.07; 95% CI=1.03-1.12; P<.01) were associated with adverse events after adjustment for age, sex, and tricuspid regurgitation vena contracta width. Receiver-operator characteristic curve analysis revealed that tethering volume (area under curve=0.73) and ratio of total leaflet length to closure length (area under curve=0.75) were most associated with adverse events at 1-year follow-up. The presence of either a large tethering volume or a low ratio of total leaflet length to closure length was predictive of an adverse outcome 1year following TA. Our study suggests that 3DE-derived TV tethering volume and ratio of total leaflet length to closure length are important preoperative measures associated with adverse events in patients undergoing TA.

Prognostic Value of Hepatorenal Function By Modified Model for End-stage Liver Disease (MELD) Score in Patients Undergoing Tricuspid Annuloplasty.

BackgroundThe Model for End‐stage Liver Disease excluding international normalized ratio (MELD‐XI) score and the modified MELD score with albumin replacing international normalized ratio (MELD‐Albumin) score, which reflect both liver and renal function, have been reported as predictors of adverse events in liver and heart disease. Nonetheless, their prognostic value in patients undergoing tricuspid annuloplasty has not been addressed.Methods and ResultsA total of 394 patients who underwent tricuspid annuloplasty were evaluated. Baseline clinical, laboratory, and echocardiographic parameters were recorded. Adverse outcome was defined as the occurrence of heart failure requiring admission or all‐cause mortality. Patients who underwent tricuspid annuloplasty had a high prevalence of preoperative hepatorenal dysfunction that was more common in patients with severe tricuspid regurgitation than those with mild to moderate tricuspid regurgitation. The MELD‐XI and MELD‐Albumin scores were excellent predictors of 1‐year adverse outcome (area under the curve: 0.69 and 0.75, respectively). Kaplan–Meier survival curve demonstrated that a high score on MELD‐XI (≥12.0) and MELD‐Albumin (≥10.7) was associated with an increased risk of adverse events. During a median follow‐up of 40 months, both MELD‐XI and MELD‐Albumin scores were significantly associated with adverse outcome, even after adjusting for potential confounding factors. Significant improvement of hepatorenal function at 1 year postoperation was noted only in patients who had no adverse events, not in those who experienced an adverse outcome.ConclusionsBoth MELD‐XI score and MELD‐Albumin score can provide useful information to predict adverse outcome in patients undergoing tricuspid annuloplasty. The present study supports monitoring of modified MELD score to improve preoperative risk stratification of these patients.

Three-port (one incision plus two-port) endoscopic mitral valve surgery without robotic assistance.

Totally endoscopic minimally invasive mitral valve surgery (MIMVS) is technically demanding and often performed with robotic assistance. We hypothesized that three-port video-assisted thoracic surgery (VATS) would facilitate endoscopic MIMVS and evaluated its feasibility and safety. From October 2010 to June 2016, we performed first-time MIMVS in 250 consecutive patients (122 male), with median age of 65 years (54-73 years, 25-75 percentile). The thoracic access ports comprised one small (3-5 cm) thoracotomy without a rib spreader plus two trocars (one for the endoscope and one for left-handed instruments), thus establishing triangular three-port VATS. Cannulas, an aortic clamp, and a left atrial retractor were inserted through the thoracotomy, and right-handed instruments were inserted through the remaining space. Cardiopulmonary bypass was established through a groin incision. The etiology of the mitral valve lesion was myxomatous degeneration in 70% of patients, rheumatic disease in 9%, infectious endocarditis in 6%, and other conditions in 15%. Mitral valve repair was performed in 233 patients and replacement in 27. Two patients underwent conversion to replacement after attempted repair. Forty-nine patients underwent tricuspid annuloplasty, and 45 underwent the Maze procedure. One in-hospital death occurred within 30 days. Two patients developed stroke, three underwent re-exploration for bleeding, one developed low output syndrome, and one required new haemodialysis. The aortic clamp, bypass, and total operation times were 119 (94-149), 166 (134-200) and 237 (204-285) min, respectively, median (25-75%). The 5-year survival and reoperation-free rates were 98.3% ± 0.9% and 96.9% ± 1.2%, respectively. Three-port endoscopic MIMVS appears reproducible and safe.

Direct Injury to Right Coronary Artery in Patients Undergoing Tricuspid Annuloplasty

Direct injury to the right coronary artery as a result of reparative operation on the tricuspid valve is a rare, probably underdiagnosed, but serious complication, which often involves dramatic clinical consequences. So far, only five cases have been described in the literature. We describe our single-center experience of this complication, and review and analyze relevant clinical and anatomic considerations related to this entity. Cases previously reported in the literature were also reviewed. We describe four cases of direct injury to the right coronary artery in patients undergoing tricuspid annuloplasty (DeVega annuloplasty, 3; ring annuloplasty, 1) in our institution since 2005. All patients had right ventricular dilatation and severely dilated tricuspid annulus. Right coronary artery occlusion always occurred between the right marginal artery and the crux of the heart. Patients presented with hemodynamic or electrical instability. Coronary flow could be restored in 2 patients (percutaneously 1; surgically 1), both of whom finally survived, while it was not technically possible in the other 2 (1 died). Occlusion of the right coronary artery in patients undergoing tricuspid annuloplasty is a rare complication that may occur if great annulus dilatation is present, thus altering both normal annular geometry and the relationship between the right coronary artery and the tricuspid annulus, particularly when DeVega annuloplasty is performed. Such an entity should be considered in the immediate postoperative period in an unstable patient, especially when complementary tests support this diagnosis. Prompt recognition and treatment can positively affect the patient's outcome, most often by means of an emergency revascularization strategy.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Repair of Functional Tricuspid Regurgitation: Comparison Between Suture Annuloplasty and Rings Annuloplasty

The purpose of this study was to review our experience with modified De Vega tricuspid annuloplasty versus ring annuloplasty for treating functional tricuspid regurgitation (TR). In all, 448 consecutive patients undergoing tricuspid annuloplasty with concomitant procedures between 2000 and 2012 were included. Modified De Vega annuloplasty was performed in 216 patients (group 1) and ring annuloplasty in 232 patients (group 2). Clinical and echocardiographic follow-up results were used to assess TR grade. Recurrent TR was defined as grade 2 or greater at echocardiography. Preoperative clinical and echocardiographic characteristics were comparable in the two groups. Early mortality was similar (group 1, 0.9%, versus group 2, 1.3%; p<0.67). Follow-up was available for 97%; New York Heart Association class and symptoms of right-side heart failure were significantly improved. Survival rates at 1 and 5 years were comparable (97% and 84% for group 1, and 96% and 82% for group 2, respectively). Postoperative echocardiography showed significant improvement in tricuspid valve function, with reduction in TR grade from 3.4 to 0.6, and no differences between groups. However, recurrence-free survival was better for group 2 than for group 1 (78.8% versus 74.5%; p<0.62). Risk factors for recurrent TR included severity of preoperative TR, atrial fibrillation, and pulmonary hypertension. The modified De Vega tricuspid annuloplasty is acceptable for repair of functional TR and improvements in clinical and echocardiographic status on a long-term basis, although the long-term recurrence-free survival appeared to be lower than that for ring annuloplasty.

Prognostic Value of Preoperative Right Ventricular Geometry and Tricuspid Valve Tethering Area in Patients Undergoing Tricuspid Annuloplasty

Patients who undergo tricuspid annuloplasty during left-side heart valve surgery have a poor postoperative clinical outcome. However, preoperative right ventricular (RV) echocardiography parameters that predict adverse events in these patients are poorly understood. We studied 74 patients (age, 58±10 years; men, 27%) with significant tricuspid regurgitation who consequently underwent tricuspid annuloplasty during left-side heart valve surgery. A total of 26 adverse events (22 heart failures and 4 cardiovascular deaths) occurred during a median follow-up of 26 months. RV midcavity diameter (hazard ratio=2.44; 95% confidence interval=1.48-4.02; P<0.01), RV longitudinal dimension (hazard ratio=1.64; 95% confidence interval=1.10-2.45; P=0.02), and tricuspid valve tethering area (hazard ratio=3.25; 95% confidence interval=1.71-6.19; P<0.01) were independently associated with adverse events after adjustment for age and New York Heart Association class III/IV. Receiver-operator characteristic curve analysis demonstrated that RV midcavity diameter (area under the curve=0.74; P<0.01) and tricuspid valve tethering area (area under the curve=0.70; P=0.04) were most associated with adverse events at the 1-year follow-up. The presence of either a large RV midcavity diameter or tricuspid valve tethering area was predictive of adverse outcome at 1 year after tricuspid annuloplasty. The present study demonstrates that RV geometry dimensions, namely RV midcavity diameter and tricuspid valve tethering area, are important preoperative measures associated with adverse events in patients undergoing tricuspid annuloplasty.

Tricuspid Annuloplasty Using the MC3 Ring for Functional Tricuspid Regurgitation

A recently introduced tricuspid annuloplasty ring, the MC(3) ring, has a 3-dimensional form that is designed to remodel the tricuspid valve annulus. The aim of this study was to investigate its clinical performance. From December 2004 to April 2008, 103 patients underwent tricuspid annuloplasty using the MC(3) ring (mean age, 52+/-13 years; 63.6% women). The average preoperative tricuspid regurgitation (TR) grade was 2.5+/-0.8, and the mean preoperative systolic pulmonary artery pressure was 48.4+/-15.0 (24-88) mmHg; the mean follow-up was 26.7+/-11.2 (0-52) months. One patient died after surgery (1.0%), because of cor pulmonale. No MC(3) ring-related complications, such as, atrioventricular block, ring dehiscence or thromboembolism, were encountered. Predischarge echocardiography showed a significant decrease in the TR grade (2.5+/-0.8 to 0.8+/-0.8, respectively; P<0.001). After a median 15 months, the mean TR grade was stable (0.9+/-0.8). The mean systolic pulmonary artery pressure was also lower than its preoperative value (33.9+/-7.9 vs 48.4+/-15.0 mmHg, respectively; P<0.001). The MC(3) ring provides good mid-term clinical and echocardiographic results for TR. However, long-term follow-up is mandatory to confirm the stability of this procedure.

Successful surgical treatment of chronic ischemic mitral regurgitation achieves left ventricular reverse remodeling but does not affect right ventricular function

To evaluate left-sided and right-sided heart echocardiographic results after restrictive mitral annuloplasty in chronic ischemic mitral regurgitation. Left atrial diameter, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, left ventricular ejection fraction, left ventricular indexed mass, coaptation depth, transmitral mean gradient, systolic pulmonary arterial pressure, tricuspid annular plane systolic excursion, right ventricular ejection fraction, and tricuspid insufficiency grading were evaluated preoperatively, postoperatively, at 6 months, and at the end of the follow-up period in 64 patients undergoing restrictive mitral annuloplasty and coronary artery bypass grafting. Recurrence of chronic ischemic mitral regurgitation was defined as 2+/4+ grade or greater mitral regurgitation at any time postoperatively. Twenty-two months of freedom from recurrent chronic ischemic mitral regurgitation was 58.2% +/- 9.8%. Recurrent chronic ischemic mitral regurgitation did not lead to reverse remodeling of left atrial diameter, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and ventricular indexed mass (P = not significant), with increased coaptation depth, parallel to follow-up chronic ischemic mitral regurgitation worsening. Effective restrictive mitral annuloplasty induced reverse remodeling of left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and ventricular indexed mass, improved left ventricular ejection fraction, shortened coaptation depth, and improved mean gradient (P <or= .014). Recurrent chronic ischemic mitral regurgitation in patients without tricuspid surgery prevented improvements of systolic pulmonary arterial pressure, tricuspid annular plane systolic excursion, right ventricular ejection fraction, worsening New York Heart Association (P = .003), and daily diuretic need (P = .008), whereas effective restrictive mitral annuloplasty progressively improved tricuspid insufficiency grading, systolic pulmonary arterial pressure, right ventricular ejection fraction, tricuspid annular plane systolic excursion, New York Heart Association, and diuretic need (P <or= .013). Patients undergoing tricuspid annuloplasty did not show any improvement of systolic pulmonary arterial pressure, right ventricular ejection fraction, and tricuspid annular plane systolic excursion regardless of the recurrence of chronic ischemic mitral regurgitation (P = not significant), although effective restrictive mitral annuloplasty improved tricuspid insufficiency grading, New York Heart Association, and daily diuretic need (P <or= .010). Effective restrictive mitral annuloplasty induces reverse left ventricular remodeling. Absence of recurrent chronic ischemic mitral regurgitation improves tricuspid insufficiency grading, systolic pulmonary arterial pressure, right ventricular ejection fraction, tricuspid annular plane systolic excursion, New York Heart Association, and diuretic need in patients who do not undergo tricuspid surgery, but only tricuspid insufficiency grading, New York Heart Association, and daily diuretic need in patients who undergo tricuspid surgery.

Isolated unguarded tricuspid valve: A rare cause of syncope and new-onset right cardiac failure in adult

An unguarded tricuspid valve is a rare congenital anomaly. We describe the clinical and echocardiographic features of two young adult African patients with syncope, new-onset right cardiac failure, in whom the diagnosis of isolated unguarded tricuspid valve was established. One of the patients underwent tricuspid annuloplasty with good surgical results.