Posterior Leaflet Of Tricuspid Valve Research Articles

Abstract 17063: Pericardial Patch Augmentation of the Anterior and Posterior Tricuspid Leaflets Relieves Leaflet Tethering and Improves Coaptation in an Acute Porcine Model

Background: Tricuspid annuloplasty is generally effective in treating functional tricuspid regurgitation (TR), but patients with severe annular dilation or leaflet tethering have a high risk of recurrence. Hypothesis: We hypothesized that anterior and posterior patch augmentation (APA) of the tricuspid valve (TV) would reduce leaflet tethering, improve coaptation, and effectively treat TR. Methods: We evaluated APA repair in an acute porcine model. The TV was accessed via a right thoracotomy and cardiopulmonary bypass (CPB) was initiated with bicaval venous and ascending aortic cannulation. The anterior and posterior TV leaflets were separated from the annulus, and a 1.5 cm wide partial reverse frustum-shaped pericardial patch was implanted. 3D transepicardial echocardiography was used to image the TV pre- and post-implantation. Geometric measurements were assessed using Tomtec and compared with paired t-tests. Results: APA repair was performed in five pigs (weight 60-80 kg). All animals were weaned from CPB in sinus rhythm. TR was trace or absent in all cases after APA repair. There were no changes in pressure gradient (0.5 vs 0.5, p>0.9) or annular area (11.2 vs 10.1 cm 2 , p=0.19). APA repair was associated with a decreased tenting height and angle of the anterior (height: 9.0 vs 4.6 mm, p=0.03; angle: 20.9° vs 16.1°, p=0.04) and posterior (height: 9.8 vs 5.5 mm, p=0.03; angle: 28.1° vs 21.8°, p=0.03) leaflets. Central coaptation length increased in all leaflets (septal: 3.8 vs 6.6 mm, p=0.04, anterior: 4.7 vs 12.7 mm, p<0.01, posterior: 4.5 vs 13.2 mm, p<0.01). Conclusions: APA repair was feasible, safe, reduced leaflet tenting, and improved coaptation. This novel repair method shows promise for patients with severe annular dilation or leaflet tethering who otherwise have a high risk of recurrence with annuloplasty alone. Furthermore, by avoiding suture placement near the conduction system, it may reduce the risk of post-operative conduction abnormalities.

An Animal Model of Functional Tricuspid Regurgitation by Leaflet Tethering Using Image-Guided Chordal Encircling Snares.

Several interventional therapies are in development to treat functional tricuspid regurgitation. Most have failed to achieve adequate efficacy, as animal models of this lesion are lacking. We developed a new image-guided technique in swine, by tethering the tricuspid valve chordae using echo-guided chordal encircling snares. Five swine underwent baseline echocardiographic assessment of tricuspid valve function, followed by echo-guided placement of snares that encircle the chordae inserting into the anterior and posterior tricuspid valve leaflets. Tethering these snares and stabilizing them on the right ventricle caused the regurgitant fraction to increase from 8.48±5.38% to 48.76±12.5%, and the valve tenting area to increase from 60.26±52.19 to 160.9±86.92 mm2. Image-guided chordal encircling snares could reproducibly induce clinically significant levels of functional tricuspid regurgitation and create a valve geometry like that seen in patients, providing a new animal model for use to study novel interventional devices.

Laparotomy in a patient with Ebsteins anomaly- from OT to ICU.

Ebstein’s anomaly (EA) is a rare cyanotic congenital heart disease, affecting 1/200,000 live births and accounts for <1% of congenital heart diseases.1 First described by Wilhelm Ebstein in 1866 2 , the anomaly consists of downward displacement of the septal and posterior leaflet of tricuspid valve resulting in atrialization of the right ventricle and tricuspid regurgitation. The resulting functional impairment of right ventricle retard the forward flow of blood through right side of the heart, thereby causing a hypoplastic Right ventricle(RV), or RV outflow tract obstruction. This creates an accessory conduction pathways resulting in tachyarrythmias, pulmonary hypertension, intracardiac shunting. 3 Acute decompensated heart failure and sudden collapse are the most common cause of death.4

Laparotomy in a Patient with Ebsteins Anomaly- From OT to ICU

Ebstein’s anomaly (EA) is a rare cyanotic congenital heart disease, affecting 1/200,000 live births and accounts for <1% of congenital heart diseases [1]. First described by Wilhelm Ebstein in 1866 [2], the anomaly consists of downward displacement of the septal and posterior leaflet of tricuspid valve resulting in atrialization of the right ventricle and tricuspid regurgitation. The resulting functional impairment of right ventricle retard the forward flow of blood through right side of the heart, thereby causing a hypoplastic Right ventricle (RV), or RV outflow tract obstruction. This creates an accessory conduction pathways resulting in tachyarrythmias, pulmonary hypertension, intra-cardiac shunting [3].Acute decompensated heart failure and sudden collapse are the most common cause of death [4].

1993. Serratia is a rare cause for Infective Endocarditis of the Tricuspid Valve

Abstract Background Serratia marcescens is a Gram-negative motile bacillus that is a facultative anaerobe and non-lactose fermenting. Serratia can be isolated from water, soil, plants, and the intestinal microbiome. Serratia produces a unique Identifying reddish pigment called prodigiosin. Serratia is responsible for only 0.14% of infective endocarditis cases, with a mortality rate of 85%. Methods A 37 YO female with a history of Intravenous heroin abuse was admitted with fevers and dyspnea. Vital signs were BP 76/50, HR 140, RR 26, temp 102 F, and SpO2 98% on room air. She was toxic-appearing. Labs: WBC 26000(4,000 – 11,000 /uL) with 14% bands, Hb 5.6 (12.6 – 17.0 g/dL), PLT 15*10^3(150-372*10^3/uL), creatinine 2.5 (0.50 - 1.60 mg/dL), lactic acid 15.8 (0.5-2.2 mmol/L). We started vancomycin, piperacillin-tazobactam, and norepinephrine for septic shock. A transthoracic echo showed a large mass on the tricuspid valve, and a transesophageal echo depicted it as vegetation. Blood cultures grew Serratia. She underwent excision of anterior and posterior tricuspid valve leaflets with reconstruction and ring annuloplasty. She reported washing her syringes with tab water and reusing them again. Serratia has a predilection for left-side heart valves even in the IVDU population but this patient presented with a tricuspid valve endocarditis. Results Serratia is a rare cause for IE in the ICE study; out of 2.761 definite IE cases identified over five years, only forty-nine instances were due to gram-negative bacilli. Of those, only four cases were due to Serratia. The clinical presentation of Serratia includes constitutional symptoms, new-onset murmur, and cutaneous and neurologic manifestations. Serratia produces multiple pathogenic factors allowing Serratia to result in valvular destruction and perivalvular complications, and distant septic emboli metastasis. Conclusion Serratia is sensitive to third and fourth-generation cephalosporins, monobactams, carbapenems, fluoroquinolones, and aminoglycosides. Treatment is complex due to the production of AmpC B-lactamase, which hydrolyzes third and fourth-generation cephalosporins. The 2005 IDSA suggested a combination of B-lactam and an aminoglycoside for Serratia endocarditis, and these are not guidelines but merely recommendations. Disclosures All Authors: No reported disclosures.

Tricuspid valve remodelling in functional tricuspid regurgitation: multidetector row computed tomography insights

Multidetector row computed tomography (MDCT) may help to understand the underlying mechanisms of functional tricuspid regurgitation (TR), a highly prevalent valve disease with novel transcatheter therapies under development. The purpose of the present study was to assess the geometrical changes of the tricuspid valve in patients with functional TR using MDCT and to correlate these changes with the TR grade assessed with echocardiography. In 114 patients undergoing transcatheter aortic valve implantation (47 men, age 81 ± 8 years), including 33 (28.9%) patients with TR ≥ 3+, the tricuspid valve and right ventricle (RV) were geometrically analysed with 320-slice MDCT. The antero-posterior and septal-lateral diameters, perimeter and area of the annulus, degree of tethering of the anterior, septal and posterior tricuspid valve leaflets, and RV volumes and ejection fraction were assessed and subsequently correlated with TR grade in multivariate models. Patients with pacemaker or implantable cardioverter defibrillator leads were excluded.Patients with TR ≥ 3+ had larger tricuspid annulus area (1539.7 ± 260.2 vs.1228.4 ± 243.5 mm(2), P < 0.001), larger septal and anterior leaflet angles, and larger RV end-systolic volumes (93.2 ± 29.8 vs. 64.2 ± 23.6 mL, P < 0.001) compared with patients with TR < 3+.The antero-posterior tricuspid annulus diameter was independently correlated with TR ≥ 3+ (odds ratio 1.35; 95% confidence interval 1.07-1.69, P = 0.010), after adjusting for estimated pulmonary pressure and RV end-systolic volume. In patients with TR ≥ 3+, MDCT demonstrated larger tricuspid annulus and RV dimensions and pronounced tethering of the anterior and septal tricuspid leaflet. The antero-posterior annulus diameter was independently correlated with the grade of functional TR.

Anesthetic management of a patient with restrictive cardiomyopathy and ebstein anomaly for femoral hernia repair

Ebstein anomaly along with restrictive cardiomyopathy is a rare entity characterized by apical displacement of the septal and posterior tricuspid valve leaflets, leading to atrialization of the right ventricle with a variable degree of malformation and displacement of the anterior leaflet along with the restriction of diastolic filling of ventricles. If patients with this anomaly present to us along atrial fibrillation and liver dysfunction due to right-sided heart failure, it would be a challenge for anesthesiologist to give anesthesia. Herein, we are providing a brief review of the clinical presentation and anesthetic consideration in these types of patients if they present for noncardiac surgeries.

Abstract 15817: Tricuspid Valve Imaging by 3D Transesophageal Echocardiography: Feasibility of Coaptation Length Measurement and Its Relationship With Severity of Regurgitation

Background: The coaptation length (CL) of the mitral valve leaflet decreases with increasing mitral regurgitation. Visualization of the CL of the tricuspid valve (TV) is challenging using conventional 2D echocardiography. The aims of this study were: (1) to test the feasibility of visualizing and quantifying the CL of the TV using three-dimensional (3D) transesophageal echocardiography (TEE), and (2) to study it relationship with the severity of tricuspid regurgitation (TR). Methods: Full-volume 3D TEE datasets of the TV were obtained in 24 patients from the transgastric approach. Using multiplanar reconstruction, short-axis plane depicting an en-face view of the TV was used to mark the central coaptation point (Fig. A). Three planes cutting through this point were then selected to view the 3 coaptation lines between: (1) anterior and posterior, (2) septal and anterior, and (3) septal and posterior TV leaflets (Figs. B-D). The CL was measured in each of these planes to obtain mean CL. The severity of tricuspid regurgitation was graded qualitatively as “none”, “trace”, “mild” and “moderate”. Results: Visualization of leaflet coaptation was feasible in 17/24 patients (71%). The mean CL was 0.89±0.03 cm in patients with no TR (N=4), 0.64±0.13 with trace TR (N=6), 0.50±0.07 with mild TR (N=3) and 0.13±0.11 with moderate TR (N=4). Since there was no overlap between the “moderate” group and the other 3 groups, the threshold of average CL for moderate TR was estimated to be between 0.25 (highest value in the “moderate” group) and 0.39 cm (lowest value in the other groups) (Fig. E). Conclusion: Visualization of the TV leaflet coaptation length from transgastric 3D TEE images is feasible in the majority of patients. TV coaptation length is inversely related to the severity of TR. The ability to visualize and quantify the CL of the TV may be useful when planning tricuspid valve repair surgery. Our findings suggest that CL below the threshold may indicate clinically significant TR.

Prolapse of posterior leaflet of tricuspid valve presenting as an undulating artifact in right atrium: A rare case report

We present a case of prolapsed posterior leaflet of tricuspid valve presenting as rapidly undulating serpentine mass in mid cavity of the right atrium during ventricle systole mimicking Chiari network. 3D echocardiography unveiled the mystery and confirmed prolapsed posterior leaflet of tricuspid valve. To the best of our knowledge such a large hypermobile artifactual echocardiographic manifestation of prolapsed posterior leaflet of tricuspid valve has not been reported in the literature.

Cardiac Magnetic Resonance Imaging Findings in a Patient with Ebstein’s Anomaly and Left Ventricular Dysfunction

Ebstein anomaly is characterized by apical displacement of the septal and posterior tricuspid valve leaflets, leading to atrialization of the right ventricle and could be diagnosed in a routine transthoracic echocardiography exam. We reported a young man with right sided heart failure symptoms who was found to have biventricular failure with suspected apical displacement of septal leaflet of tricuspid valve. For better evaluation, cardiac magnetic resonance imaging (CMR) was performed and nicely proved the diagnosis of Ebstein's anomaly with late intramyocardial enhancement of both left and right ventricles. CMR has the potential for providing information while echocardiography cannot, especially regarding the right ventricle and related myocardial problems, and Ebstein’s anomaly with decreased left ventricular (LV) systolic function.

Three-dimensional echocardiography in classification of Ebstein’s anomaly: a case report on agenesis of the tricuspid valve posterior leaflet

Cardiologia CROATICA We present an echocardiographic evaluation of a 27-yearold young male patient who was referred to our institution after a loud systolic murmur was found during his occupational health check-up.. Besides the murmur, his physical exam, and results of his laboratory tests were normal. He has no significant complaints. His first 2D transthoracic echocardiogram (TTE) revealed severely dilated right ventricle (RV area greater than left ventricular area), volume overloaded and excentrically hypertrophied (wall thickness >6 mm), with severe tricuspid regurgitation (vena contracta 12 mm), large abundant sail-like anterior leaflet of the tricuspid valve (TV), apically displaced short septal leaflet (17 mm), and in the same time normal left ventricular systolic function and dimensions. These findings, especially apical displacement of septal leaflet indicate Ebstein’s anomaly. Ebstein’s anomaly is a rare congenital heart defect that occurs in only about <1% of congenital heart disease. In normal human hearts the apical displacement of the septal and posterior TV leaflets is <8 mm/m body surface area from the level of anterior mitral valve insertion. Differential diagnosis includes TV dysplasia, TV prolapse, TV endocarditis, and arrhythmogenic right ventricular cardiomyopathy, to name a few. With 2D TTE we were positive that this patient had some form of Ebstein’s anomaly, however we could not generate important information about valvular apparatus, such as morphology of the leaflets, the true origin of septal and posterior leaflets as well as precise coaptation. Those information are necessary in order to complete classification of TV pathology. Therefore we obtained 3D TTE and 3D TEE, and with multiplanar review mode and 3D reconstruction revealed complete agenesis of the posterior leaflet leaving almost unguarded tricuspid orifice with a large zone of lack of coaptation as the origin of severe tricuspid regurgitation. Subsequent 3D analysis also verified absence of complete posterior leaflet subvalvular apparatus, or in the context of embryological development, complete absence of posterior leaflet delamination. We used 2D echocardiography to study morphology and function of right ventricle, but 3D echocardiography provided additional important information regarding the morphology and orientation of TV and its apparatus. Only 3D TEE obtained agenesis of the posterior leaflet. According to parameters derived by 2D TTE and 3D TEE this patient was classified as type I Ebstein’s anomaly.

Ebstein Anomaly

Ebstein anomaly (EA) is a rare congenital malformation of the heart that is characterized by apical displacement of the septal and posterior tricuspid valve leaflets, with atrialization of the right ventricle and variable degree of malformation and displacement of the anterior leaflet. Patients can have a variety of symptoms related to the anatomic abnormalities of EA and their hemodynamic effects or associated structural and conduction system disease. Most frequently cyanosis, palpitations, fatigue and dyspnea can be observed. In severe forms edema and ascites. Treatment of EA is complex and depends of the severity of the disease itself and the effect of accompanying congenital structural and electrical abnormalities. Options of treatment include medical therapy, radiofrequency ablation, and surgical therapy. Main aim of the surgical therapy is to correct the underlying tricuspid valve, right ventricular abnormalities and any associated intracardiac defects if exist. Palliative procedures and cardiac transplantation can be considered in most sever EA patients. JRCD 2013; 1 (4): 5–9

Recurrent Inflammatory Myofibroblastic Tumor of the Heart

A previously healthy 15-year-old boy was admitted after 6 months of intermittent fevers, night sweats, and 9 kg weight loss. A systolic murmur was appreciated at the left upper sternal border. Laboratory data revealed elevated white blood cells (11 800/μL), erythrocyte sedimentation rate (75 mm/h), and C-reactive protein (10.5 mg/dL). The results of blood cultures were negative. Imaging demonstrated a hypermetabolic 2×2×4.5 cm pedunculated mass in the right ventricle, suggestive of a neoplasm with overlying thrombus (Figures 1A, 2A and 2B and online-only Data Supplement Movie I). Figure 1. Cardiac magnetic resonance imaging demonstrating the initial IMT originating from the interventricular septum near the right ventricular outflow tract ( A ) and the recurrent IMT near the tricuspid annulus ( B ). IMT indicates inflammatory myofibroblastic tumor. Figure 2. Transthoracic echocardiography before and after resection of the initial inflammatory myofibroblastic tumor. A and B , Preoperative images showed a large echogenic mass in the apex of the right ventricle extending superiorly through the right ventricular outflow tract. C and D , Postoperative echocardiography revealed no evidence of residual tumor. A4C indicates apical 4-chamber view; Ao, aorta; LA, left atrium; LV, left ventricle; PA, pulmonary artery; PSAX, parasternal short axis view; RA, right atrium; RV, right ventricle; RVOT, right ventricular outflow tract; Pre-op, preoperative; and Post-op, postoperative. Arrow denotes the tumor. At surgery, the mass was found to originate from the midportion of the interventricular septum and was covered with thrombus. …

Recurrent Transient Ischemic Attacks in a 48-Year-Old Patient With an Undiagnosed Ebstein's Anomaly: A Case Report

Ebstein ’ s anomaly is a rare congenital malformation of the heart characterized by apical displacement of the septal and posterior tricuspid valve leaflets, leading to atrialisation of the right ventricle with a variable degree of malformation and displacement of the anterior leaflet. Its presentation depends on the severity of the anomaly. Mild forms are often undiagnosed until adulthood due to its benign course. Importantly, interatrial communications are present in 80% of the patients with EA through which a paradoxical embolism may occur whenever a right-to-left shunt exists. The authors describe a case of a 47-year-old white man that presented with acute recurrent transitory ischemic brain attacks and progressive exertional dyspnea. A brain CT scan revealed infarcts in multiple vascular territories. Echocardiographic studies revealed an Ebstein ’ s anomaly with a right-to-left shunt through an interatrial communication and severe right heart failure. Doppler study of the cervical and extremities ’ vessels was negative for a possible thrombotic source. A diagnosis of transient ischemic attacks presumably secondary to paradoxical embolism with unknown source was established. The patient was successfully submitted to heart surgery and improvement of symptoms and heart function was observed. At follow-up he remains well and without further neurological events. doi:10.4021/jmc439w

Recurrent Transient Ischemic Attacks in a 48-Year-Old Patient With an Undiagnosed Ebstein’s Anomaly: A Case Report

Ebstein’s anomaly is a rare congenital malformation of the heart characterized by apical displacement of the septal and posterior tricuspid valve leaflets, leading to atrialisation of the right ventricle with a variable degree of malformation and displacement of the anterior leaflet. Its presentation depends on the severity of the anomaly. Mild forms are often undiagnosed until adulthood due to its benign course. Importantly, interatrial communications are present in 80% of the patients with EA through which a paradoxical embolism may occur whenever a right-to-left shunt exists. The authors describe a case of a 47-year-old white man that presented with acute recurrent transitory ischemic brain attacks and progressive exertional dyspnea. A brain CT scan revealed infarcts in multiple vascular territories. Echocardiographic studies revealed an Ebstein’s anomaly with a right-to-left shunt through an interatrial communication and severe right heart failure. Doppler study of the cervical and extremities’ vessels was negative for a possible thrombotic source. A diagnosis of transient ischemic attacks presumably secondary to paradoxical embolism with unknown source was established. The patient was successfully submitted to heart surgery and improvement of symptoms and heart function was observed. At follow-up he remains well and without further neurological events. J Med Cases. 2012;3(1):54-59 doi: https://doi.org/10.4021/jmc439w

Sudden cardiac death in Ebstein's malformation due to a cardiac haemangioma

A previously well 22-year-old man suddenly collapsed during a football game. Prolonged resuscitation of 50 min was unsuccessful. Pathological examination demonstrated Ebstein's malformation with apical displacement by 30 mm of the septal and posterior tricuspid valve leaflets ( Panel A ), and rotation of the septal leaflet into the right ventricular outflow tract (RVOT). The anterior …

Diagnosis of the downward displacement of the posterior leaflet of tricuspid valve from apical right heart two chamber view by echocardiography

Objective To evaluate the value of echocardiography method for diagnosis of the downward displacement of the posterior leaflet of tricuspid valve with apical right heart two chamber view (AP-RH-2CV). Methods Rotating the probe clockwise from apical four chamber view(AP-4CV) to AP-RH-2CV at the septial and posterior leaflet of tricuspid valve, the shape, moving and position of the posterior leaflet of the tricuspid valve were observed by displaying the degree of downward displacement of the septial and posterior leaflet of tricuspid valve. The location of the orifice of tricuspid regurgitation was examined by color Doppler flow imaging(CDFI). Results In 15 patients with Ebstein's anomaly from the AP-RH-2CV, the downward displacement of posterior leaflet of tricuspid valve was clearly observed at the AP-RH-2CV. These results of echocardiography were confirmed by surgery except one ease missing out mild downward displacement of the anterior leaflet of tricuspid valve. Moreover, all 15 patients showed the obvious downward displacement of the location of the orifice of tricuspid regurgitation from AP-RH-2CV by CDFI. Conclusions The AP-RH-2CV is an ideal view in diagnosis of the downward displacement of the posterior leaflet of tricuspid valve by echocardiography. The downward displacement of the location of the orifice of tricuspid regurgitation is a critical character for diagnosis of the downward displacement of the posterior leaflet of tricuspid valve by CDFI. Key words: Echocardiography; Ebstein's anomaly

The cone reconstruction of the tricuspid valve in Ebstein’s anomaly. The operation: early and midterm results

We sought to describe a new technique for tricuspid valve repair in Ebstein's anomaly and to report early echocardiographic results, as well as early and midterm clinical outcomes. From November 1993 through August 2005, 40 consecutive patients with Ebstein's anomaly (mean age, 16.8 +/- 12.3 years) underwent a new surgical repair modified from Carpentier's procedure, the principal details of which are as follows. The anterior and posterior tricuspid valve leaflets are mobilized from their anomalous attachments in the right ventricle, and the free edge of this complex is rotated clockwise to be sutured to the septal border of the anterior leaflet, thus creating a cone the vertex of which remains fixed at the right ventricular apex and the base of which is sutured to the true tricuspid valve annulus level. Additionally, the septal leaflet is incorporated into the cone wall whenever possible, and the atrial septal defect is closed in a valved fashion. There was 1 (2.5%) hospital death and 1 late death. Early postoperative echocardiograms have shown good right ventricular morphology and reduction in tricuspid regurgitation grade from 3.6 +/- 0.5 to 1.2 +/- 0.5 (P < .0001). After mean follow-up of 4 years, the functional class (New York Heart Association) improved from 2.6 +/- 0.7 to 1.2 +/- 0.4 (P < .0001). Two patients required late tricuspid valve re-repair, and there was neither atrioventricular block nor tricuspid valve replacement at any time. This surgical technique for Ebstein's anomaly can be performed with low mortality and morbidity. Early echocardiograms showed significant reduction of tricuspid insufficiency, and the follow-up showed improvement in patients' clinical status and low incidence of reoperation.

A new technique for aortic valve dysfunction: reconstruction by posterior leaflet of tricuspid valve

Valve repair for aortic dysfunction may provide an alternative approach to aortic valve replacement in selected patients. This repair by using posterior leaflet of tricuspid valve could be either an attempt at permanent correction, or palliative to avoid the use of anticoagulation and improve the anticalcification and durability of the implanted cusp. Two patients with aortic valve dysfunction underwent valve repair by this technique. The procedure included tricuspid valvuloplasty and posterior leaflet preparation, reconstruction of the aortic sinus, and posterior leaflet reimplantation to the new aortic sinus. There were no hospital deaths or other valve-related complication in either patient. Both patients had no tricuspid valve stenosis or regurgitation. Echocardiography in the first patient showed no aortic regurgitation and transvaluvular gradient of 23 mm Hg, and mild aortic insufficiency and no stenosis in the second patient. Short-term follow-up (6 months) showed no recurrent aortic dysfunction in either patient. This technique has provided satisfactory early results and could be considered an interesting corrective or palliative surgical approach.

Ebstein's anomaly associated with a definite atrial left to right shunt—Case report

A case with Ebstein's anomaly associated with large left to right atrial shunt was operated upon. The patient did not demonstrate any tricuspid insufficiency in spite of the downward displacement of the septal and posterior leaflets of tricuspid valve. The surgical closure of the atrial septal defect relieved the impending heart failure. The pulmonary congestion disappeared but the cardiomegaly persisted after the operation.