Septal Leaflet Of Tricuspid Valve Research Articles

Characterization of aneurysmal transformation in perimembranous ventricular septal defects: an adhered anterior leaflet of tricuspid valve predisposes to the development of left ventricular-to-right atrial shunt

Background: The most common type of left ventricular-to-right atrial shunts are those associated with perimembranous ventricular septal defect when the defects diminish in size via aneurysmal transformation. This study is to characterize the echocardiographic features and to determine the possible mechanisms. Methods and results: From January 1986 to December 1992, of 930 consecutive patients with isolated perimembranous ventricular septal defect, 692 showed evidence of aneurysmal transformation. Excluding those with subaortic ridge, echocardiographic analysis was based on 664 of them. Of these, 94 patients had left ventricular-to-right atrial shunts, 115 had their defects spontaneously closed and in 455 only interventricular shunt persisted. Four types of echocardiographic findings featured in the aneurysmal transformation process: type A, both the anterior and septal leaflets of tricuspid valve contributed to the process; type B was similar to type A, but the arc-like structure from the anterior leaflet is much less evident; in type C, only the septal leaflet, and in type D, other adjacent tissues, contribute to the aneurysmal transformation. Type A morphology was closely associated with the development of left ventricular-to-right atrial shunt while types C and D were most commonly seen in those spontaneously closed defects and those with only interventricular shunt. The vegetations of infective endocarditis were located at the atrial side of the tricuspid valve in patients with left ventricular-to-right atrial shunts, while they were in the right ventricle in those with only interventricular shunt. Conclusion: The morphology of the aneurysmal transformation in perimembranous ventricular septal defect can be characterized by echocardiograms. Although the septal leaflet of the tricuspid valve is usually involved in this process, it is the incorporation of the anterior leaflet that predisposes to the development of left ventricular-to-right atrial shunts.

Ventricular septal defect with tricuspid pouch with and without transposition

In a 10-year review, patients operated on for ventricular septal defect and tricuspid valve pouch were divided into two groups, because the effect of the tricuspid valve pouch is influenced by which ventricle has the higher pressure. Group I comprised patients with ventricular septal defect without transposition of the great arteries and group II, ventricular septal defect with transposition. In 72 of 392 group I patients, the septal tricuspid valve leaflet was incised to expose the edges of the hidden ventricular septal defect to accomplish proper anatomic repair. Forty-eight patients had a tricuspid valve pouch, the diagnosis being established by angiography, echocardiography, or at operation. Ages at operation ranged from 5 months to 22 years and the pulmonary-systemic flow ratio ranged from 1 to 3.4, with 16 being less than 1.5. In one patient the pouch produced a 40 mm Hg pressure gradient in the right ventricular outflow tract. At operation, through a transatrial approach, the tricuspid valve pouch was opened radially, the actual ventricular septal defect patched, and the tricuspid valve leaflet repaired. There were no deaths, no significant intraoperative or postoperative morbidity, and no tricuspid valve dysfunction. The average postoperative hospital stay was 4.8 days. In group II, six of 83 patients operated on for transposition with ventricular septal defect had significant left ventricular outflow tract obstruction from the tricuspid valve pouch. Five of six had a Mustard procedure, two requiring a left ventricular-pulmonary artery conduit, and in two of the six the ventricular septal defect was closed through the pulmonary artery. One patient had heart transplantation after a Mustard repair and tricuspid valve replacement. The sixth patient in group II had a successful arterial switch at 9 years of age, after the presence of left ventricular outflow tract obstruction was proved to be due to the pouch. The presence of a tricuspid valve pouch in group I may lead the surgeon to close false small openings produced by the pouch rather than the actual ventricular septal defect. Incising the pouch is safe and essential for proper exposure and secure closure of the true defect. In group II, the systemic right ventricular pressure can push the pouch into the left ventricular outflow tract, causing significant obstruction, and may contribute to tricuspid valve insufficiency after atrial baffle repair. Arterial switch is preferred because it returns the obstructive tricuspid valve pouch and abnormal tricuspid leaflet to the lower pressure pulmonic right ventricle.

Entodermal Inclusion Cyst of the Tricuspid Valve

This is a report on an epithelial inclusion cyst covering the septal leaflet of the tricuspid valve. The tumor was an accidental finding in a 5 1/2 years-old boy with congenital heart disease including double-chambered right ventricle, ventricular and atrial septal defects and subvalvular aortic stenosis. Histological examination showed a two-layered ciliated epithelium, typically present in the respiratory system. Embryologic tissue heterotopia arising from sequestered entodermal elements from the primitive foregut during cardiac organogenesis is a possible explanation for the locality and histology of the tumor. To our knowledge, a similar case has never been presented before.

An association between left axis deviation and an aneurysmal defect in children with a perimembranous ventricular septal defect.

Conspicuous left axis deviation was found in two thirds (27 patients) of 44 children with a perimembranous ventricular septal defect, echocardiographic signs of apposition of the septal tricuspid valve leaflet, and an aneurysm of the membranous septum. In 10 patients earlier electrocardiograms did not show left axis deviation; this feature appeared when the aneurysm of the membranous septum was first seen on the echocardiogram. None of the 44 controls with perimembranous ventricular septal defect but without an aneurysm had left axis deviation. This study suggests that the appearances of conspicuous left axis deviation in a patient with ventricular septal defect indicate a spontaneous reduction in the defect by apposition of the septal tricuspid valve leaflet and by the formation of an aneurysm of the membranous septum.

Two-dimensional and color Doppler assessment of ventricular septal defect of congenital origin

Two-dimensional echocardiography and color Doppler examinations were performed in 53 patients with 58 ventricular septal defects (VSD) proven surgically or anatomically. All patients also had angiocardiograms. Two-dimensional echocardiography/color Doppler examination detected all VSDs and correctly categorized the site and extension of VSDs in 50 of 58 (86%). All 40 perimembranous VSDs were diagnosed in the left ventricular outflow tract short-axis plane as an area of discontinuity adjacent to septal tricuspid valve leaflet attachment. Fourteen of 16 VSDs with inlet extension showed initial color flow signals along the septal tricuspid leaflet and along the ventricular septum. Of 23 perimembranous VSDs with outlet extension, 19 had flow signals moving directly toward the right ventricular outflow tract. One perimembranous VSD with trabecular extension showed flow signals directed anterolaterally toward the right ventricular free wall. Eleven of 13 muscular VSDs were similarly categorized correctly by color Doppler as inlet, outlet and trabecular. All 5 doubly committed VSDs were correctly diagnosed as an area of discontinuity adjacent to the pulmonary valve in the short-axis view with flow signals directly moving through VSD into right ventricular outflow and pulmonary artery. Angiography correctly detected all VSDs and correctly classified their site and extension in 45 of 58 (77.5%). It misclassified 8 of 40 perimembranous, 3 of 13 muscular and 2 of 5 doubly committed VSDs. Color Doppler compares favorably with angiocardiography in the detection and localization of VSDs.

Echocardiographic assessment of the right ventricle in Ebstein's anomaly: Relation to clinical outcome

Two-dimensional echocardiography was performed in 16 patients with Ebstein's anomaly to assess right ventricular anatomy and function in relation to clinical features and prognosis. Measurements of right ventricular anatomy and function were established in 10 normal subjects for comparison. Ten patients were in New York Heart Association functional class I, four in class II and one each in classes III and IV. Right ventricular morphology and the three tricuspid valve leaflets were assessed from right ventricular inflow tract and apical four chamber views. The anterior tricuspid leaflet was abnormal but not displaced in all patients; the septal and posterior leaflets were displaced in 14 (88%) and 11 (69%) patients respectively. The posterior leaflet was best visualized from the right ventricular inflow tract, and in two patients this view was required for the echocardiographic diagnosis of Ebstein's anomaly, based on displacement of the septal tricuspid valve leaflet. An index of right ventricular function, the fractional area contraction, was defined as the difference between the end-diastolic and the end-systolic area, normalized to the end-diastolic area. This index was calculated for both the proximal (atrialized) right ventricle and the total right ventricle. Total right ventricular end-diastolic area and fractional area contraction exceeded 95% confidence limits when compared with values in the normal group. During a median follow-up period of 4 years three patients died. They had severe right heart morphologic or functional abnormalities; two were in functional class III or IV and one was asymptomatic. None of the survivors had severe symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Mitral valve cleft without cardiac septal defect causing severe mitral regurgitation but allowing long survival

Partial atrioventricular “defect” includes a spectrum of 5 anatomic anomalies. Some patients have all 5 and others have only 1 or 2. The 5 are the following: (1) defect in the lower portion of the atrial septum, so-called primum atrial septal defect; (2) defect in, or absence of, the posterobasal portion of ventricular septum; (3) cleft, anterior mitral leaflet; (4) anomalous chordae tendineae from the anterior mitral leaflet to the crest of the ventricular septum; and (5) partial or complete absence of the septal tricuspid valve leaflet. There are at least 4 potential functional consequences of these 5 anatomic anomalies: (1) shunt at the atrial level, (2) shunt at the ventricular level, (3) mitral regurgitation (MR), and (4) obstruction to left ventricular outflow. Well over 95% of patients with partial atrioventricular defect have a primum type atrial septal defect, and most of those without a primum defect have a shunt at the ventricular level. The occurrence of MR from a cleft in the anterior mitral leaflet unassociated with a defect in either atrial or ventricular septa is extremely rare. Such was the case, however, in the patient to be described herein.

“Offsetting” of the septal tricuspid leaflet in normal hearts and in hearts with ebstein's anomaly: Anatomic and echographic correlation

Apical displacement of the septal tricuspid valve leaflet is considered the most reliable criterion to diagnose Ebstein's anomaly. This feature is best assessed using 2-dimensional echocardiography. However, the anatomy in Ebstein's anomaly is highly variable; therefore, the problem arises as to how to distinguish between the abnormal displacement in borderline cases of Ebstein's disease and the lowered septal offsetting of the tricuspid valve in normal persons. To solve this problem the minimal and maximal differences in offsetting of the tricuspid and mitral valves have been studied, both anatomically and echocardiographically, in fetuses, infants, children and adults. In fetuses in the first trimester of pregnancy it was impossible to measure a difference in offsetting of the 2 atrioventricular valves. Thereafter, a gradual increase occurred with age. In normal hearts the most significant separation was usually recorded in anteriorly angulated 4-chamber views, whereas in hearts with Ebstein's anomaly maximal separation appeared to posteriorly angulated views. The anatomic and echographic measurements showed a constant relation. When the minimal distances in offsetting were measured, an overlap was found between cases with and those without Ebstein's anomaly. The maximal values, however, clearly discriminated between the 2 conditions. The critical difference in children was 15 mm, and in adults the discriminating value was 20 mm.

Closure of membranous ventricular septal defect of heart by septal leaflet of tricuspid valve

A case of spontaneous closure of a membranous ventricular septal defect by adhesion of the septal leaflet of the tricuspid valve is reported. There was evidence to suggest that thrombi developed in a pouch formed by the adherent leaflet, giving rise to emboli producing remote and recent infarcts in the brain.

An Unusual Mechanism for a Fistulous Communication Between the Aorta and Right Side of the Heart

A case of infective endocarditis is reported in which a fistulous communication developed from the septal tricuspid valve leaflet, throught the membranous ventricular septum, into the non-coronary aortic cusp. From a nidus of infection in the uterus, the tricuspid valve was seeded, leading eventually to the fistula. The particular course of the perforation avoided conduction system damage until late in the clinical course, when idioventricular rhythm and eventual cardiac arrest supervened.

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.