Septal Leaflet Research Articles

Abstract 13878: A Case of Severe Tricuspid Regurgitation, Recurrent Ascites, Worsening Renal Function Leading to Hemodialysis Secondary to RV Lead Impingement, Resolved Completely With Lead Extraction

Introduction: 1. In contemporary practice, implantation of Cardiovascular Implantable Electronic Devices (CIED) is associated with low complication rate peri-procedurally. 2. However, in some patients these complications can have high morbidity and mortality; namely pneumothorax, pericardial tamponade, pacemaker syndrome, and rarely tricuspid regurgitation (TR) secondary to lead impingement. 3. TR secondary to RV lead impingement is not uncommon but infrequently lead to severe TR and worsening heart failure symptoms. 4. We present a case of severe TR secondary to RV lead impingement leading to splanchnic congestion and recurrent ascites, worsening renal failure leading to hemodialysis (HD), all of which resolved with lead extraction. Case: A 77-year-old woman with known CAD with prior PTCA, paroxysmal AF, and prior watchman implantation, evaluated in our clinic for severe TR. She had recurrent admissions for ascites needing paracentesis. Her liver function and ultrasound was normal. Her renal function worsened and HD was initiated. ECHO showed normal LVEF, severe TR with RVSP of 74mmHg, and mild RV dysfunction. Pericardial physiology was normal. The lead was noted to be impinging on the septal leaflet, and adherent. Normal pulmonary valve function. Follow up: We proceeded to perform RV lead extraction and implanted a new leadless pacemaker [MICRA-AV, Medtronic Inc]. Her follow up ECHO in 2 weeks showed mild TR and normal RV function. RVSP had dropped significantly to 34mmHg. Surprisingly, her needs for paracentesis came down and by 3 months follow up she did not need paracentesis anymore. Her renal function improved, and her HD needs stopped. Conclusions: 1. CIED implantations are associated with low complication rate (less than 5% in total) in most patient cohorts but in some patients it can be associated with significant complications increasing their morbidity and sometimes mortality. 2. Severe TR is a well-recognized complication of pacemaker implantation. It led to recurrent ascites needing paracentesis, ESRD requiring HD and multiple hospital admissions and thus increasing the morbidity. 3. It is important to recognize the uncommon complications of such commonly used intracardiac devices for electrophysiologists, cardiologists and PCPs.

Abstract 13195: A Case of Ebstein Anomaly Diagnosed Following Tricuspid and Pulmonic Valve Infective Endocarditis in an Adult Patient

Background: We present a rare case of infective endocarditis (IE) involving both tricuspid (TV) and pulmonic valves (PV) in the setting of newly diagnosed Ebstein anomaly (EA) with isolated, small membranous VSD. Case: A 48 yo woman with no known medical history presented with two weeks of fever, flu-like symptoms, and dyspnea. Vitals showed fever, tachycardia, and tachypnea. Poor dentition, grade III systolic murmur, and S3 gallop were noted on physical exam. EKG showed sinus tachycardia and right bundle branch block. Laboratory studies showed leukocytosis and elevated CRP. A chest CT revealed bilateral lung infiltrates in a rounded configuration concerning for septic emboli. Blood cultures grew Streptococcus mitis , and IV antibiotics were initiated. TTE revealed 3.2cm apical displacement of the TV resulting in right ventricular atrialization, diagnostic for EA. TTE also found a 26x17mm vegetation on the septal and anterior leaflets of the TV with moderate tricuspid regurgitation and an 11x6mm vegetation on the PV, confirmed by TEE. Cardiac MRI also noted a focal aneurysm of the membranous interventricular septum with a hemodynamically insignificant shunt. Discussion: While interatrial communications are seen in a majority of EA patients (80-94% of cases), this patient presented solely with a small membranous VSD and absence of ASD and PFO. Moreover, this patient had no PDA to depend on for pulmonary flow. Remarkably, she had an asymptomatic course with EA until the development of endocarditis. It is believed the presence of an isolated VSD in this patient’s severe EA likely promoted forward pulmonic flow in an already inadequate right ventricle. Right-sided IE is itself rare (5-10% of cases) with isolated PV involvement being even rarer (2% of cases). This patient’s uncorrected EA with redundant TV and PV leaflet tissue likely contributed as a nidus for simultaneous infection of both valves.

Abstract 10157: A Rare Case of Triple-Valve Endocarditis Managed Surgically

Introduction: Triple-valve endocarditis is an extremely rare condition associated with poor prognosis and limited guidelines regarding its management. We report the unique case of a patient diagnosed with triple-valve endocarditis who underwent successful surgical intervention of all three valves. Case: A 79-year-old male with a history of benign prostatic hyperplasia requiring chronic indwelling urinary catheter presented with progressive dyspnea, lower extremity edema, and fevers. Physical exam was remarkable for a new holosystolic murmur at his right upper sternal border and jugular vein distention. Chest radiograph was consistent with pulmonary edema and cardiomegaly. A transthoracic echocardiogram revealed a large vegetation on his aortic valve with severe aortic regurgitation, moderate mitral and tricuspid valve regurgitation, and normal ejection fraction. Blood and urine cultures grew Enterococcus faecalis and Enterococcus avium , respectively. A transesophageal echocardiogram showed multiple mobile vegetations attached to his aortic valve, and small vegetations involving his mitral and tricuspid valve (Figure 1). He subsequently underwent surgical aortic valve replacement (23-mm Edwards), mitral valve replacement (27-mm Edwards), and repair of the tricuspid valve septal leaflet after excision of a 3 mm vegetation. He was discharged on ceftriaxone and ampicillin to complete 6 weeks of therapy. During his follow up visit 2 months after surgery, patient was feeling well and engaging in physical therapy. Discussion: There is a limited number triple-valve endocarditis by E. Faecalis in the current literature, and this is the first report of a patient successfully managed with three-valve surgery in this setting. We highlight the importance of early recognition and prompt surgical intervention to achieve favorable outcomes in this population.

Abstract 14105: Stent Ahoy: Ventricular Tachycardia Due to Stent Migration Into the Right Ventricle

Case: A 46-year-old female with PMHx of ESRD on dialysis and prothrombin gene mutation presented with acute onset of left breast swelling, redness and pain for nearly 24 hours. She was found to have SVC occlusion and underwent successful SVC recanalization and stent placement with an uncovered 14x40 mm nitinol stent. She presented 4 days later with complaints of chest pain and shortness of breath. Initial vitals were notable for tachypnea with oxygen saturations of nearly 70%, and a blood pressure of 114/71 mmHg. Physical exam demonstrated an obese female in distress. Shortly after arrival in the emergency department, she developed a non-sustained episode of ventricular tachycardia (NSVT). Amiodarone and lidocaine were started, however, she continued to have runs of NSVT. Initial CXR found no acute process but failed to demonstrate the previously placed SVC stent. ECG demonstrated normal sinus rhythm with frequent PVCs and runs of NSVT. A limited echo demonstrated a free edge of an endovascular stent within the right ventricle. TEE demonstrated the stent appeared to be tethered to the septal leaflet of the tricuspid valve with the leading edge free within the right ventricle. Endovascular retrieval was proposed but given the degree of entanglement within the tricuspid leaflets, large stent size, and recurrent NSVT, was deemed an unsuitable therapeutic strategy. Urgent open-heart surgery was performed for removal. The patient tolerated the procedure well and had no further recurrence of NSVT. Discussion: Stent migration is a rare but feared complication of venous stent deployment, with only 32 reported cases over the past 30 years. While NSVT is often attributed to the RVOT, the etiology being the result of migrated stents has been rarely reported. This is the first case to our knowledge of SVC stent migration leading to runs of NSVT. Conclusion: Clinicians must remain cognizant of the risk for venous stent migration and unusual clinical presentations resulting from migration.

Pregnancy outcomes in women with Ebstein's anomaly: data from the EORP Registry of Pregnancy and Cardiac Disease (ROPAC)

Abstract Background Ebstein's anomaly is a rare congenital cardiac condition characterized by displacement of the posterior and septal leaflets of the tricuspid valve towards the apex of the right ventricle. The ESC Guidelines for the management of cardiovascular diseases during pregnancy categorize women with uncomplicated Ebstein's anomaly as modified World Health Organization (mWHO) risk class II. However, data regarding pregnancy outcomes in women with Ebstein's anomaly are scarce. Purpose To evaluate the maternal and perinatal risks of pregnancy in women with Ebstein's anomaly. Methods All patients with Ebstein's anomaly who had been included in the Registry of Pregnancy and Cardiac Disease (ROPAC), which is an international, prospective, observational registry of pregnant women with underlying cardiac disease (n=5739), were evaluated. The primary outcome was the occurrence of a major adverse cardiac event, defined as maternal mortality, heart failure, arrhythmia, thromboembolic events or endocarditis. The secondary outcomes were obstetric and perinatal outcomes and the influence of pregnancy on tricuspid valve regurgitation. Results Thirty-six hospitals in 22 countries enrolled 81 women with Ebstein's anomaly (mean age 29.7 years, 46.9% nulliparous). Seven (8.6%) women had a history of tricuspid valve repair and a further eight (9.9%) of tricuspid replacement. Most women (67.9%) were in NYHA class I. At least one major adverse cardiac event occurred in 8 (9.9%) pregnancies, including heart failure (n=6), supraventricular arrhythmia (n=3) and thromboembolic events (n=2). There was no maternal death. Almost half of the women underwent a Caesarean section (49%) and preterm delivery occurred in 24.7%. Neonatal mortality was 2.5% and four (4.9%) infants had neonatal congenital heart disease. Serial echocardiographic data pre- and postpregnancy were available in 14 women. There was no clear deterioration in tricuspid regurgitation (see Picture 1). Conclusion Although mortality was zero, in 10% of the pregnant women with Ebstein's anomaly a major adverse cardiac event occurred, most frequently heart failure or arrhythmia. Therefore, women with Ebstein's anomaly should be categorized as mWHO risk class II at least, but perhaps more correctly as II–III. Preconception counseling is crucial, so that women are aware of the potential risks of maternal morbidity, preterm delivery and congenital heart disease and the need for careful monitoring during pregnancy. Funding Acknowledgement Type of funding sources: None.

Percutaneous edge-to-edge repair for systemic tricuspid valve regurgitation in patients with congenital heart disease: the first descriptive cohort

Abstract In patients with congenital heart diseases (CHD) systemic tricuspid regurgitation (STR) is frequent. Here, we report our experience with percutaneous edge-to-edge repair (PETER) in a series of 12 CHD patients with STR using the MitraClip system. Twelve patients (median age = 35 years, 83% males) with severe STR (ccTGA (n=5), asTGA (n=3), SV (n=4)), at high-risk for surgical treatment, gave informed consent for treatment using PETER. The XTR MitraClip device (Abbott, Santa Clara, CA) was used. At baseline, 7/12 patients were in NYHA functional class ≥ III. Standard femoral venous access was successfully used in 10/12 patients. In SV patients, the systemic valve was accessed directly through the right atrium (n=2), after a Fontan conduit puncture (n=1), or after direct atrial surgical access (n=1). In TGA patients, either transseptal (ccTGA patients, n=4) or transbaffle (asTGA patients, n=3) puncture was performed (4). Mitraclip devices were successfully implanted in 11/12 patients (Figure 1). One procedural complication was reported for a patient with SV in whom a septal leaflet rupture occurred following clip release, leading to severe STR; the patient died from refractory cardiac failure one week later. Peri-procedural complications included one case of left femoral vein injury and one case of atrial flutter treated by catheter ablation. After a median follow-up of 12-months (range 1–25) following device implantation, no death had occurred. The patients had significant reduction in STR (from severe to moderate in 10/11 patients) and clinically improved (10/11 patients were in NYHA class I or II). To conclude, percutaneous edge-to-edge therapy of STR in CHD patients is feasible, safe and effective to reduce STR and SRV dilatation. This reduction is associated with a significant clinical improvement. Funding Acknowledgement Type of funding sources: None.

Ebstein's anomaly of the tricuspid valve management – the importance of right ventricle assessment

Abstract Background Ebstein's anomaly (EA) is a rare congenital heart disease (CHD) characterized by well known echocardiographic (ECHO) features. The golden standard method for evaluating these patients is cardiac magnetic resonance (CMR) although not easily accessible. The aim of the study was to evaluate the correlation between ECHO and CMR parameters and to determine the optimal parameters for long-term follow-up. Performed was a retrospective cross-section analysis from our registry, which we consider national, as we serve as the only national adult CHD centre. Material and methods Of the 48 patients in the EA national registry, 28 non-operated adults (60% male, median age 39 (18–64) years) with performed CMR were included. Analyzed were ECHO and CMR right ventricular (RV) characteristics, NTproBNP and 6-minute walking distance (6MWD). ECHO parameters were evaluated as follows: 1. morphometric [tricuspid valve septal cusp displacement (mm), long-axis RV end-diastolic dimension (RVEDD,mm), long-axis end-diastolic right to left ventricle diameter ratio (RV/LV)] and 2. functional [tricuspid annular plane systolic excursion (TAPSE,mm), RV fractional area change (FAC,%), RV tissue Doppler myocardial velocity (m/s)]. CMR-derived analyzed paramaters were: ejection fraction (EF,%) and end-diastolic volume (EDV,ml) indexed per body surface area (BSA,m2). According to CMR-derived EDV, patients were divided into groups: 1. normal size RV (55–105ml/m2), 2. dilated RV (>105ml/m2) and 3. small RV (<55ml/m2). Results For ECHO morphometric measurements, Spearman's correlation (R) showed strong, statistically significant correlation of CMR-derived EDV with ECHO-based RV/LV ratio (R=0.6989, P<0.0001); and moderate, statistically significant correlation with ECHO-based RVEDD (R=0.55, P=0.004); No significant correlations between CMR-derived EF and ECHO parameters were found. CMR-derived EF and EDV were independent of the severity of septal leaflet displacement; CMR-derived EF was shown to be conditional to RV EDV, with mean EF in Groups 1/2/3 as follows: 57%/36.5%/25.8% (P=0.0013). CMR-derived Group 3 (small RV) compared to Groups 1 and 2 exhibited worst 6MWD (mean 416m) and highest NTproBNP (mean 1021ng/l) though without statistical significance. Conclusions The assessment of RV in EA seems more critical than the morphology of the tricuspid valve itself. Therefore, as in the context of our results, more emphasis needs to be placed on RV size. In particular, small-capacity RV, as we found, showed strong relation to reduced RV function and some (though not significant) to NTproBNP and 6MWD. CMR-derived EDV and EF are accepted as the gold standard method for RV evaluation. Since we detected significant correlation of CMR with simply gained ECHO parameters (RV/LV ratio and RVEDD), we assume that easily accessible ECHO remains a pertinent method in routine follow-up, able to reflect the complex hemodynamic situation in EA. Funding Acknowledgement Type of funding sources: None.

SYMMETRIC LEAFLET EXPANSION WITH MILD PROGRESSIVE LEAFLET TETHERING IS A NORMAL DEVELOPMENTAL FEATURE OF TRICUSPID VALVE MATURATION DURING YOUTH: A QUANTITATIVE THREE-DIMENSIONAL ECHOCARDIOGRAPHY (3DE) STUDY

SYMMETRIC LEAFLET EXPANSION WITH MILD PROGRESSIVE LEAFLET TETHERING IS A NORMAL DEVELOPMENTAL FEATURE OF TRICUSPID VALVE MATURATION DURING YOUTH: A QUANTITATIVE THREE-DIMENSIONAL ECHOCARDIOGRAPHY (3DE) STUDY

Tricuspid Valve Blood Cysts Mimicking Thrombus or Vegetation on Echocardiogram in a Neonate.

A 2-month-old male infant, born premature with a birth weight of 865g, was found to have a tricuspid valve mass mimicking thrombus and vegetation by echocardiogram on the fourth day of life. The patient was treated with antibiotics and anticoagulation with no change in the size of the mass on serial follow-up echocardiography. The patient died of severe pulmonary vein stenosis and complex neurological disability. Postmortem cardiac examination revealed numerous cardiac blood cysts with two dominant ones (1.6 and 1.5mm) on the septal leaflet of the tricuspid valve, which based on the location and position corresponded to the suspected vegetation and thrombus on imaging. Cardiac blood cysts on valve leaflets are a common incidental finding during autopsy within the first 6months of life; however, they are rarely detected on imaging because of their minute size, often < 0.5mm. In this case, the sizable blood cysts were thought to represent thrombus or vegetation on echocardiogram, which influenced the patient management.

Multimodality Imaging in Ebstein Anomaly.

Ebstein anomaly is the most common form of tricuspid valve congenital anomalies. The tricuspid valve is abnormal with different degrees of displacement of the septal leaflet and abnormal rotation of the valve towards the right ventricular outflow tract. In severe forms, it results in significant tricuspid regurgitation and requires surgical repair. There is an increased interest in understanding the anatomy of the tricuspid valve in this lesion as the surgical repair has evolved with the invention and wide adoption of the cone operation. Multimodality imaging plays an important role in diagnosis, follow-up, surgical planning and post-operative care. This review provides anatomical tips for the cardiac imagers caring for patients with Ebstein anomaly and will help provide image-based personalized medicine.

Benchtop characterization of the tricuspid valve leaflet pre-strains

The pre-strains of biological soft tissues are important when relating their in vitro and in vivo mechanical behaviors. In this study, we present the first-of-its-kind experimental characterization of the tricuspid valve leaflet pre-strains. We use 3D photogrammetry and the reproducing kernel method to calculate the pre-strains within the central 10×10 mm region of the tricuspid valve leaflets from n=8 porcine hearts. In agreement with previous pre-strain studies for heart valve leaflets, our results show that all the three tricuspid valve leaflets shrink after being explanted from the ex vivo heart. These calculated strains are leaflet-specific and the septal leaflet experiences the most compressive changes. Furthermore, the strains observed after dissection of the central 10×10 mm region of the leaflet are smaller than when the valve is explanted, suggesting that our computed pre-strains are mainly due to the release of in situ annulus and chordae connections. The leaflets are then mounted on a biaxial testing device and preconditioned using force-controlled equibiaxial loading. We show that the employed preconditioning protocol does not 100% restore the leaflet pre-strains as removed during tissue dissection, and future studies are warranted to explore alternative preconditioning methods. Finally, we compare the calculated biomechanically oriented metrics considering five stress-free reference configurations. Interestingly, the radial tissue stretches and material anisotropies are significantly smaller compared to the post-preconditioning configuration. Extensions of this work can further explore the role of this unique leaflet-specific leaflet pre-strains on in vivo valve behavior via high-fidelity in-silico models. Statement of significanceThis study provides a first of its kind benchtop characterization of tricuspid valve leaflet pre-strains. We used 3D photogrammetry to reconstruct the central region of the tricuspid valve leaflets in three configurations. The associated configurational changes revealed compressive, leaflet-specific strains after dissection of the valve from its in situ environment. Interestingly, we found that biaxial preconditioning did not restore the measured pre-strains of the leaflets. Depending on the selection of the stress-free reference configuration, this led to substantial differences in the leaflet mechanics. Our findings and methodology are crucial when it comes to relating in vitro mechanical behaviors to valve function in vivo. Future studies can integrate our quantified pre-strains into in-silico simulations to get more realistic predictions about the valve function.

Combination of the Modified Loop Technique and De Vega Annuloplasty in Dogs with Mitral Regurgitation.

Simple SummaryDogs, like humans, may develop valvular disease, which is particularly common in older, small-sized dogs and is one of the most common causes of canine death. Canine valvular disease generally has a good prognosis. However, approximately 30% of dogs develop congestive heart failure, particularly when the mitral valve is affected, and most dogs with severe congestive heart failure die within a year of pulmonary edema. Although cardiac surgery with extracorporeal circulation can be performed in dogs and can significantly prolong survival, the dogs’ small size is challenging from a surgical perspective, and the success rate depends on the surgeon’s skill. Mitral valve repair in dogs involves suturing cardiac tendons using polytetrafluoroethylene sutures, which are slippery and difficult to ligate at the targeted length. Moreover, the appropriate length of the artificial tendon in dogs has not been determined. The mitral annulus surrounding the mitral valve also needs to be stitched down, but the amount that should be stitched down in dogs is not known because prosthetic valve rings were not manufactured for dogs. Due to the lack of reports detailing surgical procedures in dogs, we describe in detail a surgical technique for canine mitral valve repair.Background: Detailed surgical techniques for treating canine mitral regurgitation have not been previously reported. Method: This case series included six consecutive client-owned dogs with mitral regurgitation. All dogs underwent a combined protocol, including the modified loop technique and De Vega annuloplasty (MODEL surgery), in 2021. Artificial loops covering 80% of the length of the strut chordae tendineae were used for chordal replacement. Mitral annuloplasty was subjectively performed, targeting the circumference of the septal leaflet. Results: The breeds were Chihuahua-mixed breed, Spitz, Pomeranian, Cavalier King Charles Spaniel, and Chihuahua, with average ages and weights of 11.4 ± 2.3 years and 5.49 ± 2.98 kg, respectively. The aortic cross-clamp, pumping, and surgery times were 64.0 ± 7.5 min, 168.5 ± 39.1 min, and 321.0 ± 53.1 min, respectively. After MODEL surgery, left atrial-to-aortic ratios significantly decreased from 2.20 ± 0.18 to 1.26 ± 0.22 (p < 0.01), and left ventricular end-diastolic internal diameter normalized to body weight significantly decreased from 2.03 ± 0.26 to 1.48 ± 0.20 (p < 0.01). In all cases, the clinical signs disappeared or improved significantly. Conclusions: MODEL surgery increased mitral valve coaptation, normalized heart sizes, and significantly improved clinical signs in dogs with mitral regurgitation.

Ebstein's Anomaly between Valve Damage and Cardiac Arrhythmia

Ebstein’s anomaly (E.A) is a congenital malformation that represents less than 1% of all congenital heart disease. They are predisposed to arrhythmias because of abnormal cardiac anatomy. We report the case of a 60-year-old female with a history of early infancy diagnosis of E.A, admitted for tachycardia with wide QRS complex. An electrophysiology study revealed an atrial rhythm and programmed atrial stimulation induced atrial tachycardia identical to the clinical tachycardia with multiple circuits. Radiofrequency ablation was not performed because of technical difficulties. At two months follow-up, the patient’s cardiac condition worsened and echocardiography revealed worsening tricuspid regurgitation. She underwent surgical repair. The postoperative course was uneventful. The diagnosis of this anomaly is mainly made by transthoracic echocardiogram, which constitutes the cornerstone of imaging examinations. Diagnosis is made when there is an apical displacement of the tricuspid septal leaflets past 8mm/m². Cardiac arrhythmias are frequent with Ebstein malformation; sudden death and accessory pathway fast-conducting AV with anterograde and retrograde conduction are commonly described in most patients. While, wide-QRS tachycardia, ventricular tachycardia (VT), or flutter through the para-septal pathway may occur. The management of tachyarrhythmias associated with E.A remains a real challenge. Even if it can be difficult given the atrial dilatation, electrophysiological exploration with possible radiofrequency ablation of symptomatic supraventricular tachyarrhythmias remains necessary. Otherwise, supraventricular tachyarrhythmia in E.A, can also be ablated surgically.

Neonatal ventricular assist device implantation for high-risk hypoplastic left heart syndrome: How we do it.

Neonatal ventricular assist device implantation for high-risk hypoplastic left heart syndrome: How we do it.

Assessment of ventricular septal defects by real-time three-dimensional echocardiography and comparison with surgical measurements

BackgroundThree-dimensional (3D) echocardiography has facilitated evaluation of a ventricular septal defect (VSD) with its true dimensions and exact localization and improved identification of various anatomical characteristics in different types of VSDs. ObjectivesWe aimed at investigating the feasibility of 3D echocardiography in assessing VSDs in comparison to two-dimensional (2D) echocardiography. MethodsWe employed both 2D and 3D echocardiography for measuring the longest diameter of VSD. The morphology, number, and size of the defect as well as its relation and distance to the tricuspid and aortic valves were analyzed by 3D echocardiography displaying the VSD from the right ventricular aspect. The size was defined in terms of maximum area, long and short axis diameters at end-diastole. The longest diameters of VSDs were compared with 2D and 3D echocardiography data in all patients as well as with the intra-operative findings in 17 patients. ResultsThe mean diameters of end-diastolic VSDs measured by 3D echocardiography from the right ventricular aspect were significantly larger than those obtained by 2D echocardiography (15.6 ± 8.2 vs 10 ± 4.2 mm, P = .02), however, there was a good correlation between them (r = 0.73, P < .001). 3D echocardiography proved to be superior to 2D echocardiography for visualizing the shape of VSD and for measuring tissue rims from the aortic and tricuspid valves. The advantage was prominent in particular for viewing defects hidden by a ventricular septal aneurysm or a tricuspid septal leaflet, which can be erased digitally to reveal the VSD underneath. The dimensions of VSDs obtained by 3D echocardiography (r = 0.85, P < .001) correlated significantly better with actual dimensions revealed during surgery as compared to those obtained by 2D echocardiography (r = 0.53, P = .03). ConclusionsThe study demonstrated that 3D echocardiography provides more reliable information from both qualitative and quantitative aspects regarding the morphology, size, and tissue rims of VSD compared to 2D views.

Preexcitation with Multiple Accessory Pathways as a First Presentation of Undiagnosed Late Stage Ebstein’s Anomaly in an Adult

Ebstein’s anomaly (EA) is a relatively rare congenital heart disease that has long been a challenge both to cardiac surgeons and electrophysiologists. In addition to the hemodynamic burden of the tricuspid valve defect itself, the electrocardiogram (ECG) is abnormal in most cases with a high incidence of tachyarrhythmias, that can often be imputable to accessory atrioventricular pathways mostly located along the tricuspid posterior and septal valve leaflets, and rarely, to multiple accessory pathways. We here report the case of a 19-year-old girl with no known cardiac history, in whom a late stage EA with Eisenmenger syndrome, was diagnosed following a syncopal episode attributed to preexcited atrial tachy-fibrillation with an aspect consistant with multiple accessory pathways with at least one of them being right postero-septal. The patient’s management was very challenging for the heart team considering the fixed pulmonary hypertension and the fact she was reluctant to catheter ablation. This case report underlines the importance of early diagnosis and treatment of EA and its rhythmic complications and explores the anatomic peculiarities of this disease with attention to features that could be important to both arrhythmogenesis and ablation therapy in this unique population.

Leaflet-to-annulus index and residual tricuspid regurgitation following tricuspid transcatheter edge-to-edge repair.

A mismatch between tricuspid leaflet size and annular dilation is one of the morphological features tied to the development of tricuspid regurgitation (TR). We assessed the association of the leaflet-to-annulus index (LAI) with residual TR after transcatheter edge-to-edge repair (TEER). Consecutive patients who underwent TEER for TR were enrolled. Significant residual TR was defined as a post-procedural TR ≥3+, and patients were divided into two groups according to the amount of residual TR. The LAI was retrospectively calculated using procedural transoesophageal echocardiography and was defined as follows: (anterior leaflet length+septal leaflet length)/septolateral tricuspid annulus diameter. Of 140 patients, 43 patients had residual TR ≥3+ after TEER. The patients with residual TR ≥3+ had a lower LAI compared to those with residual TR <3+ (1.04±0.10 vs 1.13±0.09; p=0.001). In multivariable analysis, the LAI was associated with residual TR ≥3+ (odds ratio [OR] [per 0.1 increase]: 0.57; 95% confidence interval [95% CI]: 0.35-0.94; p=0.02), independent of baseline TR severity or coaptation gap size. Patients with residual TR ≥3+ had a higher incidence of the composite outcome, consisting of all-cause mortality and heart failure hospitalisation within one year after TEER (47.1% vs 26.6%, p=0.02). Residual TR ≥3+ was an independent predictor of the composite outcome within one year (hazard ratio: 2.04; 95% CI: 1.01-4.11; p=0.04). The leaflet-to-annulus mismatch (i.e., LAI) is associated with residual TR ≥3+ after TEER for TR. A detailed echocardiographic analysis of the tricuspid valve will be conducive to identifing suitable subjects for TEER.

Percutaneous Edge To Edge Repair for the treatment of severe Tricuspid valve Regurgitation in high-surgical risk patients with Systemic Right Ventricle: A Multicentric French Cohort (PETER TRESRIV)

Patients with systemic right ventricle (SRV) (mostly congenitally-corrected transposition of thegreat arteries or transposition of the great arteries corrected by atrial switch) commonly developsignificant systemic tricuspid valve regurgitation and systemic right ventricular dysfunction inadulthood, both of which being a therapeutic dilemma for the care team. Until recently, the onlytherapeutic option has been surgery but the rate of complications is high. Percutaneous edge to edgerepair could be an alternative, especially for high-surgical risk patients. To describe clinical and paraclinical follow up of high-surgical risk patients with SRV and severe TR undergoing PETER. 10 high-risk surgical patients with severe systemic tricuspid regurgitation (TR) undergoing apercutaneous repair with the Mitraclip or Triclip system (Abbott) were included between May 2019and October 2021. We collected and compared clinical (symptoms, quality of life questionnaires), biological (renal function, BNP/ntproBNP levels), VO2 max testing, echocardiographic, and crosssectionnalimaging (tricuspid regurgitation severity, right ventricle dilatation and dysfunction) dataat baseline and 6 months after the procedure. We report a percutaneous implant success of 80%, one early death due to septal leaflet tear and 2early common flutters successfully ablated. Clinically, we describe a median improvement after 6months of functional status as well as physical (+10,3 points) and mental (+12,2 points) quality oflife scores. Biologically, BNP and ntproBNP median blood levels decreased (respectively of 162and 178 μmol/L). VO2 max testing parameters did not change significantly. TTE TR severityparameters EROA and regurgitation volume improved of respectively 20 mm 2 and 11 mL while MRIor TDM SRV volumes decreased in median of 25 ml/m 2 for diastolic and 22 ml/m 2 for systolicvolume, with an increase in RVEF of 18,5%. Percutaneous edge to edge repair of systemic tricuspid regurgitation might be a safe and effectivetherapeutic option in high-risk surgical adult patients.

Mechanistic Insights into Tricuspid Regurgitation Secondary to Pulmonary Arterial Hypertension

The simultaneous presence of pulmonary arterial hypertension (PAH) and secondary tricuspid regurgitation (STR) portends particularly poor outcomes. However, not all patients with PAH develop significant STR, and the mechanisms and clinical implications underlying this phenomenon remain unclear. We sought to describe the functional, anatomic, hemodynamic, and clinical characteristics of patients with PAH with and without STR. Patients diagnosed with PAH between 2007 and 2013 were included. STR, defined by absent primary tricuspid valve disease on transthoracic echocardiogram, was considered significant if ≥ moderate in severity. The characteristics of right-sided chambers and tricuspid valve annuli and leaflets were compared between patients with significant versus nonsignificant STR using a transthoracic echocardiogram, cardiac computed tomography, and right-sided cardiac catheterization. These features were then correlated with the composite outcome of all-cause mortality and PAH hospitalization. Of 88 included patients, 52 had significant STR. No baseline clinical differences, including atrial fibrillation, were observed. Patients with significant STR had worse right ventricular dysfunction (tricuspid annular planar systolic excursion=1.5 vs 2.1 cm; p=0.02) and increased right ventricular sphericity (sphericity index=1.8 vs 2; p=0.004), with similar annular dimensions/shape, lengths/angles of the mural and septal leaflets, and tenting height. After a median of 54 months, right atrial mean pressure was independently associated with the composite outcome on multivariable analysis (hazard ratio=1.07, p=0.02). In conclusion, anatomic and functional alterations in the right ventricle rather than the tricuspid valve are implicated in developing significant STR in PAH. Multimodality imaging provides mechanistic insight, and hemodynamic assessment may offer prognostic guidance in this population.

Composite reconstruction of right ventricle and tricuspid valve for cardiac angiosarcoma

Composite reconstruction of right ventricle and tricuspid valve for cardiac angiosarcoma