Significant Tricuspid Valve Regurgitation Research Articles

Unloading of right ventricle by bidirectional superior cavopulmonary anastomosis in hypoplastic left heart syndrome patients promotes remodeling of systemic right ventricle but does not improve tricuspid regurgitation

To evaluate the influence of volume unloading by bidirectional superior cavopulmonary anastomosis on the systemic right ventricle in patients with hypoplastic left heart syndrome. A total of 90 consecutive patients with hypoplastic left heart syndrome, who had survived the early postoperative period after bidirectional superior cavopulmonary anastomosis, were studied. Seven patients were excluded because of tricuspid valve surgery before or in association with bidirectional superior cavopulmonary anastomosis. The echocardiograms of the remaining 83 patients were reevaluated for tricuspid valve regurgitation and the size of the tricuspid annulus before bidirectional superior cavopulmonary anastomosis and at the last available follow-up examination before total cavopulmonary connection. Echocardiograms were performed a median of 5 days before bidirectional superior cavopulmonary anastomosis. Tricuspid valve regurgitation was graded as 0 in 11 patients, I in 37 patients, II in 24 patients, and III in 11 patients. Follow-up echocardiograms were performed a median of 17 months after bidirectional superior cavopulmonary anastomosis. Postoperatively, tricuspid valve regurgitation was graded as 0 in 14 patients, I in 37 patients, II in 21 patients, III in 6 patients, and IV in 5 patients. Postoperatively, the mean Z value of the tricuspid annulus stayed the same in patients with significant tricuspid valve regurgitation (grade III or IV) after bidirectional superior cavopulmonary anastomosis but had decreased in the remaining patients. No significant change was seen in the level of tricuspid valve regurgitation after bidirectional superior cavopulmonary anastomosis compared with the preoperative data. The relative size of the tricuspid annulus in patients with hypoplastic left heart syndrome decreases after bidirectional superior cavopulmonary anastomosis, most likely owing to volume unloading and promotion of the remodeling of the systemic right ventricle. However, this remodeling of the right ventricle does not improve the grade of tricuspid regurgitation.

Tricuspid valve regurgitation after orthotopic heart transplantation: prevalence and etiology.

Background. Tricuspid valve regurgitation (TR) after orthotopic heart transplantation (OHT) is common. The aims of this study were to determine the prevalence of TR after OHT, to examine the correlation between its development and various variables, and to determine its outcomes. Methods. All 163 OHT patients who were followed up between 1988 and 2009 for a minimal period of 12 months were divided into those with no TR/mild TR and those with at least mild-moderate TR, as assessed by doppler echocardiography. These groups were compared regarding preoperative hemodynamic variables, surgical technique employed, number of endomyocardial biopsies, number of acute cellular rejections, incidence of graft vasculopathy, and clinical outcomes. Results. At the end of the followup (average 8.2 years) significant TR was evident in 14.1% of the patients. The development of late TR was found by univariate, but not multivariate, analysis to be significantly correlated with the biatrial surgical technique (P < 0.01) and the presence of graft vasculopathy (P < 0.001). TR development was found to be correlated with the need for tricuspid valve surgery but not with an increased mortality. Conclusions. The development of TR after OHT may be related to the biatrial anastomosis technique and to graft vasculopathy.

Impact of Tricuspid Valve Regurgitation in Patients Treated With Implantable Left Ventricular Assist Devices

The progression of tricuspid valve regurgitation (TR) and the impact of preoperative TR on postoperative outcomes in patients having left ventricular assist device (LVAD) implantation has not been studied. One hundred seventy-six consecutive implantable LVAD procedures were retrospectively reviewed. A total of 137 patients comprised the final study group with complete preimplant characteristics, before and after echocardiogram assessment of TR, and outcomes data. Patients were divided into two groups: insignificant TR (iTR) consisting of those with preimplant TR grades of none, trace, and mild; and significant TR (sTR) consisting of those with moderate and severe TR grades. Relative to patients with iTR, patients with sTR were younger (53.6±12.8 versus 58.4±10.0 years, p=0.02) and more commonly had nonischemic cardiomyopathies (69% versus 38%, p<0.001). The preimplant incidence of iTR and sTR was 51% and 49%. Immediately after the LVAD implant procedure, TR did not significantly change. At late follow-up (156±272 days), 32% had moderate or severe TR. Also, 41% of the original sTR group persisted with moderate or severe TR. Relative to patients with iTR, patients with sTR required longer postimplant intravenous inotropic support (8.5 versus 5.0 days, p=0.02), more commonly required a temporary right ventricular assist device, and had a longer postimplant length of hospital stay (27.0 versus 20.0 days, p=0.03). There was also a trend toward decreased survival for sTR versus iTR (log rank=0.05). Tricuspid regurgitation is not reduced immediately after LVAD implantation. Significant TR is associated with longer postimplant inotropic support and length of hospital stay.

Evaluation of pulmonary arterial hypertension: invasive or noninvasive?

In medical research animal models have demonstrated their value in elucidating (1) mechanisms of disease, (2) factors implicated in morbidity and mortality of the disease, and (3) new therapeutic avenues to treat the disease. For acute as well as chronic diseases, models for translational medicine have been developed and applied with great benefit. The use of experimental animals should comply with both the Animal Welfare Act and the Guide for the Care and Use of Laboratory Animals in which researchers demonstrate that they have carefully considered the three R’s of animal testing alternatives: (1) Reduction of the numbers of animals used, (2) Refinement of techniques and procedures to reduce pain and distress, and (3) Replacement of animals by other models than living animals. Particularly the condition to reduce the number of animals necessary to test a hypothesis is difficult to meet, but the use of animal models and techniques that allow longitudinal measurements from the same animals may lead to a wealth of data from a limited number of animals. In translational research of cardiovascular disease the use of echocardiography allows longitudinal studies of natural history and therapeutic success. In the current issue of the International Journal of Cardiovascular Imaging, Koskenvuo and coworkers [1] used echocardiography in a rat model of monocrotaline-induced pulmonary arterial hypertension (PAH). The authors evaluated whether invasive measurements of blood pressures, vascular resistances, right ventricular (RV) wall thickness and RV cavity size could be replaced accurately by corresponding echocardiographic measurements. The authors succeeded to acquire echocardiographic images that produced parameters of PAH with low ( 25 mmHg, the authors found a sensitivity of 86.4%, a specificity of 97.6%, a positive predictive value of 92.3%, and a negative predictive value of 93.8%. At day 21, noninvasive assessment of PAH demonstrated large differences between invasively measured systolic PAP and echocardiographically assessed systolic PAP (39.5 ± 15.5 and 66.4 ± 18.8 mmHg, respectively) and between invasively measured total pulmonary vascular resistance (TPVR) and echocardiographically assessed TPVR (3.5 ± 2.3 and 7.7 ± 2.8 104*dyn.s.cm−5). The authors held these large differences responsible to the absence of significant tricuspid valve regurgitation (TR) jet in several rats with developing PAH. This seems a very likely explanation as at day 35 both invasively measured systolic PAP and TPVR approached echocardiographically assessed systolic PAP and TPVR much better. Of note, TPVR has not previously been studied in rodents using echocardiography. It was concluded that the use of non-invasive parameters may replace invasive measurements in detecting successful disease induction and to complement invasive data in the evaluation of PAH severity in a rat model. The difficulty of performing invasive measurements in animals with advanced PAH is an important limitation of all invasive parameters and underscores the importance of innovative noninvasive measurements. The highly vulnerable status of the RV and more generally of the heart in rats with severe PAH often hampers extensive characterization of RV function with the pressure-conductance catheter as we have experienced ourselves [2–4]. As a result, echocardiography may have a specific new role in evaluating PAH. The main disadvantage of electrocardiographic assessment of PAH is to accurately assess the functional characteristics of RV. In the present study, in 13 out of 75 (17%) studies no adequate echocardiographic RV measurements could be performed. Generally, assessment of the RV is cumbersome by echocardiography due to limited acoustic window and the abnormal shape of the RV [5–16]. These limitations might be to a certain extent overcome by using transesophageal or 3D-echocardiography [17–21], but magnetic resonance imaging often provides a better visualization of the RV, allowing improved quantification [22–33]. In the current study [1], however, it was clearly shown that employment of echocardiography in animals allows assessment of in vivo RV function without additional harm to the animals. In addition, echocardiography enabled longitudinal measurements thereby lowering the number of animals included in the study. Knowledge and experience in echocardiography of small rodents, so elegantly shown by the authors, is hard to acquire but this is certainly the way to go in future translational research of chronic cardiovascular diseases.

A chronic compression of the upper mediastinal veins by a retrosternal goiter

We present images of chronic venous compression by a retrosternal goiter in a 77-year-old female. The woman was sent to our department for echocardiographic evaluation due to increasing dyspnea and gradual decrease in physical activity tolerance. On physical examination, enlarged tortuous superficial veins were seen on the upper part of the thorax (Panel A, arrows). Echocardiography revealed enlargement of the right ventricle and the right atrium, and significant tricuspid valve regurgitation. Subsequent computed tomographic angiography of the chest revealed a severely enlarged thyroid gland with calcifications. The lower parts of both thyroid lobes were located within the anterior mediastinum down to the manubrium. The brachiocephalic trunk, common carotid arteries, and subclavian arteries were dislocated posteriorly by the goiter. The right brachiocephalic vein was visualized only up to 6 cm from the superior vena cava. The right brachiocephalic vein was compressed adjacent to the anterolateral surface of the goiter (Panel B, arrow 1), and the left subclavian vein was also compressed (Panel B, arrow 2). A network of prominent superficial venous collaterals was visualized, which corresponded to her examination findings (Panel B, arrow 3; Panel C, arrow). The patient refused surgical treatment and was treated with levothyroxine and diuretics with some improvement in her symptoms. She remains a patient of the Endocrinology Clinic. Retrosternal goiter is an unusual cause of venous compression or occlusion. 1 A slowly growing goiter allows for development of sufficient venous collateral circulation, often without the presence of venous congestion. Congestion might be demonstrated with elevation of the

Transient tricuspid valve regurgitation following surgical treatment of cor triatriatum dexter in a dog

Echocardiographically documented tricuspid valve regurgitation appeared immediately after surgical treatment of cor triatriatum dexter in a two-month-old rottweiler. Medical treatment was instituted with benazepril, spironolactone and furosemide. Pimobendan was added after five months, and all treatment was discontinued two months later when clinical signs of ascites and hepatomegaly had resolved and tricuspid valve regurgitation was markedly reduced on echocardiography. To the authors' knowledge, this is the first report describing the development and spontaneous improvement of haemodynamically significant tricuspid valve regurgitation following surgical treatment of cor triatriatum dexter in a dog. It is hypothesised that the increase in right atrial volume and pressure following cor triatriatum dexter repair and transient ischaemia of papillary muscles led to dilatation of the right atrioventricular annulus and subsequent severe tricuspid valve regurgitation in the face of an anatomically normal valve. Time and pharmacological preload reduction as well as normalisation of right atrial inflow and subsequent cardiac remodelling substantially reduced tricuspid valve regurgitation and eliminated clinical signs of heart failure. It is also possible that heart recovery has been spontaneous.

Tricuspid Valve Chordal Tissue in Endomyocardial Biopsy Specimens of Patients With Significant Tricuspid Regurgitation

Tricuspid regurgitation is the most common valvular abnormality after orthotopic heart transplantation, with multiple etiologic factors implicated. The purpose of this study was to determine if the endomyocardial biopsy specimens of patients who developed significant tricuspid valve regurgitation (TVR) after cardiac transplantation had evidence of chordal tissue. The echocardiograms of 98 patients who had cardiac transplantation between 1986 and 2002 were reviewed for evidence of significant TVR greater than mild. The biopsy specimens of all patients with significant TVR were then reviewed for histologic evidence of tricuspid chordal tissue and frequency and severity of rejection episodes. Clinical information collected included the presence of any systolic murmurs, significant dyspnea, and invasive hemodynamic measurements. The incidence of significant TVR was 19% (n = 19 patients). Histologic evidence of chordal tissue was present in 9 patients (47%) with significant TVR. Patients whose biopsy specimens evidenced chordal tissue tended to have a greater degree of TVR, but this was not statistically significant (odds ratio, 2.07; 95% confidence interval, 0.537-8.01, p = 0.32). There was no statistically significant difference in the number of biopsy specimens (p = 0.798), the number of rejection episodes (p = 0.73), or overall left or right ventricular systolic function between the patients with and without biopsy specimen evidence of chordal tissue disruption. Most of the patients with evidence of significant TVR after chordal tissue biopsy were clinically asymptomatic, with no significant change in their hemodynamics. Histologic evidence of chordal tissue in endomyocardial biopsy specimens was present in 47% of patients with significant TVR and did not relate to the number of biopsy procedures performed or the frequency of rejection episodes. This study provides histologic evidence that chordal tissue damage can occur after cardiac biopsy, resulting in significant TVR; however, it is clinically well tolerated by affected patients.

Noncompacted myocardium in ebstein's anomaly: initial description in three patients

Exercise intolerance in Ebstein's anomaly is usually attributed to desaturation secondary to right-to-left shunting as a result of a small or distorted left ventricle (LV), significant tricuspid valve regurgitation, right ventricular dysfunction, or a combination of these. We observed one boy (age 15 years) and two women (ages 20 and 29 years) with severe Ebstein's anomaly and strikingly abnormal LV myocardium resembling the features described for LV noncompaction. LV size and systolic function were normal in the two women; the boy had a dilated LV with severely diminished ejection fraction. The LV myocardium was found to be unusually coarse and hypertrabeculated, with small intertrabecular recesses and an irregular endocardial surface. The findings in these 3 patients represent the whole spectrum of mild to severe LV noncompaction. Diastolic dysfunction was present in 2 of the 3 patients. Exercise tolerance was diminished in all. There was no mitral or aortic valve disease. The 15-year-old boy underwent heart transplantation 6 months later for biventricular failure. Thus, Ebstein's anomaly does not seem to be a pathology confined to the right ventricle, but may rarely lead to LV noncompacted myocardium. This LV pathology may be an additional explanation for exercise intolerance or signs of left heart failure in patients with Ebstein's anomaly.

Prenatal Ultrasound May Predict Fetal Response to Therapy in Non-Hydropic Fetuses with Supraventricular Tachycardia

Objective: To study the fetal response to prenatal therapy in non-hydropic fetuses with supraventricular tachycardia (SVT) as a function of fetal haemodynamic status at presentation. Study Design: Retrospective study. Material and Methods: Between 1990 and 2000, 40 non-hydropic fetuses presented with SVT. Twenty-eight had reciprocating SVT and 12 had atrial flutter. Ten fetuses had significant tricuspid valve regurgitation. All fetuses were treated prenatally. The main outcome measurement was fetal response to therapy as assessed by the rate of prenatal SVT reduction and by the mean time interval to sinus rhythm restoration. Results: The mean gestational age at presentation was 29 ± 4.9 weeks. Overall, there were 39 liveborns and 1 intrauterine death. Reduction of SVT was achieved prenatally in 32 cases (80%). Among the 30 cases without tricuspid regurgitation, prenatal conversion to sinus rhythm was achieved in 27 cases (90%) with a mean time interval of 7 days. Among the 10 fetuses presenting with tricuspid regurgitation, the rate of prenatal conversion was significantly lower (5/10) and the mean time interval to conversion was significantly longer (24 days; p = 0.04, Mann-Whitney test). In the subgroup treated by digoxin as first-line therapy (n = 32), the interval to sinus rhythm restoration was also significantly higher in the presence of tricuspid regurgitation, with a slightly but not significantly lower reduction rate. Conclusion: The response to prenatal therapy may be poorer in cases presenting with tricuspid regurgitation.

De Vega tricuspid annuloplasty for tricuspid regurgitation in children

Background. Significant tricuspid valve regurgitation (TR) occurs with other congenital heart defects, typically after repair of right-sided obstructive lesions. Since 1991, we applied the De Vega tricuspid annuloplasty technique for TR in children. Methods. Forty-one children, aged 5 months to 22.7 years (mean, 9.9 years) underwent 42 De Vega tricuspid annuloplasties for moderate or severe TR during correction of other heart defects. One child had a De Vega during primary ventricular septal defect repair. The remaining patients had prior repair of tetralogy of Fallot or pulmonary atresia, or both (19 patients), double-outlet right ventricle (6 patients), pulmonary stenosis (4 patients), pulmonary atresia and intact ventricular septum (3 patients), complete atrioventricular septal defect (3 patients), and other diagnoses (6 patients). At the time of the De Vega, 37 patients (88%) had pulmonary valve replacement or right ventricular to pulmonary artery conduit replacement. Other procedures included aortic or mitral repair or replacement (6 patients), atrial septal defect and ventricular septal defect closure (5 patients), pulmonary arterioplasty (6 patients), and tracheoplasty (1 patient). Results. There were no deaths at follow-up of 3.4 ± 2.1 years; 1 child required cardiac transplantation 17 months postoperatively. Early postrepair echocardiography quantified TR as absent or mild (34 patients; 81%), mild-to-moderate (4 patients), moderate (3 patients), and severe (1 patient). The most recent echocardiogram showed moderate TR in 11 patients and severe TR in 2 patients (both with recurrent right ventricular hypertension). One child required tricuspid valve replacement 3 years later and 1 child had redo De Vega at the time of conduit re-replacement. No other child has symptomatic TR, significant tricuspid stenosis, or De Vega-related pacemaker implantation. Conclusions. The De Vega tricuspid annuloplasty safely provides excellent relief of TR, usually in children undergoing pulmonary valve replacement or conduit replacement. Although echocardiographic TR tends to increase with time (especially with right ventricular hypertension), it rarely requires reintervention or causes symptoms.

Insertion of a pacing lead via the tricuspid valve does not affect cardiac function and tricuspid valve regurgitation in young dogs.

A preliminary experimental study in dogs was conducted to evaluate the feasibility of transvenous cardiac pacing in the fetus with complete heart block associated with hydrops. Four young mongrel dogs were anesthetized with intravenous administration of sodium pentobarbital and mechanically ventilated, and a pacing lead was inserted via the tricuspid valve. The right ventricular cardiac output, aortic pressure and central venous pressure were measured, and the tricuspid valve regurgitation was measured semi-quantitatively using echo-Doppler color flow imaging. The relationship between the location of the pacing lead and the tricuspid valve regurgitation and cardiac function was examined. The mean right ventricular cardiac output when the pacing lead was inserted into the superior vena cava (126 +/- 54 mL/min per kg) was not significantly different from that when it was inserted into the right ventricle (110 +/- 43 mL/min per kg). The aortic pressure was 66 +/- 7.7 mmHg and 67 +/- 6.6 mmHg, respectively, and the central venous pressure 5.9 +/- 1.7 mmHg and 5.7 +/- 1.6 mmHg, respectively, under the two conditions (not significantly different). The ratio of demonstrating significant tricuspid valve regurgitation was 4/13 into the superior vena cava and 5/13 into the right ventricle, respectively (not significantly different). The location of the pacing lead did not change the cardiac function or the amount of the tricuspid valve regurgitation in our experimental study. It was therefore concluded that the transvenous cardiac pacing technique has potential application in intrauterine transvenous cardiac pacing in the fetus with complete heart block.

Hypoplastic left heart syndrome: Hemodynamic and angiographic assessment after initial reconstructive surgery and relevance to modified fontan procedure

After undergoing initial reconstructive surgery for hypoplastic left heart syndrome performed between August 1985 and March 1989, 59 patients (age range 3 to 27 months, mean 13.8 ± 4.5) underwent elective cardiac catheterization in anticipation of a modified Fontan procedure. Five important hemodynamic and anatomic features considered to be components or successful reconstructive surgery were specifically addressed. 1) Interatrialcommunication: Only two patients had a measured pressure difference of >4 mm Hg across the atrial septum. 2) Tricuspid valve function:Angiography demonstrated significant tricuspid valve regurgitation in only five patients (moderate in two and severe in three). 3) Aortic arch:Pressure tracings from the right ventricle to the descending aorta revealed a gradient >25 mm Hg in only two patients. 4) Pulmonary vasculatare:Ten patients had a calculated pulmonary vascular resistance >4 U · m2; 51 (86%) of the 59 patients had no evidence of distortion (stenosis or hypoplasia) of either the left or the right pulmonary artery. 5) Right ventricular function:Five patients had an end-diastolic pressure in the right ventricle >12 mm Hg and two patients had qualitative assessment of decreased ventricular function.Comparison of catheterization data between survivors and nonsurvivors of the subsequent modified Fontan procedure showed that only significant tricuspid regurgitation is a possible predictor of poor outcome. After first stage reconstructive surgery for hypoplastic left heart syndrome, most survivors have favorable anatomy and hemodynamics at follow-up cardiac catheterization for a subsequent Fontan procedure.