Symptoms Of Right Heart Failure Research Articles

A CASE OF RIGHT HEART FAILURE: WHEN IT IS NOT PULMONARY EMBOLISM

Abstract A 66–year–old patient, showing exertional dyspnea and atypical chest pain, came to our attention with instrumental findings at echocardiogram of right ventricular failure and was hospitalized due to worsening signs and symptoms of right heart failure. Signs of right ventricular strain and the McGinn–White sign (S1Q3T3 pattern) were seen on the ECG, leading to the suspicion of pulmonary thromboembolism (PE). Pulmonary CT angiography confirmed bilateral PE involving the main pulmonary artery. Oral anticoagulant therapy was initiated with initial partial benefit and relief of symptoms. However, after four weeks, the patient was readmitted for severe heart failure and signs of low cardiac output. Echocardiography showed the presence of a conspicuous, mobile, isoechoic mass occupying most of the main pulmonary artery, suggesting thrombosis. The patient underwent urgent surgical thromboendoarterectomy extended to the third segmental left branches and to the second segmental right branches of the pulmonary artery; a severe pulmonary valve regurgitation was observed and therefore the valve was replaced with a Edwards–Magna pericardial bioprosthetic valve. ECMO (Extracorporeal Membrane Oxygenation) was initiated due to haemodinac instability. In the postoperative period, the severe heart failure worsened, unresponsive to pharmacological treatments and mechanical support, leading to the patient passing away in the following days. Unexpectedly, histological analysis of the surgical specimen revealed neoplastic cells with vascular/endothelial differentiation; fluorescence in situ hybridization (FISH) detected the MDM2 gene (cfr.23–F–00275), involved in the p53 protein regulation mechanisms, which is consistent with a diagnosis of angiosarcoma. Pulmonary–artery angiosarcomas are extremely rare (few anecdotical cases are described in literature) and resemble the CT–signs and clinical features of PE, seriously delaying the diagnosis. They are usually associated with a worse prognosis than PE, one and a half months survival time when inoperable. Radical surgery, associated with thirty six and a half months survival time, is often unfeasible because of locally advanced disease or metastatic disease already present at diagnosis. The main differences with PE are the more proximal and almost–occluding involvement of the pulmonary artery, the absence of peripheral vein thrombosis and the absence of response to anticoagulant therapy.

Right ventricular dysfunction in chronic heart failure: clinical laboratory and echocardiographic characteristics. (the RIVED-CHF registry).

Right ventricular dysfunction (RVD) and pulmonary hypertension have been recognized as two important prognostic features in patients with left side heart failure. Current literature does not distinguish between right heart failure (RHF) and RVD, and the two terms are used indiscriminately to describe pulmonary hypertension and RVD as well as clinical sign of RHF. Therefore, the right ventricle (RV) adaptation across the whole spectrum of left ventricular ejection fraction (LVEF) values has been poorly investigated. This is a multicenter observational prospective study endorsed by the Italian Society of Cardiology aiming to analyze the concordance between the signs and symptoms of RHF and echocardiographic features of RVD. The protocol will assess patients affected by chronic heart failure in stable condition regardless of the LVEF threshold by clinical, laboratory, and detailed echocardiographic study. During the follow-up period, patients will be observed by direct check-up visit and/or virtual visits every 6 months for a mean period of 3 years. All clinical laboratory and echocardiographic data will be recorded in a web platform system accessible for all centers included in the study. The main study goals are: to investigate the concordance and discordance between clinical signs of RHF and RVD measured by ultrasonographic examination; to evaluate prognostic impact (in terms of cardiovascular mortality and heart failure hospitalization) of RVD and RHF during a mean follow-up period of 3 years; to investigate the prevalence of different right ventricular maladaptation (isolated right ventricular dilatation, isolated pulmonary hypertension, combined pattern) and the related prognostic impact. With this protocol, we would investigate the three main RVD patterns according to heart failure types and stages; we would clarify different RVD and pulmonary hypertension severity according to the heart failure types. Additionally, by a serial multiparametric analysis of RV, we would provide a better definition of RVD stage and how much is it related with clinical signs of RHF (ClinicalTrials.gov Identifier: NCT06002321).

Late presentation of traumatic tricuspid valve chordal rupture and pericardial rupture with cardiac herniation: a case report

BackgroundAlthough chest trauma happens very often, accompanying tricuspid valve injuries occur rarely and may be manifested by scarce symptoms and signs. Pericardial rupture with cardiac herniation is even a bigger rarity. Transthoracic echocardiography plays a key role in the diagnosis of valve injuries but is of limited value in cardiac herniation.Case presentationWe present the case of 58-year-old man who experienced severe chest trauma in a car accident. Symptoms of right heart failure occurred 10 years after the injury, due to the loss of tricuspid leaflet support caused by the rupture of tendinous chords with significant tricuspid regurgitation. Intraoperatively, old posttraumatic pericardial rupture into left pleura was also found, with partial cardiac herniation and pressure of the edge of pericardium on all left-sided coronary arteries simultaneously. The patient was successfully operated and is free of symptoms 4 years later.ConclusionsThis case emphasizes the importance of timely diagnosis and underlines a mechanism that leads to delayed rupture of the tricuspid valve apparatus. Repeated echocardiography in all patients who experienced chest trauma could be of great importance. Also, given the limited value of echocardiography in posttraumatic pericardial rupture and cardiac herniation, cardiac computed tomography should be performed.

Case Report of Absent Pulmonary Valve with Intact Interventricular Septum

Abstract Absent pulmonary valve syndrome is a rare cardiac malformation, usually associated with tetralogy of Fallot. Its presence with intact interventricular septum is even less common with case reports or very small series in the literature. We describe a case who presented with symptoms of right heart failure due to an absent pulmonary valve with severe pulmonary regurgitation and small atrial septal defect. Diagnostic evaluation revealed grossly dilated main pulmonary artery and rudimentary leaflets of the pulmonary valve with severe regurgitation. Ventricular septum was intact and there was no patent ductus arteriosus. Later, the patient underwent surgical prosthetic pulmonary valve implantation.

The Early Detection of Pulmonary Hypertension.

Up to 1% of the world population and 10% of all persons over age 65 suffer from pulmonary hypertension (PH). The latency from the first symptom to the diagnosis is more than one year on average, and more than three years in 20% of patients. 40% seek help from more than four different physicians until their condition is finally diagnosed. This review is based on publications retrieved by a selective literature search on pulmonary hypertension. The most common causes of pulmonary hypertension are left heart diseases and lung diseases. Its cardinal symptom is exertional dyspnea that worsens as the disease progresses. Additional symptoms of right heart failure are seen in advanced stages. Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are rare, difficult to diagnose, and of particular clinical relevance because specific treatments are available. For this reason, strategies for the early detection of PAH and CTEPH have been developed. The clinical suspicion of PH arises in a patient who has nonspecific symptoms, electrocardiographic changes, and an abnormal (NT-pro-)BNP concentration. Once the suspicion of PH has been confirmed by echocardiography and, if necessary, differential-diagnostic evaluation with a cardiopulmonary stress test, and after the exclusion of a primary left heart disease or lung disease, the patient should be referred to a PH center for further diagnostic assessment, classification, and treatment. If both the (NT-pro-)BNP and the ECG are normal, PH is unlikely. Knowledge of the characteristic clinical manifestations and test results of PH is needed so that patients can be properly selected for referral to specialists and experts in PH.

Intravascular leiomyomatosis with cardiac extension, a case report

BackgroundIntravascular leiomyomatosis (IVL) is a histologically benign smooth muscle tumor arising from the uterus that can spread through the pelvic veins and, on rare occasions, extend as far as the heart via the inferior vena cava. Despite its benign characteristics, it can behave like a malignant tumor leading to significant morbidity and even mortality if left untreated.Case presentationThe patient is a 42-year-old woman with a past medical history of uterine leiomyomas. She presented with heavy bleeding and frequent spotting; therefore, she went to her gynecologist. After further evaluation, a mass within the uterus that expanded into the pelvic veins, inferior vena cava, and right atrium was discovered. After the complete removal of the mass, the patient underwent full recovery. IVL with cardiac extension was the final diagnosis.ConclusionAlthough IVL is rare, it must be considered in women who underwent previous hysterectomies or myomectomies and present with symptoms of right heart failure. The ideal therapy will need the aid of a multidisciplinary team and will depend on the patient’s symptoms, previous operative history, the tumor’s extension, and resectability.

Abstract P129: Cardiovascular Safety Of Severe And Sustained Hypoxia Exposure In Physically Fit Patients Following Myocardial Infarction

In mice, hypoxia exposure corresponding to 8000 m altitude over several weeks induced myocardial proliferation and improved left ventricular ejection fraction following myocardial infarction. To enable translation of these findings from mice to patients with myocardial infarction, we determined whether exposure to severe sustained hypoxia is limited by right ventricular failure secondary to hypoxia-induced pulmonary hypertension. We enrolled three men who suffered myocardial infarctions 49-126 months prior to the study (left ventricular ejection fraction 47±7 %) but were otherwise healthy and one male, healthy control person. We induced hypoxia by adding nitrogen to ambient air until alveolar oxygen partial pressure decreased to 35 mmHg. Normobaric hypoxia was then maintained for 14 consecutive days (FiO2=0.095) corresponding to 6062- 6224 m altitude. We added 1% oxygen over night to ameliorate sleep and prevent acute mountain sickness. We conducted echocardiography at baseline, during hypoxia in hypoxic conditions and 3 days after reconditioning. Measurements included right ventricular to atrial pressure gradient as surrogate for pulmonary artery systolic pressure (PAPsys), tricuspid annulus systolic excursion (TAPSE) and right ventricular (RV) free wall strain. Hypoxia induced pulmonary hypertension, that rapidly abated in recovery (baseline: 35±3 mmHg, hypoxia: 47±9, recovery: 28±1, p=0.0292). TAPSE was not reduced by hypoxic exposure (baseline: 28±3 mmHg, hypoxia: 26±1 recovery: 29±2, p=0.0693) and right ventricular free wall strain was maintained (baseline: -22.4±3.9 mmHg, hypoxia: -24±5.4 recovery: -22.7±1.5, p=0.8493). The healthy control person showed similar responses. No signs or symptoms of right heart failure occurred throughout the study. In highly selected patients with myocardial infarction, substantial normobaric hypoxia induced pulmonary hypertension, however, right ventricular function was well preserved. These observations pave the way for translational studies on hypoxia-induced cardiovascular regeneration and may have implications for patients traveling to high altitude.

La clasificación 4A para pacientes con insuficiencia tricuspídea

Introduction and objectivesSignificant tricuspid regurgitation (TR) is associated with increased morbidity and mortality. Clinical evaluation of TR patients is challenging. Our aim was to establish a new clinical classification specific for patients with TR, the 4A classification, and evaluate its prognostic performance. MethodsWe included patients with isolated TR that was at least severe and without previous episodes of heart failure (HF) who were assessed in the heart valve clinic. We registered signs and symptoms of asthenia, ankle swelling, abdominal pain or distention and/or anorexia and followed up the patients every 6 months. The 4A classification ranged from A0 (no A) to A3 (3 or 4 As present). We defined a combined endpoint consisting of hospital admission due to right HF or cardiovascular mortality. ResultsWe included 135 patients with significant TR between 2016 and 2021 (69% females, mean age 78±7 years). During a median follow-up of 26 [IQR, 10-41] months, 39% (n=53) patients had the combined endpoint: 34% (n=46) were admitted for HF and 5% (n=7) died. At baseline, 94% of the patients were in NYHA I or II, while 24% were in classes A2 or A3. The presence of A2 or A3 conferred a high incidence of events. The change in 4A class remained an independent marker of HF and cardiovascular mortality (adjusted HR per unit of change of 4A class, 1.95 [1.37-2.77]; P<.001). ConclusionsThis study reports a novel clinical classification specifically for patients with TR that is based on signs and symptoms of right HF and has prognostic value for events.

Double-Chambered Right Ventricle Presenting in Adulthood With Aortic and Pulmonic Valve Endocarditis

A 55-year-old woman admitted with symptoms of right heart failure received a diagnosis of double-chambered right ventricle and a ventricular septal defect with aortic and pulmonic valve endocarditis. This case highlights the use of multimodality imaging and importance of adult congenital heart disease expertise in the diagnosis and treatment of such patients. (Level of Difficulty: Intermediate.)

Diagnosis and surgical management of pericardial constriction after cardiac surgery

ObjectivesPrevious cardiac surgery is an increasingly common etiology of constrictive pericarditis, but there is a paucity of data on clinical presentation and outcome of surgical treatment. MethodsWe reviewed data of 263 patients who underwent pericardiectomy for postoperative constriction from January 1, 1993, through July 1, 2017. Outcomes of interest were early and late mortality, as well as features of clinical presentation. ResultsMedian patient age was 64 (56-72) years, and the median interval between previous operation and pericardiectomy was 2.7 years (range, 0-54 years). Previous operations included coronary artery bypass grafting in 114 (43%), valve surgery in 85 (32%), combined coronary artery bypass grafting and valve surgery in 33 (13%), and other procedures in 31 (12%). Common presentations were symptoms of right heart failure in 221 (84%) or dyspnea in 42 (16%). Moderate-to-severe tricuspid valve regurgitation was present in 108 (41%) patients. There were 14 (5.5%) deaths within 30 days postoperatively, and survival at 5 and 10 years postoperatively was 61% and 44%. On multivariate analysis, older age (P = .013), diabetes (P = .019), and nonelective pericardiectomy within 2 years of cardiac surgery (P < .001) were associated with decreased long-term survival. ConclusionsPericardial constriction after cardiac surgery can present at any interval postoperatively. Symptoms and signs of right heart failure in patients with previous cardiac surgery should alert physicians to the possibility of pericardial constriction followed by a correct diagnosis. Pericardiectomy performed urgently following cardiac operation has poor long-term outcomes.

The Role of Transthoracic Echocardiography for Assessment of Mortality in Patients with Carcinoid Heart Disease Undergoing Valve Replacement

Patients with carcinoid heart disease (CHD) are referred for valve replacement if they have severe symptomatic disease or evidence of right ventricular (RV) failure and an anticipated survival of at least 12 months. Data are lacking, however, on the role of transthoracic echocardiography in predicting outcomes. We carried out a retrospective, single-centre cohort study of patients with a biopsy-confirmed neuroendocrine tumour (NET) and CHD undergoing valve replacement for severe valve disease and symptoms of right heart failure. The aim was to identify factors associated with postoperative mortality, both within one year of surgery and during long-term follow-up. Of 88 patients with NET, 49 were treated surgically (mean age: 64.4 ± 7.6 years; 55% male), of whom 48 had a bioprosthetic tricuspid valve replacement for severe tricuspid regurgitation; 39 patients had a pulmonary valve replacement. Over a median potential follow-up of 96 months (interquartile range: 56-125), there were 37 deaths, with 30-day and one-year mortality of 14% (n = 7) and 39% (n = 19), respectively. A significant relationship between RV size and one-year mortality was observed, with 57% of those with severe RV dilatation dying within a year of surgery, compared to 33% in those with normal RV size (p = 0.039). This difference remained significant in the time-to-event analysis of long-term survival (p = 0.008). RV size was found to reduce significantly with surgery (p < 0.001). Those with persisting RV dilatation (p = 0.007) or worse RV function (p = 0.001) on postoperative echocardiography had significantly shorter long-term survival. In this single-centre retrospective study of patients undergoing surgery for CHD, increasingly severe RV dilatation on preoperative echocardiography predicted adverse outcomes, yielding a doubling of the one-year mortality rate relative to normal RV size. These data support the possibility that early surgery might deliver greater long-term benefits in this patient cohort.

The 4A classification for patients with tricuspid regurgitation

Introduction and objectivesSignificant tricuspid regurgitation (TR) is associated with increased morbidity and mortality. Clinical evaluation of TR patients is challenging. Our aim was to establish a new clinical classification specific for patients with TR, the 4A classification, and evaluate its prognostic performance. MethodsWe included patients with isolated TR that was at least severe and without previous episodes of heart failure (HF) who were assessed in the heart valve clinic. We registered signs and symptoms of asthenia, ankle swelling, abdominal pain or distention and/or anorexia and followed up the patients every 6 months. The 4A classification ranged from A0 (no A) to A3 (3 or 4 As present). We defined a combined endpoint consisting of hospital admission due to right HF or cardiovascular mortality. ResultsWe included 135 patients with significant TR between 2016 and 2021 (69% females, mean age 78±7 years). During a median follow-up of 26 [IQR, 10-41] months, 39% (n=53) patients had the combined endpoint: 34% (n=46) were admitted for HF and 5% (n=7) died. At baseline, 94% of the patients were in NYHA I or II, while 24% were in classes A2 or A3. The presence of A2 or A3 conferred a high incidence of events. The change in 4A class remained an independent marker of HF and cardiovascular mortality (adjusted HR per unit of change of 4A class, 1.95 [1.37-2.77]; P<.001). ConclusionsThis study reports a novel clinical classification specifically for patients with TR that is based on signs and symptoms of right HF and has prognostic value for events.

Features of post-infarction chronic heart failure in patients with a new coronavirus infection COVID-19

Background. The coronavirus pandemic has caused a rapid increase in the number of cases and high deaths worldwide. A new coronavirus infection in the presence of an initial cardiac pathology can provoke decompensation of chronic heart failure.&#x0D; Aim. To study the clinical features of postinfarction chronic heart failure occurring against the background of a new coronavirus infection.&#x0D; Material and methods. The study included 80 patients with decompensated chronic heart failure. Three groups have been formed. In patients of the first group (n=40), who underwent inpatient treatment for a new coronavirus infection, the cause of chronic heart failure was a previous Q-myocardial infarction. In patients of the second group (n=20), who did not tolerate COVID-19 earlier and at the time of the current hospitalization, the cause of chronic heart failure was a previous Q-myocardial infarction. The third group (n=20) consisted of patients with chronic heart failure of ischemic etiology without postinfarction cardiosclerosis, not previously and at the time of examination infected with the SARS-Cov-2 virus. Statistical analysis was carried out using the IBM SPSS Statistics V26 program. The KolmogorovSmirnov, KruskalWallis, and Pearson 2 tests were used.&#x0D; Results. Symptoms of left and right ventricular heart failure were equally common in all groups. Patients of the studied groups had a history of paroxysmal and permanent forms of atrial fibrillation, while the latter variant was more common in patients of the first group with chronic heart failure with postinfarction cardiosclerosis and coronavirus infection. According to echocardiography, the most pronounced structural and functional changes in the myocardium were also found in patients of the first group with postinfarction heart failure and a new coronavirus infection. Thus, statistically significant differences related to the size of the left atrium, end diastolic volume and end systolic volume of the left ventricle, systolic pressure in the pulmonary artery. An increase in the end systolic volume of the left ventricle by 94.6% was registered in the first group compared with the third group of patients (p=0.001). Systolic pressure in the pulmonary artery in the first group was 14.2% higher than the normal values (p 0.001), while in patients of the second and third groups this indicator was within the normal range.&#x0D; Conclusion. In patients with postinfarction cardiosclerosis suffering from a new coronavirus infection, symptoms of chronic heart failure are more pronounced, characterized by a significant decrease in exercise tolerance; cardiac arrhythmias are more often recorded, and structural and functional changes in the myocardium are of a maladaptive nature.

The 4A classification for patients with tricuspid regurgitation

Abstract Background Significant Tricuspid Regurgitation (TR) is associated with increased morbi-mortality. Clinical evaluation of TR patients is challenging. Purpose To establish a new clinical classification specific for patients with TR, the 4A classification, and evaluate its performance on prognosis. Methods Consecutive patients with isolated at least severe TR and absence of episodes of heart failure (HF) evaluated in the Heart Valve Clinic were included. Signs and symptoms of Asthenia, Ankle swelling, Abdominal pain or distention and/or Anorexia where registered, follow up was performed every 6 months. 4A classification ranged from A0 (no A) to A4 (three or four A's present). A combined endpoint of hospital admission due to right HF and cardiovascular mortality was defined. Results 135 patients with significant TR between 2016 and 2021 were included (69% females, mean age was 78±7 years). During a median follow-up of 26 months (IQR: 10–41 months), n=53 patients (39%) reached the combined endpoint. 52 (38%) admitted for heart failure and 11% (n=15) died. At baseline 94% of patients were in NYHA I or II whereas 24% presented A2 or A3. The presence of A2 or A3 showed a high incidence of events (figure). The change in 4A class and GGT remained independent predictor of HF and cardiovascular mortality (adjusted HR per unit of change of 4A class 1.95 [1.37–2.77], p&amp;lt;0.001) Conclusions For the first time, we show the use of a new clinical classification, specific for patients with TR based on signs and symptoms of right HF that is prognostic of events. Funding Acknowledgement Type of funding sources: None.

Right Heart Failure as an Atypical Presentation of Chronic Type a Aortic Dissection - Multimodality Imaging for Accurate Diagnosis and Treatment. A Case Report and Mini-review of Literature.

BackgroundAn intrapericardial organized haematoma secondary to chronic type A aortic dissection is an extremely rare cause of right heart failure. Imaging studies are essential in recognising and diagnosis of this distinctive medical condition and guiding the anticipated treatment.Case presentationA 70-year-old male patient was admitted for progressive symptoms of right heart failure. His cardiovascular history exposed an aortic valve replacement 22 years before with a Medtronic Hall 23 tilting valve with no regular follow-up. Classical signs of congestion were recognized at physical examination. Transthoracic two-dimensional echocardiography and thoraco-abdominal computed tomography angiography, as essential parts of multimodality imaging algorithm, established the underlying cause of right heart failure. Under total cardiopulmonary bypass and cardiac arrest, surgical removal of the haematoma and proximal repair of the ascending aorta with a patient-matched vascular graft were successfully performed. The patient was discharged in good condition with appropriate pharmacological treatment, guideline-directed; no imagistic signs of acute post-surgery complications were ascertained.ConclusionThis paper highlights the importance of recognizing and providing a timely clinical and imagistic diagnosis of this very rare, potentially avoidable cause of right heart failure in patients with previous cardiac surgery.

Intravenous Leiomyomatosis Complicated by Arteriovenous Fistula: Case Series and Literature Review.

BackgroundUterine intravenous leiomyomatosis (IVL), a rare type of uterine leiomyoma, is defined by the intravascular proliferation of a histologically benign smooth muscle cell tumor. Pelvic arteriovenous fistula (AVF) is a rare vascular malformation that is most commonly congenital, post-traumatic, or iatrogenic. The link between leiomyomatosis and AVF has received little attention in the medical literature.ResultsWe provide a case series of seven patients, four of whom were from our center, who had IVL complicated by a pelvic AVF. The symptoms of right heart failure were noted as swelling in the abdomen and two legs as well as a significant amount of ascites. Coil embolization of AVFs may be beneficial in minimizing bleeding during IVL surgery. A review of all accessible literature published on IVLs from 2000 to 2020 was conducted, and data were retrieved from 78 papers totaling 262 cases. Complications and recurrence were associated with pelvic mass excision and intravascular remnant tumor, respectively.ConclusionIntravenous leiomyomatosis combined with AVF aggravates congestion symptoms of surrounding organs. It is worth noting the uncommon combination of AVF and IVL, stressing the importance of a thorough assessment and surgical approach in IVL treatment.

P234 A RARE CASE OF ACUTE RIGHT HEART FAILURE PRESENTED IN A CASE REPORT

Abstract Case Summary A 62–year–old male with multiple cardiovascular risk factors, presented at the ED with signs and symptoms of right heart failure, Doppler echocardiography showed a severe dilatation and dysfunction of the right ventricle and left ventricular diastolic dysfunction. After initial stabilization with diuretics and inotropes, the patient performed a coronary angiogram with evidence of severe multivessel coronary artery disease and combined pre–capillary and post–capillary pulmonary hypertension as shown by the right heart catheterization. After complete revascularization, the diastolic function of the left ventricle improved dramatically, and the right ventricle recovered completely. Discussion We presented a paradigmatical case of acute right heart failure secondary to left ventricular diastolic impairment in a patient affected by severe ischemic coronary artery disease. Several risk factors are associated with RVD in HFpEF: atrial fibrillation, male sex, chronic obstructive pulmonary disease. Diastolic performance of the LV is one of the main determinants of the right ventricular function, which, in turn, is proven to have prognostic implication in HFpEF. Nowadays, there is no evidence–based treatment for right heart failure secondary to decompensated HFpEF and therapy should be tailored to the individual patient’s response.

Extracorporeal membrane oxygenator as a bridge to heart–liver en bloc transplant in a patient with Fontan circulation

Extracorporeal membrane oxygenator as a bridge to heart–liver en bloc transplant in a patient with Fontan circulation

Prognostic implications of staging right heart failure in patients with significant tricuspid regurgitation undergoing tricuspid valve surgery

Abstract Introduction Mortality of tricuspid valve (TV) surgery for severe secondary tricuspid regurgitation (TR) remains relatively high. Current guidelines advise surgery in patients with symptomatic severe TR as a concomitant procedure to left-sided valve surgery. Right ventricular (RV) dysfunction is an important prognostic marker and may appear late in the natural history of TR. How a staging algorithm of right heart failure (RHF) may impact on TV surgery outcomes has not been evaluated. Purpose To evaluate the impact of staging RHF on survival of patients with significant TR undergoing TV surgery. Methods Patients diagnosed with significant (moderate and severe) TR who subsequently underwent TV surgery, were staged into 4 groups of progressive disease according to the diagnosis of RV dysfunction and the presence of RHF: stage 1, at risk for RHF; stage 2, RV dysfunction without clinical symptoms of RHF; stage 3, RV dysfunction with symptoms of RHF, and stage 4, RV dysfunction with refractory symptoms of RHF (Figure 1). The study endpoint was all-cause mortality. Results A total of 279 patients (mean age 64±12 years, 49% male), were included in the analysis, of which 20 patients (7%) were in stage 1, 14 patients (5%) were in stage 2, 141 patients (51%) were in stage 3 and 104 patients (37%) were in stage 4. The majority of the patients (266 patients, 95%) underwent TV annuloplasty. Most patients had TV surgery concomitant to left-sided valve surgery or coronary artery bypass grafting (254 patients, 91%). In per-group analysis, patients in stage 4 had significantly larger left ventricular (LV) and RV dimensions, lower LV ejection fraction and more severe diastolic dysfunction than patients in other RHF stages. During a median follow-up of 65 [15 - 106] months after TV surgery, 145 deaths (52%) occurred. The cumulative survival rates were 88%, 77% and 60% at 1 month, 1 year and 5 years, respectively. The Kaplan-Meier curves for overall survival according to RHF stage are shown in Figure 2. Survival rates at 5 years were significantly worse in more advanced stages of RHF: 71% (stage 1 and 2), 66% (stage 3) and 49% (stage 4); log-rank chi-square: 11.302; p=0.004. Right heart failure stage was independently associated with all-cause mortality following adjustment for age, gender, LV ejection fraction, kidney function, TV annulus diameter, concomitant mitral valve surgery and time delay from diagnosis until surgery (p=0.021). Conclusion Patients diagnosed with significant TR may benefit from earlier referral for surgical intervention, before presenting with RV dysfunction and before the onset of symptoms of RHF. Funding Acknowledgement Type of funding sources: None. Figure 1. Stages of right heart failureFigure 2. Kaplan-Meier curves for overall survival

Isolated Enterococcus faecalis pulmonary valve endocarditis without precipitating risk factors: A case report describing delayed need for surgery three years after antimicrobial therapy.

Introduction and importanceIsolated Enterococcus faecalis pulmonary valve endocarditis (PVE) without precipitating risk factors is exceeding rare, as fewer than ten cases have been published in the literature, most of which did not require surgical intervention.Case presentationAn elderly individual presented for evaluation of dyspnea, fatigue, dizziness, weight loss, and a low-grade fever. The patient denied intravenous drug abuse, blood-borne viral infection, cardiac trauma, congenital heart disease, and immunocompromise. Echocardiography identified a large vegetation on the right pulmonary valve leaflet consistent with isolated PVE. Blood cultures grew E. faecalis. Computed tomography failed to reveal an infectious source. The patient completed a six-week course of antibiotics and was followed with serial echocardiography for three years, but subsequently developed severe pulmonic insufficiency and right heart failure necessitating pulmonary valve replacement.Clinical discussionIsolated PVE is responsible for less than 2.0% of all cases of infective endocarditis. The vast majority of reported cases are associated with risk factors and are caused by gram-positive organisms including Staphylococcus species and Streptococcus viridans. Echocardiography identifies most cases of isolated PVE. Septic embolization of vegetation fragments to lung parenchyma is common. Surgery is reserved for patients who are unresponsive to antibiotics or those who develop severe pulmonary insufficiency with symptoms of right heart failure, as seen here.ConclusionWe present an unusual case of isolated E. faecalis PVE without known risk factors that required pulmonary valve replacement three years after antimicrobial therapy.