Tricuspid Ring Research Articles

Optimizing ring selection for secondary tricuspid regurgitation: the role of body size.

To investigate whether a larger prosthetic ring relative to a patient's body surface area (BSA) is associated with an increased risk of tricuspid regurgitation (TR) recurrence after tricuspid annuloplasty and adverse effects on long-term outcomes. We retrospectively enrolled 239 patients who underwent tricuspid ring annuloplasty and mitral valve surgery between 2011 and 2016. The tricuspid annuloplasty ring index (TARI) was calculated by dividing the size of the annuloplasty ring (mm) by the BSA (m2). Risk factors for recurrent TR were determined using multivariate analysis. Long-term clinical outcomes were compared between propensity score-matched large and small TARI groups. The annuloplasty ring size unadjusted for BSA did not affect TR recurrence (P = 0.388). TARI (subdistribution hazard ratio 1.34; 95% CI 1.07-1.67, P = 0.009) and right ventricular dimension (P = 0.020) were independent risk factors for recurrent TR in multivariate analyses. The cutoff value for discriminating the small from the large TARI group was 19.0 mm/m2. In the matched cohort, the cumulative TR recurrence at 3 years postoperatively was 0% in the small TARI group and 7.1% (95% CI 0-14.8%) in the large TARI group(P = 0.025). The cumulative incidence of adverse events at 3 years postoperatively was 8.3% (95% CI 5.1-16.2%) in the small TARI group and 13.2% (95% CI 3.3-23.0) in the large TARI group (P = 0.085). The patient's body size might better be considered when determining the tricuspid ring size.

Mid-term outcomes of tricuspid annuloplasty using the Tri-Ad Adams tricuspid annuloplasty ring.

The Tri-Ad Adams tricuspid annuloplasty ring is a recent innovative prosthesis characterized by a semi-rigid central component and fully flexible extremities. The goal of this study was to assess the short-term and mid-term results following implantation of the Tri-Ad Adams ring. A retrospective analysis was conducted on patients who underwent tricuspid annuloplasty using the Tri-Ad Adams ring between August 2016 and October 2021. Our study enrolled a total of 248 participants. The median age was 64.0 (interquartile range: 56.0-71.5) years. The median EuroSCORE II was 4.3% (2.7-7.5%), with 37 patients (14.9%) having a history of cardiac operations. Tricuspid regurgitation of grade 2-3 was observed in 63.7% of cases, and the median tricuspid annular diameter was 3.3 (2.8-3.6) cm. Concurrent procedures included mitral valve replacement (n = 160, 64.5%), mitral valve repair (n = 75, 30.2%), aortic valve replacement (n = 72, 29.0%) and the maze procedure (n = 170, 68.5%). Immediate postoperative tricuspid regurgitation≥moderate was present in 1 patient (0.4%). Early death occurred in 14 patients (5.6%). Major complications included low cardiac output syndrome (n = 18, 0.3%), acute kidney injury (n = 14, 5.6%) and permanent pacemaker placement (n = 15, 6.0%). According to the Kaplan-Meier analysis, the 4-year rates of freedom from overall mortality and moderate-to-severe tricuspid regurgitation were 96.9% and 91.6%, respectively. There were no incidents of tricuspid valve reoperations, ring detachment or significant tricuspid stenosis (trans-tricuspid valve gradient ≥ 5 mmHg). Tricuspid annuloplasty utilizing the Tri-Ad Adams ring demonstrated favourable outcomes in both the early and midterm periods. Further studies are warranted to confirm the long-term results.

Bivalirudin for cardiopulmonary bypass in a patient with heparin allergy

BackgroundHypersensitivity reactions to heparin are uncommon conditions but pose a serious clinical problem for patients requiring cardiopulmonary bypass. Bivalirudin is a reversible direct thrombin inhibitor that can be used instead of heparin.Case ReportA 49-year-old male patient was admitted to our hospital for coronary artery bypass graft operation with mitral insufficiency and tricuspid valve insufficiency. Heparin allergy was confirmed by skin biopsy and skin tests. Due to this allergy, we used bivalirudin (Bivacard VEM drug, Turkey) during the surgery. A loading dose of 1.0 mg/kg (100 mg) bivalirudin was administered through the central line and a continuous infusion of 2.5 mg/kg/h of the anticoagulant was initiated following the approved protocol. Serial ACTs were obtained at 15-minute intervals during the procedure and the measurements were 330s, 320s, 350s, 360s, and 340s consecutively. Additional boluses of 0.5 mg/kg (50 mg) were administered for each measurement. Left anterior descending, obtuse marginal arteries and the right coronary artery were grafted with the left internal mammary and saphenous veins. Also, mitral valve replacement with St Jude mechanical heart valve and tricuspid ring annuloplasty was performed with Medtronic Duran ring. After the surgery, the patient had an uneventful period in the postoperative intensive care unit with a total of 600ml and 300ml chest tube drainage for two days and was discharged on the 7th day.ConclusionAlternative anticoagulation strategies are needed for cardiopulmonary bypass in patients unable to use heparin. Bivalirudin may be recommended as a viable alternative anticoagulant in patients with heparin allergy during cardiopulmonary bypass. However, each patient should be evaluated individually and it should not be forgotten that more than recommended doses may be needed.

Subfertility versus ART: unraveling the origins of fetal cardiac programming.

Do spontaneously conceived (SC) fetuses from subfertile couples show the same signs of cardiac remodeling as those observed after IVF treatments? As opposed to fetuses from IVF, SC fetuses from subfertile couples do not show cardiac remodeling and present a similar cardiac structure and function to those of SC fetuses from fertile couples. Subjects conceived by IVF present signs of cardiac remodeling and suboptimal function in utero and during childhood, including larger atria, more globular and thicker ventricles, reduced longitudinal motion, and impaired relaxation as compared to SC individuals from fertile couples. There are no previous publications investigating the independent cardiac programming effects of infertility in SC fetuses from subfertile couples (with time-to-pregnancy (TTP) over 12 months). A prospective cohort study of 289 singleton pregnancies exposed and not exposed to subfertility recruited from 2019 to 2021, including 96 SC pregnancies from fertile couples (TTP under 12 months), 97 SC from subfertile couples (TTP over 12 months), and 96 from IVF after fresh embryo transfer. Fetal echocardiography was performed in all pregnancies. Epidemiological data and perinatal outcomes were collected in all pregnancies. The overall attrition rate was 15.7%. SC from subfertile couples and IVF pregnancies were identified as eligible at pregnancy diagnosis, and eligible SC pregnancies from fertile couples who attended our maternal-fetal unit were invited to participate at third trimester, being matched to the other groups by maternal age. Fetal echocardiography was performed at 29-34 weeks of pregnancy to assess cardiac structure and function, and results were adjusted by parental age, maternal smoking status, child's birth order, birthweight centile, gestational age, and estimated fetal weight at scan. Parental age, ethnicity, BMI, and smoking exposure, median gestational age and estimated fetal weight were similar in all study groups. There were no significant differences in infertility duration or etiology between the subfertile and the IVF populations (TTP: subfertile median 35 months (interquartile range 20-48) versus IVF: 47 (25-61); P-value = 0.051). While both fertile and subfertile SC groups presented similar fetal cardiac results, IVF fetuses showed larger atria (right atria-to-heart ratio: IVF mean 18.9% (SD 3.4) versus subfertile 17.8% (3.5) versus fertile 17.6% (3.3); adjusted P-value < 0.001), more globular ventricles (right ventricular sphericity index: IVF 1.56 (0.25) versus subfertile 1.72 (0.26) versus fertile 1.72 (0.26); <0.001), and thicker myocardial walls (relative wall thickness: IVF 0.86 (0.22) versus subfertile 0.64 (0.13) versus fertile 0.64 (0.18); <0.001). Whereas SC fetuses from fertile and subfertile couples had preserved cardiac function, IVF fetuses showed signs of suboptimal systolic and diastolic function, with reduced tricuspid ring displacement (IVF 7.26 mm (1.07) versus subfertile 8.04 mm (1.18) versus fertile 7.89 mm (1.51); <0.001) and increased left myocardial performance index (IVF 0.49 (0.08) versus subfertile 0.45 (0.09) versus fertile 0.45 (0.10); <0.001). A sub-analysis including only unexplained infertility cases in subfertile SC and IVF groups showed similar results. The fetal cardiac changes reported here are subclinical, and most of the cardiovascular parameters were within normal ranges. Although echocardiographic changes are recognized as potential cardiovascular risk factors, their association with long-term cardiovascular disease remains to be demonstrated. Subfertility per se does not seem to be associated to fetal cardiac remodeling, which has been previously described in IVF fetuses. Future studies are warranted to further investigate other factors related to the observed fetal cardiac changes associated with ART. This project has been partially funded with support from the Erasmus + Programme of the European Union (Framework Agreement number: 2013-0040). This publication reflects the views only of the author, and the Commission cannot be held responsible for any use, which may be made of the information contained therein. Additionally, the research leading to these results has received funding from 'la Caixa' Foundation under grant agreement LCF/PR/GN18/10310003, the Instituto de Salud Carlos III (PI15/00130, PI16/00861, PI17/00675, PI18/00073, INT21/00027)-co-funded by the European Union, Cerebra Foundation for the Brain Injured Child (Carmarthen, Wales, UK) and AGAUR 2017 SGR grant no 1531. The authors have no conflicts of interest to declare. N/A.

The prognostic significance of right ventricular basal diameter in addition to tricuspid annulus diameter in patients underwent to tricuspid valve surgery

Abstract Funding Acknowledgements Type of funding sources: None. Background Functional tricuspid valve regurgitation occurs as a result of enlargement of the tricuspid annulus (TA) despite the normal valve structure (1). However, the tendency of the tricuspid annulus to enlarge in the posterior annular part suggests that the mediolateral diameter measurement measured by 2-dimensional (2-D) echocardiography does not provide an accurate anatomical evaluation (2). Inaccuracies in these measurements also affect the selection of the tricuspid ring in patients undergoing surgery and thus affect the short- and long-term outcomes (3). Therefore, new methods and reference points have developed in the measurement of the tricuspid annulus. Purpose In this study, we aimed to investigate the importance of apical 4-chamber tricuspid annulus diameter and right ventricular basal diameter measurements in choosing a surgical tricuspid ring size. Methods The records of 359 patients who underwent tricuspid ring annuloplasty for functional tricuspid valve regurgitation between 2018 and 2022 were retrospectively reviewed. Tricuspide anulus and right ventricular basal diameter measurements were re-evaluated echocardiographically, and surgical tricuspid ring sizes were recorded. Results There was no significant relationship between 2-D measurement of tricuspid annulus diameter and choosing surgical ring sizes (OR 0.74, 95% CI 0.51 – 1.09, p = 0.257), however, the increase in RV basal diameter size was associated with larger ring size selection (OR 2.63, 95%). CI 1.72 – 4.02, p&amp;lt;0.0001). Among the 5 models that predicted the surgical ring size according to the ordinal regression analysis, the models that most accurately predicted the surgical ring size were model-4, which included RV basal diameter, and model-5, which included RV basal diameter and TA diameter. (Table 1). Also, in model-5, RV basal diameter was superior to TA-diameter in showing variation in surgical ring size. Also, when the TA diameter is &amp;lt; 40 mm and the RV basal diameter is &amp;lt; 45 mm, the large ring selection rate (34 or 36) is 36.2%, but this rate is 70.9% when the TA diameter is &amp;lt; 40 mm and the RV basal diameter is ≥ 45. Conclusions In conclusion, when the measurements in the apical 4-chamber were compared, the effectiveness of the measurement of the tricuspid annulus in determining the surgical ring size was lower than the RV basal diameter. During pre-operative evaluation, RV basal measurement in addition to the tricuspid annulus may help in the selection of patients who require tricuspid valve annuloplasty and in determining the ring sizes.

How should right ventricle remodeling be assessed in women and men with chronic mitral regurgitation?

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Haukeland University Hospital Introduction Right ventricular (RV) dysfunction has a negative impact in patients with mitral regurgitation (MR), yet its assessment by two-dimensional (2D) echocardiography remains challenging. It is unclear which echocardiographic parameter best reflects RV remodeling in chronic MR. Purpose To assess 2D and three-dimensional (3D) measures of RV size and function in relation to MR severity. Methods Patients in the 3D-PRIME (3D Echocardiography and Cardiovascular Prognosis in Mitral Regurgitation) study with moderate or severe MR by combined transthoracic/transesophageal assessment and no other severe valve disease were examined at our heart valve clinic between 2020–2022. RV remodeling was assessed in 2D by the basal diameter, tissue Doppler peak systolic velocity at the lateral tricuspid ring (RV s´), tricuspid annular plane systolic excursion (TAPSE), and RV free wall longitudinal strain (RV FWS); and in 3D by end-diastolic volume (3D RVEDV), end-systolic volume (3D RVESV), ejection fraction (3D RVEF) and fractional area change (3D RVFAC). Results 100 patients with moderate or severe MR (54 with degenerative MR; 26 with atrial functional MR; 20 with ventricular functional MR) were included. Women (n=38) had smaller MR regurgitation volumes and RV size, similar TAPSE and RV s´, but higher 3D RVEF, 3D RVFAC and RV strain normalized for 3D RVEDV (all p &amp;lt;0.05). More severe RV remodeling with larger volumes, and lower 3D RVFAC (all p &amp;lt;0.05), and 3D RVEF (p = 0.05) was detected in severe MR by 3D, but not by 2D RV measures (Figure). In ROC analyses, 3D RVESV was strongest associated with severe MR (area under curve 0.68, p &amp;lt;0.01, Figure). In linear regression analysis, increasing 3D RVESV was associated with higher body mass index, larger MR regurgitation volume, male sex, and larger 3D left atrial volumes (R2 0.48, p &amp;lt;0.001). Conclusion RV remodeling in severe MR is detected by 3D, but not by routine 2D echocardiography. The 3D RV end-systolic size best reflects MR severity.

Papillary muscle approximation in chronic ovine functional tricuspid regurgitation

ObjectiveIsolated tricuspid ring annuloplasty remains the surgical standard for functional tricuspid regurgitation repair but offers suboptimal results when right ventricular dilation and remodeling along with papillary muscle displacement is present. Addressing subvalvular remodeling with papillary muscle approximation may improve clinical outcomes. MethodsFunctional tricuspid regurgitation and biventricular dysfunction were induced in 8 healthy sheep by rapid ventricular pacing (200-240 bpm) for 27 ± 6 days. Subsequently, animals underwent cardiopulmonary bypass for implantation of sonomicrometry crystals on the tricuspid annulus, right ventricle, and papillary muscle tips. Papillary approximation sutures were anchored between anterior-posterior and anterior-septal papillary muscles and externalized through right ventricular free wall to epicardial tourniquets. After weaning from cardiopulmonary bypass, sequential papillary muscle approximations were performed. Simultaneous hemodynamic, sonomicrometry, and echocardiographic data were collected at baseline and after each papillary muscle approximation. ResultsWith rapid pacing, right ventricular fractional area change decreased from 59 ± 6% to 38 ± 8% (P < .001), whereas tricuspid annulus diameter increased from 2.4 ± 0.3 cm to 3.3 ± 0.6 cm (P = .003). Tricuspid regurgitation (0-4+) increased from +0 ± 0 to +3.3 ± 0.7 (P < .001). Both anterior–posterior and anterior–septal papillary muscle approximation significantly reduced functional tricuspid regurgitation from +3.3 ± 0.7 to +2 ± 0.5 and +1.9 ± 0.6, respectively (P < .001). Reduction of tricuspid insufficiency with both subvalvular interventions was associated with decreased distance of the anterior papillary muscle to the annular centroid. ConclusionsPapillary muscle approximations were effective in reducing severe ovine functional tricuspid regurgitation associated with right ventricular dilation and papillary muscle displacement. Further studies are needed to evaluate efficacy of this adjunct to ring annuloplasty in repair of severe functional tricuspid regurgitation.

Septal annular dilation in chronic ovine functional tricuspid regurgitation

IntroductionAnnular reduction with prosthetic rings represents the current surgical treatment of functional tricuspid regurgitation (FTR). However, alterations of annular geometry and dynamics associated with FTR are not well characterized. MethodsFTR was induced in 29 adult sheep with either 8 weeks of pulmonary artery banding (PAB, n = 15) or 3 weeks of tachycardia-induced cardiomyopathy (TIC, n = 14). Eight healthy sheep served as controls (CTL). At the terminal procedure, all animals underwent sternotomy, epicardial echocardiography, and implantation of sonomicrometry crystals on the tricuspid annulus (TA) and right ventricular free wall while on cardiopulmonary bypass. Simultaneous hemodynamic, sonomicrometry, and echocardiographic data were acquired after weaning from cardiopulmonary bypass and stabilization. Annular geometry and dynamics were calculated from 3-dimensional crystal coordinates. ResultsMean FTR grade (0-4) was 3.2 ± 1.2 and 3.2 ± 0.5 for PAB and TIC, respectively, with both models of FTR associated with similar degree of right ventricular dysfunction (right ventricular fractional area contraction 38 ± 7% and 37 ± 9% for PAB and TIC, respectively). Left ventricular ejection fraction was significantly reduced in TIC versus baseline (33 ± 9%, vs 58 ± 4%, P = .0001). TA area was 651 ± 109 mm2, 881 ± 242 mm2, and 995 ± 232 mm2 for CTL, FTR, and TIC, respectively (P = .006) with TA area contraction of 16.6 ± 4.2%, 11.5 ± 8.0%, and 6.0 ± 4.0%, respectively (P = .003). Septal annulus increased from 33.8 ± 3.1 mm to 39.7 ± 6.4 mm and 43.1 ± 3.2 mm for CTL, PAB, and TIC, respectively (P < .0001). ConclusionsOvine FTR was associated with annular dilation and reduced annular area contraction. Significant dilation of septal annulus was observed in both models of FTR. As tricuspid rings do not completely stabilize the septal annulus, continued remodeling may contribute to recurrent FTR after repair.

Interventional treatment and early-stage follow-up of pulmonary atresia with intact ventricular septum

Objective: To explore the application value of percutaneous peripheral interventional therapy in pulmonary atresia with intact ventricular septal (PA-IVS). Methods: Retrospective case summary. The data was collected from 25 children who were hospitalized at the Children's Hospital,Zhejiang University School of Medicine from August 2019 to August 2022, had been diagnosed with PA-IVS by echocardiography, and underwent interventional treatment. The sex, age, weight, operation time, radiation exposure time, and radiation dose of the patients were collected. The patients were divided into the arterial duct stenting group and the non-stenting group. Preoperative tricuspid annular diameters and Z scores, right ventricular length diameters, and right ventricular/left ventricular length-diameter ratios were compared by paired t-tests. Right ventricular systolic pressure difference, oxygen saturation, lactic acid before and after the surgery were compared for 24 children who received percutaneous balloon pulmonary valvuloplasty. Right ventricular improvement in 25 children after operation was analyzed. The correlation between postoperative oxygen saturation and postoperative right ventricular systolic blood pressure difference, the degree of pulmonary valve opening and the Z value of tricuspid valve ring in the non-stenting group were analyzed. Results: A total of 25 patients with PA-IVS were enrolled in the study, of whom 19 were males and 6 females, with an age at surgery of 12 (6, 28) days and a weight of (3.7±0.5) kg. One of them underwent only stenting of the arterial duct; 20 children underwent only percutaneous pulmonary valve perforation and balloon angioplasty; 4 children underwent both procedures. The Z-value of the tricuspid ring was -1.5±1.2 in the group with arterial duct stenting, and -0.1±0.4 in the group without stenting (t=2.77, P=0.010). The tricuspid regurgitant flow rate 1 month after surgery was significantly lower than the preoperative ((3.4±0.6) vs. (4.8±0.9) m/s, t=6.62,P<0.001). In the 24 children with percutaneous pulmonary valve perforation and balloon angioplasty, the preoperative right ventricular systolic blood pressure was (110±32) mmHg, and the postoperative systolic blood pressure was (52±19) mmHg (1 mmHg=0.133 kPa) (F=59.55, P<0.001). The factors that may affect postoperative oxygen saturation in 20 cases of non-stenting group were analyzed. The results suggested that the pre and post-operative right ventricular systolic blood pressure differences (r=-0.11, P=0.649), and the pulmonary valve orifice opening (r=-0.31, P=0.201) and tricuspid annulus Z value (r=-0.18, P=0.452) at 1 month after the operation were not significantly correlated with the postoperative oxygen saturation. Conclusions: Interventional therapy can be used as the first choice for one-stage operation of PA-IVS. Percutaneous pulmonary valve perforation and balloon angioplasty are more suitable for children with well-developed right ventricles, tricuspid annulus, and pulmonary arteries. While the smaller the tricuspid annulus, the more dependent it is on the ductus arteriosus and thus patients are more suitable for arterial duct stenting.

Arrhythmia in a COVID-19 patient: A case report

In this study, we considered an 83-year-old male patient admitted to the Al-Zahra hospital emergency department in Isfahan. He complained of fatigue, weakness, headache, and cough. In addition, he had hallucinations and delusions for two days; but he had no fever and chill. His physical examination showed a blood pressure of 170/100 mm Hg, heart rate of 142 beats per minute (bpm), respiratory rate of 23 pbm, oxygen saturation (in room air) of 83%, and oxygen bag reserve mask of 93%. We realized cardiac involvement during hospitalization, including sinus bradycardia, first-degree atrioventricular (AV) block, recurrent premature ventricular from tricuspid ring, atrial tachycardia (AT) rhythm with variable AV conduction block, increased heart rate with functional bundle branch block, and negative troponin. The patient was treated with medicines to control heart rate and admitted to the cardiac care unit (CCU). Next, the patient was intubated due to a worsening lung condition. Afterward, he was admitted to the intensive care unit (ICU) and died the next day. According to the literature, compromised cardiac vascular is the most common complications in hospitalized patients due to COVID-19 infection and has a higher mortality risk. Cardiac arrhythmias are additionally common clinical manifestations. These arrhythmias seem to be caused by inflammatory responses in the myocardium, electrolyte disorders, and hypoxia. Our patient showed that the COVID-19 virus might induce different types of arrhythmias.

Not Just a One-Way: Mahaim Accessory Pathway Concomitantly Supporting Orthodromic Atrioventricular Re-Entrant Tachycardia

We report the case of a 41-year-old female with documented narrow QRS tachycardia. During electrophysiological study, both orthodromic and antidromic atrioventricular reentry tachycardia (AVRT) were demonstrated as well as short episodes of pre-excited atrial fibrillation. Programmed atrial stimulation resulted in decremental anterograde conduction on the AP, thus confirming an unexpected Mahaim accessory pathway (AP) diagnosis. Limited 3D activation maps of the right atrium during orthoAVRT, respectively, and the right ventricle (RV) during antiAVRT were constructed and helped accurately describe the atrial and ventricular insertion points, which were superposed on the tricuspid ring, confirming the existence of a single short atrio-ventricular right free wall AP. Short atrioventricular APs with anterograde Mahaim-type conduction concomitantly sustaining orthodromic AVRT are extremely rare. Electroanatomical 3D mapping may help both to clarify the diagnosis and increase the success rate by accurately describing the insertion points of complex accessory pathways.

Transcoronary sinus repair of a severely dilated and tortuous right coronary artery fistulized to coronary sinus complicated with tricuspid valve insufficiency

BackgroundRight coronary artery (RCA) fistulized to the coronary sinus is rare condition in adult cardiac anomalies, and the management and operative indication are controversial.Case presentationWe describe the case of a 45-year female patient who presented with exertional dyspnea, accompanied by intermitted lower limbs and facial edema. She was diagnosed with severe tricuspid regurgitation second to a severely dilated RCA fistulized to the coronary sinus. After multidisciplinary discussion, she underwent surgery through routine medium sternotomy, the right atrium was opened under cardiopulmonary bypass. The coronary arteriovenous fistula from the distal portion of RC to a severely enlarged coronary sinus was found. Trans-coronary sinus closure of the fistula was performed with continuous stitching and a tricuspid ring annuloplasty was done. The patient recovered uneventful post operation.ConclusionAccording to current literatures, surgical treatment was adopted for this case, instead of endovascular intervention. The optimal approach for these cases should consider the heart’s anatomical characteristics. But we need to be aware of the occurrence of myocardial infarction and tricuspid regurgitation in the early and late stage after operation.

Sequential percutaneous tricuspid and pulmonary valve implantation in a young child operated previously for Ebstein Anomaly.

We report a successful percutaneous tricuspid valve implantation followed by a percutaneous pulmonary valve implantation in a young child with Ebstein's anomaly of tricuspid valve and pulmonary stenosis who was previously treated surgically at 1 year of age with tricuspid ring annuloplasty and a transannular outflow patch. This article shows the feasibility of sequential implantation of two valves in young patients with severe tricuspid and pulmonary valve insufficiency.

3D-Printing to Plan Complex Transcatheter Paravalvular Leaks Closure.

Background: Percutaneous closure of paravalvular leak (PVL) has emerged as an alternative to surgical management in selected cases. Achieving complete PVL occlusion, while respecting prosthesis function remains challenging. A multimodal imaging analysis of PVL morphology before and during the procedure is mandatory to select an appropriate device. We aim to explore the additional value of 3D printing in predicting device related adverse events including mechanical valve leaflet blockade, risk of device embolization and residual shunting. Methods: From the FFPP registries (NCT05089136 and NCT05117359), we included 11 transcatheter PVL closure procedures from three centers for which 3D printed models were produced. Cardiac CT was used for segmentation for 3D printed models (3D-heartmodeling, Caissargues, France). Technology used a laser to fuse very fine powders (TPU Thermoplastic polyurethane) into a final part-laser sintering technology (SLS) with an adapted elasticity. A simulation on 3D printed model was performed using a set of occluders. Results: PVLs were located around aortic prostheses in six cases, mitral prostheses in four cases and tricuspid ring in one case. The device chosen during the simulation on the 3D printed model matched the one implanted in eight cases. In the three other cases, a similar device type was chosen during the procedures but with a different size. A risk of prosthesis leaflet blockade was identified on 3D printed models in four cases. During the procedure, the occluder was removed before release in one case. In another case the device was successfully repositioned and released. In two patients, leaflet impingement was observed post-operatively and surgical device removal had to be performed. Conclusion: In a case-series of complex transcatheter PVL closure procedures, hands-on simulation testing on 3D printed models proved its usefulness to plan and facilitate these challenging procedures.

Impact of reductive tricuspid ring annuloplasty on right ventricular size, geometry and strain in an ovine model of functional tricuspid regurgitation.

OBJECTIVESReductive ring annuloplasty of the tricuspid annulus represents the contemporary surgical approach to functional tricuspid regurgitation (FTR). We set out to investigate the influence of moderate reductive tricuspid ring annuloplasty on tricuspid regurgitation and right ventricular (RV) size, geometry and strain in an ovine model of chronic FTR.METHODSEight healthy Dorsett male sheep (62.8 + 2kg) underwent a left thoracotomy for placement and tightening of pulmonary artery band to at least double proximal pulmonary artery blood pressure. After 8 weeks of recovery, animals underwent sternotomy, epicardial echocardiography and sonomicrometry crystal implantation. Six crystals were placed around tricuspid annulus and 13 on RV free wall epicardium along 3 parallels defining 3 wall regions (basal, mid and lower) and 1 on the RV apex. All animals underwent beating heart implantation of 26 mm MC3 annuloplasty ring during a second cardiopulmonary bypass run after baseline data acquisition. Simultaneous haemodynamic, sonomicrometry and echocardiography data were acquired at Baseline and after reductive tricuspid ring annuloplasty.RESULTSImplantation of reductive ring annuloplasty resulted in 47 ± 7% annular area reduction (996 ± 152 mm vs 516 ± 52 mm2, P = 0.0002) and significantly decreased RV end-diastolic volume (185 ± 27 vs 165 ± 30 ml, P = 0.02). Tricuspid ring annuloplasty effectively reduced FTR grade (3.75 ± 0.6 vs 0.3 ± 0.5, P = 0.00004) and had little influence on RV function, cross-sectional area, radius of curvature or free wall regional strains.CONCLUSIONSIn adult sheep with 8 weeks of pulmonary artery banding and FTR, tricuspid annulus reduction of 47% with prosthetic ring annuloplasty effectively abolished FTR while maintaining regional RV function and strain patterns.

Intracardiac Echocardiography for Subvalvular Ablation of Tricuspid Ring PVCs

Intracardiac Echocardiography for Subvalvular Ablation of Tricuspid Ring PVCs

P-771 Subfertility versus in vitro fertilization procedures: unravelling the origins of fetal cardiac remodeling in assisted reproductive technologies

Abstract Study question Do spontaneously conceived (SC) fetuses from subfertile couples present signs of cardiac remodeling as those observed after in vitro fertilization (IVF) treatments? Summary answer SC fetuses from subfertile couples do not associate cardiac remodeling, and their cardiac structure and function are similar to those of SC from fertile couples. What is known already Fetuses and children from IVF associate cardiac remodeling and suboptimal function, including dilated atria, more globular and thicker ventricles, reduced longitudinal motion and impaired relaxationin uteroand after birth. Fetal cardiac changes have been demonstrated both after fresh and frozen embryo transfer. The SC fetuses used as ‘controls’ in our previous publications were conceived by fertile couples thus making it difficult to separate the contribution of infertilityper sefrom the IVF procedures on cardiac programming. There are no previous cardiovascular studies investigating the independent effects of infertility in SC fetuses from subfertile couples (time-to-pregnancy (TTP) over 12 months). Study design, size, duration Prospective cohort study of 289 singleton pregnancies recruited from 2017 to 2021, including 96 SC pregnancies from fertile couples (TTP less than 12 months), 97 SC from subfertile couples (TTP over 12 months) and 96 from IVF after fresh ET. Fetal echocardiography was performed in all pregnancies. Epidemiological data and perinatal outcomes were collected in all pregnancies. Participants/materials, setting, methods IVF pregnancies from our centre were identified as eligible at pregnancy diagnosis. Eligible SC pregnancies from fertile and subfertile couples who attended our Maternal-Fetal Unit were invited to participate at third trimester, being matched to the IVF pregnancies by maternal age. Fetal echocardiography was performed at 29-34 weeks of pregnancy to assess cardiac structure and function. Echocardiographic comparisons were adjusted by nulliparity, birthweight centile, gestational age and estimated fetal weight at scan. Main results and the role of chance Parental age, ethnicity, body mass index and smoking exposure, median gestational age and estimated fetal weight were similar in all study groups. There were no significant differences in infertility duration or aetiology between the subfertile and the IVF populations (TTP: subfertile median 30 months [IQR 20-54] versus IVF: 47 [25-61]; p-value=0.052). While both fertile and subfertile SC groups presented similar fetal cardiac results, IVF fetuses showed larger atria (right atria-to-heart ratio: IVF mean 18.9% [SD 3.4] versus subfertile 17.8% [3.5] versus fertile 17.6% [3.3]; adjusted P-value&amp;lt;0.001), more globular ventricles (right ventricular sphericity index: IVF 1.56 [0.25] versus subfertile 1.72 [0.26] versus fertile 1.72 [0.26]; &amp;lt;0.001), and thicker myocardial walls (relative wall thickness: IVF 0.86 [0.22] versus subfertile 0.64 [0.13] versus fertile 0.64 [0.18]; &amp;lt;0.001). Whereas SC fetuses from fertile and subfertile couples had preserved cardiac function, IVF fetuses showed signs of suboptimal systolic and diastolic function with reduced tricuspid ring displacement (IVF 7.26 mm [1.07] versus subfertile 8.04 mm [1.18] versus fertile 7.89 mm [1.51]; &amp;lt;0.001) and increased left myocardial performance index (IVF 0.49 [0.08] versus subfertile 0.45 [0.09] versus fertile 0.45 [0.10]; &amp;lt;0.001). A sub-analysis including only unexplained infertility cases in subfertile SC and IVF groups showed similar results. Limitations, reasons for caution The fetal cardiac changes reported here are subclinical, with most cardiovascular parameters lying within normal ranges. Although echocardiographic changes are recognized as potential cardiovascular risk factors, their association with long-term cardiovascular disease remains to be proven. Wider implications of the findings Subfertility per se does not seem to be associated to fetal cardiac remodeling, which have been previously described in IVF fetuses. Future studies are warranted to further investigate the factors related to fetal cardiac changes associated to ART. Trial registration number Not a trial

Management of diffuse large B-cell lymphoma with cardiac and extra-cardiac locations.

A 71-year-old man presented with 6 kg weight loss since 4 months and asthenia. He also had mild cough for a few weeks, sudden stabbing thoracic pain recurring at rest without radiation, and no dyspnea. The patient had a history of chronic weaned alcoholism, active smoking, hypertension on triple therapy, and professional exposure to paint. The last transthoracic echocardiography (TTE) performed 6 months before his admission showed an isolated septal hypertrophy at 13 mm without supplementary cardiac abnormalities. At admission, hemoglobin was 138 g/L, platelet and leukocyte counts were 369 × 109/L and 10.1 × 109/L, respectively, C-reactive protein was 51 mg/L, lactate dehydrogenase (LDH) was 8.57 μkat/L, and troponin I was 86.6 μg/L. Neither clinical nor electrocardiogram additional abnormalities were identified. TTE exhibited a significant necrotic intracardiac mass. Computed tomography (CT) highlighted an 80 × 80 mm infiltrating heart mass centered on the right atrioventricular septum with extension to the tricuspid ring (Figure 1, left image), a mediastino-hilar lymphadenopathy, a 15 mm right posterobasal pulmonary nodule, and a thin layer of right pleural effusion. A biopsy of the mediastinal lesion by endoscopic ultrasound revealed large B cells, strongly positive for CD20 antigen as well as CD19, CD5 (low intensity), CD10, CD38, CD79b, and FMC7 marker proteins with a Ki-67 of 70%. Although biopsy was not large, the pathological diagnosis suggested a diffuse large B-cell lymphoma. During hospitalization, a repeated CT showed increased necrotic areas in mediastinal mass, layer of right pericardial effusion, right posterobasal pulmonary nodule, bilateral pleural effusions with passive atelectasis precluding another biopsy, and hepatosplenomegaly. After occurrence of second-degree atrioventricular (AV) block, a pacemaker was implanted in the right ventricular apex. Overall, these clinical, radiological, and histological observations were consistent with diagnosis of diffuse large B-cell lymphoma (DLBCL). Due to the accelerated progression of disease, patient started a first chemotherapy cycle without definitive histological diagnosis including intravenous cyclophosphamide, vincristine, and prednisone without anthracycline. Following six cycles of R-CHOP (Rituximab, Cyclophosphamide, Hydroxy-doxorubicin, Vincristine and Prednisone) combination regimen for treatment of DLBCL with extranodal involvement, CT scan showed highly significant regression of cardiac tumors masses (Figure 1, right image artifacted due to the pacemaker) as well as pleural effusions, lymphadenopathy, pulmonary mass, and hepatosplenomegaly. A complete metabolic response was highlighted by positron emission tomography 8.6 months after the first day of CVP. To date, both primary and secondary cardiac lymphomas (CL) remain aggressive diseases, reported in less than 1% and 10% of patients with DLBCL, respectively. We acknowledged that additional sampling procedures were precluded by the concurrence of rapid progression of DLBCL in a few weeks associated with the onset of high-grade AV block. Therefore, it remained difficult to definitively establish the primary origin of CL versus secondary cardiac involvement of lymphoma, although timeline of clinical and radiological events and the histopathological data argue for a primary CL in the first instance. Despite an improvement of cardiac lymphoma diagnosis through multimodal imaging, biopsy techniques, and chemotherapy regimen including rituximab, the prognosis of CL patients remains poor. The authors declare they have no conflicts of interest. Written informed consent was obtained from the patient. The data that support the findings of this study are available from the corresponding author upon reasonable request.

New trend: Surgical correction of Ebstein's anomaly using modified cone repair and a combination of different techniques.

Ebstein's anomaly,a rare cardiac disease that accounts for <1% of all congenital heart diseases, is a right ventricular myopathy with varying degrees of delamination in the endocardium under the tricuspid valve. Cone reconstruction, first described by da Silva in 2004, is a modification of the Carpentier technique. An alternative surgical treatment for Ebstein's anomaly, it is now the preferred surgical corrective technique. This study demonstrates that our modifications of the cone repair procedure to correct Ebstein's anomaly improve valve coaptation and stabilization in the early and midterm. Of the 134 patients diagnosed with Ebstein's anomaly in our clinic between January 2012 and October 2020, 10 underwent a cone procedure and its modifications and were thus included in the study. The mean age of these patients was 28.6 ± 18.79 years and ranged from 1 to 61 years. Thirty percent of the patients were male and 70% were female. The additional procedures performed were an isolated cone procedure (two patients), anomalous pulmonary venous return repair in addition to a cone procedure (one patient), single-vessel coronary artery bypass (one patient), Glenn procedure (two patients), and tricuspid ring annuloplasty (four patients). Based on the results of this study, which assesses the outcomes of patients who underwent cone repairs with surgical modifications, we argue that right ventricular oblique plication, tricuspid valve delamination, surgical valve rotation, and tricuspid ring annuloplasty protect valve coaptation and function in the early and midterm, thereby having beneficial effects on right ventricle remodeling.

Cirugía de reparación multivalvular en pacientes congénitos: ¿es posible?

Introduction and objectiveCongenital heart valve disease is a wide and heterogeneous spectrum of valvular anomalies with low incidence. We analysed the results and follow-up of all our patients with 2 or more surgical heart valve repairs over a period of 15 years. MethodsWe retrospectively analysed all combined valve repairs performed from January 2007 to June 2021 in a tertiary referral hospital. ResultsTwenty-five patients were operated with a median age of 4 years: 8 adults with a median age of 54 years, and 17 children with a median age of 13.5 months. Twenty-two patients presented mitral regurgitation, 8 aortic regurgitation, 2 mitral stenosis, and one severe aortic stenosis. Eighteen patients presented tricuspid regurgitation. Sixteen mitro-tricuspid, 7 mitro-aortic, one tricuspid-pulmonary, and one triple mitro-aortic-tricuspid combined heart valve plasties were performed. Three primary plasty failures required reintervention, and one resulted in death. Three patients required a permanent pacemaker in the immediate postoperative course, and one suffered from perioperative myocardial infarction due to right coronary artery kinking secondary to a tricuspid ring suture. Median follow-up was 45.3 months, without late deaths. Two patients were reoperated during follow-up. In the last follow-up echocardiogram, 2 patients had severe mitral regurgitation, one moderate aortic regurgitation, and one severe tricuspid regurgitation, all of them clinically well tolerated. ConclusionHeart valve plasties of 2 or more valves in patients with congenital heart disease is viable with good short-midterm results. It could be performed as a definitive solution or as palliative treatment in favour of annular growth.