Septal Tricuspid Leaflet Research Articles

Microscopic Topography of Atrioventricular Conduction System–A Feature of Potential Clinical Significance

ObjectivesProximity of atrioventricular (AV) conduction system to tricuspid, mitral and aortic valves renders it susceptible to injury leading to disturbances in patients undergoing valve operations and radiofrequency catheter ablations. Hence, the knowledge of topography of AV conduction system and its relations with surrounding cardiac structures is indispensible.MethodsIn 20 cases, a tissue block of 3×4 cm at AV septal junction was excised which included the borders of Koch's triangle. The block was divided into three equal segments by parallel vertical incisions made perpendicular to insertion of septal leaflet of tricuspid valve. Each segment was processed for Hematoxylin & Eosin and Gomori stain.ResultsThe upper pole of compact AV node was at the level of mitral valve leaflet in 50% cases. Lower pole of AV node was vertically above tricuspid septal leaflet and at the level of muscular IV septum in 100% and 66.7% cases respectively. The subendocardial depth of upper and lower pole of AV node was 1.45±0.6 mm and 0.92±0.3 mm respectively. Minimum subendocardial depth (0.68±0.2mm) was seen at the center of compact AV node. Penetrating bundle of His was seen at the level of tricuspid septal leaflet just deep to it, while Branching bundle of His was 1.98±1.5 mm below the tricuspid septal leaflet. AV nodal extensions began at the level of mitral valve leaflet while its inferior extension ended 2.92±1.3 mm above tricuspid septal leaflet.ConclusionPrior knowledge of distances of AV conduction system from the surrounding landmarks might help in surgical incision planning, safe suture placement and successful device insertion.Support or Funding InformationFrom Director PGIMER, Chandigarh, India.

Transcatheter closure of left ventricle to right atrial communication using cera duct occluder

Left ventricle—right atrial communication could be congenital (Gerbode defect) or acquired as a complication of surgery or infective endocarditis and leads to volume overloading of pulmonary circulation. Two types, direct and indirect types are known depending on the involvement of septal tricuspid leaflet. Transcatheter closure of this defect is feasible and appears an attractive alternative to surgical management. Various devices like Amplatzer duct occluder I, II, Muscular ventricular septal defect device etc. have been used to close this defect. We report two patients, a preteen boy with direct left ventricle-right atrial communication as post operative complication and an adult female with indirect communication who underwent transcatheter closure with Cera duct occluder (Lifetech Scientific (Shenzhen), China).

Ebstein’s anomaly treated surgically in an adult female

A 21-year-old woman with Ebstein’s anomaly was admitted with syncope on exertion, fatigue and dyspnea (NYHA III). Physical examination revealed systolic apical murmur. Echocardiography showed normal LVEF, apical displacement of the septal tricuspid leaflet, severe tricuspid regurgitation, right ventricle dilatation and dysfunction. After detailed evaluation, surgery of the right atrioventricular ostium was proposed. Five months after surgery the patient reported an improvement in exercise tolerance (NYHA II). Echocardiography showed mild residual tricuspid regurgitation.

Ebstein’s Anomaly with Gerbode Defect: A Rare Association

Panel A: Two-dimensional and colour flow TTE from Apical four chamber view showing apically displaced STL and sail like ATL with a defect in ventriculoatrial septum (*) with LV to RA flow being simultaneously demonstrated. Panel B: Three-dimensional TTE showing the same defect. Panel C: Two-dimensional TTE from Parasternal long axis view demonstrating the defect (*) with colour flow image confirming the presence of highly turbulent jet from LV to RA. Panel D: Three-dimensional TTE which clearly depicts the defect. Panel E: Continuous Wave Doppler demonstrating a high peak instantaneous gradient of 113 mm Hg across the defect. A 7 year old boy underwent transthoracic echocardiography (TTE) for evaluation of effort intolerance and frequent palpitations with a harsh pansystolic murmur audible all over the precordium. TTE revealed the presence of Ebstein’s anomaly with apically displaced septal tricuspid leaflet (STL) and ‘sail like’ anterior tricuspid leaflet (ATL). There was a direct ventriculoatrial shunt from Left ventricle (LV) to Right atrium (RA) –Gerbode defect with a peak systolic gradient of 113 mm Hg. Ebstein’s anomaly is commonly associated with various other congenital heart defects but association of Ebstein’s with Gerbode defect is very rare (Panel A-E).

Ebstein anomaly in an asymptomatic nonagenarian: A case report

Ebstein’s anomaly (EA) is a rare cardiac congenital malformation characterized by apical displacement of the septal and posterior tricuspid leaflets, resulting in atrialization of the right ventricle. Many congenital cardiac anomalies may be associated with EA. Clinical presentation depends on anatomical severity and other associated cardiac anomalies. Here, a case of EA in an asymptomatic 92-year-old woman who had given birth seven times is presented.

Absent right bundle branch block: Is it a clue of pre-excitation in Ebstein's anomaly?

A 14-year-old male with a history of symptomatic tachycardia was referred for ablation. Sinus rhythm electrocardiogram was not showing any pre-excitation. Tachycardia episode was showing antidromic tachycardia with left bundle branch block morphology. Echocardiographic examination was showing Ebstein's anomaly with septal tricuspid leaflet displaced 24mm apically. The right bundle branch block (RBBB) was concealed during sinus rhythm. The RBBB was revealed with ablation of right posterior atriofascicular accessory pathway.

Tricuspid valve remodelling in functional tricuspid regurgitation: multidetector row computed tomography insights

Multidetector row computed tomography (MDCT) may help to understand the underlying mechanisms of functional tricuspid regurgitation (TR), a highly prevalent valve disease with novel transcatheter therapies under development. The purpose of the present study was to assess the geometrical changes of the tricuspid valve in patients with functional TR using MDCT and to correlate these changes with the TR grade assessed with echocardiography. In 114 patients undergoing transcatheter aortic valve implantation (47 men, age 81 ± 8 years), including 33 (28.9%) patients with TR ≥ 3+, the tricuspid valve and right ventricle (RV) were geometrically analysed with 320-slice MDCT. The antero-posterior and septal-lateral diameters, perimeter and area of the annulus, degree of tethering of the anterior, septal and posterior tricuspid valve leaflets, and RV volumes and ejection fraction were assessed and subsequently correlated with TR grade in multivariate models. Patients with pacemaker or implantable cardioverter defibrillator leads were excluded.Patients with TR ≥ 3+ had larger tricuspid annulus area (1539.7 ± 260.2 vs.1228.4 ± 243.5 mm(2), P < 0.001), larger septal and anterior leaflet angles, and larger RV end-systolic volumes (93.2 ± 29.8 vs. 64.2 ± 23.6 mL, P < 0.001) compared with patients with TR < 3+.The antero-posterior tricuspid annulus diameter was independently correlated with TR ≥ 3+ (odds ratio 1.35; 95% confidence interval 1.07-1.69, P = 0.010), after adjusting for estimated pulmonary pressure and RV end-systolic volume. In patients with TR ≥ 3+, MDCT demonstrated larger tricuspid annulus and RV dimensions and pronounced tethering of the anterior and septal tricuspid leaflet. The antero-posterior annulus diameter was independently correlated with the grade of functional TR.

Effects of urokinase type plasminogen activator and plasminogen activator inhibitor-1 expressions on the formation of aneurysm of perimembranous ventricular septal defect

The exact mechanisms of defect closure in patients with perimembranous ventricular septal defect (PMVSD) remain unknown. We hypothesized that the expression of urokinase type plasminogen activator (uPA) and plasminogen activator inhibitor-1 (PAI-1) may mediate extracellular matrix (ECM) remodeling in aneurysms. Seven normal heart tricuspid septal leaflet and 33 aneurysms were collected in Shanghai Renji Hospital and Shanghai Children's Medical Center from January 2008 to June 2010. Immunohistochemical expression of uPA and PAI-1 in 4 normal heart valvular tissues and 15 aneurysms was detected with immunohistochemical methods. The expression of uPA and PAI-1 mRNA in 3 normal heart valvular tissues and 7 aneurysms was studied by real time fluorescent PCR; the protein expression of uPA and PAI-1 in 4 normal heart valvular tissues and 11 aneurysms was tested with Western blotting. The surface of the aneurysms were completely covered by endothelial cells. Two types of granulation tissue, myxoid and fibrous, were associated with the aneurismal formation. uPA were recognized predominantly in valvar interstitial cells (VICs) which located mainly in regions adjacent to the endothelium and smooth muscle cells of blood vessels. PAI-1 was found in both VICs which located mainly in granulation tissue and endothelial cells. Nine aneurysms expressed a higher uPA activity than 4 normal valvular tissues ((74.6±11.8)% vs. (49.5±7.4)%; t = 3.87, P = 0.003) and six aneurysms expressed a low uPA activity ((10.3±3.1)% vs. (49.5±7.4)%; t=11.78, P=0.000) and a high PAI-1 activity ((55.2±1.7)% vs. (50.8±3.8)%; t=2.55, P=0.034) using immunohistochemical methods. uPA / PAI-1 ratio of protein expression tested by Western blot was 0.88±0.22 in four normal heart vavular tissues; five aneurysms expressed high uPA activity and low PAI-1 activity and uPA/PAI-1 ratio was 4.26±2.04; while the other 6 cases expressed low uPA activity and high PAI-1 activity and uPA/PAI-1 ratio was 0.30±0.07; the difference among the three groups was statistically significant (P<0.05). The rate of uPA/PAI-1 in relative copy of mRNA expression among normal heart valvular tissue, high uPA expressed aneurysms and low uPA expressed aneurysms are also significantly different (2.14±0.17 vs. 0.45±0.04; 2.14±0.17 vs. 4.38±1.41, P<0.05) respectively. The expression of uPA and PAI-1 in VICs suggests that interactions among these molecules contribute to the aneurysm formation and development. This provides a potential mechanism for defect closure in patients with PMVSD.

Ruptured tricuspid septal leaflet aneurysm in a patient with aortic and mitral valve replacement

Ruptured tricuspid septal leaflet aneurysm in a patient with aortic and mitral valve replacement

Predictors of mid-term functional tricuspid regurgitation after device closure of atrial septal defect in adults: Impact of pre-operative tricuspid valve remodeling

BackgroundFunctional TR occurs in adults with congenital atrial septal defect (ASD) due to left-to-right inter-atrial shunting and enlarged right heart. The prevalence and the predictors of TR following ASD closure in adults remain unknown. Moreover, whether preoperative anatomical parameters of tricuspid valve related to TR after ASD closure is understudied. MethodsComprehensive transthoracic echocardiography was performed in 64 consecutive secundum ASD patients before and at 3months after device closure. Tricuspid valve parameters [annulus diameter (TAD), tenting area, tenting height, distal tricuspid septal leaflet angle (TSLA)], right ventricular (RV) function, pulmonary arterial pressures and severity of TR were recorded. Post-closure TR was defined as PISA radius ≥6mm at 3months. ResultsThe TR severity was reduced after ASD closure with post-closure TR in 31 patients (48%) at follow-up. TR patients had larger ventricles, more TR, greater TAD, and larger tenting area/height and TSLA but similar RV long-axis function and pulmonary pressures at baseline. Pre-closure TAD [odds ratio (OR): 6.076, p=0.032] and TSLA (OR: 1.218, p=0.001) were the independent predictors for TR. A TAD >3.5cm and a TSLA >30° had sensitivity, specificity, and area under the curve of 97%, 76%, and 0.82 and 100%, 78%, and 0.84, respectively. Assessment of TSLA showed an incremental value over TAD for predicting TR after closure (χ2=21.3 vs. 9.9, p<0.001). ConclusionNearly half of adults had TR following device closure of ASD. It was related to the excessive pre-operative structural remodeling in tricuspid valve rather than changes in RV.

Predicting atrial tachycardia and major cardiovascular events in adults with unrepaired Ebstein's anomaly of the tricuspid valve

Heart Association class >2 (Hazard ration (HR 7.66[95% CI 1.535-38.204],p=0.013), left ventricular (LV) ejection fraction (HR) 0.43[95%CI 0.245-0.742],p=0.003/5%), LV stroke volume (HR 0.69[95%CI 0.515-0.923],p=0.013/ 5mL) and right ventricular (RV) ejection fraction (HR 0.49[95%CI 0.276-0.856],p=0.012/5%); all remained significant even when tested solely for mortality. In all but one patient VT/death was preceded by AT and AT was predictive of major adverse cardiovascular events (HR 11.16[95%CI 1.299-95.813],p=0.028), emphasizing its role as an early marker of long-term adverse events. Freedom from first-onset AT (n=17 patients, 21.5%) declined during the follow-up. Univariate predictors for first-onset AT included RV ejection fraction (HR 0.65 [95%CI 0.463-0.907],p=0.011/5%)], RV/LV end diastolic volume ratio (HR 1.65[95%CI 1.207-2.258],p=0.002) and apical tricuspid septal leaflet displacement indexed to LV length (HR 1.03[95%CI 1.002-1.068],p=0.040); when used together as a score, risk prediction was further enhanced (HR 4.84[95%CI 1.615-14.522],p=0.005). Conclusions

Successful device closure in a congenital Gerbode defect.

A 22-year-old man was admitted to our department due to mild exertional dyspnea for 2 months. He had no other cardiac symptoms and his medical history was unremarkable. 4/6 systolic murmur was heard at the left sternal border and at the apex. Electrocardiogram revealed sinus rhythm with negative T waves in leads V1 to V4. Two-dimensional transthoracic echocardiography (2D TTE) revealed a clear systolic jet across a defect (7 mm) between the left ventricular outflow tract (LVOT) and right atrium (RA) consistent with a Gerbode type defect located above the tricuspid septal leaflet (Figure 1A). Qp/Qs ratio, maximal velocity (Vmax) and trans-shunt pressure gradient were 2.1, 5.1 m/s and 103 mm Hg, respectively. Right ventricular systolic pressure (RVSP) was estimated at 51 mm Hg assuming a right atrial pressure of 15 mm Hg. The direction of the Doppler signal confirmed our diagnosis (Figure 1B). Furthermore, three-dimensional transthoracic echocardiography (3D TTE) also demonstrated a supravalvular connection between these chambers in detail. Due to the proximity of the defect to the septal tricuspid valve leaflet, the Amplatzer duct occluder (AGA Medical Corporation; Golden Valley, USA) provided a reasonable fit because it has no right-sided disk that might interfere with tricuspid valve motion. The defect size and trans-shunt pressure gradient were compatible with echocardiographic evaluation. The patient refused the surgery; therefore we suggested device closure. After the patient's consent, the defect was successfully closed percutaneously with an Amplatzer Duct Occluder (size: 10-8 mm) (Figure 1C). After the successful implantation, no complications or residual shunt were found. Figure 1 A – 2D TTE revealed tunnel-like appearance of Gerbode defect between LVOT and RA in parasternal short-axis view (see arrow). B – Color Doppler echocardiography demonstrated clear systolic jet directed from the LVOT to the RA (see arrow). ... The Gerbode defect is a rare form of ventricular septal defect (VSD) that allows for communication between the left ventricle (LV) and RA. The congenital form of the LV-RA shunt is uncommon and the incidence is 0.08% of all catheterized congenital defects. Anatomically, two types of Gerbode defect are defined, supravalvular (less common) and subvalvular, depending on whether the defect in the membranous septum is above or below the tricuspid valve. Shunting from the LV to the RA mainly occurs in systole, resulting in a high-velocity jet by spectral Doppler between these chambers [1–3]. The LV-RA shunt is traditionally corrected surgically, but device closure is more comfortable new method. Six case reports of successful transcatheter closure in adults have been reported in the literature. Five patients were over 60 years old, and one patient was 22 years old. Five of these cases were performed after mitral valve surgery, and one was performed after VSD repair. Three communications were closed with Amplatzer duct occluders (ADO), one with VSD, and two with atrial septal defect occluders. Residual shunt of only trivial to mild degree was noted in four of those 6 cases. There were no major complications. All reported cases of catheter-based closure seemed to have 100% survival based on reviewing these case reports [4].

PREVALENCE OF RIGHT VENTRICULAR DYSFUNCTION IN PERMANENT ATRIAL FIBRILLATION AND CHANGE OVER TIME

PREVALENCE OF RIGHT VENTRICULAR DYSFUNCTION IN PERMANENT ATRIAL FIBRILLATION AND CHANGE OVER TIME

Comparison of the offset distance of the tricuspid septal leaflet in neonates with Ebstein’s anomaly and neonates with pulmonary atresia with intact ventricular septum

An indexed offset distance of the tricuspid septal leaflet ⩾8 mm/m2 is a quantitative criterion for the diagnosis of Ebstein's anomaly. The purpose of this study was to investigate the validity of this criterion for the discrimination of Ebstein's anomaly from pulmonary atresia with intact ventricular septum in neonatal patients. A total of 122 neonatal patients, 56 with Ebstein's anomaly and 66 with pulmonary atresia with intact ventricular septum, were enrolled. Diagnosis of each anomaly was based on typical morphologic features. Echocardiographic variables, including the offset distance of the tricuspid septal leaflet, were measured via an offline analysis of images recorded before 1 month of age. The offset distance of the tricuspid septal leaflet was indexed by the body surface area, and the indexed offset distances in the Ebstein's anomaly and pulmonary atresia with intact ventricular septum groups were 34.2 mm/m2 (7.1-119.1 mm/m2) and 7.2 mm/m2 (0.0-25.6 mm/m2), respectively. The indexed offset distance was ⩾8 mm/m2 in 29 (43.9%) of the patients with pulmonary atresia with intact ventricular septum; clinical and echocardiographic characteristics were comparable between these 29 patients and the remaining 37 patients with pulmonary atresia with intact ventricular septum. When an indexed offset distance ⩾8 mm/m2 was applied as a cut-off for the diagnosis of Ebstein's anomaly, the sensitivity was 0.963 and the specificity was 0.561. In conclusion, indexed offset distance ⩾8 mm/m2 cannot be used as a cut-off for the diagnosis of complicated Ebstein's anomaly in neonatal patients with pulmonary atresia with intact ventricular septum.

Three-dimensional Echocardiographic Evaluation of Severe Tricuspid Regurgitation due to Leaflet Damage by Endocardial Pacing Lead

A 76-year-old woman developed congestive heart failure within a year following permanent pacemaker implantation. She was found to have moderate to severe functional mitral regurgitation and severe tricuspid regurgitation. However, two-dimensional echocardiography was unable to delineate the impact of pacing lead on tricuspid regurgitation. Subsequent three-dimensional echocardiography visualized that the pacing lead had passed through the tricuspid septal leaflet causing severe regurgitation. This finding was confirmed during successful mitral and tricuspid repair.

Abstract 19141: Natural History of Tricuspid Annulus and Right Atrial Remodeling in Permanent Atrial Fibrillation

Background: The natural history of tricuspid annulus and right atrial (RA) remodeling in patients with permanent atrial fibrillation (AF) has not been assessed. We aimed to determine the rate of change in tricuspid annulus diameter and RA volume in patients with permanent AF. Methods: This cohort study included 160 patients with a history of permanent AF who had at least 2 transthoracic echocardiograms performed between 2005 and 2010 at Vancouver General Hospital in British Columbia. Patients with structural valve disease at onset, congenital heart disease, and patients with more than mild-moderate tricuspid or mitral regurgitation were excluded from analyses. The tricuspid annulus diameter, defined as the distance between the points of attachment of the anterior and septal tricuspid leaflets from the apical 4-chamber view, was measured during end-systole and end-diastole. Maximal RA size was measured in terms of RA volume using single plane Simspon’s method from 4 chamber view. Linear mixed effects modelling was used in analyzing the changes in measurements over time. Results: Of the 160 subjects included in this analysis, 100 were men (62.5%). The mean age at study entry was 74±10 yrs. The median number of echocardiographic studies performed was 3 (range 2 - 6). All 160 patients showed progressive increase in tricuspid annulus diameter over time. There was a significant increase in tricuspid annulus diameter at end-systole and end-diastole over a mean follow up time of 3.2 ± 2.8 years. Respectively, the increase was 0.68 mm/ year, 95% CI 0.232 -1.02, P=0.0027) and end-diastole 0.63 mm/year, 95% CI 0.182-0.93, P=0.0015). Mean RA volume increased from a mean of 39 mL/m2 to 81 mL/m2 for the cohort, or 13 mL/m2 per year, which was significantly greater than the increase in left atrial volume (10 mL/m2 per year, P&lt;0.001). Conclusions: Permanent AF was associated with significant increase in tricuspid annulus diameter and RA volume over time. The rate of changes appeared greater on the right side than on the left. How these differential changes relate to the frequent findings of right heart failure in these patients warrant further investigations.

Cardiac device-related endocarditis in the patient with end-stage renal failure in the course of Fabry disease

Cardiac device-related endocarditis in the patient with end-stage renal failure in the course of Fabry disease

Membranous Septal Aneurysm: An Unusual Case for Sub-Pulmonary Obstruction in cTGA

cTGA; Membranoz Septal Anevrizma; Pulmoner Stenoz Abstract Aneurysm of the membranous portion of the interventricular septum is an uncommon congenital cardiac malformation that is rarely diagnosed during life. Perimembranous ventricular septal defects are the most common type of the ventricular septal defects and originates from morphologically membranous interventricular septum. Surgical exposure and accurate closure of a ventricular septal defect with a membranous septal aneurysm beneath the tricuspid septal leaflet carries a risk of tricuspid valve insufficiency and conduction disturbances. The current study presents a case with membranous septal aneursym with congenitally corrected transposition of the great arteries and sub-pulmonary obstruction, which was surgically corrected.

Tricuspid Valve Repair for a Patient with Congenital Isolated Severe Tricuspid Regurgitation

Severe tricuspid regurgitation commonly results from left-sided heart disease and secondary pulmonary hypertension, while isolated tricuspid regurgitation requiring surgical intervention is extremely rare. We describe a case of an 81-year-old man presenting with congenital isolated severe tricuspid regurgitation due to annular dilatation and tricuspid valve leaflet dysfunction. Echocardiography revealed enlargement of the right atrium and dilatation of the tricuspid annulus. Significant downward displacement of the tricuspid septal leaflet (>10mm) suggesting Ebstein’s abnormality was not seen. Right cardiac catheterization confirmed elevated right atrial pressure, and no left-to-right shunt was detected at the right atrium. Upon surgery, severe annular dilatation of the tricuspid valve with a deformed anterior tricuspid leaflet was visualized. Tricuspid annuloplasty with a prosthetic ring and tricuspid repair was successfully performed with subsequent resolution of the patient’s condition.

Cardiac benign tumors: echocardiography and computed tomography findings in two cases with histopathologic correlation

The aim of this study is to present two patients with cardiac tumors, which by their localization, size and histopathological lineage, can be considered very rare. The clinical, echocardiographic, computed tomography and pathological findings obtained in two examples were analyzed. The first case was a 54-year-old female who had progressive dyspnea with small efforts and presyncope of 1 month of evolution, most likely related to obstructive tricuspid valve myxoma-generated process, which protruded into the right ventricle reaching the apex, as was demonstrated in bidimensional color Doppler and tridimensional echocardiography. The second case was a 66-year-old male with a 6-month history of fatigue, weakness and dyspnea with great effort. The echocardiogram showed an heterogeneous ovoid mass in the right ventricle, attached to the interventricular septum with tricuspid septal leaflet infiltration. The cardiac computed tomography (CT) corroborated the presence of tumor with calcification and fat components, suggestive of teratoma, because mature cartilage tissue is not always identifiable with CT and Hounsfield units of cartilages are variable. The calcium density on the CT image is considered to be bone or cartilage, but is not specific. The differential diagnosis with liposarcoma is described in discussion. Two-dimensional echocardiography is the primary diagnostic imaging modality in the morphological evaluation of intracardiac masses, it is also useful in the following-up of the possible recurrences. This technique is non-invasive, low cost and provides real-time imaging with high spatial and temporal resolution. Three-dimensional echocardiography is a useful tool that provides additional information and better morphological characterization of intracardiac masses. Computed tomography can accurately identify the components of the tumor and it contributed to the proper diagnosis of teratoma. In both patients, the diagnosis was early and precise, with surgical curative resection of the tumors and good prognoses.