Tricuspid Valve Annulus Research Articles

Right ventricular performance in patients with heart failure with mildly reduced ejection fraction: the forgotten ventricle.

Right ventricular (RV) function is a major determinant of prognosis and adverse outcomes in patients with heart failure (HF). It is largely unknown if HF with mildly reduced ejection fraction (HFmrEF) patients have some special characteristics in RV function (RVF) that may distinguish them from HF with reduced or preserved ejection fraction (HFrEF or HFpEF) patients. Standard echocardiography was performed to estimate RVF [tricuspid annular systolic velocity (TDSV), plane systolic excursion (TAPSE), TAPSE to pulmonary artery systolic pressure (TAPSE/PASP) and RV myocardial performance index (MPI-TEI index)] in a cross-sectional study. In 306 participants, the RV systolic function evaluated with TAPSE and TDSV was impaired in 39.1 and 24.2%, respectively. TAPSE, TAPSE/PASP and TDSV were lower in HFmrEF compared with HFpEF and higher compared with HFrEF (p < 0.001 for among-groups comparison). RV diastolic dysfunction varied between 12.6 and 43.8% depending on the echocardiographic parameter. Diastolic RVF determined by tricuspid inflow E/A wave ratio (Et/At) was impaired in less patients with HFmrEF compared with those with HFpEF or HFrEF (25.9% vs 48.4% vs 56.3%; p = 0.030, respectively). RV diastolic dysfunction by et'/at' (tissue Doppler tricuspid valve annulus e' and a' waves) was impaired in less patients with HFmrEF compared with HFrEF (11.8% vs 33.3%; p = 0.019). A multivariate regression analysis revealed a significant association between RV and LV systolic dysfunction. The present study shows a high prevalence of RV dysfunction in HFmrEF patients. Study findings provides some new insights on RV and LV systolic dysfunction coupling whereas RV diastolic dysfunction was not dependent on LV systolic dysfunction.

Outcome Predictors in Catheter Interventions for Severe Right Ventricular Outflow Tract Obstructions.

Introduction & aim of workTranscatheter treatment for critical pulmonary stenosis and membranous pulmonary atresia has become the gold standard of care in many centers. We aimed at evaluating the predictors of outcome in interventions for treatment of duct-dependent right ventricular outflow tract obstruction with intact interventricular septum.Subjects & methods68 cases with pulmonary atresia with intact interventricular septum (PA/IVS) and 50 cases with critical pulmonary stenosis (CPS), all younger than 3 months of age, were operated during the period of 10 years; excluding patients with tricuspid valve annulus Z-score smaller than −4, evidence of right ventricular-dependent coronary circulation or additional malformations.ResultsAge, weight, body surface area as well as tricuspid & pulmonary valve Z-scores were significantly less in PA/IVS; right ventricular pressure was similar in both groups however procedural success and survival to hospital discharge was higher in the CPS group. Lower age, weight and body surface area were associated with procedural failure. Weight was the only predictor of procedural success; while weight and lower post-procedural right ventricular pressure were independent predictors for survival to hospital discharge. Post-procedural right ventricular pressure and length of stay were less in the CPS group. tricuspid and pulmonary valve annulus Z-scores were the only independent predictors of the post-procedural milrinone duration in PA/IVS.ConclusionWe advocate for the use of larger balloon/pulmonary annulus ratio, to achieve a lower right ventricular pressure not fearing excessive pulmonary regurgitation that might be beneficial for right ventricular growth; and for the combination with ductal stenting in borderline or bipartite right ventricles.

Valvuloplasty of fetal pulmonary atresia with intact ventricular septum and hypoplastic right heart: Mid-term follow-up results

ObjectiveThis study aimed to analyze and evaluate the results of mid-term follow-up after fetal pulmonary valvuloplasty (FPV) in fetuses with pulmonary atresia with intact ventricular septum (PA/IVS). MethodsFrom August 31, 2018, to May 31, 2019, seven fetuses with PA/IVS and hypoplastic right heart were included in this study. All underwent echocardiography by the same specialist and were operated on by the same team. Intervention and echocardiography data were collected, and changes in the associated indices noted during follow-up were analyzed. ResultsAll seven fetuses successfully underwent FPV. The median gestational age at FPV was 27.54 weeks. The average FPV procedural time was 6 ​min. Persistent bradycardia requiring treatment occurred in 4/7 procedures. Finally, five pregnancies were successfully delivered, and the other two were aborted. Compared to data before fetal cardiac interventions (FCI), tricuspid valve annulus diameter/mitral valve annulus diameter (TV/MV) and right ventricle diameter/left ventricle diameter (RV/LV) of all fetuses had progressively improved. The maximum tricuspid regurgitation velocity decreased from 4.60 ​m/s to 3.64 ​m/s. The average follow-up time was 30.40 ​± ​2.05 months. During the follow-up period, the diameter of the tricuspid valve ring in five children continued to improve, and the development rate of the tricuspid valve was relatively obvious from 6 months to 1 year after birth. However, the development of the right ventricle after birth was relatively slow. It was discovered that there were individual variations in the development of the right ventricle during follow-up. ConclusionThe findings support the potential for the development of the right ventricle and tricuspid valve in fetuses with PA/IVS who underwent FCI. Development of the right ventricle and tricuspid valve does not occur synchronously during pregnancy. The right ventricle develops rapidly in utero, but the development of tricuspid valve is more apparent after birth than in utero.

Clinical and Echocardiographic Outcomes of Tricuspid Regurgitation After Percutaneous Transmitral Commissurotomy: Prospective Cohort

PURPOSE: The gap in evidence in the management of multivalvular lesions can be addressed by providing more data on clinical and echocardiographic outcomes after percutaneous transmitral commissurotomy (PTMC) in patients with concomitant significant tricuspid regurgitation (TR) at baseline. METHODS: This is a single-center cohort study of adult Filipinos 19 years or older, admitted between January 2019 and October 2020 due to severe mitral stenosis with moderate to severe TR subjected to PTMC. The outcome post-PTMC was divided into 2 groups: significant TR, which included the progression of moderate to severe TR or persistence of severe TR, and insignificant TR group, which included those with mild TR, regression of moderate to mild TR, severe to moderate, or persistence of moderate TR. The clinical and echocardiographic parameters of these groups were compared at baseline, at 24 hours, 1 month, and 6 months postprocedure. The numerical data between significant and nonsignificant TR were compared using nonparametric Mann–Whitney U test and categorical data using the χ2 test. RESULTS: Thirty-eight patients with significant mitral stenosis and TR post-PTMC were analyzed. At 24 hours post-PTMC, the significant TR group had significantly higher right atrial volume index (42.3 vs 26.1, P = 0.004), right ventricular dimension (RVD) mid (3.81 vs 2.92, P = 0.001), systolic pulmonary arterial pressure (60.5 vs 38.5, P = 0.003), and right ventricular outflow tract (2.8 vs 2.2, P = 0.001) and lower mitral valve (MV) planimetry (1.25 vs 1.58, P = 0.009). At 1 month, RVD mid (3.4 vs 2.8, P = 0.02) and tricuspid valve (TV) annulus (3.35 vs 2.76, P = 0.10) were significantly higher in the significant TR group. At 6 months, right atrial volume index (59 vs 24.7, P = 0.001), RVD mid (4 vs 2.73, P = 0.006), and TV annulus (4.5 vs 2.67, P = 0.001) were significantly higher in the significant TR group. The insignificant TR group on the sixth month had significantly improved functional class New York Heart Association I (32 vs 5 P = 0.019). CONCLUSION: Percutaneous transmitral commissurotomy improved functional class and echocardiographic parameters of systolic pulmonary arterial pressure, MV planimetry, and MV gradient on short-term follow-up on both groups of TR. The majority of outcomes after the procedure had insignificant TR. However, those with significant TR had higher RVD mid and TV annulus from 24 hours to 6 months when compared with the insignificant TR group. KEYWORDS: rheumatic heart disease, mitral stenosis, percutaneous transmitral commissurotomy, tricuspid regurgitation

Unexpected Huge Prevalence of Intracardiac Extension of Wilms Tumor-A Single Center Experience from a Ugandan Hospital.

Wilms tumor (WT) is the most common primary renal malignancy in young children. WT vascular extension to the inferior vena cava (IVC) occurs in 4–10% of cases and can reach the right atrium (RA) in 1%. Data on WT clinical presentation and outcome in developing countries are limited. The aim of the present study is to describe the prevalence of intracardiac extension in a consecutive population of WT patients observed in a large non-profit Ugandan hospital. A total of 16 patients with a histological diagnosis of 29 WT were screened in a 6-month period. Patient n°2, a 3 y/o child, presented with a 3-week history of abdominal distension, difficulty in breathing, and swelling of the lower limbs. A cardiovascular system exam showed rhythmic heart sounds, a heart rate of 110 beats per minute, and a pansystolic murmur on the tricuspid area; the abdomen was grossly distended with a palpable mass in the right flank, hepatomegaly, and splenomegaly. An abdomen ultrasound showed an intra-abdominal tumor, involving the right kidney and the liver and extended to the IVC. An ultrasound guided biopsy showed a picture consistent with WT. Cardiac echo showed a huge, mobile, cardiac mass attached to the right side of the interatrial septum, involving the tricuspid valve annulus, causing a “functional” tricuspid stenosis. The patient died of cardiogenic shock 7 days after admission. Patient n°3, a 3 y/o child, presented with analogue symptoms and the same diagnosis. The cardiac echo showed a round mass in the RA. Thirteen more patients were screened with cardiac echo, showing a normal heart picture. In our limited series, we found WT cardiac extension in three patients over 16 (19%). Cardiac echo performed routinely can lead to a better staging, prognostic, and therapeutic assessment. In our setting, the intra-cardiac extension could be more frequent than previously reported and might have prognostic implications.

Novel Computed Tomography Variables for Assessing Tricuspid Valve Morphology: Results from the TRIMA (Tricuspid Regurgitation IMAging) Study.

Background: Computed tomography (CT) is the recommended imaging technique for defining the anatomical suitability for current transcatheter technologies and planning tricuspid valve (TV) intervention. The aim of the Tricuspid Regurgitation IMAging (TRIMA) study was to assess the geometrical characteristics of the TV complex using novel CT parameters. Methods: This prospective, single-center study enrolled 22 consecutive patients with severe tricuspid regurgitation, who underwent a cardiac CT study dedicated to the right chambers. The following variables were obtained: annulus area and perimeter, septal-lateral and antero-posterior diameters, tenting height, and anatomical regurgitant orifice area. Moreover, the following novel annular parameters were assessed: distance between commissures, distance between TV centroid and commissures, and angles between centroid and commissures. Results: A significant phasic variability during the cardiac cycle existed for all variables except for eccentricity, angles, and distance between the postero-septal and antero-posterior commissure and distance between the centroid and antero-posterior commissure. There was a significant relationship between the TV annulus area and novel annular parameters, except for annular angles. Additionally, novel annular variables were found to predict the annulus area. Conclusions: These novel additional variables may provide an initial platform from which the complexity of the TV annular morphology can continue to be better understood for further improving transcatheter therapies.

Anatomy for ablation of ventricular extrasystoles and tachycardia in the right ventricle

Catheter ablation of ventricular tachycardias (VTs) is one of the most complex tasks in interventional electrophysiology. It is complicated by the fact that VT can recur during treatment which can affect the hemodynamic stability of the patient. In addition, navigation with the ablation or mapping catheter through the valvular apparatus and the trabecularization of the ventricle can be challenging. In most cases, athree-dimensional mapping system is used to facilitate orientation and the search for the site where the tachycardia originates. Access to the right ventricle is usually via the tricuspid valve, but in exceptional cases it may also be necessary to use the epicardial venous system. The structures most commonly responsible for an arrhythmia from the right ventricle are the right ventricular outflow tract, the moderator band and the tricuspid valve annulus. The right ventricle is adjacent to vulnerable neighboring structures in many places: In the right ventricular outflow tract, the sinus valsalva, the pulmonary artery and the left ventricular endocardial transition between the aortic and mitral valves must be considered. When ablating along the tricuspid valve annulus, the proximity to the septum and thus to the specific conduction system is particularly important. Knowledge of the surrounding structures helps, on the one hand, to draw the right conclusions about the point of origin in the surface ECG, and, on the other hand, to carry out the ablation successfully and safely.

Computationally Assessed 3D Anatomical Proximities and Spatial Relationships Among the Tricuspid Valve Annulus, Right Coronary Artery, and Triangle of Koch: Implications for Transcatheter Tricuspid Annuloplasty Repair

BackgroundTranscatheter-based annuloplasty therapies for tricuspid regurgitation have demonstrated significant development over recent years. However, the tricuspid valve and neighboring vasculature and conductive tissue regions can present anatomical and device deployment challenges. This present study investigated the anatomical dimensions and spatial relationships of the cardiac structures essential to percutaneous annuloplasty procedures: the tricuspid annulus (TA), right coronary artery (RCA), and triangle of Koch border region. MethodsMeasurements were derived from computational three-dimensional reconstructions of static magnetic resonance imaging scans of perfusion-fixed human hearts (n = 82) with preserved right-sided heart anatomies. This specimen set included heart samples presenting with prediagnosed atrioventricular valvular regurgitation. ResultsOur anatomical assessments demonstrated that the TA to RCA proximities were intensified with the presence of atrioventricular valvular regurgitation, compared with healthy heart specimens. The minimal distances were frequently located between the lateral and posterior annular points. This annular region corresponds to the RCA distal segments and posterior descending branch origins. Greater portions and incidences of the RCA coursing parallel or inferior to the TA plane were recorded for these diseased hearts. Patient demographic variables (gender, age, and body mass index) were insignificant determinants of change for a majority of our results. ConclusionsThese three-dimensional reconstructions provide insights to guide the development and future iterations of transcatheter tricuspid valve annuloplasty systems with regards to device anchoring, annular geometry, tissue proximities, and implantation considerations.

A pilot investigation of the tricuspid valve annulus in newborns with hypoplastic left heart syndrome

ObjectiveHypoplastic left heart syndrome (HLHS) is a congenital disease characterized by an underdevelopment of the anatomical components inside the left heart. Approximately 30% of newborns with HLHS will develop tricuspid regurgitation, and it is currently unknown how the valve annulus mechanics and geometry are associated with regurgitation. Thus, we present an engineering mechanics-based analysis approach to quantify the mechanics and geometry of the HLHS-afflicted tricuspid valve (TV), using 4-dimensional echocardiograms. MethodsInfants born with HLHS (n = 8) and healthy newborns (n = 4) had their TVs imaged, and the data were imported to 3D Slicer. The annular curves were defined at 5 points in the cardiac cycle. The geometry and deformation (strain) of the TV annulus were calculated to elucidate the mechanics of this critical structure and to compare them between neonates with and without HLHS. ResultsFor the annular geometry, HLHS-afflicted newborns had significantly larger annular circumferences (20%-30%) and anteroposterior diameters (35%-45%) than the healthy patients. From a biomechanics' perspective, the HLHS patients had significantly smaller strains in the anterior segments (–0.1 ± 2.6%) during end-diastolic and end-isovolumetric relaxation (1.7 ± 3.0%) compared with the healthy counterparts (–13.3 ± 2.9% and 6.8 ± 0.9%, respectively). ConclusionsThe image-based analysis presented in this study may provide novel insights into the geometric and mechanistic differences in the TV annulus between the healthy and HLHS newborns. Future longitudinal studies of the biomechanics of TV annulus and other subvalvular structures may inform our understanding of the initiation and development of tricuspid regurgitation and the design of optimal repairs in this challenging population.

Effect of interventional edge-to-edge repair in tricuspid regurgitation on dimensions of the annulus

Abstract Funding Acknowledgements Type of funding sources: None. Background The technique of percutaneous tricuspid valve edge-to-edge repair (pTVR) depends upon the connection of leaflets in the area of regurgitation using a coaptation device. By closing the coaptation device a considerable tractive force is applied on the leaflets, which might have an effect on the valve annulus. The aim of this study was to examine the impact of device implantation on tricuspid annular dimensions. Methods During pTVR, 3D zoom loops of the tricuspid valve (TV) were acquired before and after clip placement using transesophageal echocardiography. Measurements of TV annular dimensions included the following parameters: annulus area (TV area), maximal diameter, minimal diameter, and eccentricity index (Figure 1). Tenting area was derived from a four-chamber view of the valve. Tricuspid regurgitation (TR) severity was graded from 1+ to 5+ by measuring vena contracta area (VCA3D) in 3D full volume color Doppler loop using multiplanar reconstruction. Right atrial (RA) and ventricular volumes (RVVd3D, RVVs3D) and function (RVEF3D) were assessed in a 3D full volume loop. Results The study population consisted of 97 patients (age 78 ± 6 years, 47 male), undergoing pTVR at our hospital. As expected, cavity dimension correlated with TV area size (for RVVd3D r = 0.51, p &amp;lt; 0.001 and for RA volume r = 0.71, p &amp;lt; 0.001). The mean TV annular area was significantly reduced (Annular area 8.53 ± 2.23 cm²/m²BSA vs. 7.55 ± 2.18 cm²/m²BSA, p &amp;lt; 0.001) and the shape of the annulus became more oval (Eccentricity index 1.2 ± 0.15 vs. 1.29 ± 0.17, p &amp;lt; 0.001) after pTVR. The reduction in annular area (12 ± 7%, range 0.7-28%) was only modestly correlated with the number of implanted coaptation devices (r = 0.30, p &amp;lt; 0.001) and the percentage reduction of VCA3D (r =0.36, p &amp;lt; 0.001). In the patient group with an annular area change ≥12%, a decrease in TR grade to ≤2+ by pTVR was achieved in 83% of cases, whereas only 62% of patients achieved moderate TR when the change in area was below 12%. Conclusion pTVR using coaptation devices reduces the area of the TV annulus. This effect may be modestly correlated to the number of devices implanted. Abstract Figure.

Relationship between right ventricular geometry and function parameters and tricuspid annuloplasty efficacy

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION The prevalence of untreated moderate and severe functional tricuspid regurgitation (TR) eventually leads to heart failure and is associated with poor prognosis. Therefore, tricuspid annuloplasty (TA) is offered as a first-line treatment for significant functional TR. However, studies to investigate factors leading to recurrent TR after TA are still scarce. AIM The aim is to investigate the relationship between right ventricular (RV) geometry and function parameters and recurrent TR after TA. METHODS Prospective observational cohort study enrolled patients with moderate or severe functional TR caused by left heart valvular disease who underwent surgical tricuspid valve (TV) repair. The dominant pathology was severe mitral regurgitation. Patients with ischemic heart disease (assessed by coronary angiography) were excluded from the analysis. The current study included 60 patients with full sets of preoperative 2D and 3D echocardiographic parameters. Echocardiographic quantification included the following parameters: the RV and RA geometry, functional (velocity of the tricuspid annular systolic motion [S’] and RV fractional area change [FAC], tricuspid annular plane systolic excursion [TAPSE] and RV ejection fraction (EF)). The severity of TR was measured quantitatively according to the recent ESC guidelines. Patients were divided into two groups according to the outcomes of TA: effective (38 pts.) and ineffective (22 pts.) TV repair. Effective TA was considered if TR 1 year after surgery was mild, while ineffective – TR was moderate or severe (recurrent TR). The statistical analysis was performed using SPSS statistical software, univariate logistic regression was used. RESULTS In 60 patients of current analysis 67% were female, mean age was 67 ± 9 years. The odds ratio for risk of ineffective TA are shown in Table 1. Age, gender, body mass index, left ventricular (LV) functional, as well as left atrial parameters did not differ between effective and ineffective TA groups. When analysing echocardiographic parameters in univariate logistic regression, RV and RA geometry, TV annulus diameter had predictive value for ineffective TA. Preoperative effective regurgitant orifice area (EROA) did not differ significantly between two groups (ineffective TA vs. effective TA; 31 [60] mm2 vs. 24 [17] mm2, p = 0.308 respectively). Meanwhile, none of the RV functional parameters were significant. CONCLUSION Recurrent moderate or severe functional tricuspid regurgitation after tricuspid annuloplasty is associated with preoperative tricuspid annulus size, RA and RV geometry, but not with changes of RV function. Abstract Figure.

Long-Term Impact of Preventive Tricuspid Valve Annuloplasty on Right Ventricular Remodeling

In patients with primary mitral regurgitation (MR), concomitant tricuspid valve (TV) annuloplasty at the time of left-sided valve surgery is indicated in case of a dilated TV annulus ≥40mm independent of the presence or severity of tricuspid regurgitation (TR). However, the long-term impact on right ventricular (RV) adverse remodeling is less well established and the benefit of preventive TV annuloplasty remains controversial. The aim of the study was to assess differences in long-term RV adverse remodeling and the development of significant TR in those patients. In total, 98 patients (mean age 65 ± 11years, 85% men) with significant primary MR and TV annulus dilatation ≥40mm without significant TR who underwent mitral valve (MV) repair with or without concomitant TV annuloplasty were included. Of the 98 patients, 28 patients underwent isolated MV repair without TV annuloplasty and 70 patients received concomitant TV annuloplasty at the time of MV surgery. The RV basal diameter (p=0.03), RV long-axis diameter (p=0.04), RV end-diastolic area (p <0.01), and RV end-systolic area (p=0.03) showed less adverse remodeling at follow-up in patients with concomitant TV annuloplasty compared with patients without TV annuloplasty. Additionally, 4 patients (14%) in the subgroup without TV annuloplasty developed significant TR during follow-up in contrast to zero patients in the subgroup with TV annuloplasty (p=0.001). In conclusion, concomitant preventive TV annuloplasty during MV surgery in patients with primary MR, no significant TR and a tricuspid annulus (≥40mm) prevented RV adverse remodeling and the development of significant TR at long-term follow-up.

A Comparison of the Electrophysiological and Anatomic Characteristics of Pacing Different Branches of the Left Bundle Conduction System.

Introduction: Left bundle branch pacing (LBBP) is a rapidly growing conduction system pacing technique. However, little is known regarding the electrophysiological characteristics of different types of LBBP. We aimed to evaluate the electrophysiological characteristics and anatomic lead location with pacing different branches of the left bundle branch.Methods: Consecutive bradycardia patients with successful LBBP were enrolled and classified into groups according to the paced electrocardiogram and the lead location. Electrocardiogram, pacing properties, vectorcardiogram, and lead tip location were analyzed.Results: Ninety-one patients were enrolled, including 48 with the left bundle trunk pacing (LBTP) and 43 with the left bundle fascicular pacing (LBFP). The paced QRS duration in the LBTP group was significantly shorter than that in the LBFP group (108.1 ± 9.9 vs. 112.9 ± 11.2 ms, p = 0.03), with a more rightward QRS transition zone (p = 0.01). The paced QRS area in the LBTP group was similar to that during intrinsic rhythm (35.1 ± 15.8 vs. 34.7 ± 16.6 μVs, p = 0.98), whereas in the LBFP group, the paced QRS area was significantly larger compared to intrinsic rhythm (43.4 ± 15.8 vs. 35.7 ± 18.0 μVs, p = 0.01). The lead tip site for LBTP was located in a small fan-shaped area with the tricuspid valve annulus summit as the origin, whereas fascicular pacing sites were more likely in a larger and more distal area.Conclusions: Pacing the proximal left bundle main trunk produced better electrical synchrony compared with pacing the distal left bundle fascicles. A visualization technique can facilitate achieving LBTP.

Tricuspid Valve Size Relationship to Right Ventricular Volume in Post-operative Tetralogy of Fallot Patients

In post-operative Tetralogy of Fallot (TOF) patients cMRI data are used for determining right ventricle (RV) dilation to justify the pulmonary valve placement. Echocardiogram analysis of RV volumes has inherent accuracy issues. There are no data exploring the relationship of transthoracic echocardiography tricuspid valve (TV) annulus size and cMRI RV dilation. Retrospective study in post-operative TOF patients. Patients less than 21years old and with high-quality transthoracic echocardiogram and MRI within 6months of each other were included. We collected demographic data, type of initial repair, echocardiographic, and cMRI data. A single reviewer measured echocardiogram TV size. Boston z-scores were used. 77 echocardiogram and cMRI pairs were analyzed. Average age was 14years old. There is not a strong linear relationship between TV z-score and indexed right ventricular end diastolic volume (RVEDVi) (R2 = 0.31). Twenty patients had RVEDVi's of greater than 150ml/m2. From those 20 patients, 9 patients had a TV z-score of > 2. No patient had a TV z-score > 2 and a normal RVEDVi. For a TV z-score < 2, there was a positive predictive value of 100%, a negative predictive value of 83%, specificity of 100%, and sensitivity of 45%. In our study population, the TV z-score is not sufficient to predict RV dilation. However, TV z-score > 2 has a high positive predictive value for an RVEDVi of > 150ml/m2. This would suggest that a cMRI should be done if the TV z-score is > 2 on echocardiography.

КЛИНИКО-ГЕМОДИНАМИЧЕСКАЯ ОЦЕНКА ПАЦИЕНТОВ С НЕРЕВМАТИЧЕСКОЙ НЕДОСТАТОЧНОСТЬЮ ТРЕХСТВОРЧАТОГО КЛАПАНА СЕРДЦА (ФУНКЦИОНАЛЬНОЙ) ПРИ ХРОНИЧЕСКИХ ФОРМАХ ИШЕМИЧЕСКОЙ БОЛЕЗНИ СЕРДЦА ИЛИ ДИЛАТАЦИОННОЙ КАРДИОМИОПАТИИ

Objectives: to study and compare the clinical and echocardiographic characteristics of patients with functional (secondary) tricuspid insufficiency, depending on its etiology and depending on the surgical methods used in surgical practice for its correction. Materials and methods: clinical and hemodynamic assessment of a population of patients with non-rheumatic tricuspid valve insufficiency (functional) in chronic forms of coronary heart disease (CHD) or dilated cardiomyopathy (DCMP) was performed. The study included 792 patients who underwent correction of non-rheumatic tricuspid valve insufficiency (functional) during a period 2011–2020: 642 participants with coronary artery disease, 150 participants with DCMP. Clinical and echocardiographic parameters were assessed. Results: In the analyzed patient population, in-hospital mortality after surgery in patients with CAD was significantly higher than in patients with DCMP, which can be explained by a number of factors, including the more severe nature of the pathology in patients with CAD (in the study, patients with multiple coronary arteries lesions and a high functional class of angina prevailed in the group of coronary artery disease), and a larger scale of surgical intervention. In patients with DCMP, a more significant dilatation of the right ventricular cavity and a significantly higher increase of right ventricle volumes were noted. At the same time, despite more significant remodeling of the left (LV) and right ventricles (RV), the level of systolic and mean pulmonary artery pressure did not differ significantly between patients with CAD and DCMP. There was no significant difference in the levels of dilatation and volume of the right atrium between patients with CHD and DCMP. Patients with DCMP showed more severe dilatation of the tricuspid valve annulus and the area of its orifice. However, when assessing the magnitude of the degree of severity of the functional tricuspid valve insufficiency, no significant differences were noted in almost all parameters, depending on the etiology. Despite a comparable volume of regurgitation and the degree of tricuspid valve insufficiency, patients with DCMP had a significantly more severe changed geometry of the tricuspid valve annulus. Ring plasty techniques were used in patients with more pronounced LV remodeling and severe LV systolic dysfunction. This, most likely, caused a more significant overload of the pulmonary circulation, causing a higher level of pulmonary hypertension and volume overload of the right heart. In patients with CHD, suture repair methods were more often used, and in patients with DCMP, ring methods of annuloplasty of the tricuspid valve were used more often. At the same time, regardless of the etiology, ring annuloplasty techniques were used with more severe functional insufficiency of the TV in patients with a significantly more significant decrease in right ventricular contractility. Conclusion: in the study population, hospital mortality was higher in the CHD group than in the DCMP group. In DCMP, a more pronounced dilatation of the tricuspid valve annulus and the area of its opening were observed, however, the degree of severity of the functional insufficiency of the tricuspid valve in all respects does not depend on the etiology. In patients with DCMP, there is a significantly more pronounced violation of the geometry of the tricuspid valve annulus. In patients with coronary heart disease, suture repair methods are more often used, and in patients with DCMP, ring methods of annuloplasty of the tricuspid valve are used. Both in CHD and DCMP, ring plasty of tricuspid valve were used in cases of more severe functional insufficiency in patients with a significantly more decreased contractility of the left and right ventricles.

Tricuspid Valve Intervention at the Time of Pulmonary Valve Replacement in Adults With Congenital Heart Disease: A Systematic Review and Meta-Analysis.

BackgroundTricuspid regurgitation (TR) is a common finding in adults with congenital heart disease referred for pulmonary valve replacement (PVR). However, indications for combined valve surgery remain controversial. This study aimed to evaluate early results of concomitant tricuspid valve intervention (TVI) at the time of PVR.Methods and ResultsObservational studies comparing TVI+PVR and isolated PVR were identified by a systematic search of published research. Random‐effects meta‐analysis was performed, comparing outcomes between the 2 groups. Six studies involving 749 patients (TVI+PVR, 278 patients; PVR, 471 patients) met the eligibility criteria. In the pooled analysis, both TVI+PVR and PVR reduced TR grade, pulmonary regurgitation grade, right ventricular end‐diastolic volume, and right ventricular end‐systolic volumes. TVI+PVR, but not PVR, was associated with a decrease in tricuspid valve annulus size (mean difference, −6.43 mm, 95% CI, −10.59 to −2.27; P=0.010). Furthermore, TVI+PVR was associated with a larger reduction in TR grade compared with PVR (mean difference, −0.40; 95% CI, −0.75 to −0.05; P=0.031). No evidence could be established for an effect of either treatment on right ventricular ejection fraction or echocardiographic assessment of right ventricular dilatation and dysfunction. There was no evidence for a difference in hospital mortality or reoperation for TR.ConclusionsWhile both strategies are effective in reducing TR and right ventricular volumes, routine TVI+PVR can reduce TR grade to a larger extent than isolated PVR. Further studies are needed to identify the subgroups of patients who might benefit most from combined valve surgery.

Narrative review of Ebstein's anomaly beyond childhood: Imaging, surgery, and future perspectives.

Ebstein's anomaly is a rare congenital heart disease with malformation of the tricuspid valve and myopathy of the right ventricle. The septal and inferior leaflets adhere to the endocardium due to failure of delamination. This leads to apical displacement of their hinge points with a shift of the functional tricuspid valve annulus towards the right ventricular outflow tract with a possibly restrictive orifice. Frequently, a coaptation gap yields tricuspid valve regurgitation and over time the "atrialized" portion of the right ventricle may dilate. The highly variable anatomy determines the clinical presentation ranging from asymptomatic to very severe with need for early operation. Echocardiography and magnetic resonance imaging are the most important diagnostic modalities to assess the tricuspid valve as well as ventricular morphology and function. While medical management of asymptomatic patients can be effective for many years, surgical intervention is indicated before development of significant right ventricular dilatation or dysfunction. Onset of symptoms and arrhythmias are further indications for surgery. Modified cone reconstruction of the tricuspid valve is the state-of-the-art approach yielding the best results for most patients. Alternative procedures for select cases include tricuspid valve replacement and bidirectional cavopulmonary shunt depending on patient age and other individual characteristics. Long-term survival after surgery is favorable but rehospitalization and reoperation remain significant issues. Further studies are warranted to identify the optimal surgical strategy and timing before adverse right ventricular remodeling occurs. It is this article's objective to provide a comprehensive review of current literature and an overview on the management of Ebstein's Anomaly. It focuses on imaging, cardiac surgery, and outcome. Additionally, a brief insight into arrhythmias and their management is given. The "future perspectives" summarize open questions and fields of future research.

Insights from 3D Echocardiography in Hypoplastic Left Heart Syndrome Patients Undergoing TV Repair.

Tricuspid regurgitation (TR) in hypoplastic left heart syndrome (HLHS) is associated with morbidity and mortality. TR mechanisms and the impact of tricuspid valve repair (TVR) are unclear. We examined HLHS TR mechanisms, TVR's impact on tricuspid valve (TV), and features of poor TVR durability. We retrospectively compared 35 HLHS TVR cases and 35 age/stage-matched HLHS controls who do not undergo TVR. Pre-operative 3-dimensional echocardiography (3DE) assessed overall TV morphology (prolapse, normal, tethered), leaflet morphology, vena contracta area, and TR location. Two-dimensional echocardiography measured TV annulus diameter, RV fractional area change (RVFAC), sphericity, and TR grade at three time points (pre-op, early post-op, and latest follow-up). Pre-op, TVR group, and controls had no difference in age, RV function or shape, or TV dimension. TVR group most commonly had anterior leaflet prolapse followed by septal leaflet prolapse or tethering. TR jet arises centrally (63%) and anterior septally (26%). Posterior annuloplasty (69%), commissuroplasty (37%), and leaflet repair (37%) were surgical techniques commonly performed. At early post-op, TR grade and TV annulus decreased. At latest follow-up, TV annulus remained reduced; however, 50% had significant TR. 25% required TV reoperation. Larger vena contracta at TVR was associated with significant TR. HLHS patients undergoing TVR had more anterior leaflet prolapse and central TR. While TVR initially reduces annular size and TR grade, 50% redevelop significant TR despite maintained annular reduction. The association of greater TR severity prior to repair with post-op recurrence raises the consideration for earlier repair of TR in HLHS patients.

Results after Repair of Functional Tricuspid Regurgitation with a Three-Dimensional Annuloplasty Ring.

Background: Tricuspid valve (TV) repair is the recommended treatment for severe functional tricuspid regurgitation (fTR) in patients undergoing left-sided surgery. For this purpose, a wide range of annuloplasty devices differing in form and flexibility are available. This study reports the results using a three-dimensional annuloplasty ring (Medtronic, Contour 3D Ring) for TV repair and analysis of risk factors. Methods: A cohort of 468 patients who underwent TV repair (TVr) with a concomitant cardiac procedure from December 2010 to January 2017 was retrospectively analyzed. Results: At follow-up, 96.1% of patients had no/trivial or mild TR. The 30-day mortality was 4.7%; it significantly differed between electively performed operations (2.7%) and urgent/emergent operations (11.7%). Risk factors for recurrent moderate and severe TR were LVEF < 50%, TAPSE < 16 mm, and moderate mitral valve (MV) regurgitation at follow-up. Preoperatively reduced renal function lead to a higher 30-day and overall mortality. Reoperation of the TV was required in six patients (1.6%). Risk factors for TV related reoperations were preoperative TV annulus over 50 mm and an implanted permanent pacemaker. Conclusions: TVr with the Contour 3D annuloplasty ring shows low TR recurrence and reoperation rates. Risk-factor analysis for the recurrence of TR revealed the importance of left- and right-ventricular function.

An off-pump biatrial mini-maze procedure for treatment of long-standing persistent atrial fibrillation

Abstract Background Surgical treatment has assumed a more prominent role in the therapy of atrial fibrillation (AF) with favorable efficiency and acceptable safety during the last decades. The traditional Cox-Maze procedure and Wolf Mini-Maze procedure focused on left atrial ablation. However, it is ubiquitous that patients with long-standing persistent atrial fibrillation (LSPAF) typically suffer from biatrial electrical and structural remodeling. The left atrial procedures are still not enough in patients with LSPAF. Purpose Herein, we aimed to introduce a modified biatrial off-pump ablation procedure based on the Wolf Mini-Maze procedure and to detect the safety and efficacy of the surgery for patients with LSPAF. Methods Between January 2016 and September 2020, 102 patients of LSPAF underwent our modified Mini-Maze procedure using bipolar radiofrequency ablation. Those patients firstly underwent a Mini-Maze procedure using Dallas lesion set, including video-assisted bilateral mini-thoracotomy, left atrial appendage excision, bilateral pulmonary vein isolation, ganglionic plexi evaluation and destruction, left atrial roof connecting lesion, and a linear lesion connecting this roofline to the root of the aorta at the junction of the left coronary and the non-coronary cusp. Secondly, a purse-string suture was performed on the right atrium, and then four ablation lesions were made to the superior vena cava, to the inferior vena cava, to the appendix of the right atrium, and to the tricuspid valve annulus from the purse-string suture point by the bipolar radiofrequency clamp. After the operation, the patients were followed up at an interval of 3, 6, 12 months, and every 1 year after that. Results No mortality No surgical re-exploration for bleeding. No permanent pacemaker implantation. 99 patients were free from LSPAF upon discharge. A follow-up at interval of 3, 6, 12, 24, 36, and 48 months showed a success rate free from LSPAF was 95.1% (97/102), 94.4% (85/90), 94.8% (73/77), 91.5% (54/59), 90.3% (28/31) and 100% (9/9), respectively Conclusions The modified biatrial Mini-Maze suggested a safe and feasible procedure. Early follow-up demonstrated an acceptable success rate free from AF. It might have the potential to become another option for clinical treatment of LSPAF. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): General Program of the National Natural Science Foundation of China Schematic of the procedure