Tricuspid Valve Dysfunction Research Articles

PO-621-02 EXTRACTION OF LEADS ACROSS THE TRICUSPID VALVE DOES NOT SIGNIFICANTLY ALTER TRICUSPID VALVE REGURGITATION

Pacemaker and defibrillator leads have been implicated in tricuspid valve (TV) dysfunction, but limited data are available regarding the effect of extracting leads across the tricuspid valve on valve function. While there is growing interest in TV intervention, including lead-related dysfunction, the effect of extraction across the valve is not well studied.

PO-686-05 IDENTIFICATION OF PACEMAKER LEAD POSITION BY FLUOROSCOPY TO AVOID SIGNIFICANT TRICUSPID REGURGITATION

The increase of life expectancy in the general population also increased permanent pacemaker (PPM) implantation. Although PPM implantation increase survival, it has the potential to cause tricuspid valve dysfunction predominantly tricuspid regurgitation (TR). The right ventricle pacemaker-lead crossing the tricuspid valve may cause fibrosis and thickening of leaflets which impairs valve mobility and coaptation. The dominant mechanism of pacemaker mediated TR is lead impingement.

Two case reports of transcatheter valve-in-valve implantation of Sapien 3 and MyVal in degenerated biological tricuspid prosthesis valves

BackgroundPatients with severe tricuspid valve stenosis or dysfunction following degeneration of biological valve prosthesis in tricuspid position are complex, have substantial comorbidity, and very high surgical risk.Case summaryWe report two cases with transcatheter tricuspid valve-in-valve implantation in patients with degenerated tricuspid bioprosthesis with transfemoral and transjugular access with Sapien 3 valve and MyVal, respectively.DiscussionIn patients with high surgical risk, transcatheter tricuspid valve implantation is a good alternative. Careful consideration of optimal access site, device size, and delivery system is paramount. This case report demonstrates technically feasible and safe transcatheter valve-in-valve implantantion in tricuspid position and highlights the importance of meticulous procedure planning.

Outcomes of isolated tricuspid valve surgery in contemporary practice.

Isolated tricuspid valve (TV) surgery is rarely performed and has been associated with high mortality and morbidity. The aim of this study was to describe the clinical outcome and functional capacity following isolated TV surgery in contemporary practice. We conducted a retrospective cohort study including all patients who underwent isolated TV surgery at our institution from 2013 to 2019. Our cohort was identified using the Western Denmark Heart Registry. Postoperative outcomes were evaluated using patients' medical records. The clinical and echocardiographic status was reported for patients who survived beyond 1 year. We included 43 patients [mean age 65.2 ± 13.8, median European System for Cardiac Operative Risk Evaluation II 1.8 (interquartile range 2.0)]. Twelve (27.9%) had prior cardiac surgery. Up to 90-day follow-up, no patient died and major morbidity was limited to 4 patients (9.3%) requiring pacemaker implantation and 1 patient requiring 2 reoperations. Within 1 year, 4 patients (9.3%) died. Nine patients (20.1%) required single readmission for cardiac reasons during the median follow-up of 38.4 months (interquartile range 30.9 months). All patients who survived beyond 1 year (n = 39) completed clinical follow-up. At follow-up, 38/39 (97.4%) patients were New York Heart Association I or II compared to 12/39 (30.8%) preoperatively (P = 0.001). The presence of oedema and intensity of diuretic treatment were significantly reduced (P = 0.005 and P = 0.008, respectively). Echocardiographic follow-up showed significant improvement of TV dysfunction in all patients. Our results suggest that isolated TV surgery can be performed safely and greatly improve patients' functional status. Our findings support the importance of optimal surgical timing and patient selection.

Lead dependent tricuspid dysfunction- diagnosis and management

Abstract Funding Acknowledgements Type of funding sources: None. Background Lead-dependent tricuspid dysfunction (LDTD) is one of complications related to cardiac implantable electronic devices. Purpose The aim of the study was to analyze transthoracic and transesophageal echocardiographic examinations with the assessment of tricuspid valve dysfunction before and after the procedure of transvenous lead extraction (TLE). Methods We analyzed data of 3343 patients undergoing TLE in years 2006-2021 in single center and separated 112 (3,35%) patients with LDTD. The mechanism of LDTD and the effect of TLE on tricuspid valve function were assessed Results are presented in the table Conclusions The most common mechanism of LDTD is to pull the leaflet down and propping the leaflet through the lead. In about 40% of patients, an effective method of therapy is removal of the lead, with reimplantation under the control of TEE or bypassing the tricuspid valve (implantation into the coronary sinus). 65% of patients, despite the lack of improvement after TLE, do not require cardiac surgery (mean follow up- 5 years). Abstract Table Abstract Figure. LDTD

The role of cardiac surgery in transvenous lead extraction. A high-volume center experience with 3207 procedures.

IntroductionThe guidelines stress the importance of cardiac surgery in the management of life-threatening complications arising from lead removal.AimTo delineate the roles of the cardiac surgeon during transvenous lead extraction (TLE).Material and methods3207 patients (38.7% F), average age 65.7 years, underwent the extraction of PM/ICD leads using standard non-powered mechanical systems within the last 14 years.ResultsProcedural success 96.1%, clinical success 97.8%, procedure-related death 0.18%, major complications 1.9% (cardiac tamponade 1.2%, hemothorax 0.2%, tricuspid valve damage 0.3%, stroke and pulmonary embolism < 1%). The roles for cardiac surgery in TLE have been categorized into five areas: 1. Emergency cardiac surgery (1.18% of all patients), 2. Late surgical intervention (TLE-related tricuspid valve dysfunction) (0.44%), 3. Cardiac surgery complementing partially successful TLE (0.68%: removal of lead fragments), 4. Epicardial pacemaker implantation through sternotomy for the above-mentioned reasons (0.65%), 5. Delayed surgical intervention after TLE to place epicardial LV leads (0.53%). Additionally, surgical experience can help in prevention and treatment of wound infection after TLE.ConclusionsEmergency cardiac surgery (mainly due to severe bleeding) is still the most frequent reason for intervention (33.63% (38/113) of all surgical procedures). The other areas of surgical interventions in lead management are: cardiac surgery complementing partially successful TLE, repair or replacement of the malfunctioning tricuspid valve secondary to lead extraction and implantation of permanent epicardial pacing leads after sternotomy or epicardial left ventricle lead to optimize cardiac resynchronization. Experience of a single high-volume lead extraction center confirms the need for close collaboration between the cardiologist and the cardiac surgeon, whose role goes far beyond mere surgical standby.

Lead Dependent Tricuspid Valve Dysfunction-Risk Factors, Improvement after Transvenous Lead Extraction and Long-Term Prognosis.

Background: Lead-related tricuspid valve dysfunction (LDTVD) has not been studied in a large population and its management remains controversial. Methods: An analysis of the clinical data of 2678 patients undergoing transvenous lead extraction (TLE) in years 2008–2021 was conducted, with a separate group of 119 patients with LDTVD. Potential risk factors for LDTVD, improvement in valve function, and long-term prognosis after TLE were assessed. Results: LDTVD was diagnosed in 4.44% of patients referred for lead extraction due to different reasons. The most common mechanism of LDTVD was propping upward or clamping down the leaflet by the lead (85.71%). The probability of LDTVD was higher in female sex, patients with valvular heart disease, atrial fibrillation, heart failure, large right ventricle and high pulmonary artery systolic pressure, the presence of only pacing lead, and in case of collision of the lead with tricuspid valve and adhesion of the lead to the heart structures. The prognosis of patients with LDTVD was worse, however, patients with improved valve function after TLE showed a significantly better long-term survival. Conclusions: Lead dependent tricuspid valve dysfunction is a potentially serious condition that requires thorough diagnostics and thoughtful management. The risk factors for LDTVD are primarily related to the course of the lead and its adhesion to the heart structures. Improvement of tricuspid valve function after TLE is observed in 35.29% of patients Patients with LDTVD have a worse long-term survival, but the improvement in valve function following TLE contributes to a significant reduction in mortality.

Concomitant use and interaction of a subcutaneous implantable defibrillator and epicardial pacemaker.

A concomitant use of S-ICD and epicardial pacemaker was established to avoid tricuspid valve dysfunction. DFT test confirmed that any bipolar pacing did no interference on the S-ICD function.

Transcatheter treatment by valve-in-valve and valve-in-ring implantation for prosthetic tricuspid valve dysfunction.

Valve degeneration after surgical tricuspid valve replacement or repair is frequent and may require repeat replacement/repair. For high-risk patients, transcatheter valve-in-valve and valve-in-ring procedures have emerged as valuable treatment alternatives. Preprocedural transthoracic echocardiography is the method of choice to detect malfunction of the prosthesis including degenerative stenosis and/or regurgitation requiring reintervention. Subsequently, computed tomography is helpful for detailed anatomical analysis and periprocedural planning. Device selection and sizing depend on the size and structural details of the implanted ring or prosthesis. The procedure is mainly guided by fluoroscopy; however, transesophageal echocardiography provides complementary guidance during device implantation. Preferred access route is the right femoral vein but in cases of more horizontal implants a jugular approach might be feasible. Suitable transcatheter valves are the Edwards Sapien 3 and the Medtronic Melody valves. Differences in surgical prostheses or annuloplasty implants are important for device selection, height consideration and additional ballooning prior to or after implantation. Transesophageal echocardiography postimplantation is convenient for the assessment of transvalvular gradients or paravalvular leaks.Supplementary InformationThe online version of this article (10.1007/s00508-021-01842-x) contains supplementary material, which is available to authorized users.

Right mini-thoracotomy approach for grown-up congenital heart disease.

Right mini-thoracotomy cardiac surgery has been recognized as a safe and effective procedure, with remarkable early and long-terms outcomes. However, most of the literature is focused on mitral valve surgery and few studies report on the minimally invasive approach applied to congenital disease. Aim of this study was to review our experience on patients with grown-up congenital heart (GUCH) undergoing right mini-thoracotomy cardiac surgery. Data of patients with GUCH undergoing right mini-thoracotomy cardiac surgery from 2006 to 2019 were retrospectively analyzed. Inclusion criteria were atrial septal defect, partial anomalous pulmonary venous return, partial atrioventricular septal defect, and mitral or tricuspid valve dysfunction in congenital heart diseases. During the study period 127 patients with GUCH underwent right mini-thoracotomy cardiac surgery. Mean age was 43.6 years and more than 60% were females; diagnosis was atrial septal defect in 57 cases (44.9%); 24 patients were redo (18.9%). No cases of stroke and major vascular complications were reported. Conversion to sternotomy was required in one case (0.8%). No residual shunts or valves dysfunction were recorded at the postoperative echocardiographic evaluation. Perioperative mortality was 1.6%. Right mini-thoracotomy cardiac surgery in selected patients with GUCH allows to avoid the big scar of the sternotomy approach and to accelerate the recovery in a young population. Moreover, in redo cases, it allows the surgeon to reach the heart and the aorta avoiding the well-known risks of a re-sternotomy procedure.

Transcatheter valve repair in congenitally corrected transposition of the great arteries.

Introduction In congenitally corrected transposition of the great arteries (CCTGA) the right ventricle (RV) is the systemic ventricle. RV dysfunction and significant regurgitation of the systemic tricuspid valve are common and associated with worse outcomes. Management of tricuspid regurgitation (TR) in CCTGA is challenging. In acquired cardiovascular disease, percutaneous repair of mitral valve regurgitation (MR) is established. Data on CCTGA with TR are limited1. We report our experience with this technique in these patients. Methods CCTGA patients with moderate-severe TR were eligible if surgery was deemed high-risk. Interventional therapy was offered, and patients provided written informed consent. ...

Prognostic Value of Preoperative Echocardiographic Findings in Patients Undergoing Transvenous Lead Extraction.

(1) Background: In patients referred for transvenous lead extraction (TLE) transesophageal echocardiography (TEE) often reveals abnormalities related to chronically indwelling endocardial leads. The purpose of this study was to determine whether the results of pre-operative TEE might influence the long-term prognosis. (2) Methods: We analyzed data from 936 TEE examinations performed at a high volume center in patients referred for TLE from 2015 to 2019. The follow-up was 566.2 ± 224.5 days. (3) Results: Multivariate analysis of TEE parameters showed that vegetations (HR = 2.631 [1.738–3.983]; p < 0.001) and tricuspid valve (TV) dysfunction unrelated to the endocardial lead (HR = 1.481 [1.261–1.740]; p < 0.001) were associated with increased risk for long-term mortality. Presence of fibrous tissue binding sites between the lead and the superior vena cava (SVC) and/or right atrium (RA) wall (HR = 0.285; p = 0.035), presence of penetration or perforation of the lead through the cardiac wall up to the epicardium (HR = 0.496; p = 0.035) and presence of excessive lead loops (HR = 0.528; p = 0.026) showed a better prognosis. After adjustment the statistical model with recognized poor prognosis factors only vegetations were confirmed as a risk factor (HR = 2.613; p = 0.039). A better prognosis was observed in patients with fibrous tissue binding sites between the lead and the superior vena cava (SVC) and/or right atrium (RA) wall (HR = 0.270; p = 0.040). (4) Conclusions: Non-modifiable factors may have a negative influence on long-term survival after TLE. Various forms of connective tissue overgrowth and abnormal course of the leads modifiable by TLE can be a factor of better prognosis after TLE.

Three-dimensional transoesophageal echocardiography allows unique assessment of pacemaker lead-related tricuspid valve dysfunction.

Three-dimensional transoesophageal echocardiography allows unique assessment of pacemaker lead-related tricuspid valve dysfunction.

Outcomes of treatment pathways in 240 patients with congenitally corrected transposition of great arteries

ObjectiveCongenitally corrected transposition of the great arteries (ccTGA) encompasses a diverse morphologic cohort, for which multiple treatment pathways exist. Understanding surgical outcomes among various pathways and their determinants are challenged by limited sample size and follow-up, and heterogeneity. We sought to investigate these questions with a large cohort of ccTGA patients presenting at different ages and representing the full therapeutic spectrum. MethodsRetrospective review of 240 patients diagnosed with ccTGA from Cleveland Clinic coupled with prospective cross-sectional follow-up. Forty-six patients whose definitive procedure was completed elsewhere were excluded. Time-related survival was described among treatment pathways using actuarial, time-varying covariate, and competing risks analyses. Temporal trends in longitudinal valve and ventricular function were assessed using nonlinear mixed-effects models. ResultsMedian follow-up was 10 years. Seventy-nine patients with ccTGA underwent anatomic repair, 45 physiologic repair, 24 Fontan palliation, and 6 primary transplant. Forty patients managed expectantly had excellent long-term survival when considered from time of presentation, but benefited from failures captured following transition to physiologic repair or transplant. Morphologic right ventricular dysfunction after physiologic repair increased from 68% to 85% after 5 years, whereas morphologic left ventricular function was stable in anatomic repair, especially with early surgery. Transplant-free survival at 15 years for anatomic and physiologic repair was 80% and 71%, respectively. ConclusionsEarly anatomic repair may be preferable to physiologic repair for select ccTGA patients. Late attrition after physiologic repair represents failure of expectant management and progressive tricuspid valve and morphologic right ventricular dysfunction compared with anatomic repair, where morphologic left ventricular function is relatively preserved.

Pay attention to the diagnosis and treatment of tricuspid valve dysfunction related to pacemaker lead

随着起搏器等心脏电子植入设备的应用日益增多，加之实时三维超声心动图等新型诊断技术的发展，人们对起搏电极相关三尖瓣功能障碍的认识更加深入。但由于三尖瓣功能障碍患者早期症状隐匿，导致诊断被低估或漏诊，而晚期发生严重右心功能不全后预后不良，治疗效果不佳。本文重点阐述起搏电极所致三尖瓣功能障碍的诊断及治疗。诊断方面首先对此类疾病需高度认识，并根据患者的病史和体格检查保持较高的临床警惕性，推荐对起搏器植入的患者常规进行超声心动图的随访检查，是及时诊断该病的有效方法，应用实时三维超声心动图有助于病因诊断并可指导治疗。治疗强调多学科团队评估并尽早干预，主要治疗策略包括药物治疗、经静脉电极拔除及三尖瓣修复或置换。.

Management and Outcomes of Transvenous Pacing Leads in Patients Undergoing Transcatheter Tricuspid Valve Replacement

ObjectivesThe aim of this study was to determine the prevalence of pacemaker lead–related complications following transcatheter tricuspid valve replacement (TTVR). BackgroundThe rate of permanent pacemaker implantation following tricuspid valve (TV) surgery is high, and many patients have transvenous leads. The feasibility, safety, and outcomes of subsequently performing TTVR in the setting of transvenous pacemaker leads have not been established. MethodsThe VIVID (Valve-in-Valve International Database) registry was used to review 329 patients who underwent TTVR following TV repair or replacement. Patients were subdivided into 3 cohorts for intergroup comparisons: no lead, epicardial lead, and transvenous lead (entrapped or not entrapped during the TTVR procedure). ResultsOf 329 patients who underwent TTVR, 128 (39%) had prior pacing systems in place, 70 with epicardial and 58 with transvenous leads. A total of 31 patients had leads passing through the TV. Three patients had the right ventricular (RV) lead extracted prior to TTVR. The remaining 28 patients had the RV lead entrapped between the transcatheter TV implant and the surgical valve (n = 22) or the repaired TV (n = 6). One patient had displacement of the RV lead during the procedure, and 2 experienced lead failure during follow-up. Overall, there was no significant difference in the cumulative incidences of competing outcomes (death, TV reintervention, TV dysfunction) between patients with and those without pacing leads or entrapped RV leads. ConclusionsTTVR in the setting of trans-TV pacemaker leads without lead extraction or re-replacement can be performed safely with a low risk for complications, offering an alternative to surgical TV replacement.

A gigantic right atrium due to tricuspid valve dysfunction.

A gigantic right atrium due to tricuspid valve dysfunction.

Impact of Right-sided Obstructive Lesions in Children & Adolescents having Cone Repair for Ebstein Anomaly

Background: Ebstein anomaly (EA) is a rare congenital heart defect characterized by apical displacement of the tricuspid valve resulting in tricuspid valve (TV) dysfunction and right ventricular myopathy. Cone reconstruction (CR) has become the standard technique for TV repair for most patients with EA. The impact of additional right-sided obstructive lesions (RSOL) on post-operative outcomes in pediatric patients undergoing CR for EA is unknown. Methods: We performed a retrospective review of all children 1 …

Tricuspid valve replacement: an appraisal of 45 years of experience.

This study provides an overview of the change over a 45-year time period in the characteristics and outcome of patients with tricuspid valve disease undergoing surgical tricuspid valve replacement (TVR). The characteristics and outcomes of all consecutive TVRs from November 1972 to November 2017 at Erasmus MC were collected retrospectively. A logistic regression analysis was conducted to identify the significant predictors of 30-day mortality. Multivariable Cox regression analysis was used to identify the potential risk factors of patient outcome and the effect of time on these factors. Ninety-eight patients with tricuspid valve dysfunction underwent 114 consecutive TVRs at a mean age of 50.1 ± 17.2 years (68.5% female). Aetiology changed over time from predominantly functional regurgitation (42.9% in 1972-1985) to predominantly carcinoid heart disease (47.7% in 2001-2017). Early mortality declined significantly from 35% in 1972-1985 to 6.7% in 2001-2017 (P < 0.001). Over time, the hazard ratio of late mortality decreased for higher New York Heart Association class, lower preoperative haemoglobin, and high central venous pressure and increased for the presence of preoperative leg oedema, higher creatinine and alkaline phosphatase. The late survival was 43.8% ± 5.89% at 10 years and was comparable among eras (P = 0.44). The cumulative incidence of reoperation at 10 years was 14.1% (2.3-26.0) in biological valves and 4.9% (0.1-10.3) in mechanical valves (P = 0.25). Patient characteristics, potential risk factors and patient outcome changed considerably over time in patients undergoing TVR. Notably, there was a shift in aetiology, completely altering the patient population and their characteristics.

Detailed computed tomography insight into the mechanism of complex bioprosthetic tricuspid valve dysfunction in a patient with Ebstein’s anomaly.

Detailed computed tomography insight into the mechanism of complex bioprosthetic tricuspid valve dysfunction in a patient with Ebstein’s anomaly.