Underwent Tricuspid Valve Replacement Research Articles

Eustachian Valve Endocarditis in an Intravenous Drug User

Case Description: We present the case of an intravenous drug user(IVDU) who presented with back pain. Initial Investigations and Management: His blood cultures demonstrated Staphylococcus aureus bacteraemia. He was diagnosed with a psoas abscess on CT scan, which was drained. He developed septic shock post operatively. CT chest demonstrated bilateral multifocal cavitating pneumonia with an inferior vena cava(IVC) thrombus for which patient had an IVC filter inserted. Transthoracic echocardiogram(TTE) demonstrated normal left and right ventricular function. The aortic and mitral valve were unremarkable, however there were vegetations visualised on the anterior(1.2 cm) and septal(1.0 cm) leaflets of the tricuspid valve with moderate regurgitation. Cardiothoracic surgical opinion was of conservative management at the time as there was no urgent indication for surgery. Despite a combination of broad spectrum antibiotics guided by the infectious disease specialists, our patient remained febrile with persistently positive blood cultures, elevated inflammatory markers and fluctuating levels of consciousness. Key Investigation: Transoesophageal echocardiogram(TOE) demonstrated anterior tricuspid valve vegetation, with aneurysm formation, localised perforation and eccentric severe regurgitation. The anteriorly directed tricuspid regurgitant jet had resulted in an infective seeding of the Eustachian valve, where a vegetation was visualised. The patient was transferred to ICU for further management of septic shock. He subsequently underwent tricuspid valve replacement, resection of the Eustachian valve, and completed the course of antibiotics, achieving a full recovery. The Eustachian valve vegetation was verified at surgery. Conclusion: This case demonstrates a rare form of endocarditis, with seeding of the Eustachian valve from a tricuspid valve jet lesion.

Abstract 11678: Tricuspid Valve Repair Versus Replacement for Very Severe Functional Tricuspid Regurgitation

Introduction: The optimal decision regarding whether to repair or replace the tricuspid valve (TV) remains controversial in patients with very severe functional tricuspid regurgitation (TR). Objectives: We sought to compare clinical outcomes of TV repair versus replacement for very severe TR associated with severe TV tethering. Methods: We included 96 consecutive patients (20 men, 58±11 years of age) who had both severe tethering of TV and very severe functional TR, and consequently underwent TV surgery during left-sided valve surgery. TV repair was performed on 79 patients (repair group), whereas 17 patients underwent TV replacement (replacement group). The primary end-point of the study was defined as the composite of operative mortality, cardiac death, repeat TV surgery and hospitalization due to congestive heart failure during follow-up. Results: The two groups had similar baseline clinical, echocardiographic and operative characteristics, but operative mortality was significantly higher in the replacement group than in the repair group (P=0.008). During a median follow-up of 87 months, 19 (24%) patients in the repair group and 8 (47%) in the replacement group attained the composite end point, and the estimated 10-year event-free survival rate was significantly higher in the repair group (75 ± 6%) than in the replacement group (43 ± 2%) (P = 0.019). TV replacement was independently associated with end points in the Cox proportional hazards analysis after adjustment with propensity score (hazard ratio, 4.033; 95% CI, 1.470 to 11.071; P=0.007). Conclusions: Compared with TV repair, replacement was associated with higher operative mortality and worse long-term clinical outcomes in patients with very severe functional TR. Repair should be the preferred surgical option even for severe TR associated with more advanced tethering and right ventricular dilatation.

Follow-up after tricuspid valve surgery in adult patients with systemic right ventricles.

In patients with congenitally corrected transposition of the great arteries (ccTGA) or after atrial (Mustard or Senning) correction for transposition of the great arteries (acTGA), the right ventricle (RV) supports the systemic circulation. The tricuspid valve (TV) (systemic atrioventricular valve) is prone to regurgitation in these patients and this is associated with impending RV failure and decreased survival. This study evaluates mid-term functional improvements, echocardiographic findings and survival after TV surgery in this patient group. From July 1999 to November 2014, 26 patients (mean age 37.1 ± 12.3 years, 14 females) with ccTGA (n = 15) or acTGA (n = 11) had TV surgery. All patients had RV dysfunction and more-than-moderate TV regurgitation (TR); 14 underwent TV replacement (TVR) and 12 had valvuloplasty (TVP). Main outcomes were New York Heart Association (NYHA) functional class, TR and RV dysfunction at 1 year postoperatively and at latest follow-up. Complications and freedom from the composite end-point of death or recurrent TR were analysed. The median follow-up time was 5.9 years (range, 0-16.1 years). Mean NYHA functional class significantly improved to 1.7 [95% confidence interval (CI): 1.3-2.1] at 1 year (P= 0.004) and was 2.1 (95% CI: 1.7-2.6) at latest follow-up (P= 0.14). TV competence significantly improved to a mean TR grade of 1.1 (95% CI: 0.5-1.7) at latest follow-up (P< 0.001). The mean grade for RV function at latest follow-up was 2.7 (95% CI: 2.3-3.0). Most encountered postoperative complications were arrhythmias and temporary haemodynamic instability due to low cardiac output. Early mortality was 11.5% (n = 3); late mortality was 15.4% (n = 4). Estimated freedom from the composite end-point of death or recurrent TR was 76.9% (95% CI: 55.7-88.9%) at 1 year and 64.8% (95% CI: 43.2-79.9%) at 5 years. In TVP patients, TV function at 1 year and at latest follow-up was significantly worse than in TVR patients (P< 0.001 and P= 0.003, respectively). Also, TVP patients had a significantly lower composite end-point survival curve compared with TVR patients (P= 0.018). In this patient group, TV surgery showed stabilization of RV function and improvement of NYHA functional class for at least several years. In this series, TVR appears superior to TVP with respect to occurrence of recurrent TR. Early and late mortality after TV surgery is substantial, and we believe that patients with significant TR should be referred earlier for surgery for better outcome.

Tricuspid annular plane systolic excursion (TAPSE) can predict the outcome of isolated tricuspid valve surgery in patients with previous cardiac surgery?

Isolated tricuspid valve replacement is rare when performed as a re-operation after a left side operation. It is important to know the factors that determine mortality and morbidity. Tricuspid Annular Plane Systolic Excursion (TAPSE) is a scoring system that is used with non-invasive Doppler echocardiography to determine right ventricular (RV) function. This study analyzed TAPSE scores and adverse outcomes of isolated tricuspid valve surgery in patients with previous cardiac surgery. All patients who underwent tricuspid valve replacement between January 2014 and December 2015 were retrospectively reviewed. Patients having concomitant mitral or aortic valve surgery were excluded. These patients were divided into two groups: TAPSE >14 mm and TAPSE ≤14 mm. In-hospital outcomes were compared. A total of 26 patients with severe tricuspid valve regurgitation underwent tricuspid valve replacement. There were 5 males (19.2%) and 21 females (80.8%). The average age at operation was 54.77±9.61 years (range, 27-69 years). There were 16 patients in the TAPSE >14 mm group and 10 patients in the TAPSE ≤14 mm group. The BNP in the TAPSE >14 mm group was significant (TAPSE >14 mm 672.34±229.98 versus TAPSE ≤14 mm 1,054.79±684.69, P=0.03). The median cardiopulmonary bypass (CPB) time and red blood cell (RBC) transfusions in the two groups were not different. The need for prolonged ventilatory support (>48 h) in the two groups was also not different (TAPSE> 14 mm 91.2±12.31 vs. TAPSE ≤14 mm 39.00±36.80, P=0.46). Moreover, hospital stays were similar between the two groups. No differences were found in postoperative renal and respiratory complications. It is important to determine the right ventricule function quantitatively. The TAPSE score is an important parameter that determines the cardiac index and right ventricle function. It should be used for the prediction of mortality and morbidity with all the other parameters as a whole.

Clinical analysis of tricuspid valve replacement

To summarize the outcome of tricuspid valve replacement. A total of 28 patients (15 males and 13 females) underwent tricuspid valve replacement from March 2000 to February 2015 in the First Affiliated Hospital of Zhengzhou University were recruited. Among them, 16 patients were Ebstein's anomaly, 7 had rheumatic valve heart disease, 3 and 2 suffered from infective endocarditis and degenerative tricuspid lesions, respectively. One patient died of multiple organ failure. Four patients were implanted permanent cardiac pacemaker because of third degree atrioventricular block occurring in the 5th day (2 patients) and in the 9th day (2 patients) after the operation, respectively. Twenty-seven patients were followed up from 1 month to 15 years. The prosthetic valves and permanent pacemakers worked well. Third degree of atrioventricular block, mostly appearing in early postoperative period, is the most common and severe complication of tricuspid valve replacement. The key point for prevention of damage is to accurately identify the anatomical relationship among the tricuspid valve, atrioventricular node, and conduction bundle.

Long-Term Results after Surgical Treatment of Ebstein's Anomaly: a 30-year Experience.

Background and ObjectivesThe aim of the study is to evaluate the long-term results after a surgical repair of Ebstein's anomaly.Subjects and MethodsForty-eight patients with Ebstein's anomaly who underwent open heart surgery between 1982 and 2013 were included. Median age at operation was 5.6 years (1 day-42.1 years). Forty-five patients (93.7%) demonstrated tricuspid valve (TV) regurgitation of less than moderate degree. When the patients were divided according to Carpentier's classification, types A, B, C, and D were 11, 21, 12, and 4 patients, respectively. Regarding the type of surgical treatment, bi-ventricular repair (n=38), one-and-a half ventricular repair (n=5), and single ventricle palliation (n=5) were performed. Of 38 patients who underwent a bi-ventricular repair, TV repairs were performed by Danielson's technique (n=20), Carpentier's technique (n=11), Cone repair (n=4), and TV annuloplasty (n=1). Two patients underwent TV replacement. Surgical treatment strategies were different according to Carpentier's types (p<0.001) and patient's age (p=0.022).ResultsThere were 2 in-hospital mortalities (4.2%; 1 neonate and 1 infant) and 2 late mortalities during follow-up. Freedom from recurrent TV regurgitation rates at 5, 10, and 15 years were 88.6%, 66.3%, 52.7%, respectively. TV regurgitation recurrence did not differ according to surgical method (p=0.800). Survival rates at 5, 10, and 20 years were 95.8%, 95.8%, and 85.6%, respectively, and freedom from reoperation rates at 5, 10, and 15 years were 85.9%, 68.0%, and 55.8%, respectively.ConclusionSurgical treatment strategies were decided according to Carpentier's type and patient's age. Overall survival and freedom from reoperation rates at 10 years were 95.8% and 68.0%, respectively. Approximately 25% of patients required a second operation for TV during the follow-up.

Postoperative tricuspid regurgitation after adult congenital heart surgery is associated with adverse clinical outcomes

ObjectiveMany patients with adult congenital heart disease will require cardiac surgery during their lifetime, and some will have concomitant tricuspid regurgitation. However, the optimal management of significant tricuspid regurgitation at the time of cardiac surgery remains unclear. We assessed the determinants of adverse outcomes in patients with adult congenital heart disease and moderate or greater tricuspid regurgitation undergoing cardiac surgery for non–tricuspid regurgitation-related indications. MethodsAll adult patients with congenital heart disease and greater than moderate tricuspid regurgitation who underwent cardiac surgery for non–tricuspid regurgitation-related indications were included in a retrospective study at the Schneeweiss Adult Congenital Heart Center. Cohorts were defined by the type of tricuspid valve intervention at the time of surgery. The primary end point of interest was a composite of death, heart transplantation, and reoperation on the tricuspid valve. ResultsA total of 107 patients met inclusion criteria, and 17 patients (17%) reached the primary end point. A total of 68 patients (64%) underwent tricuspid valve repair, 8 patients (7%) underwent tricuspid valve replacement, and 31 patients (29%) did not have a tricuspid valve intervention. By multivariate analysis, moderate or greater postoperative tricuspid regurgitation was associated with a hazard ratio of 6.12 (1.84-20.3) for the primary end point (P = .003). In addition, failure to perform a tricuspid valve intervention at the time of surgery was associated with an odds ratio of 4.17 (1.26-14.3) for moderate or greater postoperative tricuspid regurgitation (P = .02). ConclusionsModerate or greater postoperative tricuspid regurgitation was associated with an increased risk of death, transplant, or reoperation in adult patients with congenital heart disease undergoing cardiac surgery for non–tricuspid regurgitation-related indications. Concomitant tricuspid valve intervention at the time of cardiac surgery should be considered in patients with adult congenital heart disease with moderate or greater preoperative tricuspid regurgitation.

Identical Twins, Matching Symptoms: Hypersensitivity Pneumonitis

PRESENTATION Shortness of breath was first attributed to the patient’s extensive history of cardiac ills, but a detailed environmental history pointed to the true source. A 58-year-old Caucasian woman presented with a 12-month history of dyspnea, nonproductive cough, and wheezing. She had been born with Ebstein’s anomaly, for which she had undergone tricuspid valve replacement with a prosthetic valve and repair of a coexisting atrial septal defect. In addition, she had an implanted pacemaker for complete heart block. Her cardiologist was considering biventricular pacing as an intervention for her dyspnea and requested a pulmonary evaluation before proceeding. The patient, who was married and a nurse, had an unremarkable pulmonary history. None of her medications posed a risk for lung toxicity. She never smoked, drank alcohol, or used illicit drugs. An identical twin sister, who lived in Texas, had similar pulmonary complaints and a presumptive diagnosis of pulmonary fibrosis. The sister’s medical records were brought to the consultation due to concern for a genetic predisposition for this progressive lung disease.

Tricuspid valve replacement: 25-year-experience at the Royal Adelaide Hospital

Background: Patients requiring tricuspid valve replacement (TVR) often present with advanced symptoms and cardiac dysfunction. TVR is still an uncommon procedure but is associated with high morbidity and mortality. The aim of this study was to review our 25-year-experience with TVR and compare the pre-operative and early post-operative results with the available literature. Methods: A retrospective chart review was undertaken of all patients undergoing TVR between 1988 and 2013 at the D’Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital. Patient demographics, pre-operative clinical status, operative details, post-operative morbidity and 30-day mortality were analysed. A literature review was conducted using PubMed. Search terms included “tricuspid valve replacement” and “tricuspid valve surgery”, alone and in combination. Full text English publications regarding isolated TVR as well as TVR combined with other procedures were included. Reports describing tricuspid valve repair were not included in this review. Results: Between 1988 and 2013, 25 patients underwent tricuspid valve replacement at the D’Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital. The mean age was 55.9 ± 18 years, and 64% were female. Pre-operative New York Heart Association functional class were II (n=2, 8%), III (n=14, 56%) and IV (n=9, 36%). Aetiology for tricuspid dysfunction was rheumatic (44%), infective endocarditis (24%), carcinoid (8%), iatrogenic (8%), trauma (4%), dilated cardiomyopathy (4%) and pulmonary hypertension (4%). Pre-operative echocardiogram showed severe tricuspid stenosis in 16% (n=4) and severe tricuspid regurgitation in the remainder (n=21, 84%). Tricuspid leaflet morphology was deemed primary (n=11, 44%) or functional (n=14, 56%). Pre-operative right ventricular systolic function was normal (36%), mild impairment (20%), moderate impairment (24%), or severe impairment (16%). Left ventricular systolic function was normal in 23 cases, and moderately impaired in 2 cases (mean LVEF 60.8%). Pre-operative right heart dilatation was mild (24%), moderate (20%) or severe (48%). Mean pre-operative systolic pulmonary artery pressure was 46.3 ± 16.2 mmHg and mean pre-operative pulmonary capillary wedge pressure was 19.25 ± 7.4 mmHg. Seven patients (28%) had previous cardiac surgery. Three patients underwent isolated minimally invasive TVR via mini-thoracotomy, while the remaining 22 patients underwent TVR via median sternotomy, 7 patients as an isolated procedure and 15 patients combined with another procedure. Five patients underwent surgery as an emergency operation. Mean aortic cross clamp time was 78.3 minutes. Three cases were done with no aortic cross clamp. Mean cardiopulmonary bypass time was 122 min. A tissue prosthesis was used in 22 cases, and a mechanical prosthesis was used in 3 cases. Post-operative morbidity included pacemaker insertion (28%), pneumonia (40%), acute kidney injury requiring dialysis (48%), bleeding requiring return to theatre (8%), and stroke (8%). Thirty-day mortality was 32% (n= 8). Conclusion: Tricuspid valve replacement is rare but the procedure is associated with significant morbidity and mortality. The decision to operate can be challenging. Careful pre-operative assessment is crucial. Aetiology, clinical presentation and right heart and pulmonary vascular haemodynamics are major determinants of the outcome.

Long Term Results Comparing Mechanical and Biological Prostheses in the Tricuspid Valve Position: Which valve types are better - mechanical or biological prostheses?

The aim of this study was to evaluate the clinical outcome of patients who underwent TVR focusing on long-term survival- and valve-related complications. Between January 1993 and June 2011, 132 patients underwent tricuspid valve replacement in our centre. Sixty-eight bioprosthetic valves (52%) and 64 mechanical valves (48%) were implanted for tricuspid position. For 51 patients (39%) this was a first-time tricuspid valve operation. Nineteen patients died during hospitalisation, yielding a hospital mortality rate of 14%. The hospital mortality and morbidity were not statistically significantly different between the two groups. Sixteen patients (14,1%) died after discharge from the hospital. Twelve-year actuarial survival after mechanical and bioprosthetic TVR was 72,1±5,9 and 61.6±6,6%, respectively. No statistically significant difference was detected between mechanical and bioprosthetic valves in regard to event-free survival. The choice between mechanical or biological prostheses in the tricuspid position should be individualised according to the clinical judgment, even though absence of any difference in the survival data supports the opinion that there is no "gold standard" for prosthetic tricuspid valve replacement.

SURGICAL TREATMENT OF INFECTIOUS ENDOCARDITIS ASSOCIATED WITH INTRAVENOUS DRUG ABUSE

Aim. The study was aimed to analyze the results of surgical treatment of infectious endocarditis associated with intravenous drug abuse. Methods and results. The study included 53 patients, 36 male and 17 female, 28,7 ± 7 years old. 60 operations were performed: 41 patients underwent tricuspid valve replacement, 7 pts – tricuspid valve repair, 7 pts – tricuspid valve rereplacement, 2 pts – mitral and tricuspidal valves replacement, 2 pts – aor- tic and tricuspid valves replacement, 1 patient – trivalve replacement. Hospital mortality was 1,7%. Conclusi- on. The used principles of surgical treatment of infectious endocarditis in drug abuse patients allow to rich a low mortality and complications rates in the postoperative period in this heavy group of patients.

Long-term Survival after Isolated Tricuspid Valve Replacement

Isolated replacement of the tricuspid valve is rare, and the decision to operate is difficult. This study reviews the in-hospital mortality and long-term survival after tricuspid valve replacement in the absence of concomitant left sided valve surgery. It identifies predictors of poor outcome. All patients who underwent tricuspid valve replacement between January 1995 and December 2011 were retrospectively reviewed. Patients having concomitant mitral or aortic valve surgery were excluded. Logistic regression was used to identify predictors of early and late death. Twenty-nine cases were identified. There were six in-hospital deaths (20.6%), and eight late deaths. Ascites was associated with in-hospital death (hazard ratio 16.96; p=0.0052). Higher dose of Frusemide was associated with late mortality (hazard ratio 1.157 per 20mg increase; p=0.0155). Frusemide dose and ascites were both significantly associated with death overall (p<0.01). Survival analysis estimated a 50% probability of surviving to 12.45 years. Isolated tricuspid valve replacement has a high peri-operative risk. Long-term survival in this study was consistent with other reports. Ascites and higher doses of Frusemide were associated with poor outcomes.

Tricuspid Valve Replacement in an Adult with Destroyed Tricuspid Valve and Refractory Right Heart Failure

year old woman with no previous heart disease history, presented with progressive worsening of right heart failure symptoms due to severe tricuspid valve regurgitation which had become refractory to medical management. Echocardiogram revealed probable rare case ofdysplastic tricuspid valve with large calcified mobile masses attached to leaflets. Calcified masses were thought to be due to healed vegetations from silent infective endocarditis of abnormal tricuspid valve which she had suffered in the past.There were no known acquired causes of tricuspid valve endocarditis. She had successfully undergone tricuspid valve replacement with bio -prosthetic valve along with a right atrial reduction surgery after which her heart failure symptoms improved markedly.

The Application of On-Pump Beating-Heart Surgery for Partial Atrioventricular Septal Defect: A Report of 87 Cases

Partial atrioventricular septal defect (P-AVSD) is a common congenital heart disease. Because of the presence of left and right atrioventricular valve deformities and the shift in the atrioventricular node and cardiac conduction bundle, the surgical repair of P-AVSD is difficult. This study was performed to compare the effects on the coronary sinus septum in the left versus the right atrium during surgical treatment for P-AVSD and report our experiences regarding the application of on-pump beating heart surgery under mild hypothermia for patients with P-AVSD. The effects of on-pump beating heart surgery were analyzed retrospectively in 87 P-AVSD patients. Of the 87 total patients, 84 with anterior mitral leaflet cleft underwent valvuloplasty and 3 underwent mitral valve replacement. Seventy-seven patients underwent tricuspid valve annuloplasty, 2 underwent tricuspid valve replacement, and 1 underwent left superior vena cava ligation, and 3 patients with atrial fibrillation were treated with radiofrequency ablation. Patients with an ostium primum atrial septal defect underwent autologous pericardial modified Kirklin repair. Of these, 46 patients had their coronary sinus septum separated into the left atrium and 41 had their coronary sinus retained in the right atrium. Fingertip oxygen saturation was compared between patients in whom the coronary sinus was separated to the left atrium and those in whom the coronary sinus was retained in the right atrium. There was 1 postoperative early death (1.15%) due to respiratory failure, and 1 patient had a III degree atrioventricular block (1.15%) and underwent implantation of a permanent pacemaker. The fingertip oxygen saturation levels of the left atrium group were 96.81 ± 3.17 preoperatively, 95.37 ± 4.62 at 7 days postoperatively, and 94.53 ± 4.95 at 3 months postoperatively. Those of the right atrium group were 98.53 ± 2.84 preoperatively, 97.19 ± 3.57 at 7 days postoperatively, and 96.89 ± 4.19 at 3 months postoperatively. During the follow-up period, which ranged from 3 months to 7 years, the cardiac function was adequately restored. On-pump beating heart surgery under mild hypothermia is a safe and feasible method. The retention of the coronary sinus in the right atrium might maintain oxygen saturation.

Tricuspid Valve Infective Endocarditis In Drug Abusers: Clinical Features and Results of Surgical Treatment

The objective of this study was to evaluate the clinical features, diagnostic criteria and indications for surgery in patients – drug abusers with tricuspid valve infective endocarditis (TVIE), and outcome of surgical treatment in these patients. From December 1999 to August 2009 35 patients (drug addicts) with TVIE were operated in the department of acquired heart diseases of Cardiac and Vascular Surgery Center, Nizhny Novgorod. 25 males and 10 females aged from 15 to 51 years were included in this study. 3 patients were re-operated due to recurrence of endocarditis. Biological prosthetic valve "Bio-Lab" was used in all patients. Intravenous drug abuse was the cause of the disease in all patients. Acute onset with hectic fever, shivering, profuse sweating, intoxication and development of multi-organ failure were the main clinical features of the disease. Embolism of the peripheral branches of pulmonary artery by septic embolus or micro thrombi were common symptoms. Ultrasound investigation played an important role in diagnosis of TVIE. It was the only criteria for the verification of the diagnosis in patients with fever of unknown origin until the appearance of valve damages and cardiac murmurs. All 35 (100%) patients underwent tricuspid valve replacement (TVR). 3 (8.57%) patients underwent redo TVR because of prosthetic valve endocarditis due to persistent intravenous drug abuse after surgery. The hospital mortality rate was 0%. Acute debut of the disease may be the first clinical feature of tricuspid valve infec­tive endocarditis in drug abusers. Ultrasound investigation is important for early diagnosis and effective treatment. Surgical treatment is indicated in cases of ineffective antibiotic therapy and massive tricuspid valve damages. Tricuspid valve replacement by a biological prosthesis was the treatment of choice in these patients. The use of biological prosthetic valve had good clinical re­sults with low thrombogenic risk and high resistance to infection. Nepalese Heart Journal | Volume 7 | No.1 | November 2010 (special issue) | Page 29-34 DOI: http://dx.doi.org/10.3126/njh.v7i1.8499

Morphology, Surgical Techniques, and Outcomes in Patients Above 15 Years Undergoing Surgery for Congenitally Corrected Transposition of Great Arteries

There is a paucity of data about morphology, surgical procedure, and results in older patients with congenitally corrected transposition of great arteries (ccTGAs). Between January 2002 and August 2012, 15 patients (7 males), median age 25 years, range 16 to 41 years underwent surgery for ccTGA. Associated lesions were tricuspid regurgitation (TR; n = 5) and ventricular septal defect (VSD) with pulmonary stenosis (PS; n = 10). Surgical procedures included tricuspid valve replacement (n = 4), tricuspid valve repair (n = 1), lateral tunnel Fontan (n = 2), extracardiac Fontan (n = 2), Kawashima procedure (n = 1), bidirectional (BD) Glenn (n = 2), Senning + Rastelli procedure (n = 1), and VSD closure + left ventricle to pulmonary artery conduit (n = 1). The details of these procedures and outcomes were analyzed. There were no early or late deaths. Mean follow-up period was 49.9 ± 26 months. All patients who underwent tricuspid valve replacement are in New York Heart Association (NYHA) class I, with no progression of right ventricular (RV) dysfunction. One patient who underwent tricuspid valve repair is in NYHA class III and has progressed to severe RV dysfunction. None of the patients undergoing single ventricle palliation had any complications related to the surgery. Both patients who underwent anatomical and physiological biventricular (BV) repair had no complications. Older patients with ccTGA present a challenge. Fontan/BD Glenn remains a good option for patients who presented with VSD PS. Both anatomic and physiological BV repairs provide acceptable results. Tricuspid valve replacement is safe for patients presenting with TR who have improvement in functional class, though the right ventricular function may not improve.

Early and Late Outcome of Surgery for Ebstein Anomaly: A 20-year Experience in Philippine Tertiary Centers

BACKGROUND: Ebstein Anomaly (EA) is a rare congenital heart disease. Clinical presentation depends on the severity of tricuspid valve displacement and associated intracardiac congenital anomalies. Surgical indications have been described on recent guidelines, resulting in favorable outcomes in well-selected patients. There is no published experience in tricuspid valve surgery for EA in the Philippines. OBJECTIVES: To describe the clinical profile of patients who underwent cardiac surgery for EA from 1992 to 2012 in the Philippines, and to compare the clinical characteristics of survivors and immediate non-survivors of tricuspid valve surgery for EA. METHODOLOGY: This was a retrospective cohort study on patients who underwent cardiac surgery from 1992 to 2012, at the Philippine Heart Center and Philippine General Hospital. Characteristics between survivors and non-survivors were compared. RESULTS: Twenty-eight patients underwent cardiac procedures for EA from 1992 to 2012 in the Philippines. The mean age at operation was 12 years. Majority of the patients were males (57%) and were at least 18 years old (75%). Among the 28 patients, 21 were identified to have undergone a definitive treatment (i.e., either tricuspid valve (TV) repair or replacement. Mean total bypass time was 148.71 minutes ± 133.31. Mean total cross-clamp time was 89.89 minutes ± 46.65. The most common surgical complications were prolonged intubation (32%) and atrial arrhythmias (21%). The average length of hospital stay was 20.67 days ± 11.64. Follow-up was possible in 20 out of the 21 patients (95%). There were three early deaths (&lt; 30 days), all of whom had TV repair. Of the 18 survivors, 15 underwent TV repair while three underwent TV replacement. Non-survivors had significantly lower arterial oxygen saturation (p=0.045), more post-operative bleeding (p=0.014), and greater post-operative need for hemodialysis (p=0.014). Exact logistic regression did not reveal any significant predictor of mortality among the various characteristics analyzed, probably due to the small number of patients in this study.

Prosthetic tricuspid valve dysfunction assessed by three-dimensional transthoracic and transesophageal echocardiography.

A 39-year-old male who had undergone tricuspid valve replacement for severe tricuspid regurgitation was admitted with palpitation and general edema. Two-dimensional (2D) echocardiography showed tricuspid prosthetic valve dysfunction. Additional three-dimensional (3D) transthoracic and transesophageal echocardiography (TEE) could clearly demonstrate the disabilities of the mechanical tricuspid valve. Particularly, 3D TEE demonstrated a mass located on the right ventricular side of the tricuspid prosthesis, which may have caused the stuck disk. This observation was confirmed by intra-operative findings.

Tricuspid Reoperation After Left-Sided Rheumatic Valve Operations

The management of late tricuspid regurgitation after left-sided valve operations in rheumatic patients remains controversial. The aim of this study was to analyze clinical and echocardiographic outcomes of tricuspid valve procedures after left-sided valve operations in rheumatic patients. This study enrolled 106 rheumatic patients with a history of left-sided valve operations who were undergoing tricuspid valve procedures (53 replacements, 53 repairs). Follow-up was 97% complete, with a mean follow-up of 62 ± 42 months. Clinical and echocardiographic data were analyzed. The early mortality rate was 1.9% (2 of 106 patients). There was no significant difference in cumulative survival at 10 years between patients who underwent tricuspid valve replacement (63.1% ± 13.2%) or repair (80.7% ± 0.8%, p = 0.317). Multivariable Cox regression analysis revealed that old age (hazard ratio [HR], 6.5; p = 0.007), anemia (HR, 10.9; p = 0.004), and left ventricular ejection fraction of less than 0.4 (HR, 10.3; p = 0.001) were predictors of major adverse cardiac events. Among patients who underwent tricuspid valve repair, multivariate analysis revealed that the aortic transprosthetic mean pressure gradient at late follow-up was an independent predictor of late tricuspid regurgitation. Tricuspid valve procedures after left-sided valve operations in rheumatic patients can be performed at low risk with good clinical outcomes. For improved clinical outcomes, early surgical intervention should be considered before the development of anemia and left ventricular dysfunction. A lower aortic transprosthetic mean pressure gradient may help prevent late progression of tricuspid regurgitation in a clinical setting.

A Case Demonstrating a Percutaneous Closure Using the Amplatzer Duct Occluder for Paravalvular Leakage after Tricuspid Valve Replacement

There has been a dramatic increase in the number and type of procedures performed in the field of cardiac intervention in the past decade. Percutaneous intervention is becoming an increasingly recognized modality for the management of prosthetic paravalvular leakages (PVLs) in severely symptomatic non-surgical candidates. Herein, we report our experience of percutaneous closure using the Amplatzer duct occluder for a PVL in a patient who underwent tricuspid valve replacement.