Exacerbation of mitral regurgitation after tricuspid valve replacement for isolated tricuspid regurgitation

A 74-year-old woman, with a history of aortic valve replacement and open mitral commissurotomy due to rheumatic aortic and mitral stenosis, presented with dyspnea. She developed severe tricuspid regurgitation (TR), requiring tricuspid valve replacement (TVR). Despite an uneventful postoperative course, she was readmitted for dyspnea 2 months later. Trans-thoracic echocardiogram revealed severe mitral regurgitation (MR), despite mild MR at the time of TVR, which has not been previously reported. The main MR mechanism was increased left ventricular preload due to improved TR. Increased diuresis has controlled her congestive heart failure, but her MR remained moderate.     

Progression of isolated tricuspid regurgitation late after mitral valve surgery for rheumatic mitral valve disease

BACKGROUND AND AIMS OF THE STUDY: Severe tricuspid regurgitation (TR) may develop late after mitral valve surgery without significant mitral stenosis, regurgitation and other causes of left heart failure. The study aim was to investigate severe isolated TR late after mitral valve surgery for rheumatic mitral valve disease. METHODS: A total of 208 patients who underwent mitral valve surgery (valve replacement in 121, commissurotomy in 62, valvuloplasty in 25) was investigated. The mean (+/-SD) follow up was 13+/-6 years. Severe isolated TR was defined clinically by elevated venous pressure, and echocardiographically by grade 4+ TR without significant mitral stenosis, regurgitation, other causes of left heart failure, pulmonary hypertension or rheumatic tricuspid valve. RESULTS: Severe isolated TR was identified in 30 patients (14%) at four to 24 years after mitral valve surgery. All patients had atrial fibrillation. Of these patients, 23 had medical treatment and seven had tricuspid valve surgery. Three of the medically treated patients were in NYHA class IV and died from multiple organ failure at three to seven years after severe TR was diagnosed. Among surgically treated patients, four were in NYHA class IV and had postoperative complications (one early death, one late death), while three NYHA class II/III patients had very few postoperative complications. CONCLUSION: Severe isolated TR was detected in 14% of patients after mitral valve surgery. It is important to detect patients with progressive heart failure and to indicate earlier reoperation in order to prevent significant late mortality.     

Ventricular assistance after tricuspid valve replacement for carcinoid heart disease

We report a case of a 71-year-old woman with carcinoid heart disease admitted in ICU after tricuspid valve replacement. She quickly developed a acute heart right failure. Optimal medical treatment failed and we implanted ventricular assistance. After 10 days of support, patient improved and the right ventricle recovered. Temporary devices can provide a successful bridge to cardiac recovery. However, the risk of infection that is a major prognosis factor should be carefully considered particularly when temporary assistance implanted on immunosuppressed patients.     

左心瓣膜置换术后远期三尖瓣关闭不全的外科治疗

目的:评价左心瓣膜置换术后三尖瓣重度关闭不全外科治疗效果。方法:对25例左心瓣膜置换术后,人工瓣膜功能正常,三尖瓣重度关闭不全患者行三尖瓣成形术或三尖瓣置换术;首次手术二尖瓣置换术17例,二尖瓣加主动脉瓣置换术8例,在首次手术中10例曾行三尖瓣DeVega法成形术。结果:三尖瓣成形术13例;三尖瓣置换术12例。术后早期死亡4例,病死率16%。随访7个月～8年,平均(5.1±2.6)年,2例三尖瓣置换患者死于心血管事件,长期生存15例,心功能Ⅱ级8例,Ⅲ级4例,Ⅳ级3例,多数仍需强心、利尿药维持,临床症状明显改善。结论:对左心瓣膜置换术后三尖瓣重度关闭不全患者外科手术是一种合适的选择。合理掌握手术指征、手术时机和良好的围手术期治疗是手术成功的关键。     

Reduced exercise capacity in patients with tricuspid regurgitation after successful mitral valve replacement for rheumatic mitral valve disease.

OBJECTIVE--To determine how severe tricuspid regurgitation influences exercise capacity and functional state in patients who have undergone successful mitral valve replacement for rheumatic mitral valve disease. DESIGN--9 patients in whom clinically significant tricuspid regurgitation developed late after mitral valve replacement were compared with 9 patients with no clinical evidence of tricuspid regurgitation. The two groups were matched for preoperative clinical and haemodynamic variables. Patients were assessed by conventional echocardiography, Doppler echocardiography, and a maximal treadmill exercise test in which expired gas was monitored by mass spectrometry. SETTING--University Hospital of Wales, Cardiff. SUBJECTS--18 patients who had been reviewed regularly since mitral valve replacement. MAIN OUTCOME MEASURE--Objective indices of exercise performance including exercise duration, maximal oxygen consumption, anaerobic threshold, and ventilatory response to exercise. RESULTS--Mitral valve prosthetic function was normal in all patients and estimated pulmonary artery systolic pressure and left ventricular function were similar in the two groups. Right ventricular diameter (median (range) 5.0 (4.3-5.6) v 3.7 (3.0-5.4) cm, p less than 0.01) and the incidence of paradoxical septal motion (9/9 v 3/9, p less than 0.01) were greater in the group with severe tricuspid regurgitation. Exercise performance--assessed by exercise duration (6.3 (5.0-10.7) v 12.7 (7.2-16.0) min, p less than 0.01), maximum oxygen consumption (11.2 (7.3-17.8) v 17.7 (11.8-21.4) ml min-1 kg-1, p less than 0.01), and anaerobic threshold (8.3 (4.6-11.4) v 0.7 (7.3-15.5) ml min-1 kg-1, p less than 0.05)--was significantly reduced in the group with severe tricuspid regurgitation. The ventilatory response to exercise was greater in patients with tricuspid regurgitation (minute ventilation at the same minute carbon dioxide production (41.0 (29.9-59.5) v 33.6 (26.8-39.3) l/min, p less than 0.01). CONCLUSIONS--Clinically significant tricuspid regurgitation may develop late after successful mitral valve replacement and in the absence of residual pulmonary hypertension, prosthetic dysfunction, or significant left ventricular impairment. Patients in whom severe tricuspid regurgitation developed had a considerable reduction in exercise capacity caused by an impaired cardiac output response to exercise and therefore experienced a poor functional outcome. The extent to which this was attributable to the tricuspid regurgitation itself or alternatively to the consequences of right ventricular dysfunction was not clear and requires further investigation.     

Insulin sensitivity and lipid profile in prolactinoma patients before and after normalization of prolactin by dopamine agonist therapy

Hyperprolactinemia has been associated with impaired metabolism, including insulin resistance. However, the metabolic effects of elevated prolactin (PRL) levels are not completely clarified. The aim of this study was to obtain more insights of metabolic consequences in hyperprolactinemia patients. Fourteen consecutive patients, eight women and six men, aged 39.7 (±13.7) years with prolactinomas (median PRL 72 [49–131] μg/L in women and 1,260 [123–9,600] μg/L in men) were included. Anthropometric data and metabolic values were studied before and after 2 and 6 months on DA agonists (Bromocriptine [5.7 (±3.9) mg/day, n = 13] or Cabergoline [0.5 mg/week, n = 1]). Euglycemic hyperinsulinemic clamps were studied in six patients before and after 6 months of treatment. PRL normalized in all patients. Anthropometric data changed only in males with a significant decrease of median body weight (95.6 [80.7–110.1] to 83.4 [77.8–99.1] kg, P = 0.046), waist circumference and fat percentage after 6 months. LDL cholesterol was positively correlated to PRL at diagnosis (r = 0.62, P = 0.025) and decreased within 2 months (3.4 [±0.9] to 2.9 [±0.6] mmol/L, P = 0.003). Insulin, IGFBP-1 and total adiponectin levels did not change. Insulin sensitivity tended to improve after 6 months; M-value from 5.7 (±1.8) to 7.8 (±2.6) mg/kg/min, P = 0.083 and per cent improvement in M-value was correlated to per cent reduction in PRL levels (r = −0.85, P = 0.034). In conclusion, beneficial metabolic changes were seen in prolactinoma patients after treatment with DA agonists, underscoring the importance of an active treatment approach and to consider the metabolic profile in the clinical management of hyperprolactinemia patients.     

Reduced exercise capacity in patients with tricuspid regurgitation after successful mitral valve replacement for rheumatic mitral valve disease.

OBJECTIVE--To determine how severe tricuspid regurgitation influences exercise capacity and functional state in patients who have undergone successful mitral valve replacement for rheumatic mitral valve disease. DESIGN--9 patients in whom clinically significant tricuspid regurgitation developed late after mitral valve replacement were compared with 9 patients with no clinical evidence of tricuspid regurgitation. The two groups were matched for preoperative clinical and haemodynamic variables. Patients were assessed by conventional echocardiography, Doppler echocardiography, and a maximal treadmill exercise test in which expired gas was monitored by mass spectrometry. SETTING--University Hospital of Wales, Cardiff. SUBJECTS--18 patients who had been reviewed regularly since mitral valve replacement. MAIN OUTCOME MEASURE--Objective indices of exercise performance including exercise duration, maximal oxygen consumption, anaerobic threshold, and ventilatory response to exercise. RESULTS--Mitral valve prosthetic function was normal in all patients and estimated pulmonary artery systolic pressure and left ventricular function were similar in the two groups. Right ventricular diameter (median (range) 5.0 (4.3-5.6) v 3.7 (3.0-5.4) cm, p less than 0.01) and the incidence of paradoxical septal motion (9/9 v 3/9, p less than 0.01) were greater in the group with severe tricuspid regurgitation. Exercise performance--assessed by exercise duration (6.3 (5.0-10.7) v 12.7 (7.2-16.0) min, p less than 0.01), maximum oxygen consumption (11.2 (7.3-17.8) v 17.7 (11.8-21.4) ml min-1 kg-1, p less than 0.01), and anaerobic threshold (8.3 (4.6-11.4) v 0.7 (7.3-15.5) ml min-1 kg-1, p less than 0.05)--was significantly reduced in the group with severe tricuspid regurgitation. The ventilatory response to exercise was greater in patients with tricuspid regurgitation (minute ventilation at the same minute carbon dioxide production (41.0 (29.9-59.5) v 33.6 (26.8-39.3) l/min, p less than 0.01). CONCLUSIONS--Clinically significant tricuspid regurgitation may develop late after successful mitral valve replacement and in the absence of residual pulmonary hypertension, prosthetic dysfunction, or significant left ventricular impairment. Patients in whom severe tricuspid regurgitation developed had a considerable reduction in exercise capacity caused by an impaired cardiac output response to exercise and therefore experienced a poor functional outcome. The extent to which this was attributable to the tricuspid regurgitation itself or alternatively to the consequences of right ventricular dysfunction was not clear and requires further investigation.     

Fusion imaging guided implantation of a Tricento transcatheter heart valve for severe tricuspid regurgitation

We report the case of a 64-year-old patient with history of chronic kidney disease on dialysis who was repeatedly hospitalized due to hydropic decompensation. Right heart failure with secondary severe tricuspid regurgitation was diagnosed. An interventional approach was recommended due to the heavy calcification of the sinus venosus and the perioperative risk (EuroScore II 3.2%) and taking into account the explicit request of the patient. After analysis of a full-cycle computed tomography, the patient was eligible for the implantation of the Tricento transcatheter heart valve. The custom-made prosthesis was implanted successfully using periprocedural transoesophageal guidance supported by fusion imaging that integrates live co-registration. After implantation of the valve prosthesis, the primary result was excellent. The patient was discharged without further complications shortly after the procedure and her status is being closely monitored.     

Isolated tricuspid valve surgery for severe tricuspid regurgitation following prior left heart valve surgery: analysis of outcome in 34 patients.

BACKGROUND AND AIMS OF THE STUDY: Patients with symptoms of right heart failure due to severe tricuspid regurgitation following a prior operation on left heart valves present a difficult problem. The outcome of tricuspid surgery in this setting is not well defined. We describe a single-center experience of isolated tricuspid valve surgery after prior left heart valve surgery, and analyze potential risk factors for a poor outcome. METHODS: Thirty-four patients who underwent isolated tricuspid valve operation for severe tricuspid regurgitation following prior valvular surgery for left-sided valve disease between 1980 and 1997 were identified. Charts were reviewed for clinical, echocardiographic, catheterization and surgical data. Follow up of survivors was conducted by telephone to ascertain functional status. RESULTS: Three patients died in hospital (early mortality rate, 8.8%). At a follow up of 71 +/- 39 months, 13 patients were alive and 21 reached an end-point (three cardiac reoperations, 18 deaths). Event-free actuarial survival at five years was 41.6 +/- 9.2%. Patients who were alive at follow up had a mean NYHA functional class of 2.1 +/- 0.6 compared with 3.4 +/- 0.5 preoperatively; 85% of survivors were symptomatically improved. Predictors of poor outcome were: increased age at the time of tricuspid surgery (p = 0.0007) and higher number of prior cardiac operations (one versus two or three, p-value 0.01, relative risk 3.4). Pulmonary artery systolic pressure, left ventricular ejection fraction, right ventricular function and size, annulus diameter, tricuspid valve pathology, and valve replacement versus repair were not predictive of outcome. CONCLUSIONS: Isolated tricuspid valve surgery for severe tricuspid regurgitation following prior surgery for left-sided heart valve disease can be performed with acceptable early mortality. There remains a high late mortality that is predicted only by age and the number of previous cardiac operations. However, in this selected group of severely symptomatic patients, significant improvement in symptoms are achieved in the survivors.     

Neo-aortic root dilation and valve regurgitation up to 21 years after staged reconstruction for hypoplastic left heart syndrome

OBJECTIVES: We sought to assess the prevalence and progression of neo-aortic root dilation and valvar regurgitation after staged reconstruction for hypoplastic left heart syndrome (HLHS). BACKGROUND: In HLHS, the pulmonary valve functions as the neo-aortic valve. Neo-aortic valve dysfunction has been observed after arterial switch operation and the Ross procedure. METHODS: Patients with HLHS born before January 1995 who had the Fontan operation and had serial echocardiograms were included. Echocardiograms were reviewed preoperatively, after each surgical reconstruction, and at most recent follow-up for neo-aortic root size and severity of neo-aortic regurgitation (AR). Potential risk factors for neo-aortic valve dysfunction were assessed. RESULTS: Fifty-three patients met inclusion criteria. Bidirectional superior cavopulmonary anastomosis as an interim procedure was performed in 39 patients (74%). Median duration of follow-up was 9.2 (range 5.1 to 21) years. During follow-up, the neo-aortic root progressively dilated out of proportion to body size over time, with 52 patients (98%) having a Z-score >2 at most recent follow-up. Neo-AR was present in 61% of patients at most recent follow-up, with progression over time in 26 patients (49%). However, neo-AR was more than mild in only three patients. Significantly larger neo-aortic root Z-scores were observed in patients with any degree of neo-AR at most recent follow-up. No other anatomic or clinical variables correlated with severity of neo-AR or root dilation. CONCLUSIONS: After staged reconstruction for HLHS, neo-aortic root dilation and neo-AR progress over time. Early volume unloading does not have a beneficial impact on dilation of the neo-aortic root. These findings raise concerns about neo-aortic valve function into adulthood.     

Evidence for rheumatic valve disease in patients with severe tricuspid regurgitation long after mitral valve surgery: the role of 3D echo reconstruction

BACKGROUND AND AIM OF THE STUDY: Although severe tricuspid regurgitation (TR) is a well-recognized, long-term complication of rheumatic mitral valve replacement that impairs the functional results of surgery, its exact basis remains unclear and its management is unsatisfactory. The study aim was to obtain a detailed assessment of tricuspid valve morphology and function using 2D transesophageal echocardiography (TEE) with 3D reconstruction, and to determine long-term clinical outcome in patients after surgery for rheumatic mitral valve disease. METHODS: A total of 42 patients (mean age 50 +/- 10 years) was followed up; 39 patients had mitral replacement and three had valvotomy. Thirty patients had developed impaired exercise tolerance, fluid retention and echocardiographic evidence of severe TR at 8.2 +/- 2.6 years after surgery; the remainder had mild regurgitation. RESULTS: Follow up showed greater mortality in the severe TR group, with approximately 50% survival at 60 months after diagnosis compared with mild TR. None of the patients with severe TR had a dysfunctional mitral prosthesis. In these patients, transthoracic echo-Doppler showed enlarged right atrium and right ventricle, a mean transtricuspid retrograde pressure drop of 15 +/- 4 mmHg and apparently normal leaflet anatomy. Twenty patients (15 with severe TR) underwent a TEE and 3D reconstruction study for further evaluation. Abnormal leaflet anatomy was demonstrated in all patients with severe TR, with restricted leaflet motion in 10, leaflet shortening and thickening in the remainder, and dilatation of tricuspid valve annular insertion suggestive of rheumatic involvement. Although diastolic transtricuspid velocities were increased (peak flow 0.8 +/- 0.1 m/s) in these patients due to increased stroke volume, significant tricuspid stenosis was present in only two cases (mean gradient 4 and 3 mmHg respectively). Histopathology confirmed the presence of leaflet vascularization and extensive fibrosis in two patients who underwent tricuspid valve replacement. CONCLUSION: Rheumatic leaflet involvement contributes to severe TR occurring long after mitral valve replacement, though overt stenosis is uncommon. Knowledge of the structural basis of this condition may thus improve its long-term management, possibly with early tricuspid valve repair.     

Outcome of significant functional tricuspid regurgitation late after mitral valve replacement for predominant rheumatic mitral stenosis

Significant tricuspid regurgitation (TR) can contribute to increased morbidity and mortality in patients undergoing mitral valve surgery for mitral stenosis. The aim of this study was to evaluate the association between the severity of preoperative functional TR and late adverse outcomes in patients undergoing mitral valve replacement (MVR). The study group comprised 68 patients (54 women, 14 men; mean age 45 +/-10 years) with rheumatic mitral stenosis (MS) who had undergone MVR without tricuspid valve surgery between 4 and 13 years (mean 8.1 +/-2.6 years) before their last clinical examination. All patients underwent a complete preoperative and late postoperative color-Doppler echocardiographic examination. The severity of TR was assessed echocardiographically by using color-Doppler flow images and flow direction in the inferior vena cava or hepatic veins. Patients were classified into 2 groups; 42 with mild (62%) and 26 with significant (38%) TR. Patients with significant TR showed longer preoperative symptomatic period and more atrial fibrillation than those with mild TR. All patients had medical treatment. Functional capacity and NYHA class of the patients in both groups improved significantly after MVR. Freedom from symptomatic heart failure (functional class III or IV) was higher (86% vs 54%) and the need for hospitalization was significantly lower for the mild TR group. Significant preoperative functional TR diagnosed by echocardiography was associated with an adverse outcome. Therefore, further studies are needed to evaluate the effect of concomitant tricuspid valve repair on the late outcome of patients undergoing mitral valve surgery in order to prevent significant late morbidity.     

Aortic valve calcification: its significance and limitation as a marker for coronary artery disease

Aortic valve calcification (AVC) is correlated with atherosclerotic risk factors; however, its significance remains largely unknown. The aim of this study was to investigate whether AVC detected by transthoracic echocardiography can be a useful marker for the identification of significant coronary artery disease (CAD), particularly in elderly patients. The study included 432 consecutive patients with suspected CAD who were admitted for the first time for coronary angiography. Two-dimensional transthoracic echocardiography and selective coronary angiography were performed in all patients. Aortic valve calcification was defined as bright dense echoes of > 1 mm on one or more cusps and decreased mobility of the involved cusp. Aortic valve calcification was detected in 64 of the 337 patients with significant CAD, but only in 9 of 95 cases with normal or mildly stenotic coronary arteries (19% vs 9%, p < 0.001). The severity of coronary artery disease (defined as the number of obstructed vessels) was not related to the presence of AVC (p > 0.05). Stepwise multiple logistic regression analysis of the study patients revealed only age (p=0.003, odds ratio= 1.56) and AVC (p<0.001, odds ratio = 2.03) as independent predictors of CAD. When the study population was divided into two groups as those below (n = 338) and above (n = 94) 75 years old, AVC failed to be a predictor of CAD in those >75 years old (p > 0.05, odds ratio = 0.8) while it remained the most significant predictor of CAD (p<0.001, odds ratio=2.19 in patients aged <75 years. In conclusion, detection of AVC by transthoracic echocardiography may be a useful noninvasive marker for identification of significant CAD in patients younger than 75 years old. Its clinical usefulness is limited in elderly patients.