New quantitative method for evaluating tricuspid regurgitation

A new quantitative method for evaluating regurgitation (TR) is proposed in order to select the most suitable treatment for functional TR associated with acquired valvular heart disease. The regurgitant volume per beat (VTR) is calculated using two-dimensional color Doppler and continuous-wave Doppler echocardiographies. In a study of 48 patients, preoperative VTR showed a significant correlation with tricuspid annular diameter at end-diastole, right atrial mean pressure and right ventricular end-diastolic pressure. Patients were classified into 3 groups according to preoperative VTR: Group I, VTR less than 10 cc (no. 18); Group II, VTR = 10-20 cc (no. 18); Group III, VTR greater than or equal to 20 cc (no. 12). This classification correlated well with the intraoperative findings of TR. In all Group I patients, VTR decreased without any tricuspid valve repair. In Group II, 17 of 18 patients underwent tricuspid annuloplasty, and showed a decrease in VTR to below 10 cc after surgery. In Group III, 10 underwent tricuspid annuloplasty and 2 tricuspid valve replacement. Three of the 10 with tricuspid annuloplasty showed a significant degree of postoperative VTR (10-20 cc). These 3 patients as well as the 2 with tricuspid valve replacement showed a preoperative peak-to-peak pressure difference across the tricuspid valve during the ejection phase (RVsp-TAv) of less than or equal to 20 mmHg and tricuspid annular diameter at end-diastole of greater than or equal to 50 mm. In conclusion, no tricuspid valve repair was required in Group I (TR I). For group II (TR II) patients, tricuspid annuloplasty was necessary and adequate for TR correction. For Group II (TR III) patients, a more substantial procedure like tricuspid valve replacement should be performed, especially when the preoperative RVsp-RAv is less than or equal to 20 mmHg and tricuspid annular diameter at end-diastole is greater than or equal to 50 mm.     

Surgical management of tricuspid regurgitation in patients undergoing mitral valve surgery--analysis of the amount of tricuspid valve annular dilatation]

As a means to determine whether correction for tricuspid regurgitation (TR) in mitral valve surgery is necessary, pulsed Doppler echocardiography was used to study 61 patients (age 49.5 +/- 9.5 years) who underwent mitral valve surgery. Early postoperative tricuspid regurgitation (average 9 +/- 3 postoperative days) was evaluated by a comparison with tricuspid valve annular dilatation and systolic annular shortening in preoperative right ventriculography. Kishimoto's method was used to measure the angiographic maximal early systolic (TVD) and minimal end-systolic diameters where as the shortening of the tricuspid annulus (STA) was expressed as a percent reduction in the maximal diameter by Ubago's methods. Patients were categorized into two groups, i.e., a group having had tricuspid annuloplasty (TAP group n = 23), and a NON-TAP group (n = 38). Preoperative right ventricular volume and hemodynamic indicator were studied with respect to both the TVD and the STA. Results are as follows: 1) The TVD significantly correlated with the end-diastolic right ventricular volume index (EDVI), regurgitant fraction of the tricuspid valve (RF), end-systolic right ventricular volume index (ESVI), pulmonary vascular resistance (PVR), mean pulmonary artery pressure (PAm), mean right atrial pressure (RAm), and right ventricular end-diastolic pressure (RVEDP) (p less than 0.01). 2) The STA was significantly correlated with EDVI, RF, ESVI, RAm and RVEDP (p less than 0.01). In the NON-TAP group, the TVD was significantly larger in patients with residual TR (average 32.5 mm/m2) than in patients having postoperative disappearance of TR (average 25.7 mm/m2) (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Intraaortic Balloon Counterpulsation Improves Right Ventricular Failure Resulting From Pressure Overload

Background. Right ventricular (RV) dysfunction is common after heart transplantation, and myocardial ischemia is considered to be a significant contributor. We studied whether intraaortic balloon counterpulsation would improve cardiac function using a model of acute RV pressure overload.

Methods. In 10 anesthetized sheep, RV failure was induced using a pulmonary artery constrictor. Baseline measurements included mean systemic blood pressure, RV peak systolic pressure, cardiac index, and RV ejection fraction. Myocardial and organ perfusion were measured using radioactive microspheres.

Results. After pulmonary artery constriction, there was an increase in RV peak systolic pressure (32 ± 2 to 60 ± 3 mm Hg; p < 0.01) and a decrease in mean systemic blood pressure (68 ± 4 to 49 ± 2 mm Hg; p < 0.01), RV ejection fraction (0.51 ± 0.04 to 0.16 ± 0.02; p < 0.01), and cardiac index (2.48 ± 0.04 to 1.02 ± 0.11; p < 0.01). Blood flow to the RV did not change significantly, but there was a significant reduction in blood flow to the left ventricle. The initiation of intraaortic balloon counterpulsation (1:1) using a 40-mL intraaortic balloon inserted through the left femoral artery resulted in an increase in mean systemic blood pressure (49 ± 2 to 61 ± 3 mm Hg; p < 0.01), cardiac index (1.02 ± 0.11 to 1.45 ± 0.14; p < 0.05), RV ejection fraction (0.16 ± 0.02 to 0.23 ± 0.02; p < 0.01), and blood flow to the left ventricle.

Conclusions. In a model of right heart failure, the institution of intraaortic balloon counterpulsation caused a significant improvement in cardiac function. Although RV ischemia was not demonstrated, the augmentation of left coronary artery blood flow by intraaortic balloon counterpulsation and subsequent improvement in left ventricular function suggest that left ventricular ischemia contributes to RV dysfunction, presumably through a ventricular interdependence mechanism. Therefore, study of the safety and efficacy of intraaortic balloon counterpulsation in the management of patients with acute right heart dysfunction is warranted.     

Long-term evaluation of treatment for functional tricuspid regurgitation with regurgitant volume: characteristic differences based on primary cardiac lesion

OBJECTIVES: The aim of this study was to characterize differences in the long-term effects of treatment for functional tricuspid regurgitation based on the primary cardiac lesion. METHODS: Ninety-six patients with valvular heart disease and 32 patients with atrial septal defects associated with tricuspid regurgitation were studied. The tricuspid annular diameter was associated with evidence of right heart failure. In valvular heart disease, a Kay annuloplasty was performed in 33 patients with a tricuspid annular diameter of >/=40 mm to 44 mm, a modified De Vega annuloplasty in 12 patients with a tricuspid annular diameter of >/=45 mm to 49 mm, and a modified De Vega annuloplasty, annuloplasty using a Carpentier ring, or tricuspid valve replacement in each of 4 patients with a tricuspid annular diameter of >/=50 mm. In atrial septal defects, a Kay annuloplasty was performed in 11 patients with a tricuspid annular diameter of >/=45 mm to 49 mm, and a modified De Vega annuloplasty was performed in 5 patients with a tricuspid annular diameter of >/=50 mm. A mean follow-up period was 79 months after operation. RESULTS: In the patients with a tricuspid annular diameter of <50 mm, the hemodynamic and clinical findings and tricuspid regurgitation remarkably improved. In the patients with valvular heart disease with a tricuspid annular diameter of >/=50 mm, however, the right heart parameters also showed improvement but less so when compared with those patients with a tricuspid annular diameter of <50 mm. In addition, 4 patients undergoing a modified De Vega annuloplasty have had a gradual increase in tricuspid regurgitation and clinical manifestations late after the operation. In contrast, all 5 patients with atrial septal defects with a tricuspid annular diameter of >/=50 mm have shown remarkable improvement, similar to those with a tricuspid annular diameter of <50 mm. Preoperative analyses revealed that the right heart function in atrial septal defects had not deteriorated to the same extent as in valvular heart disease. CONCLUSION: In the patients with a severely dilated tricuspid anulus (>/=50 mm), the postoperative change of tricuspid regurgitation differed between those patients with valvular heart disease and atrial septal defects.     

Effect of variable annular reduction on functional tricuspid regurgitation and right ventricular dynamics in an ovine model of tachycardia-induced cardiomyopathy

ObjectiveTo investigate the effect of variable tricuspid annular reduction (TAR) on functional tricuspid regurgitation (FTR) and right ventricular (RV) dynamics in ovine tachycardia-induced cardiomyopathy.MethodsNine adult sheep underwent implantation of a pacemaker with an epicardial lead and were paced at 200 to 240 bpm until the development of biventricular dysfunction and functional TR was noted. During reoperation on cardiopulmonary bypass, 6 sonomicrometry crystals were placed around the tricuspid annulus (TA) and 14 were placed on the RV epicardium. Annuloplasty suture was placed around the TA and externalized to an epicardial tourniquet. After weaning from cardiopulmonary bypass, echocardiographic, hemodynamic, and sonomicrometry data were acquired at baseline and during 5 progressive TARs achieved with suture cinching. TA area and RV free wall strains and function were calculated from crystal coordinates.ResultsAfter pacing, changes in left ventricular (LV) ejection fraction and RV fractional area decreased significantly. Mean TA diameter increased from 25.1 ± 2.9 mm to 31.5 ± 3.3 mm (P = .005), and median TR (range, 0-3+) increased from 0 (0) to 3 (2) (P = .004). Progressive suture cinching reduced the TA area by 18 ± 6%, 38 ± 11%, 56 ± 10%, 67 ± 9%, and 76 ± 8%. Only aggressive annular reductions (67% and 76%) decreased TR significantly, but these were associated with deterioration of RV function and strain. A moderate annular reduction of 56% led to a substantial reduction of TR with little deleterious effect on regional RV function.ConclusionsA moderate TAR of approximately 50% may be most advantageous for correction of functional TR and simultaneous maintenance of regional RV performance. Additional subvalvular interventions may be needed to achieve complete valvular competence.     

联合二瓣化和改良Kay成形术处理左心瓣膜手术患者三尖瓣瓣环扩张的初步疗效观察

目的观察用联合二瓣化和改良Kay成形术处理左心瓣膜手术患者三尖瓣瓣环扩张的临床结果。方法回顾性分析2010年1月至2011年5月华西医院158例伴有三尖瓣瓣环扩张(三尖瓣瓣环径/体表面积≥21 mm/m2)的左心瓣膜手术患者应用联合二瓣化和改良Kay成形术处理三尖瓣的临床资料,其中男27例,女131例;年龄17～74(45.9±10.4)岁,心房颤动92例,窦性心律66例。三尖瓣反流(TR)程度根据超声心动图评价分为0～5级。结果 158例患者均康复出院。体外循环时间54～273(100.8±30.5)min,升主动脉阻断时间25～162(64.5±22.0)min,阻断期间最低食管温度26.3～34.1(28.5±1.1)℃。术后随访3～19(11.0±5.0)个月。手术前、后三尖瓣反流程度差异有统计学意义(2.2±1.3 vs.0.4±0.8,P<0.05)。与术前相比,患者术后右心房内径、右心室内径及左心房内径明显缩小,手术前、后右心房内径、右心室内径及左心房内径之间的差异有统计学意义[(56.5±11.1)mm vs.(47.5±8.9)mm,P<0.05;(22.4±4.4)mm vs(.20.1±3.3)mm,P<0.05;(62.8±20.1)mm vs(.51.9±14.1)mm,P<0.05]。随访期间有中度以上TR 5例(3.2%,5/158),其中中度TR 4例,中-重度TR 1例。患者手术前、后左心室射血分数的变化不明显(60.4%±7.9%vs.59.6%±8.2%,P>0.05)。结论以三尖瓣瓣环径/体表面积≥21 mm/m2作为左心瓣膜手术患者三尖瓣成形手术指征较为合理。应用联合二瓣化和改良Kay成形术处理三尖瓣防止伴有三尖瓣瓣环扩张的患者术后TR的残留或加重是有效的。     

Tricuspid annuloplasty--modified technique

A modification of the DeVega's tricuspid annuloplasty (TAP) in the treatment of tricuspid regurgitation (TR) is described. Using a double-ended 2-0 Ethibond suture buttered with a Teflon felt pledget, a double suture line is begun at the center of the annulus of the anterior tricuspid valve leaflet. The two suture lines 2 to 3 mm apart are run around the edge of the annular ring of the anterior and posterior tricuspid valve leaflets, going over the posteroseptal commissure by 1.5 cm. A tiny piece of Teflon felt is placed at the end of the sutures. The annulus is narrowed to sungly allow passage of a prove with a diameter of 28 or 30 mm. The tricuspid function is assessed by injecting saline into the right ventricle through the right atrium. Between March 1986 and July 1989, 28 patients with functional TR secondary to mitral valve diseases have been operated on by this technique. There are one early and one late deaths, none being related to tricuspid valve annuloplasty. All 26 survivors had a significant drop in right atrial pressure and an associated improvement in clinical status. Follow-up of the 27 patients who survived this TAP ranges from 2 to 38 months (mean 17 months). This annuloplasty is a safe, effective and readily teachable method for the surgical management of TR.     

Tighter tricuspid annuloplasty with DeVega technique for secondary tricuspid regurgitation

More effective surgical treatment of secondary tricuspid regurgitation was investigated on the basis of intraoperative assessment of tricuspid regurgitation (TR) and clinicopathological study of right ventricular muscle biopsy. From March 1986 to February 1989, more aggressive narrowing of tricuspid valve ring using DeVega's method was performed on 29 patients. They were 8 men and 21 women, with the age of 28 to 71 (mean 53.5). Tricuspid annular diameter before procedure ranged from 31 to 45 mm in size, with the mean of 36.9 mm. Tricuspid annuli were constricted to 27 mm in 20 patients, and to 25 mm in 9 patients. Intraoperative evaluation of TR was done by digital examination from right atrium, contrast echocardiography, and filling regurgitation test on arrested or rebeating heart. But these intraoperative assessment of regurgitation did not predict postoperative residual tricuspid regurgitation. There was no early mortality. Postoperative residual tricuspid regurgitation was observed in only two patients (8.7%) of total cases within a follow-up period of 12 months. Quantitative study of extent of diffuse interstitial fibrosis of the right ventricular wall and diameter of right ventricular myocardial cells obtained by open transmural biopsy were done. The degree of diffuse interstitial fibrosis was assessed by the point-counting method, and mean percentage fibrosis (%fibrosis) was noted as 27.9%. Mean diameter of right ventricular myocardial cells was 19.5 microns in size. The diameter of right ventricular myocardial cell was correlated with pulmonary arterial pressure (r = 0.56).(ABSTRACT TRUNCATED AT 250 WORDS)     

风湿性心脏病左心瓣膜置换术后晚期重度三尖瓣关闭不全的外科治疗

目的 探讨风湿性心脏病(风心病)左心瓣膜置换术后晚期重度三尖瓣关闭不全(TR)的发生机制、手术指征、手术方法和疗效.方法 风心病左心瓣膜置换术后5～16年出现重度TR病人37例,均有不同程度的右心衰竭表现,左室射血分数(LVE)0.52±0.05,肺动脉收缩压(37.6±7.8)mm Hg.经右胸前外侧切口或正中切口再次手术行三尖瓣置换(TVR)25例,改良DeVega环缩术4例,带环成形术8例.结果 术后住院死亡4例,其中死于呼吸衰竭2例、多脏器功能衰竭和肾功能衰竭各1例.随访2个月～10年,死于右心衰竭3例,严重心律失常1例;生存的25例临床症状均有明显改善.结论 左心瓣膜置换术后晚期重度TR与肺动脉高压持续存在、风湿性三尖瓣病变、初次未作三尖瓣环缩术或方法不确实等有密切关系.左心功能良好、右室收缩功能无严重损害,无严重肺动脉高压是再次手术的指征,并主张尽早行TR纠正术.保留全瓣结构行三尖瓣置换有助于提高手术疗效.影响术后长期疗效仍是右室收缩功能.     

Reduction of tricuspid annular doppler tissue velocities in pediatric heart transplant patients.

BACKGROUND: Orthotopic heart transplantation is a life-saving therapy for children with end-stage heart disease. However, 50% of these transplanted children die or require re-transplantation 12 years later. Progressive deterioration of cardiac function is a common feature of long-term survivors; however, quantitative evaluation of the state of the right ventricle has been lacking. Tissue Doppler imaging (TDI) has been used to measure alterations in right ventricular (RV) function in other illnesses. The purpose of this study was to quantitate abnormalities in tricuspid annular systolic and diastolic velocities as an indicator of RV dysfunction, and to evaluate if time since transplantation and the presence of tricuspid regurgitation are associated with quantitative changes in tricuspid annular velocities in pediatric heart transplant recipients. METHODS: TDI was performed and velocities recorded during systole and early and late diastole at the tricuspid annulus, septum and mitral annulus in transplanted patients and in a control group with normal hearts. Pulsed wave Doppler mitral and tricuspid inflows were also measured and the severity of tricuspid regurgitation was estimated using color flow mapping. Patients with biopsy evidence of active cellular rejection or left ventricular ejection fraction of <60% were excluded from study. RESULTS: Thirty-five patients were divided into a normal heart group (n = 14) and a transplant group (n = 21), aged from 1 to 23 years. Systolic and early diastolic velocities at the tricuspid annulus and septum in the transplant group were reduced significantly compared with the normal group (p < 0.05): tricuspid annular systolic, 5.8 +/- 1.4 vs 9.4 +/- 1.7 cm/sec; early diastolic, -6.4 +/- 2.6 vs -9.7 +/- 2.6 cm/sec; septum systolic, 3.9 +/- 1.5 vs 5.8 +/- 1.4 cm/sec; and early diastolic, -6.3 +/- 2.4 vs -9.1 +/- 2.5 cm/sec. Patients were divided into early (<5 years) and late (>5 years) term groups since transplantation. Tissue velocities at the tricuspid annulus in the late term group had further reduction in systole, 4.9 +/- 1.4 vs 6.4 +/- 1.1 cm/sec, and early diastole, -5.3 +/- 1.5 vs -7.1 +/- 2.9 cm/sec (p < 0.05). Patients with severe tricuspid regurgitation had systolic and early diastolic velocities at the tricuspid annulus that were further reduced. Left ventricular mitral inflow Doppler early/late diastolic ratios became significantly different from the normal group 5 years after transplantation (p < 0.05). CONCLUSIONS: TDI demonstrated that tricuspid annular systolic and early diastolic velocities were abnormal in children after transplantation and became significantly more abnormal with prolonged time after transplantation. These alterations were not dependent on the presence of severe tricuspid regurgitation but appeared to be exacerbated by its presence. Evidence of diastolic left ventricular dysfunction was not detected before 5 years after transplantation in this unselected group. A prospective study may be required to define the evolution and progression of right and left ventricular dysfunction in children after heart transplantation.     

以三尖瓣瓣环径作为三尖瓣成形手术指征的初步临床观察

目的初步观察采用三尖瓣瓣环径作为三尖瓣成形术指征是否有助于减少二尖瓣置换术（MVR）患者术后中重度三尖瓣反流（TR）的发生。方法选择2005年4月至2006年6月期间我科56例术前无或轻度TR的MVR患者纳入研究。以三尖瓣瓣环径/体表面积≥21mm/m2将患者分为三尖瓣成形组（TA组）和非三尖瓣成形组（NTA组）。TA组：22例,男8例,女14例;年龄45.0±7.7岁;三尖瓣瓣环径36.8±3.8mm,体表面积1.57±0.15m2;心功能分级（NYHA）级18例,～级4例;窦性心律2例,心房颤动20例。NTA组：34例,男9例,女25例;年龄42.9±11.0岁;三尖瓣瓣环径28.5±4.4mm,体表面积1.58±0.13m2;心功能分级级28例,～6例;窦性心律9例,心房颤动25例。TA组患者采用Kay法施行三尖瓣成形术。术后随访及术后6个月完成超声心动图检查。结果56例患者术后均康复出院。术后随访11.0±2.4个月,除2例外54例患者完成术后6个月超声心动图复查。两组患者一般临床特征比较差异无统计学意义（P〉0.05）。与NTA组比较,术前TA组患者右房径（49.3±7.0mm）、三尖瓣瓣环径较大（36.8±3.8mm）,有三尖瓣反流的患者较多（P〈0.05）,术后TA组患者右房径（44.1±8.9mm）、三尖瓣瓣环径（28.9±6.1mm）明显缩小,三尖瓣反流程度明显改善（P〈0.05）。NTA组患者术前、术后右房径、三尖瓣瓣环径和三尖瓣反流程度变化不明显（P〉0.05）,有3例患者出现TR。结论对术前无或轻度TR的MVR患者,采用三尖瓣瓣环径作为三尖瓣成形手术指征可能有助于减少这些患者术后中-重度TR的发生。     

Right Ventricle Dysfunction in Patients With Adult Cystic Fibrosis Enlisted for Lung Transplant

Knowledge of preoperative right heart function of adult patients with cystic fibrosis (CF) awaiting lung transplant (LUTX) is limited. The echocardiography of adult patients with CF enlisted for LUTX was retrospectively analyzed and compared with standards and invasive analyses (right heart catheterization, multigated radionuclide ventriculography). We included 49 patients (reported as mean ± standard deviation; 29 ± 9 years of age; forced expiratory volume in first second of expiration, 31% ± 11% predicted; lung allocation score, 36 ± 5; invasive mean pulmonary artery pressure, 17 ± 5 mm Hg; multigated radionuclide ventriculography right ventricle [RV] ejection fraction, 50% ± 9%). Patients had increased RV end-diastolic area, RV wall thickness, and increased pulmonary artery acceleration time with subnormal tricuspid annular plane systolic excursion, tissue Doppler positive peak systolic velocity, and fraction area change. Subnormal tricuspid annular plane systolic excursion (< 23 mm), tissue Doppler positive peak systolic velocity (< 14 cm/s), and fraction area change (< 49%) had high sensitivity and negative predictive value in predicting impaired RV.ejection fractionA good correlation between echocardiographic estimated and invasively measured systolic pulmonary artery pressure was observed (R² = 0.554, P < .001). Adults with CF awaiting LUTX have morphologic alterations of the right heart, with subclinical impairment of RV systolic function. Echocardiography may be used as a bedside, repeatable, and reliable noninvasive test to screen further deterioration in RV function while on the waiting list for LUTX. More prospective follow-up echocardiographic studies are necessary to confirm such a hypothesis.     

A single-size band, 50mm long, for tricuspid annuloplasty.

A technique for tricuspid annuloplasty is presented, using a flexible 50mm long band, where the annular circumference is reduced to a fixed value of 78.5mm (circumference of #25mm sizer). From June to February 2007, 15 consecutive patients with tricuspid regurgitation (TR) underwent tricuspid repair using this technique. The first suture is passed at the level of the anteroseptal commissure, the last one in the zone of the septal annulus, 28.5mm from the first one. The remaining sutures are passed as usual. All the sutures are then adapted to a 50mm long band. After a mean of 5.4 months from surgery, all patients are alive and asymptomatic. One patient showed residual 2/4 TR, due to enlarged RV with high pulmonary pressure despite a well functioning mitral prosthesis. Mean gradient across the tricuspid valve was 2.5+/-0.4mmHg. This technique for tricuspid repair is simple and reliable, providing effective and reproducible results.     

Left Ventricular Assist Device Implantation in Patients With Optimal and Borderline Echocardiographic Assessment of Right Ventricle Function

Background

Left ventricular assist devices (LVADs) are used for treatment of end-stage heart failure. Outcomes are dependent on right ventricle (RV) function. Prediction of RV function after LVAD implantation is crucial for device selection and patient outcome.The aim of our study was to compare early LVAD course in patients with optimal and borderline echocardiographic parameters of RV function.

Surgical treatment of pulmonary atresia with intact ventricular septum in infancy--analysis of right ventricular growth potential after pulmonary valvotomy

Our surgical experience involving pulmonary atresia with intact ventricular septum (PPA) between the years 1981 and 1989 is reviewed. Twelve infants aged 3 days to 11 months were studied for right ventricular growth potential with angiocardiography and hemodynamics after transventricular pulmonary valvotomy (TVPV). Ten infants were divided into two groups, 5 infants (Group I) were treated with TVPV only, and the other 5 infants (Group II) required additional surgery after the initial operation (TVPV in 2 cases and TVPV with shunt in 3 cases). Post-operative RV growth potential was evaluated with right ventricular index (RVI) based on the tricuspid valve annulus, right ventricular inlet, and right ventricular outlet dimensions, and with tricuspid annular index (TVI) based on the tricuspid valve annulus normalized by aortic diameter. Follow-up (3-69 months after initial operation) studies demonstrated that the RV cavity increased in Group I (RVI of 15.75 +/- 2.92 preoperatively versus 17.00 +/- 1.57 postoperatively, TVI of 3.04 +/- 0.63 versus 3.85 +/- 0.40). In contrast, the RV cavity in Group II demonstrated a lack of growth (RVI of 9.24 +/- 2.60 versus 9.85 +/- 2.76, TVI of 1.46 +/- 0.46 versus 1.70 +/- 0.80). PPA infants with RVI greater than 11 have been treated successfully with TVPV alone, which may maximize the potential for RV growth, but infants with RVI less than 11 have not experienced RV growth + postoperatively and, therefore, have required second intracardiac operations.     

Direct imaging of the tricuspid valve annular motions by fiberoptic cardioscopy in dogs. I. Does De Vega's annuloplasty preserve the annular motions?

Applying the technology of direct imaging by fiberoptic cardioscopy, physiologic and pathophysiologic motions of the tricuspid valve anulus were studied in 10 anesthetized normal dogs (control group) and in 9 dogs that had chronic tricuspid regurgitation (TR group). The heart was perfused with transparent modified Tyrode's solution by working heart method, and the anuli, outlined by sutured beads, were observed and recorded on a high-speed video system in real time. Tricuspid valve annular area was calculated at 14 points during the cardiac cycle. The control group was studied in the normal condition, and the tricuspid regurgitation group was studied during four interventions: nontricuspid annuloplasty group and three tricuspid annuloplasty groups with reducing tricuspid valve annular area to 80%, 65%, and 50% of that of the non-tricuspid annuloplasty group by De Vega's procedure. Tricuspid valve annular area in the control group increased by 7% during atrial systole and was reduced by 34% mainly during ventricular systole, in which the free wall annular area and the septal annular area narrowed by an equal 34%. Chronic tricuspid regurgitation lessened tricuspid valve annular area narrowing to 20% in percent reduction (p < 0.01). In the TR group the decrease in tricuspid valve annular area narrowing was attributed mainly to lessened narrowing of the free wall anulus (percent reduction of tricuspid valve annular area, 19%; p < 0.01). The amplitudes in tricuspid valve annular area narrowing were unchanged in the tricuspid annuloplasty groups even when tricuspid valve annular area, was reduced to 50% by De Vega's tricuspid annuloplasty (percent reduction of tricuspid valve annular area, 16%; not significant). These findings suggest that De Vega's tricuspid annuloplasty is a reasonable method that does preserve the physiologic annular motions in the opening and closing mechanism of the tricuspid valve.     

Assessment of the tricuspid valve: a comparison of four transesophageal echocardiographic windows

OBJECTIVE: Tricuspid valve annular dilation is associated with persistent tricuspid valve regurgitation (TR) after cardiac surgery. The purpose of this study is to compare assessment of the tricuspid valve annulus from 4 different echocardiographic windows. DESIGN: Prospective study. SETTING: Single tertiary care hospital. PATIENTS: Twenty patients undergoing cardiac surgery, including right atriotomy. METHODS: Measurements of the tricuspid valve annular diameter during ventricular diastole (TVADd) and of TR jet dimensions, obtained from 3 different transesophageal and 1 transgastric echocardiographic window, were compared with each other and with that measured by the surgeon during cardiopulmonary bypass. Data were compared using correlation statistics, bias analysis, and analysis of variance for repeated measures. RESULTS: TVAD measured by the surgeon both agreed and correlated best with TVADd measured from the transgastric right ventricular inflow/outflow window (r = 0.98; mean bias 0.04 cm). The proximal TR jet widths and TR jet lengths were larger when measured from midesophageal 4-chamber and midesophageal right ventricular inflow/outflow windows compared with other windows (p < 0.01). CONCLUSION: TVADd was more accurately measured from transgastric windows, whereas the measurements of the TR jet were greater from esophageal windows. These data support imaging from multiple windows to obtain a more comprehensive assessment of the tricuspid valve anatomy and function.     

Preoperative risk factors for right ventricular failure after implantable left ventricular assist device insertion

Background. Implantable left ventricular assist device (LVAD) insertion complicated by early right ventricular (RV) failure has a poor prognosis and is generally unpredictable.

Methods. To determine preoperative risk factors for perioperative RV failure after LVAD insertion, patient characteristics and preoperative hemodynamics were analyzed in 100 patients with the HeartMate LVAD (Thermo Cardiosystems, Inc, Woburn, MA) at the Cleveland Clinic.

Results. RV assist device support was required for 11 patients (RVAD group). RVAD use was significantly higher in younger patients, female patients, smaller patients, and myocarditis patients. There was no significant difference in the cardiac index, RV ejection fraction, or right atrial pressure between the two groups preoperatively. The preoperative mean pulmonary arterial pressure (PAP) and RV stroke work index (RV SWI) were significantly lower in the RVAD group (p = 0.015 and p = 0.011, respectively). Survival to transplant was poor in the RVAD group (27%) and was 83% in the no-RVAD group.

Conclusions. The need for perioperative RVAD support was low, only 11%. Preoperative low PAP and low RV SWI were significant risk factors for RVAD use.     

Surgical assessment of tricuspid valve replacement for severe tricuspid regurgitation without stenosis.

Eight patients undergoing tricuspid valve replacement (TVR) for severe tricuspid regurgitation (TR) without stenosis were subjected to the study. Four patients had primary TR due to trauma, infective endocarditis, or Ebstein's anomaly, and the other 4 had secondary TR associated with mitral valve lesions. The right heart pressure as well as clinical manifestations due to right heart failure showed deteriorated values in both the primary and secondary TR groups, though pulmonary arterial pressure was higher in the latter group. In 2 patients, initial annuloplasty procedures could not reduce TR sufficiently and were instantly abandoned for TVR. These 2 patients, one with congenital and one with secondary TR, died of intractable right heart failure early postoperatively, while the remaining 6 patients are alive to date, in the New York Heart Association (NYHA) functional class I, during the follow-up period of 6-192 (mean, 104) months. The 2 patients who died had shown a longer morbid duration and a lower preoperative right ventricular systolic function indicated by stroke work to pulmonary artery resistance. This paper might suggest that an earlier surgical intervention in severe TR is recommended before the right ventricular function deteriorates.     

Severe tricuspid regurgitation after mitral valve surgery: the risk factors and results of the aggressive application of prophylactic tricuspid valve repair

Purpose

This study aimed to examine the risk factors for severe postoperative tricuspid regurgitation (TR) in patients undergoing mitral valve surgery. We also studied the effects of prophylactic tricuspid valve repair (TVR) on severe postoperative TR.

Methods

We retrospectively studied 125 patients without severe TR who underwent mitral valve surgery from 1987 to 2006. Patients did not undergo TVR before 1998 (the early period, n = 54). In 1998 (the late period, n = 71), patients with a preoperative tricuspid annular diameter of ≥35 mm underwent TVR using an annuloplasty ring (n = 52).

Results

In the analysis of the early period, the rates of freedom from severe TR at 10 and 20 years after surgery were 76 and 59 %, respectively. A multivariate analysis identified moderate preoperative TR as a significant risk factor for severe TR. In the late period, none of the 52 patients who underwent TVR developed severe TR. However, 4/19 patients who did not undergo TVR developed severe TR, and all of these four patients had a preoperative tricuspid annular diameter of ≤35 mm.

Conclusions

Moderate preoperative TR is a significant risk factor for severe postoperative TR in patients undergoing mitral valve surgery. The aggressive application of TVR can prevent severe postoperative TR; however, tricuspid annular dilatation might not be a good indicator for TVR.