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.     

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.     

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.     

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.     

Hemodynamic changes during dynamic exercise in patients after mitral valve replacement for chronic mitral regurgitation.

To evaluate hemodynamic changes during dynamic exercise, we investigated 13 patients after mitral valve replacement (MVR) for chronic mitral regurgitation (MR) and 5 control subjects by right heart catheterisation during supine bicycle exercise. According to the sizes of the St. Jude Medical (SJM) prosthesis during MVR, patients were divided into group A (n = 8) with SJM 31mm and group B (n = 5) with SJM 29mm. Significant rise in cardiac index (CI) was noted during exercise in both groups A and B (from 3.3 +/- 0.8 to 5.5 +/- 0.9 l/min/m2, p < 0.01 and from 3.0 +/- 0.6 to 5.6 +/- 0.6 l/min/m2, p < 0.01 respectively) and also in control subjects (from 3.4 +/- 0.7 to 6.2 +/- 0.6 l/min/m2, p < 0.01). Mean pulmonary artery and pulmonary capillary wedge pressure were significantly higher during exercise in patients of both groups A and B than control subjects (p < 0.05 and p < 0.01 respectively). Total pulmonary vascular resistance was significantly higher during exercise in both groups A and B than control subjects (p < 0.05 and p < 0.01 respectively). No difference in hemodynamics were noted between the patients of group A and B during exercise. It is concluded that response of CI to exercise in patients after MVR for chronic MR was adequate in comparison to control subjects irrespective of two different valve sizes.     

Recurrence of tricuspid regurgitation in a patient with a rheumatic fever after mitral valve implantation with concomitant tricuspid valve annuloplasty

A case of a 62-year-old female with a recurrence of tricuspid regurgitation is presented. This complication occurred after mitral valve implantation and tricuspid valve annuloplasty. Diagnosis and treatment of this condition following rheumatic fever are discussed.     

Functional tricuspid regurgitation following replacement of the mitral valve.

In this series, the effect of replacement of the mitral valve was examined in 86/900 (9.6%) patients who had developed moderate functional tricuspid regurgitation, secondary to rheumatic mitral valvar disease. These patients were subdivided according to the severity of pulmonary hypertension and impairment of right ventricular function. Forty-six patients presented with severe pulmonary hypertension and 40 patients had moderate pulmonary hypertension (mean main pulmonary arterial pressure: 78 +/- 14 mmHg vs 41 +/- 6 mmHg; P less than 0.05). The latter had more advanced disease, greater impairment of right ventricular function and dilatation of the right heart chambers. Functional tricuspid regurgitation regressed in 38/42 survivors with severe pulmonary hypertension and persisted or progressed significantly in 22/34 survivors with impaired right ventricular function despite successful replacement of the mitral valve. The latter underwent replacement of the tricuspid valve (n = 16) or tricuspid annuloplasty (n = 6), at a mean interval of 44 +/- 4.4 months after replacement of the mitral valve, which resulted in 8/22 (23.5%) early deaths. Functional tricuspid regurgitation is more likely to persist in patients with advanced right ventricular failure. Tricuspid valvar competence should be restored in these patients at initial replacement of the mitral valve.     

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.     

Mitral valve stenosis and pure tricuspid valve regurgitation: comparison of necropsy patients having simultaneous mitral and tricuspid valve replacements with necropsy patients having simultaneous mitral valve replacement and tricuspid valve anuloplasty

Clinical and morphologic observations are described in 30 patients (23 [77%] of whom were in functional class III or IV) who underwent replacement of the mitral valve for mitral stenosis and either simultaneous replacement (13 patients, group I) or anuloplasty (17 patients, group II) of the tricuspid valve for pure tricuspid valve regurgitation. Comparison of the 13 patients in group I with the 17 patients in group II disclosed similar mean ages (55 vs 58 years), similar average preoperative right ventricular systolic pressures (64 vs 61 mm Hg), similar average right atrial mean pressures (10 vs 9 mm Hg), similar average left ventricular systolic pressures (126 vs 120 mm Hg), similar average pulmonary artery wedge-left ventricular mean diastolic pressures (16 vs 18 mm Hg), similar cardiac indexes (2.1 vs 2.0 liters/min/m2), similar mean heart weights (507 vs 535 g), and similar percents with grossly visible foci of left ventricular necrosis (15% vs 12%) and fibrosis (23% vs 12%). Of the 13 patients in group I, 10 (77%) died early (less than or equal to 60 days of tricuspid valve replacement) and 3 (23%) died late (29, 37 and 120 months); of the 17 patients in group II, 14 (82%) died early and 3 (18%) died late (4, 9 and 98 months). The causes of early death in the 2 groups were different: of the 10 patients in group I who died early, the cause was excessive bleeding in 5, low cardiac output of undetermined etiology in 3, dysfunction of both prostheses in 1 and cerebral insult in 1; of the 14 patients in group II who died early, none died from excessive bleeding, 4 from decreased cardiac output of uncertain cause, 5 from left ventricular inflow obstruction (produced by a Starr-Edwards ball-valve prosthesis in 4 and from a Starr-Edwards disc prosthesis in 1), 1 from left ventricular outflow obstruction (by a porcine bioprosthesis), 2 from technical mishaps (incision into left ventricular free wall with rupture in 1 and ligation of the left circumflex coronary artery with resulting acute myocardial infarction in 1) and 2 died suddenly for reasons not determined. Of the 6 patients dying greater than 60 days after operation, 4 died from chronic congestive cardiac failure, 1 from a cerebral embolus and 1 from prosthetic valve endocarditis.     

Late tricuspid regurgitation following mitral valve surgery.

The development of late tricuspid regurgitation is an important complication of mitral valve surgery, as it is associated with a severe impairment of exercise capacity and a poor symptomatic outcome. The pathogenesis of this condition remains poorly defined, but it is usually attributable to a functional abnormality of the tricuspid valve. Whilst its development may indicate an increased afterload on the right heart as a consequence of persistent pulmonary hypertension, mitral prosthetic dysfunction, progressive aortic valve disease or left ventricular failure, late tricuspid regurgitation may also develop in the absence of these factors and then may reflect right ventricular dysfunction and/or a localized abnormality of the tricuspid anulus. Failure to recognize and correct tricuspid regurgitation at the time of initial surgery may also account for many cases of tricuspid regurgitation but its re-appearance following tricuspid annuloplasty is uncommon and usually reflects a failure of the mitral prosthesis. A reduction in the prevalence of late tricuspid regurgitation is an important objective in view of the high operative mortality and disappointing long term results associated with reoperation for tricuspid regurgitation. This may be best achieved through combining earlier mitral valve surgery with the accurate detection and liberal correction of accompanying tricuspid incompetence at the time of initial surgery.(ABSTRACT TRUNCATED AT 250 WORDS)     

二尖瓣疾病相关的三尖瓣反流

二尖瓣疾病患者常常有三尖瓣反流(TR),后者与不良预后有关。风湿性二尖瓣置换术后如果没有同期处理三尖瓣病变,则TR很常见。纠正二尖瓣病变后TR可能不会消失,可在二尖瓣手术后很多年出现。对三尖瓣疾病患者应详细评估三尖瓣,包括测量三尖瓣环直径。在二尖瓣手术同期用成形环进行三尖瓣环成形是纠正或预防TR的最好方法,可改善生存,预防晚期TR和心力衰竭。     

两种麻醉方法在风湿性心脏病患者二尖瓣置换术中的应用比较

目的对比七氟醚全程吸入麻醉与丙泊酚全程靶控输注麻醉在风湿性心脏病患者二尖瓣置换术中的应用效果。 方法选取2015年3月至2018年4月胶州市人民医院行风湿性心脏病患者116例,均行二尖瓣置换术,依照麻醉方式不同分为七氟醚组(58例)与丙泊酚组(58例)。丙泊酚组接受丙泊酚全程靶控输注麻醉,七氟醚组接受七氟醚全程吸入麻醉。观察对比两组意识消失时间、拔管时间及不同时点心肌酶[肌酸激酶同工酶(CK－MB)、心肌钙蛋白Ⅰ(cTnⅠ)]水平。 结果麻醉后七氟醚组意识消失及拔管时间短于丙泊酚组(P<0.05);T₁～T₃七氟醚组血清cTnⅠ水平低于丙泊酚组(P<0.05);T₃七氟醚组血清CK－MB水平低于丙泊酚组(P<0.05)。 结论与丙泊酚全程靶控输注麻醉相比,七氟醚全程吸入麻醉应用于风湿性心脏病患者二尖瓣置换术中可有效缩短意识消失及拔管时间,减轻心肌损伤。     

Clinical and anatomic observations in patients having mitral valve replacement for mitral stenosis and simultaneous tricuspid valve replacement

Certain clinical and morphologic findings are described in 67 patients (aged 23 to 76 years [mean 52]; 55 women [82%]) who had mitral valve replacement for mitral stenosis (with or without associated regurgitation), and simultaneous tricuspid valve replacement for pure tricuspid regurgitation (58 patients) or tricuspid stenosis (all with associated regurgitation; 9 patients). Of the 58 patients with pure tricuspid regurgitation, 21 had anatomically normal and 37 had anatomically abnormal (diffusely fibrotic leaflets) tricuspid valves. Among these 58 patients, no clinical or hemodynamic variable was useful before surgery in distinguishing the group without from that with anatomically abnormal tricuspid valves. All 9 patients with stenotic tricuspid valves had anatomically abnormal tricuspid valves. The latter group had a lower average right ventricular systolic pressure (tricuspid valve closing pressure) than those with pure tricuspid regurgitation, and none had severe pulmonary arterial hypertension (present in 20 [30%] of the 58 patients with pure tricuspid regurgitation).     

风心病二尖瓣置换术后有效瓣口面积的超声定量评价

目的 比较压差降半时间法（PHT）和连续方程法（CE）对于二尖瓣置换术后瓣口狭窄程度的评估价值。方法 将2012年12月～2015年12月在四川大学华西医院、中南大学湘雅三医院因风湿性心脏病二尖瓣病变行单纯二尖瓣机械瓣置换术且在术后≥1年进行超声心动图随访的61例患者纳入本研究。根据术前心律,分为房颤心律组（AF）和窦性心律组(SR)。测量二尖瓣血流平均跨瓣压差(PG)、采用PHT法和CE法分别计算二尖瓣有效瓣口面积EOA-PH和EOA-CE,进行比较和相关分析。结果 61例患者PG为5.24±1.84mmHg, EOA-PHT、EOA-CE分别为2.18±0.36cm2、1.82±0.42cm2,无论是否合并房颤,EOA-PHT测值均明显高于EOA-CE。整体分析：PG、EOA-PHT、EOA-CE之间呈两两相关, PG与EOA-CE之间的相关性强于PG与EOA-PHT之间的相关性。分组分析：SR组PG、EOA-PHT、EOA-CE两两之间相关性良好。AF组PG与EOA-CE、EOA-PHT与EOA-CE仍有良好相关性,但PG与EOA-PHT相关性差。结论 压差降半时间法和连续方程法均可较为准确地评价二尖瓣置换术后瓣口的狭窄程度,但对于合并房颤的患者,连续方程法对有效瓣口面积的评价更为稳定。     

Echocardiographic variables associated with mitral regurgitation after aortic valve replacement for aortic valve stenosis

BackgroundMitral regurgitation (MR) is frequently associated with aortic stenosis. Previous reports have shown that coexisting mitral insufficiency can regress after aortic valve replacement (AVR) while others recommend dealing with examination.AimThe study aimed to assess the severity of MR before and after aortic valve replacement for aortic stenosis and to define the determinants of its postoperative evolution.MethodsFor this purpose, 30 adult patients referred for aortic valve surgery underwent pre- and 1 month postoperative transthoracic echocardiography including 2D, MM, PW, CW and color Doppler examination.ResultsPostoperative MR improved in 68.4% of the 19 patients (63.3%) who had preoperative moderate MR (p = 0.002). The effect of the valve size on the postoperative MR was statistically insignificant (0.059) but was significant on regression of the mass (p = 0.001) and drop in mean PG (p = 0.04) across AV. Patients with persistent moderate MR after surgery were all in AF and had significantly larger left atrial size (45 ± 26 mm), compared to none and a smaller left atrial (37 ± 19 mm) in patients in whom MR regressed or disappeared after surgery; respectively, p < 0.05. The postoperative variables associated with moderate MR were peak PG across AV (29.4 ± 5.1 vs 38.0 ± 5.7 p = 0.004), mean PG (15.04 ± 4.4 vs 22.8 ± 5.8 p = 0.009) and LVMI (124.7 ± 19.3 vs 147.2 ± 31.6 p = 0.065).ConclusionPreoperative predictors of residual postoperative MR were large LA and AF while the postoperative variables were high peak and mean pressure gradient across the aortic valve and high LVMI.