Effect of tricuspid annuloplasty in mitral/aortic valve replacement on the clinical aspects and global function of the right heart chamber

The clinical improvement after mitral or aortic valve surgery is primarily due to the correction of the aortic/mitral valve function and the subsequent decrease of pulmonary artery pressure. The hemodynamic effect of an additional tricuspid annuloplasty, however, is still unclear. To assess the influence of a tricuspid annuloplasty using DeVega- or Carpentier-technique on the clinical outcome, hemodynamics, and right ventricular function in patients with moderate to severe tricuspid insufficiency, 38 patients were studied pre- and 11 +/- 4 months postoperatively. The clinical degree of left heart failure was graded according to the criteria of the NYHA. The extent of right heart failure (RHF) was determined using a clinical score from 0 (no signs) to 3 (severe RHF with pleural effusion/ascites). Mean pulmonary artery pressure (PAPm), end-diastolic volume index (RVEDVI), and ejection fraction (RVEF) of the right ventricle using biplane cineventriculography, as well as the angiographic and dopplerechocardiographic degree of tricuspid insufficiency were determined. The patients were assigned to three groups: gr.I (n = 12): preoperatively no tricuspid insufficiency (TI), gr. II (n = 12): with preop. TI and without tricuspid annuloplasty (TA), gr. III (n = 14): with preop. TI and TA. The patients of all three groups improved postoperatively from NYHA functional class III to class II (p less than 0.001). The clinical score of RHF decreased from 0.8 +/- 0.5 to 0.3 +/- 0.5 in gr. I, from 1.4 +/- 1.1 to 0.6 +/- 0.7 in gr. II, and from 1.7 +/- 1.0 to 0.8 +/- 0.8 in gr. III (p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)     

Traumatic aortic and mitral valve injury following blunt chest injury with a variable clinical course

Blunt trauma is uncommonly followed by intracardiac valvar injuries. The resulting valvar insufficiency rapidly or progressively leads to congestive heart failure or death unless surgically corrected. Three patients with sustained blunt chest trauma were found to have two aortic valve and one mitral valve ruptures. They had variable clinical courses. However, after the diagnosis was established, surgical intervention was attempted promptly, which consisted of two aortic valve replacements and one mitral valvoplasty. Their postoperative courses were uneventful. Careful observation and repeated physical examination, aided by echocardiography, were required after the blunt chest trauma.     

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)     

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.     

全胸腔镜二尖瓣置换术同期心脏不停跳三尖瓣成形术安全性及有效性的临床研究

目的 比较全胸腔镜二尖瓣置换术同期行三尖瓣人工瓣环成形术与正中开胸二尖瓣置换术同期行三尖瓣人工瓣环成形术的手术结果及短期疗效。方法 回顾性分析2014年1月至2021年12月在广西壮族自治区人民医院接受二尖瓣置换术同期行三尖瓣人工瓣环成形术治疗三尖瓣反流(TR)的94例患者临床资料。68例接受正中开胸二尖瓣置换术同期心脏不停跳三尖瓣人工瓣环成形术(正中开胸组),26例接受全胸腔镜二尖瓣置换术同期心脏不停跳三尖瓣人工瓣环成形术(全胸腔镜组)。通过倾向性匹配评分(PSM)减少选择偏倚,最终得到26对病例进行分析。比较两组基本信息、手术治疗及术后随访资料,包括心脏彩超结果、手术住院相关指标等。结果 全胸腔镜组手术时间、体外循环时间及阻断时间长于正中开胸组,差异有统计学意义(P<0.05)。术后1个月心脏彩超检查结果显示,两组二尖瓣收缩期血流速度、二尖瓣压差、压力减半时间(PHT)、TR面积、右心房内径(RAD)、右心室内径(RVD)以及房颤发生率比较差异无统计学意义(P>0.05)。两组术后24个月TR复发率比较差异无统计学意义(P>0.05)。术后24个月心脏彩超检查结果...     

Iatrogenic left ventricular-right atrial fistula following mitral valve replacement and tricuspid annuloplasty: diagnosis by transthoracic and transesophageal echocardiography

Acquired left ventricle-to-right atrium communications are a known complication of valvular heart surgery. Previous reports have described the clinical features and diagnosis using cardiac catheterization. We report two cases of acquired left ventricle-to-right atrium fistula following mitral valve replacement. Particular emphasis is placed on the diagnosis using transthoracic and transesophageal echocardiography, obviating the need for cardiac catheterization before repair.     

Proteomics of ascending aortic aneurysm with bicuspid or tricuspid aortic valve

Bicuspid aortic valve is often associated with lesions of the ascending aorta, which differ histologically from those in tricuspid valve patients. We undertook proteomic analyses to assess differences at the proteome level. Aortic samples were collected from 20 patients undergoing aortic valve and/or ascending aortic replacement; 9 had a bicuspid valve: 5 with aortic aneurysm (diameter > 50 mm) and 4 without dilation; 11 had a tricuspid valve: 6 with aortic aneurysm and 5 without dilation. Patients with histologically proven connective tissue disorders were excluded. Samples were dissected, solubilized, and subjected to 2-dimensional gel electrophoresis. Gel patterns showed an average of 580 protein spots in samples from bicuspid valve patients, and 564 spots in those with tricuspid valves. Comparative analysis revealed a correlation coefficient of 0.93 for protein expression in the bicuspid valve group compared to the tricuspid group. Three protein spots were significantly over-expressed and 4 were significantly down-regulated in the bicuspid group compared to the tricuspid group. The lowest correlation in protein expression was between non-dilated aortic tissues. These differences between aortic tissues of bicuspid and tricuspid valve patients suggest that mechanisms of aortic dilation might differ, at least in part, between such patients.     

In-vivo motion of mitral valve annuloplasty devices

BACKGROUND AND AIM OF THE STUDY: The long-term outcomes of mitral valve repairs are enhanced with an annuloplasty device. Although, in general, semirigid and rigid annuloplasty devices remodel the shape of the mitral valve annulus, the effect of geometric alteration on annular motion has not been fully assessed. Hence, the study aim was to investigate the influence of semi-rigid annuloplasty devices on the motion of the mitral valve annulus in adult sheep. METHODS: Sonomicrometric crystals were attached to semi-rigid annuloplasty devices (CG Future Band and CG Future COMPOSITE Ring), as well as to intra- and epicardiac sites for motion assessment in 13 sheep. Following implantation, hemodynamic and sonomicrometric measurements were collected under normal sinus rhythm and during dobutamine challenge conditions. RESULTS: Sonomicrometric measurements showed variations in the degree of device motion and timing of motion changes, depending on device size and type. Measurement of transverse device width demonstrated a pre-systolic decrease in width. For devices with the largest annular motion, the transverse device width increased during ventricular systole, with an out-of-phase increase in mitral annular septal-lateral distance during diastole. However, the geometric device septal-lateral distance showed minimal change across all devices, indicating maintenance of posterior remodeling geometry. Three-dimensional analyses revealed vertical elevation of the anterior annulus above the posterior annular plane during ventricular systole, consistent with anterior annular folding. The maximum calculated annular area occurred during early to mid-ventricular diastole, providing for maximal valve orifice area during opening of the mitral valve. The minimum annular area occurred near end-diastole to early systole, consistent with valve closing. CONCLUSION: The study results suggest that semi-rigid posterior annuloplasty devices with absent or flexible anterior mitral valve annular segments allow for a dynamic anterior annulus while maintaining aggressive posterior annular remodeling. Future studies should be undertaken to investigate the interaction between the anterior mitral valve annulus and the aortic root following annuloplasty device implantation.     

Different clinical outcome of paravalvular leakage after aortic or mitral valve replacement

Although aortic valve replacement (AVR) and mitral valve replacement (MVR) are the most commonly performed prosthetic valve replacement operations, it is unclear whether clinical outcomes of paravalvular leakage (PVL) after MVR or AVR are different. It was hypothesized that clinical outcomes of PVL after AVR would be more favorable than after MVR because the pressure gradient is much larger in PVL occurring at the mitral position, which happens at the systolic phase, than at the aortic valve. Over a 12-year period, 82 patients with PVL were identified. After excluding patients who required immediate surgical repair for severe symptoms, patients with Beh?et disease or infective endocarditis, and those with PVL involving both valves, 54 remaining patients (21 women, mean age 56 ± 14 years, 23 AVRs) with mild to moderate leakage constituted the study population. The end points were cardiac death, all-cause mortality, repeat surgery, and urgent admission for heart failure. During a median follow-up period of 35 months, there were 27 events, including 23 repeated surgeries, 2 cardiac deaths, 1 noncardiac death, and 1 admission for heart failure. Cox regression analysis revealed that the valve location of PVL was the only independent clinical predictor of event-free survival. The estimated 8-year event-free survival rate was significantly higher in patients with PVL after AVR than those after MVR (70 ± 12% vs 16 ± 8%, p <0.0001). In conclusion, PVL after AVR demonstrated more favorable long-term clinical outcomes compared to that after MVR. In patients who develop PVL after AVR, repeat surgery may be deferred. However, in patients with PVL after MVR, more aggressive therapeutic approaches should be considered.     

Rheumatoid arthritis and simultaneous aortic, mitral, and tricuspid valve incompetence

We describe a 72-year-old woman with aortic, mitral, and tricuspid valve incompetence secondary to a rheumatoid granulomata. The cardiac valvular lesions developed simultaneously and deteriorated rapidly. The patient died after a transient relief of symptoms by high dose steroid therapy.     

Hospital outcome of concomitant tricuspid annuloplasty during totally endoscopic mitral valve surgery: a propensity matched study

BackgroundThis study aimed to determine how concomitant tricuspid annuloplasty (TAP) affects the clinical outcomes of patients undergoing totally endoscopic mitral valve surgery.MethodsThis was a single-centre, retrospective study. Between January 2019 and June 2020, 143 patients who underwent totally endoscopic mitral valve surgery in our institution were enrolled. Ninety-two patients who underwent isolated mitral valve surgery were categorized into the minimally invasive mitral valve surgery (MIMVS) group (n=92), and patients who underwent mitral valve surgery with concomitant TAP were categorized into the MIMVS-TAP (n=51) group. Clinical data were collected from all patients, including demographic and perioperative data. We conducted propensity score matching (PSM) by using one-to-one ratio nearest-neighbour matching for baseline demographic data and tricuspid valve-related parameters. Forty patients in each group were matched in this way. Parametric and nonparametric tests were performed for data analysis.ResultsStatistically, postoperative mortality within 30 days was not significantly different between the two groups (P=1). No differences were found in serious adverse events, such as stroke or third-degree conduction block, between the two groups after 1:1 PSM (P=1 and P=0.480, respectively). The mean operation time for the MIMVS+TAP group was longer (232.13±36.05 min) than that for the MIMVS group (204.25±28.49 min; P<0.001). The same was true for the cardiopulmonary bypass (CPB) time (169.48±25.96 vs. 153.10±23.00 min; P=0.004) and aortic clamp time (110.80±17.37 vs. 101.00±14.38 min; P=0.005). The duration of the intensive care unit stay and the overall postoperative length of stay were not different between the two groups (P=0.734 and P=0.472, respectively). The postoperative systolic pulmonary artery pressure differed between the two groups [38.00±8.45 (MIMVS); 33.65±7.34 (MIMVS + TAP), P=0.022].ConclusionsOur study showed that totally endoscopic mitral valve surgery with concomitant TAP is just as safe and effective as isolated totally endoscopic mitral valve surgery, even with a long surgery duration. Our study also suggested that totally endoscopic mitral valve surgery with concomitant TAP can improve tricuspid function in patients.     

全胸腔镜下与传统二尖瓣置换、三尖瓣环形成术的比较

目的比较全胸腔镜下和传统胸正中切口行二尖瓣置换、三尖瓣环形成术的临床效果。 方法选择2017年1月至2018年12月于海口市人民医院(中南大学湘雅医学院附属海口医院)和暨南大学附属第一医院就诊的患者60例,按照患者意愿选择手术方式,全胸腔镜下手术为试验组31例,传统胸正中切口手术为对照组29例。试验组做全胸腔镜下二尖瓣置换、三尖瓣环形成术,对照组做传统胸正中切口二尖瓣置换、三尖瓣环形成术。记录两组患者的手术时间、升主动脉阻断时间、心肺转流时间、切口范围、术后机械呼吸时间、监护室停留时间、术后住院时间、胸液引流量和引流管拔除时间,并观察患者术后并发症的发生情况。 结果试验组的手术时间、心肺转流时间、切口范围、关胸时间均小于对照组(P<0.05),而升主动脉阻断时间差异无统计学意义(P>0.05)。试验组术后机械呼吸时间、监护室停留时间、术后住院时间、胸液引流量和引流管拔除时间均小于对照组(P<0.05)。试验组气胸发生1例,肺部感染发生2例,心律失常发生1例,总不良反应发生率为6.56%,对照组气胸发生2例,肺部感染发生4例,心律失常发生3例,总不良反应发生率为14.52%(P<0.05)。 结论全胸腔镜下二尖瓣置换、三尖瓣环形成术的手术时间、心肺转流时间、关胸时间、术后机械呼吸时间、监护室停留时间、术后住院时间、引流管拔除时间更短,手术切口更小,术后引流物少,并且并发症少,安全性和实用性较高。     

Incidence and concomitant factors of tricuspid valve insufficiency in patients with aortic and mitral valve diseases

Invasive data about the frequency and associated factors of tricuspid regurgitation in normals and in patients with aortic and mitral valve disease are still rare. Thus, right ventricular biplane angiograms (RAO/LAO projection), the mean pulmonary artery pressure and the presence of atrial fibrillation were analyzed with regard to tricuspid regurgitation in 30 normals and 165 patients with pure mitral regurgitation, mitral stenosis, aortic regurgitation, aortic stenosis, combined mitral valve disease or combined aortic valve disease. Patients with tricuspid stenosis or coronary artery disease were excluded. In 52 of the 195 patients tricuspid regurgitation was present. Tricuspid regurgitation occurred statistically more often in patients with mitral stenosis (33%), mitral regurgitation (48%) or combined mitral valve disease (68%) than in patients with aortic regurgitation (4%) or combined aortic valve disease (3%). In patients with aortic stenosis and in normals tricuspid regurgitation was not present. In patients with combined mitral valve disease, tricuspid regurgitation was more often present than in patients with pure mitral stenosis (p less than 0.002), despite comparable values of the mean pulmonary artery pressure, the right ventricular enddiastolic and endsystolic volume indexes, the right ventricular ejection fraction and the frequency of atrial fibrillation. Only in patients with pure mitral regurgitation tricuspid regurgitation was associated with an elevated mean pulmonary artery pressure (p less than 0.02). Differences in the right ventricular size and function did not occur between normals and patients with mitral or aortic valve disease. Therefore, the mean pulmonary artery pressure, atrial fibrillation and the size and function of the right ventricle are not major determinants for the occurrence of tricuspid regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)