Severe tricuspid regurgitation due to entrapment of the anterior leaflet of the valve by a permanent pacemaker lead: role of real time three-dimensional echocardiography

Pacemaker leads may impair tricuspid valve coaptation and they are a well-known cause of mild tricuspid regurgitation. Occasionally, right ventricular leads worsen tricuspid regurgitation over time and patients develop late-onset symptoms of right-sided heart failure. The exact mechanism of this clinical entity is rarely identifiable by 2D-echocardiography only. This case report details a patient with severe tricuspid regurgitation secondary to immobilization of the anterior leaflet of the tricuspid valve by a permanent ventricular pacing lead. The mechanism of regurgitation was clarified by real time three-dimensional echocardiography that showed the location of the ventricular lead and its interference with the tricuspid valve.     

Tricuspid valve repair for treatment and prevention of secondary tricuspid regurgitation in patients undergoing mitral valve surgery

Secondary or functional tricuspid regurgitation occurring late after mitral valve surgery is associated with high morbidity and mortality. In this article, we review the pathophysiology of secondary tricuspid regurgitation and the evidence supporting the use of tricuspid valve annuloplasty for preventing and treating secondary tricuspid regurgitation. Liberal application of tricuspid valve annuloplasty is recommended to prevent progression of secondary regurgitation, as contrary to widely held opinion, fixing the left-sided valve dysfunction often does not resolve secondary tricuspid valve dysfunction. Based on existing literature, assessing the tricuspid valve annular dimensions can be recommended as part of all mitral valve operations, and annuloplasty strongly considered in patients with tricuspid annular dilatation or moderate to severe tricuspid regurgitation.     

Tricuspid valve replacement after cardiac transplantation

PURPOSE OF REVIEW: Tricuspid valve regurgitation is the most frequent valvular complication following orthotopic cardiac transplantation. It leads to diminished quality of life and predicts shortened long-term survival. The optimal surgical management of refractory tricuspid valve regurgitation in this setting is unclear. RECENT FINDINGS: Tricuspid valve regurgitation following cardiac transplantation is likely related to accumulated injury from repeated endomyocardial biopsies. Durability of repair in this setting was shown to be suboptimal. Replacement with a bioprosthesis was found to be durable and relieves symptoms of heart failure associated with tricuspid valve regurgitation in the majority of patients. Prophylactic tricuspid valve annuloplasty at transplantation was found to significantly decrease the incidence of early and late tricuspid valve regurgitation; long-term benefits remain unclear. SUMMARY: Results of tricuspid valve repair in the post-cardiac transplant setting are not ideal, and this strategy is better suited to treating functional tricuspid valve regurgitation resulting from annular dilatation. Tricuspid valve replacement with a bioprosthesis is a safe, durable, and effective method of treating tricuspid valve regurgitation following transplantation and allows for future endomyocardial biopsies to be performed. Mechanical valves should be avoided. A randomized controlled trial examining the long-term outcomes of prophylactic tricuspid annuloplasty is warranted.     

Tricuspid valvular disease in the patient with chronic pulmonary thromboembolic disease

Chronic thromboembolic pulmonary hypertension is associated with right ventricular dilatation, high right-sided filling pressures, and functional tricuspid regurgitation. The tricuspid regurgitation resulting from this disease has been postulated to be caused by tricuspid annular dilatation with displacement of the papillary muscles. Pulmonary endarterectomy is an operation that corrects the pulmonary hypertension resulting from chronic thromboemboli. As a result of this operation, most patients show significant improvement in tricuspid valve function. Thus, pulmonary endarterectomy is one of the few cardiac operations in which surgery remote to a valve restores valve function. This review analyzes the factors responsible for changes in tricuspid valve regurgitation after pulmonary endarterectomy and provides a strategy to predict the small subset of patients who will not show improvement in tricuspid valve function after this operation.     

Tricuspid cleft or tetracuspid valve? Usefulness of three-dimensional echocardiogram in the assessment of isolated tricuspid regurgitation in pediatrics

Tricuspid regurgitation (TR) in children may be secondary to congenital anomalies of the tricuspid valve complex which is composed by annulus, leaflets, commissures, chordae tendineae, and papillary muscles. The most common congenital cause is Ebstein's anomaly; however, there are less frequent causes such as abnormal number of tricuspid leaflets, tricuspid cleft, leaflet prolapse, double orifice tricuspid valve, and congenital tricuspid valve dysplasia. Identifying the precise cause is important to plan an appropriate repair surgery. In this article, the case of a 4-year-old patient with a tetracuspid valve with significant tricuspid regurgitation is presented and the morphological analysis was made by two-dimensional (2D) and three-dimensional (3D) transthoracic echocardiography. The morphological differences between a tetracuspid valve and a cleft of the anterior leaflet tricuspid valve are exposed. 3D echocardiographic evaluation of the tricuspid valve allowed a better understanding of the tricuspid valve anatomy, which includes evaluation of the tricuspid annulus, leaflets, commissures, and subvalvular apparatus. Recognizing the accurate cause of isolated tricuspid regurgitation allows better planning of the surgical technique.     

Evaluation of secondary tricuspid regurgitation by intraoperative epicardial pulsed Doppler echocardiography

Since 1985, we have evaluated secondary tricuspid regurgitation associated with acquired mitral valve disease in patients undergoing open mitral surgery by intraoperative epicardial two-dimensional and pulsed Doppler echocardiography. We found intraoperative pulsed Doppler echocardiography to be a sensitive, safe technique allowing surgeons to evaluate the severity of tricuspid regurgitation intraoperatively, even in critically ill patients who cannot afford preoperative cardiac catheterization. To assess the severity of tricuspid regurgitation intraoperatively, the transducer was placed directly on the right atrium. The ultrasound beam was transmitted into the right atrium at right angles to the tricuspid valve orifice to record intraoperative four-chamber two-dimensional echocardiograms, which were used to detect the sites of eight sample volumes, one in the right ventricle and seven in the right atrium, for pulsed Doppler echocardiography. The pulsed Doppler signals were recorded in each sample volume before and after cardiac procedures. The pansystolic abnormal signals lasting from tricuspid valve closure to the subsequent opening and consisting of components moving away from the tricuspid valve were interpreted as tricuspid regurgitant flows. Without operative correction of the tricuspid valve, secondary tricuspid regurgitation can resolve following mitral valve surgery alone. However, to our knowledge, there are no published reports of objective findings of intraoperative changes of secondary tricuspid regurgitation. Here we present the unique intraoperative pulsed Doppler echocardiographic features of tricuspid regurgitation before and after cardiac procedures. A 30-year-old woman with preoperative diagnosis of aortic regurgitation, mitral stenosis and severe tricuspid regurgitation underwent aortic and mitral valve replacement. The intraoperative pulsed Doppler echocardiograms recorded after pericardiotomy and before cannulation of the heart showed tricuspid regurgitant flow signal in all of the seven sample volumes in the right atrium, which was interpreted as severe tricuspid regurgitation. After surgical procedures, no regurgitant flow from the tricuspid orifice to the right atrium was detected in the eight sample volumes. This suggested that preoperative secondary tricuspid regurgitation improves without operative procedures for the tricuspid valve. All intraoperative echocardiographic procedures were performed within 5 min, and no arrhythmias or other complications related to this technique were noted. Epicardial pulsed Doppler echocardiography is helpful in assessing tricuspid valve function of patients undergoing mitral valve surgery bef     

Percutaneous Treatment of a Four-Leaf Clover Valve Using the MitraClip Technology

Percutaneous treatment of tricuspid valve regurgitation using MitraClip can be performed safely achieving improvement in reduction of regurgitation. Tricuspid valve shows different anatomic variations, in particular regarding the number of leaflets, which could represent a challenge for transcatheter valve intervention. We present a case of massive tricuspid regurgitation in a 4-leaf clover valve. We implanted a first MitraClip into the anteroseptal commissure and then a second one between the 2 posterior leaflets, with a successful reduction of residual regurgitation. In conclusion, this approach can be safely performed in a 4-leaflet right ventricular valve.     

Determination of the severity of tricuspid valve insufficiency using Doppler echocardiography

In 187 patients with combined mitral and aortic valve lesions, to assess and quantify tricuspid regurgitation, biplane right ventriculograms were obtained and Doppler echocardiography performed for study of the tricuspid valve and right atrium. After definition of regurgitant turbulance across the tricuspid valve with pulsed Doppler, on mapping the right atrium the maximal length of regurgitant flow in the right ventricular inflow tract was determined from the short-axis parasternal view. In seven of 70 patients in whom angiographically tricuspid regurgitation was not detected, Doppler echocardiography demonstrated holosystolic insufficiency of the valve. In all patients with the angiographic diagnosis of tricuspid regurgitation grades I to III, this lesion was also documented Doppler echocardiographically with only slight divergence of the regurgitant area in the right atrium as viewed from the short-axis parasternal transducer position. In all patients, the tricuspid valve was morphologically unremarkable. In 32 patients, in agreement with angiographic findings, grade I tricuspid regurgitation was diagnosed; in seven patients the angiographic severity was overestimated by one grade. In 44 patients, in agreement with angiographic findings, tricuspid regurgitation grade II was detected; in four patients the Doppler echocardiographic severity was overestimated and five patients underestimated by one grade. In 23 patients with grade II tricuspid regurgitation angiographically, there was agreement with Doppler echocardiographic findings; in two patients the severity was underestimated by one grade.(ABSTRACT TRUNCATED AT 250 WORDS)     

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)     

改良三尖瓣成形术对继发性三尖瓣关闭不全的疗效评价

目的:改良Cosgrove-Edwards(CE)三尖瓣成形术对继发性三尖瓣关闭不全(TI)的临床疗效评价.方法:2002-08至2007-12,连续对51例左心系统瓣膜病变,合并中量以上反流的三尖瓣关闭不全患者进行矫治.2004年以前的患者,采用经典的CE三尖瓣成形术(CE组,η=14);2004年后的患者,采用CE改良术(改良CE组,η=37).51例患者根据术中发现,单纯三尖瓣瓣环扩大的为非风湿者(η=37),同时合并风湿性改变的为风湿者(η,=14).术后50例存活患者获得远期随诊,平均术后随诊时间为(47.08±22.08)个月.结果:三尖瓣成形效果的比较①改良CE组与CE组比较,术后三尖瓣瓣环直径[(26.2±1.7)mm vs(27.7±2.0)mm]、三尖瓣成形环的尺寸(28.1±2.1 V8 29.5±1.5)均缩小,术后1周左右残余三尖瓣中量反流的发生率降低(2.7%V8 21.4%),差异有统计学意义(P<0.05).②风湿者与非风湿者三尖瓣成形结果比较:术前既往瓣膜手术史的发生率高(50.0%VS 13.5%),舒张期三尖瓣流速增加[(1.4±0.4)m/s vs(0.9±0.2)m/s],肺动脉收缩压降低[(54.6±22.2)mmHg vs(72.5±22.6)mmHg,1 mmHg=0.133 kPa],三尖瓣瓣环直径[(37.0±6.2)mm vs(48.2±8.3)Inm]缩小,差异均有统计学意义(P<0.05).结论:改良三尖瓣成形术即选择性小号人工瓣环成形方法,对于继发性TI治疗效果良好;同时继发性,TI是一种进行性病变,对其矫治,也应个体化,以期达到最佳的治疗效果.     

Tricuspid valve insufficiency in patients with rheumatic mitral valve disease: angiographic diameter of the tricuspid ring and function of the right ventricle

Dilatation of the right ventricle and a consecutive enlargement of the tricuspid valve ring are thought to be the main causes of functional tricuspid regurgitation in patients with rheumatic mitral valve disease. To study the effect of right ventricular dilatation as well as the dimension of the tricuspid valve ring, right ventricular volume indices, ejection fraction, regional shortening, pulmonary artery pressure, and the diameter and systolic shortening of the tricuspid valve were determined in 67 patients with rheumatic mitral valve disease (NYHA class II and III) from biplane ventriculographies. Patients with right ventricular enlargement (greater than 90 ml/m2) were divided into groups with (group IIA) and without (group IIB) tricuspid regurgitation and compared with patients with normal right ventricular size and function without tricuspid regurgitation (group I). There was no difference in the end-diastolic volume index, in the afterload or in the diameter of the tricuspid ring. Right ventricular ejection fraction was decreased in group IIA (51 +/- 9% vs. 59 +/- 10% (IIB) and 61 +/- 6% (control); (p less than 0.05). Regional function was also decreased in group IIA. 73% of the patients with tricuspid regurgitation had right ventricular enlargement, but only 44% of the patients with right ventricular enlargement had tricuspid regurgitation. Thus right ventricular dilatation promotes the development of a tricuspid insufficiency, but is not the only cause. Additional factors like decreased local wall motion, alterations of the valve or the valve apparatus may also account for functional tricuspid regurgitation.     

Tricuspid and pulmonary valve disease evaluation and management

The clinical detection and quantification of tricuspid valve disease, although important, is not entirely accurate. Diagnostic evaluation is based on echocardiography, and color flow Doppler is useful for quantifying tricuspid regurgitation. Echocardiography provides information on heart chamber dimensions, right ventricular function, and the degree of pulmonary hypertension. In addition, tricuspid stenosis can be accurately assessed using mean and end-diastolic pressure gradient measurements. The treatment options for tricuspid stenosis include balloon valvuloplasty and surgical valve repair. Functional tricuspid regurgitation associated with left heart disease may require surgical attention during an operation to treat the left heart disease. Severe tricuspid regurgitation usually requires surgery to be performed in association with mitral valve surgery. Mild-to-moderate tricuspid regurgitation requires surgery when annular dilatation or severe pulmonary hypertension is present. The surgical options include tricuspid valve repair, with or without an annuloplasty ring. In patients with a primary anatomic deformity of the tricuspid valve, replacement of the valve with a bioprosthesis or mechanical valve may be considered. Intermediate and long-term results favor annuloplasty valve repair over valve replacement. Pulmonary valve disease is predominantly congenital, and generally takes the form of pulmonary stenosis. Pulmonary regurgitation often results from surgical or balloon valvuloplasty and is associated with deleterious long-term sequelae. The recent development of percutaneous valve replacement was a major advance.     

Transient neonatal tricuspid regurgitation: a Doppler echocardiographic study of three cases.

Three patients with normal hearts and no pulmonary abnormality had neonatal tricuspid regurgitation causing cardiorespiratory distress and cyanosis. The signs of tricuspid regurgitation resolved over a few weeks. In the acute phase echocardiography showed gross dilatation of the right atrium and ventricle. The interatrial septum bulged into the left atrium during the whole cardiac cycle. Doppler echocardiography showed clinically significant tricuspid regurgitation, a right to left shunt through the foramen ovale, reduced flow through the pulmonary valve, and in two patients ductal flow into the pulmonary artery. In one patient tricuspid regurgitation was so great that it impeded the opening of the pulmonary valve and produced functional "atresia" of the pulmonary valve. The presence of regurgitant blood flow through the pulmonary valve showed that the "atresia" was functional rather than organic. Doppler echocardiographic study is useful in distinguishing functional neonatal tricuspid regurgitation from structural abnormality of the tricuspid valve.     

Transient neonatal tricuspid regurgitation: a Doppler echocardiographic study of three cases

Three patients with normal hearts and no pulmonary abnormality had neonatal tricuspid regurgitation causing cardiorespiratory distress and cyanosis. The signs of tricuspid regurgitation resolved over a few weeks. In the acute phase echocardiography showed gross dilatation of the right atrium and ventricle. The interatrial septum bulged into the left atrium during the whole cardiac cycle. Doppler echocardiography showed clinically significant tricuspid regurgitation, a right to left shunt through the foramen ovale, reduced flow through the pulmonary valve, and in two patients ductal flow into the pulmonary artery. In one patient tricuspid regurgitation was so great that it impeded the opening of the pulmonary valve and produced functional "atresia" of the pulmonary valve. The presence of regurgitant blood flow through the pulmonary valve showed that the "atresia" was functional rather than organic. Doppler echocardiographic study is useful in distinguishing functional neonatal tricuspid regurgitation from structural abnormality of the tricuspid valve.     

Cryopreserved mitral homograft in the tricuspid position for infective endocarditis: a valve that can be repaired in the long-term (13 years)

Herein is reported the long-term repair of a cryopreserved mitral homograft in the tricuspid position. A 34-year-old HIV-infected patient underwent tricuspid valve replacement in 1991 with a cryopreserved mitral homograft because of infective endocarditis. Chronic tricuspid regurgitation secondary to repeated endocarditis led to reoperation 13 years later. Mitral valve repair was performed with a rigid ring as there was annular dilatation; the valve tissue was intact. One year later, transthoracic echocardiography showed no tricuspid regurgitation. The cryopreserved mitral homograft is a potentially repairable valve in the long-term.     

Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads

OBJECTIVES: We report a series of patients with severe tricuspid valve regurgitation due to a permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) lead. BACKGROUND: Severe tricuspid regurgitation caused by a PPM or ICD lead is an under-recognized but treatable etiology of severe right heart failure. METHODS: We reviewed the records of 41 patients who underwent tricuspid valve operation for severe tricuspid regurgitation caused by previously placed PPM or ICD leads. RESULTS: During surgery, severe tricuspid regurgitation was found to be caused by the PPM or ICD leads in all 41 patients. There was a perforation of the tricuspid valve leaflet by the PPM or ICD lead in 7 patients, lead entanglement in the tricuspid valve occurred in 4 patients, lead impingement of the tricuspid valve leaflets occurred in 16 patients, and lead adherence to the tricuspid valve occurred in 14 patients. The septal leaflet was most often perforated (6 of 7). In the preoperative evaluation, valve malfunction due to the PPM or ICD lead was diagnosed preoperatively in only 5 of 41 (12%) patients by transthoracic echocardiography. All patients underwent successful tricuspid valve operation (22 tricuspid valve replacement), with one perioperative death occurring. During follow-up (range, 1 to 99 months), there was one patient who died from left-sided heart failure and three patients died of other causes. The remaining patients showed improvement in signs and symptoms of heart failure. CONCLUSIONS: Damage to the tricuspid valve by PPM or ICD leads may result in severe symptomatic tricuspid regurgitation and may not be overtly visualized by echocardiography. This etiology should be considered when evaluating patients with severe right heart failure after PPM or ICD implantation.     

Transcatheter Tricuspid Valve Interventions: Landscape,Challenges, and Future Directions

Tricuspid regurgitation is a common finding in patients with left-sided valvular or myocardial disease, often being a marker for late-stage chronic heart failure with a grim prognosis. However, isolated tricuspid valve surgery remains infrequent and is associated with the highest mortality among all valve procedures. Hence, a largely unmet clinical need exists for less invasive therapeutic options in these patients. In recent times, multiple percutaneous therapies have been developed for treating severe tricuspid regurgitation, including tricuspid valve repair and, more recently replacement, opening an entirely new venue for managing tricuspid regurgitation. The aim of this review is to provide an updated overview and a clinical perspective on novel transcatheter tricuspid valve therapies, highlighting potential challenges and future directions.     

A new technique: Right ventriculography using a preshaped catheter

Right ventriculography with a preshaped catheter (J- or L-shaped) was evaluated in make the diagnosis of tricuspid regurgitation. Thirty normal subjects who did not have valvular disease showed no evidence of tricuspid regurgitation or premature ventricular contractions during injection except in one case. On the other hand, 24 patients with combined aortic and mitral valve disease showed mild to moderate tricuspid regurgitation in 11 patients and severe tricuspid regurgitation in eight patients. Only two patients developed frequent run of premature ventricular contraction during injection. Seven patients with severe tricuspid regurgitation were found to have severe tricuspid regurgitation during surgery. No evidence of tricuspid regurgitation was found In all six patients with isolated aortic valve disease. We can conclude that right ventriculography by the preshaped catheter improves the diagnostic accuracy of tricuspid regurgitation and a grading system of tricuspid regurgitation by angiography is proposed.     

Tricuspid regurgitation in tricuspid valve prolapse demonstrated with contrast cross-sectional echocardiography

To determine the prevaience of tricuspid regurgitation in patients with tricuspid valve prolapse and to define further the criteria for the diagnosis of tricuspid regurgitation on contrast echocardiography, evaluation was made of 45 patients who had adequate contrast studies. There were four groups of patients: Group A, 10 healthy control subjects with no evidence of structural heart disease on cardiac catheterizattion; group B, 10 patients with classic clinlcal evidence of tricuspid regurgitation; group C, 10 patients with cross-sectional echocardiographic evidence of mitral valve prolapse without tricuspid valve prolapse; and group D, 15 patients with both mitral and tricuspid valve prolapse on cross-sectional echocardiography.Tricuspid regurgitation was sought in each group by using the subxiphoid echocardiographic approach with peripheral venous injection of saline solution. The diagnosis required the presence of microcavitations in both the inferior vena cava and hepatic veins for at least three consecutive cardiac cycles. Tricuspid regurgitation was observed in no patients in group A, 10 of 10 patients in group B, 0 of 10 in groups C and 6 of 15 (40 percent) in group D. Contrast cross-sectional echocardiography proved to be a reliable technique for identifying tricuspid regurgitation with a high degree of specificity and sensitivity. Patients with tricuspid valve prolapse had a 40 percent prevalence rate of tricuspid regurgitation. This finding may identify a subgroup that requires particularly careful clinical follow-up care.     

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).