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.     

Multimodality imaging to guide transcatheter treatment of severe degenerative tricuspid regurgitation with tricuspid valve-in-ring implantation and paravalvular leak closure

Tricuspid valve (TV) degeneration after surgical repair with an annuloplasty ring is problematic as redo operation carries high mortality. This can be addressed with transcatheter therapies to implant a valve within in prior ring (tricuspid valve-in-ring). When an incomplete ring is present, paravalvular leak is commonly encountered after tricuspid valve-in-ring (TViR) implant; however, this can be addressed with paravalvular leak closure devices. Multimodality imaging including cardiac computed tomography and three-dimensional (3D) transesophageal echocardiography (TEE) are important for successful TViR implant. We report a case of tricuspid regurgitation after tricuspid repair with an incomplete annuloplasty ring and subsequent paravalvular leak closure.     

Tricuspid valve repair for biopsy-induced regurgitation in a heart transplant recipient

Tricuspid regurgitation (TR) is a frequent complication after heart transplantation. The etiology of TR is multifactorial, but biopsy-induced flail leaflet is one of the most important mechanisms. A 61-year-old woman underwent heart transplant, but experienced several rejection episodes which required multiple surveillance endomyocardial biopsies. At three months after transplant, she required tricuspid valve repair due to symptomatic severe TR. The anterior leaflet was flail, with rupture of primary and secondary chordae. Valve repair was performed with a triple leaflet edge-to-edge technique. The procedure consisted of suture fixation of the prolapsed anterior leaflet joining to the septal and posterior leaflets, and placement of a 30-mm annuloplasty ring. The patient was uneventfully discharged home on day 7 with trivial TR. At a four-years post-transplant evaluation, she was in NYHA functional class I, with preserved ventricular function and trivial TR. She has been followed closely because of post-transplant coronary artery disease.     

Surgical treatment of late tricuspid regurgitation after left cardiac valve replacement

BACKGROUND: The development of late tricuspid regurgitation (TR) following left cardiac valve replacement is an important complication, as it is associated with a severe impairment of exercise capacity and a poor symptomatic outcome. The pathogenesis of this condition remains poorly defined. It is still a challenge in terms of its prevention, treatment and indications for surgical correction. AIMS: To investigate the possible pathogenesis and report the surgical results of the late TR after left cardiac valve replacement. METHODS: There were 56 patients with moderate to severe TR after left cardiac valve replacement, divided into normal prosthesis group (10 patients with normal prosthetic valve function) and dysfunctional prosthesis group (46 patients with prosthetic valve dysfunction). In the normal prosthesis group, 4 patients underwent mitral valve replacement (MVR) and 6 patients underwent combined mitral and aortic valve replacement (DVR). Patients in the dysfunctional prosthesis group included MVR in 36, aortic valve replacement (AVR) in 4 and DVR in 6, with bioprosthetic valve dysfunction occurring in 18, mechanical prosthetic valve obstruction in 22 and periprosthetic valve leakage in 6 patients. At the initial operation, 10 patients underwent DeVega's tricuspid annuloplasty and 46 patients' tricuspid valves were normal. At the second operation, the surgical treatment of TR included tricuspid valve replacement (TVR) in 9 and tricuspid annuloplasty in 47. RESULTS: Two patients died postoperatively giving a 3.6% hospital mortality. The 54 survivors were followed up for 6-132 months (mean of 79.4 months). Heart function improved significantly in 8 with TVR and in 40 with tricuspid annuloplasty. Echocardiography showed moderate TR in 5 and severe TR in 1 patient with tricuspid annuloplasty who need a further surgical treatment. CONCLUSION: Pulmonary hypertension, myocardial dysfunction, and atrial fibrillation might be responsible for the development of late TR after left cardiac valve replacement. Tricuspid annuloplasty, as the surgical method of first choice, resulted in improvement in 87% of patients with late TR after left cardiac valve replacement. TVR can also be safely applied to repair organic disease and the extremely dilated tricuspid valve annulus. If the TR area is more than 25cm(2), the TVR is recommended.     

Tricuspid valve repair with artificial chordae in a 72-year-old woman

Expanded polytetrafluoroethylene sutures have been used for the replacement of chordae tendineae since 1985, especially for mitral valve prolapse. There are only a few reports of artificial chordae tendineae to treat tricuspid valve regurgitation. We report on a 72-year-old woman in NYHA class III preoperatively, who underwent successful tricuspid valve repair after preoperative echocardiography revealed tricuspid valve regurgitation grade IV, caused by prolapse of the anterior leaflet (A1-A2) and annular dilatation. Tricuspid valve repair was performed using artificial chords consisting of two polytetrafluoroethylene sutures and a ring annuloplasty. Postoperative echocardiography revealed mild tricuspid valve regurgitation of less than 1°, even after three years. Gore-Tex? sutures as used in mitral valve repair are an excellent option to replace chordae tendineae in tricuspid valve prolapse. This approach represents a safe and effective technique for tricuspid valve repair.     

Safety of endomyocardial biopsy in children

Endomyocardial biopsy in children remains important in the evaluation of cardiomyopathy, myocarditis, and rejection following cardiac transplantation. We sought to evaluate the morbidity associated with endomyocardial biopsy on the basis of a large experience from a single institution. We reviewed records of all endomyocardial biopsies performed at our institution. Complications were defined as adverse events resulting from the biopsy requiring intervention or additional observation. We also reviewed the most recent echocardiogram from all the patients for the presence and severity of tricuspid valvar regurgitation. Between November 1986 and April 2002, we performed 1051 endomyocardial biopsies in 135 patients ranging in age from 9 days to 18 years. The internal jugular vein was the site of vascular access in 68% of the procedures. There were 10 acute procedural complications requiring intervention or additional observation. Severe tricuspid regurgitation developed in two patients who had undergone multiple biopsies after cardiac transplantation, one of whom underwent subsequent replacement of the tricuspid valve. There were no deaths or cardiac perforations. The total incidence of morbidity was 1.1%. No demographic or procedural factors were identified to be predictive of complications. In experienced hands, therefore, endomyocardial biopsy can be safely performed in children with very low morbidity.     

Transcatheter tricuspid valve replacement With the Edwards SAPIEN valve

We describe a case of percutaneous tricuspid valve implantation in a 20‐year‐old man with previous tricuspid valve replacement in the setting of pulmonary atresia with intact ventricular septum. He developed symptomatic endocarditis‐induced tricuspid regurgitation of the tricuspid bioprosthesis. Tricuspid valvar competence was restored with implantation of a 26‐mm Edwards SAPIEN valve. © 2011 Wiley‐Liss, Inc.     

Tricuspid repair for infective endocarditis: clinical and echocardiographic results.

We report our retrospective experience in the treatment of infective tricuspid endocarditis with valve repair From January 1981 through January 1999, 238 cases of infective endocarditis were seen at our institution, with tricuspid involvement in 19 cases. Tricuspid valve repair was performed in 9 patients whose valves had infective lesions involving a single leaflet. One goal of the repair was to avoid implanting any prosthetic material. At surgery, the posterior leaflet was completely excised and annuloplasty was performed in 4 patients. Wide quadrangular resection of the anterior leaflet and De Vega annuloplasty were performed in the other 5 patients. All patients had a good postoperative recovery Postoperative echocardiography showed no tricuspid regurgitation in 4 patients, mild regurgitation in 3, and moderate in 2. Follow-up ranged from 21 to 155 months (mean, 4756 +/- 50 [SD] months). Two late deaths occurred: one, 2 months postoperatively (sudden death), and the other, 108 months postoperatively (lung carcinoma). Late postoperative echocardiography showed no tricuspid regurgitation in 4 patients, mild in 2, and moderate in 2. No recurrent infection was observed. Tricuspid valve repair rather than valvulectomy or replacement is indicated in cases of right-sided endocarditis with single-leaflet involvement. Tricuspid repair enables eradication of the infection without implantation of prosthetic material.     

Indications and results of surgery of organic involvement of the tricuspid valve

In this study the long-term results of 121 repairs for organic lesions of the tricuspid valve are presented, and a attempt is made at selecting the respective indications for valve replacement (VR) and valvoplasty. Tricuspid valve correction was effected by VR in 37 cases (mechanical prosthesis 26, bioprosthesis 11) and by plastic procedures in 84 cases (commissurotomy 62, alone in 12 cases and combined with annuloplasty in 51 cases; annuloplasty alone in 21 cases). The early mortality rate was 9 p. 100. Subsequently, 28 patients (25 p. 100) died and 12 were lost sight of. Deaths related to the tricuspid valve (n = 7) comprised occlusive thrombosis of mechanical prosthesis (MP) in 4 cases and 3 failures of plastic surgery including 2 commissurotomies alone (TC) and 1 commissurotomy combined with annuloplasty (CA). Among the 70 survivors who could be followed up for 36 to 230 months (mean 98 months), there were: --8 failures, 5 of which required reoperation: 3 belonged to the MP group (3 occlusive thromboses) and 5 to the TC group (failure expressed as major tricuspid valve leakage); --4 mediocre results (1 bioprosthesis, 3 plastic operations). The failures of plastic surgery were mostly due to inadequate right ventricular function; --58 successful results, principally with bioprosthesis, CA and annuloplasty alone. Altogether, 93 p. 100 of CA and 92 p. 100 of bioprostheses were free from complications, as against 37 p. 100 of TC and 65 p. 100 of MP. It is concluded that TC completed by annuloplasty ensures satisfactory results, thus allowing the indications conservative tricuspid valve surgery to be enlarged.(ABSTRACT TRUNCATED AT 250 WORDS)     

Tricuspid Valve Imaging and Intervention in Pediatric and Adult Patients With Congenital Heart Disease

Tricuspid valve abnormalities in congenital heart disease comprise a wide spectrum, with the most common being Ebstein anomaly and tricuspid valve dysplasia. Tricuspid valve dysfunction may also be secondary to other types of congenital heart disease, including functional tricuspid regurgitation seen in right heart volume overload conditions, such as atrial septal defect and repaired tetralogy of Fallot with severe pulmonary valve regurgitation. Congenitally corrected transposition and Mustard and Senning procedures maintain the right ventricle as the systemic ventricle, and the tricuspid valve is subject to unique hemodynamic stress not typically seen in normal circulation. Surgical treatment of tricuspid valve disease remains the mainstay of therapy; primary catheter-based interventions are uncommon. However, once a tricuspid valve has been replaced with a bioprosthesis, the patient may be a candidate for tricuspid valve-in-valve catheter-based replacement.     

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 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 repair: a rational alternative

BACKGROUND AND AIMS OF THE STUDY: The prosthetic ring annuloplasty and incompletely encircling suture techniques are effective methods of tricuspid valve repair when the problem is only annular dilatation, but not when organic tricuspid valve disease is present. A surgical technique of valve repair has been developed that is equally effective in correcting purely functional as well as organic valvular incompetence. METHODS: The Manipal method of repairing the incompetent tricuspid valve consists of three steps: (i) anteroseptal commissurotomy and asymmetric 'U-on-side' suture annuloplasty, to push the plane of coaptation of the anterior and septal leaflets into the right ventricle; (ii) a semicircular De Vega-type of plicating suture through the annulus, starting and ending just cephalad to the posteroseptal commissure and extending anticlockwise to a point just caudal to the meridian, to exclude the posterior leaflet; and (iii) tying the plicating suture after positioning a 3M Starr-Edward valve sizer across the tricuspid valve (in an adult), to ensure that the valve orifice is not excessively narrowed. RESULTS: Between July 1986 and January 1997, the Manipal method was used to repair 52 tricuspid valves, always combined with surgery for the mitral and/or aortic valve. Tricuspid stenosis of varying degree was present in 61% of cases. One of two hospital deaths was related to the repaired valve. Although the proportion of patients followed up fell progressively to 33% at 10 years, none of the patients either seen personally or who had replied to a postal questionnaire (78% of total patients) required reoperation for valve regurgitation or obstruction. No patient had more than mild tricuspid regurgitation clinically, even seven and 10 years after tricuspid valve repair surgery. CONCLUSION: This alternative method of tricuspid valve repair is simple to execute, is equally effective in correcting both pure tricuspid regurgitation and organic tricuspid valve disease, and appears to be extremely stable.     

Twenty-five years' clinical experience with repair of tricuspid insufficiency

BACKGROUND AND AIM OF THE STUDY: Tricuspid regurgitation secondary to pulmonary hypertension due to left-sided heart valve lesions is common. Here, the results are reported of 25 years' experience with three surgical techniques; the De Vega semicircular annuloplasty, the Bex flexible linear reducer, and the Carpentier-Edwards prosthetic ring annuloplasty. METHODS: Between 1976 and 2002, 463 patients underwent 478 tricuspid annuloplasty procedures to correct valve regurgitation during associated left-sided valve surgery. Patients were followed prospectively at the Montreal Heart Institute Valve Clinic. RESULTS: A total of 107 patients (23%) underwent the De Vega semicircular annuloplasty, 267 (58%) the Bex flexible linear reducer, and 89 (19%) the Carpentier-Edwards prosthetic ring annuloplasty. Excluding 30-day mortality, the mean 5-, 10- and 15-year patient survival was 82+/-4%, 58+/-6% and 30+/-6% respectively after the De Vega semicircular annuloplasty, 76+/-3%, 54+/-4% and 36+/-6% respectively after the Bex flexible linear reducer, and the mean five-year patient survival was 88+/-4% after the Carpentier-Edwards prosthetic ring annuloplasty (p = 0.65, for comparison of the three survival curves). The mean freedom rate from tricuspid repair failure (clinical right heart failure, redo annuloplasty, tricuspid valve replacement at follow up) was 95+/-3%, 93+/-3% and 72+/-8% at 5, 10 and 15 years respectively after the De Vega semicircular annuloplasty, and 97+/-1%, 87+/-4% and 66+/-9% after the Bex flexible linear reducer. The mean freedom rate from repair failure was 94+/-3% at five years after the Carpentier-Edwards prosthetic ring annuloplasty (p = 0.18 for comparison of the three freedom from failure curves). CONCLUSION: All three techniques of tricuspid valve repair resulted in a low rate of failure, and in good patient survival at long-term follow up.     

Mitral valve re-replacement for impaired bioprosthesis after 19 years in a patient undergoing steroid treatment

A 59-year-old man underwent closed mitral commissurotomy for mitral stenosis at the age of 19 years, and mitral valve replacement (MVR) with a Hancock standard bioprosthesis and tricuspid annuloplasty at the age of 40 years. Two years after the second operation, the patient developed human T-lymphotropic virus type-1 infection, manifesting as myelopathy/tropical spastic paraparesis, and has required steroid therapy for 17 years. He was well for 18 years after the MVR, but has recently developed severe congestive heart failure, orthopnea and enlarged liver. Doppler echocardiography showed severe transvalvular regurgitation of the prosthesis and tricuspid valve. The patient underwent re-MVR with a 27 mm St. Jude Medical prosthesis, and tricuspid annuloplasty. The surgery was well tolerated, without any significant infectious complication. Some tears and perforations were found in the leaflets of the explanted bioprosthesis, but soft X-ray analysis showed minimal calcification. Mild changes and longer durability of the bioprosthesis may be related to the long-term use of steroid therapy.     

Tricuspid valve repair for torrential tricuspid regurgitation after permanent pacemaker lead extraction

Tricuspid regurgitation secondary to percutaneous lead extraction is uncommon, and it rarely requires surgical intervention. Most tricuspid regurgitation occurs during the implantation of tined leads, which can be entrapped in the tricuspid valve apparatus and may require immediate withdrawal. Severe tricuspid regurgitation as a sequela of extracting chronically implanted leads has rarely been reported. Herein, we report a case of torrential tricuspid regurgitation in a 67-year-old woman after the extraction of a permanent pacemaker lead. The regurgitation was confirmed on transesophageal echocardiography during lead extraction, and the tricuspid valve was successfully repaired with suture bicuspidization of the valve and the support of ring annuloplasty. A short review of the relevant literature follows the case report.     

Replacement of the tricuspid valve in children with congenital cardiac malformations

BACKGROUND AND AIM OF THE STUDY: When replacing the regurgitant tricuspid valve in children, the decision to use either a bioprosthesis or a mechanical valve remains controversial. METHODS: The atrioventricular valve for the pulmonary circulation was replaced in 11 young patients aged between 8 months and 13 years. Complications of congenital cardiac malformation were present in seven patients, and Ebstein's anomaly in three; tricuspid valvular regurgitation was an isolated lesion in one patient. A bioprosthesis was implanted on seven occasions, and a bileaflet mechanical valve on eight, including re-replacement of the valve in four patients. RESULTS: One patient died two years after implantation due to respiratory problems. Tricuspid stenosis due to valve calcification occurred in four bioprostheses at between four and nine years after initial replacement (57%). In three of these cases the native valve leaflets had not been removed. Thrombosis occurred in one patient with a mechanical valve; rereplacement was successful. Anticoagulant-related hemorrhage occurred in another patient. Among patients receiving a mechanical valve, 83% of valves were dysfunction-free after five and ten years. CONCLUSION: When replacing an atrioventricular valve for the pulmonary circulation in children, we prefer to use a low-profile mechanical valve, especially when extensive repair of intracardiac malformation has been carried out, but ventricular function is good. In children with poor cardiac performance, a bioprosthesis is preferred, with total resection of the native valve leaflets.     

Surgery for tricuspid valve endocarditis: A selective approach

Summary The authors report their 18-year experience in the surgical treatment of infective tricuspid endocarditis. Between January 1981 and January 1999, 238 cases of infective endocarditis were seen, with a tricuspid involvement in 21 cases (8.8%). Tricuspid valve repair was performed in 9 patients with infective lesions involving one single leaflet. The surgical principle of the repair was to avoid any prosthetic material implantation. Posterior leaflet vegetectomy was performed in another 2 patients with infected intracavitary leads. Tricuspid valve replacement was performed in 10 patients with involvement of the whole valvular apparatus. One patient died of septic shock 3 days postoperatively. All the other patients had a good postoperative recovery. Follow-up ranged between 12 and 155 months (mean 68.9 ± 55 months). Five cases of late mortality were observed: 3 for cardiac reasons and 2 of cancer. All the other patients are alive. Late postoperative echocardiography in the patients with tricuspid repair showed tricuspid regurgitation to be absent in 6 patients, mild in 2, moderate in 1, and severe in 1. No recurrent infections were observed either in patients with valve repair or in those with valve replacement. Good early and long-term results can be achieved in the surgical treatment of tricuspid endocarditis as long as complete excision of the infected tissue is performed and risk factors are controlled.     

Clinical efficacy of two different tricuspid annuloplasty techniques in left cardiac valve surgery

Objective: To investigate the mid-and long-term clinical effects of tricuspid valvuloplasty with the implantation of an artificial plastic ring.Methods: Data of 677 patients who had functional tricuspid regurgitation and left cardiac valve disease and underwent tricuspid valvuloplasty and left cardiac valve surgery were retrospectively.Among these patients, 353 underwent simple suture annuloplasty(group A) while the rest 324 patients underwent artificial plastic ring annuloplasty(group B).The two-year and more-than-two-year clinical and ultrasonocardiograph(UCG) follow-up data of the two groups were obtained and compared.Results: A total of 600 patients(88.6%) completed the long-term follow-up(more than two years).The two-year follow-up showed no significant difference in the incidence of mild tricuspid regurgitation between the two groups(82.2% vs.92.7%, P=0.37).However, there were significantly more cases that developed into moderate to severe tricuspid regurgitation in group A than in group B(17.8% vs.7.3%, P=0.031).The long-term follow-up revealed that the recurrence rate of tricuspid regurgitation in group B was significantly lower than that in group A(11.0% vs.25.0%, P=0.029), and the ratio of cases developing into moderate to severe tricuspid regurgitation in group A was significantly higher than that in group B(28.9% vs.9.9%, P=0.007).The comparison between the two intra-group time segments showed that the development of tricuspid regurgitation in group A was significantly increased(28.9% vs.17.8%, P=0.022), but in group B it was relatively stable(9.9% vs.7.3%, P=0.52).Conclusions: Artificial ring annuloplasty is associated with significantly less tricuspid regurgitation than simple suture annuloplasty.     

Congenital cleft of the anterior tricuspid leaflet with severe tricuspid regurgitation in adults.

OBJECTIVES AND BACKGROUND. Severe primary tricuspid regurgitation in the adult is a rare finding. This study describes the diagnostic findings and the treatment of an isolated congenital cleft of the anterior leaflet of the tricuspid valve as the morphologic substrate for severe tricuspid regurgitation. METHODS. The clinical, echocardiographic findings and the follow-up findings of five patients (all male, 20 to 56 years old) with this disorder are described. Four of the five patients underwent cardiac surgery that confirmed the diagnosis. RESULTS. In three of five patients, exertional fatigue was the limiting symptom (New York Heart Association functional classes II and III). The clinical findings included a holosystolic murmur and supraventricular arrhythmias in all patients. Cardiac catheterization, performed in four patients, yielded the incorrect diagnosis of Ebstein's anomaly in three. In one patient the cleft was associated with an atrial septal defect of the secundum type. In four of five patients successful reconstruction of the tricuspid valve with a DeVega annuloplasty was performed. One patient had a partial excision of the right atrium, and one had a closure of a coexisting atrial septal defect. One patient refused operation. CONCLUSIONS. Tricuspid valve anomalies can be accurately identified by Doppler echocardiography. Surgical repair is the treatment of choice in patients with severe tricuspid regurgitation due to a congenital cleft of the anterior leaflet of the tricuspid valve.