Tricuspid valve repair: durability and risk factors for failure

OBJECTIVES: To compare durability of tricuspid valve annuloplasty techniques, identify risk factors for repair failure, and characterize survival, reoperation, and functional class of surviving patients. METHODS: From 1990 to 1999, 790 patients (mean age 65 +/- 12 years, 51% New York Heart Association functional class III or IV, and mean right ventricular systolic pressure 56 +/- 18 mm Hg) underwent tricuspid valve annuloplasty for functional regurgitation using 4 techniques: Carpentier-Edwards semi-rigid ring, Cosgrove-Edwards flexible band, De Vega procedure, and customized semicircular Peri-Guard annuloplasty. Of these patients, 89% had concomitant mitral valve surgery. A total of 2245 follow-up transthoracic echocardiograms were retrieved. Tricuspid regurgitation was analyzed, and risk factors for worsening regurgitation were identified, by multivariable ordinal longitudinal methods. RESULTS: Tricuspid regurgitation 1 week after annuloplasty was 3+ or 4+ in 14% of patients. Regurgitation severity was stable across time with the Carpentier-Edwards ring (P =.7), increased slowly with the Cosgrove-Edwards band (P =.05), and rose more rapidly with the De Vega (P =.002) and Peri-Guard (P =.0009) procedures. Risk factors for worsening regurgitation included higher preoperative regurgitation grade, poor left ventricular function, permanent pacemaker, and repair type other than ring annuloplasty. Right ventricular systolic pressure, ring size, preoperative New York Heart Association functional class, and concomitant surgery were not risk factors. Tricuspid reoperation was rare (3% at 8 years), and hospital mortality after reoperation was 37%. CONCLUSIONS: Tricuspid valve annuloplasty did not consistently eliminate functional regurgitation, and across time regurgitation increased importantly after Peri-Guard and De Vega annuloplasties. Therefore, these repair techniques should be abandoned, and transtricuspid pacing leads should be replaced with epicardial leads.     

应用彩色多普勒对二尖瓣置换术后三尖瓣功能的远期随访

目的应用彩色多普勒超声评价二尖瓣置换术后远期三尖瓣功能及形态变化。方法对接受二尖瓣置换术的903例病人术后三尖瓣功能进行了2～9年,平均(3.6±2.4)年的跟踪观察。所有病例术前均有不同程度的三尖瓣环扩大或关闭不全,其中未行三尖瓣成形术者201例;行Kay或改良DeVega成形术者686例;三尖瓣成形术同时加成形环者16例。结果未行三尖瓣成形术者术后2～3年有46例出现三尖瓣重度关闭不全;行Kay或改良DeVega成形术者,术后3～5年150例出现中重度三尖瓣关闭不全;三尖瓣成形术同时加成形环者仅1例术后2年出现三尖瓣轻-中度关闭不全。结论二尖瓣置换术后远期三尖瓣功能性关闭不全与三尖瓣环扩大、右心功能损害和严重肺动脉高压有关,三尖瓣环扩大是其重要的原因。对二尖瓣置换术者,手术中一旦发现有三尖瓣环扩大,即使无三尖瓣关闭不全,亦应行三尖瓣成形术,重度三尖瓣关闭不全、瓣环明显扩大者最好在环缩术的同时加成形环。     

Tricuspid valve annuloplasty with a flexible prosthetic band

This study evaluates the application to the tricuspid valve of a flexible prosthetic band originally devised for mitral repair. Between March 2001 and May 2005, 53 consecutive patients (age 66.2+/-8.5 years) with significant tricuspid regurgitation and dilatation of the right-sided cardiac chambers underwent tricuspid valve annuloplasty with the band and concomitant mitral repair or replacement. Thirty-one patients (58.5%) were in NYHA class III or IV, and 33 (62.3%) had a history of right heart failure. Follow-up was 19.2+/-14.0 months. Three patients (5.7%) died before discharge, and one during follow-up. One late reoperation was required for mitral endocarditis. NYHA class decreased in survivors from 2.7+/-0.8 to 1.4+/-0.6 (P<0.0001), and the symptoms of right heart failure improved significantly after surgery. Tricuspid regurgitation was mild or absent in 44 survivors (89.8%) and moderate in 5 (10.2%). Regurgitation significantly decreased even in patients with risk factors for tricuspid repair failure or with persistent left ventricular dysfunction. The 4-year actuarial freedom from tricuspid regurgitation grade >1 was 88.7%. By univariable analysis, preoperative tricuspid regurgitation grade >2, right ventricular shortening fraction <35%, and permanent pacemaker were associated with the risk of recurrent moderate regurgitation, though only probably so (P=0.077, 0.061, and 0.097, respectively).     

CT19PTRICUSPID VALVE REPAIR IN ‘TORRENTIAL TRICUSPID REGURGITATION’ FOLLOWING PERMANENT PACEMAKER LEAD EXTRACTION – A CASE REPORT

Introduction Traumatic tricuspid regurgitation secondary to blunt chest trauma has been reported in literature. We report our experience with a case of ‘Torrential Tricuspid Regurgitation’ following permanent pacemaker lead extraction which was successfully treated with tricuspid valve repair and annuloplasty. Report A 67 year old woman was treated for Sick sinus syndrome with permanent pacemaker implant. She had three generator changes for end of life and repositioning.Erosion of generator, led cardiologist to plan lead and generator extraction with the surgical backup. During lead extraction a small piece of papillary muscle was avulsed. The patient remained hemodynamically stable in the theatre. However in ward she developed right sided cardiac failure not responding to conservative therapy. A transthoracic echo (TTE) revealed torrential tricuspid regurgitation with a freely mobile posterior leaflet with attached chordae and avulsed papillary muscle.During surgery the tricuspid valve was successfully repaired and transesophageal (TOE) images showed trivial to mild tricuspid regurgitation at the end of repair procedure. Additional procedure also included ligation of both atrial appendages and implantation of epicardial leads and pacemaker. Patient made good recovery from operation. Conclusion To the best of our knowledge this is first report of repair of tricuspid valve in ‘Torrential Tricuspid Regurgitation’ following pacemaker lead extraction. We share our experience with tricuspid valve repair technique and annuloplasty.     

New quantitative method for evaluating tricuspid regurgitation

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

Intraoperative transesophageal echocardiography for the evaluation of mitral, aortic and tricuspid valve repair A tool to optimize surgical outcome

The present study reviews the clinical applicability and usefulness of intraoperative transesophageal echocardiography (TEE) during valve repair. Intraoperative TEE was performed in 48 consecutive patients, who were divided into three groups: 1. mitral valve repair (MVR), 2. aortic valve repair (AVR), 3. tricuspid valve repair (TVR). Residual valve regurgitation was assessed by color Doppler echocardiography on a scale from 0 to 4. The ratios of the jet area (JA) to the left- and right-atrial areas (JA/LAA and JA/RAA) were analyzed before and after cardiopulmonary bypass (CPB). In group 1, 14 patients were scheduled for MVR, of which 4 patients underwent valve replacement and 10 MVR. Post-repair TEE studies showed a significant decrease of mitral regurgitation. In 2 of the 10 patients, TEE demonstrated severe residual regurgitation requiring valve replacement during the same thoracotomy. In group 2, 11 patients underwent aortic commissurotomy. Post-repair TEE showed an increase in the systolic opening diameter and opening area of the aortic valve. One patient underwent valve substitution because of severe aortic regurgitation. In group 3, 23 patients were scheduled for TVR. In 3 of them TEE showed no significant regurgitation thus rendering tricuspid valve surgery unnecessary. Twenty patients underwent TVR of whom two showed unacceptable post-repair regurgitation requiring further surgery. Eighteen patients showed a significant reduction of valve regurgitation after TVR, and a further reduction was achieved by adjusting the tricuspid annuloplasty under TEE guidance.     

继发性三尖瓣关闭不全的外科治疗进展

继发于左心系统瓣膜病变的三尖瓣关闭不全,多为三尖瓣瓣环扩大导致的功能性三尖瓣关闭不全,也有少数患者同时合并三尖瓣风湿性等器质性改变。对三尖瓣反流的处理,目前主张如果能通过瓣膜成形方法恢复三尖瓣瓣膜功能,应尽量行三尖瓣成形手术。三尖瓣成形方法主要包括线性成形和人工瓣环成形技术,但目前各种手术成形方法的适应证选择和临床应用尚无统一的标准,多年来一直是困扰心脏外科医师的难题和研究热点,是否需要同期行三尖瓣成形术,采用什么成形方法才能达到最佳的三尖瓣成形效果。因此,对继发性三尖瓣关闭不全患者三尖瓣病变程度的判定、矫治标准及手术方法等进行综述。     

Evaluation of long-term results of bicuspidalization annuloplasty for functional tricuspid regurgitation. A seventeen-year experience with 133 consecutive patients

Between 1968 and 1985, 133 consecutive patients underwent bicuspidalization annuloplasty for moderate to severe functional tricuspid regurgitation associated with mitral or combined mitral and aortic valve disease. Over this period, the incidence of tricuspid valve replacement was only 2.3% (3/136 patients). There were 18 early deaths (13.5%) in the entire series--three (5.0%) of 60 patients in the last 5 years of the study--and 10 late deaths (8.7%). Actuarial survival rate for the entire series, excluding early deaths, was 91.0% +/- 3.0% at 10 and 17 years. There were seven reoperations (6.1%) on the tricuspid valve, needed because of residual or recurrent mitral valve lesions after the initial operation. Actuarial rates of freedom from reoperation on the tricuspid valve were 93.6% +/- 3.0% (10 years) and 69.7% +/- 16% (17 years) for the entire series: 78% +/- 10% (15 years) for the open mitral commissurotomy plus tricuspid annuloplasty group (44 patients); 90% +/- 9.0% (15 years) for the mitral plus tricuspid annuloplasty group (10); 75.2% +/- 22% (17 years) for the mitral replacement plus tricuspid annuloplasty group (58); and 92.6% +/- 7.0% (16 years) for the combined aortic and mitral valve surgery plus tricuspid annuloplasty group (21). Ninety-eight percent of the survivors were in New York Heart Association class I or II postoperatively. Of 21 randomly selected patients investigated by pulsed Doppler echocardiography, 14 (67%) had no regurgitation or grade 1/4 tricuspid regurgitation and the remaining seven (33%) had grade 2/4 regurgitation postoperatively. Our experiences suggest that bicuspidalization annuloplasty can be a reliable method in the vast majority of patients with functional tricuspid regurgitation.     

The value of Doppler echocardiography in the treatment of tricuspid regurgitation in patients with mitral valve replacement. Perioperative and two-year postoperative findings

The treatment for tricuspid regurgitation in patients who have mitral valve replacement remains controversial partly because of the lack of a convenient method for measuring reflux. The purpose of this study was to assess Doppler measurement of tricuspid regurgitation in selecting patients for surgical or nonsurgical management and in evaluating the results. Thirty-three patients who had mitral valve surgery had three ultrasound examinations: before operation, before discharge from hospital, and 2 years after operation. Seventeen patients were assigned to tricuspid annuloplasty and 16 to no procedure. Assignment was based on visual grading of regurgitant velocity maps and intraoperative grading by direct palpation. Before operation patients in the annuloplasty group had larger mean jet velocity areas, right atrial size, and diastolic transvalvular velocities than had the nonsurgical group. However, the overlap of data precluded the definition of thresholds for separating the patients into either of two regimens. Early after operation the patients with annuloplasties showed decreased regurgitant indexes similar to the preoperative levels of patients who had no procedure; the latter preoperative levels had not changed. Late after operation both groups showed stabilization or trends toward less regurgitation, and continued decreases in tricuspid diastolic flow velocities. Thus Doppler ultrasonography played a complementary role in selecting patients for annuloplasty or nonsurgical management and a major role in the longitudinal evaluation of treatment.     

Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. II. Nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement

The incidence, preoperative and intraoperative diagnosis, methods, and the clinical and hemodynamic features of patients with and without tricuspid regurgitation associated with chronic mitral regurgitation were presented in Part I. This study (Part II) compares the early and late results in patients with chronic, pure mitral regurgitation undergoing isolated mitral valve replacement, mitral replacement and tricuspid valve annuloplasty, and mitral and tricuspid valve replacement. The mean follow-up interval was 6 years. Those with the longest duration of symptoms (18 years) required tricuspid and mitral valve replacement (11 patients), whereas those with the shortest duration (8.1 years) had only mitral replacement (22 patients). Eight patients had minimal tricuspid regurgitation by digital palpitation, with no procedure performed, and six had tricuspid valve annuloplasty, only one of whom received a ring support. Operative mortality rate was similar in all groups (13% to 18%). All but two of the surviving patients improved by at least one New York Heart Association functional class, and no statistically significant differences were found between preoperative and postoperative hemodynamic data. There were no statistically significant differences in survival at 1, 5, or 8 years (85%, 70%, and 60%, respectively) for patients with or without TR. Only two of the surviving five patients who underwent tricuspid valve annuloplasty were alive 3 years after operation, whereas 70% to 80% of those with mitral replacement or mitral and tricuspid replacement were alive after the same time interval. It is not clear whether or not the pathogenesis of tricuspid regurgitation resulting from mitral regurgitation is different from that of tricuspid regurgitation resulting from mitral stenosis. It is our contention that whether tricuspid regurgitation arises because of anatomic destruction of the tricuspid valve or because of right ventricular dilatation with tricuspid annular enlargement, the underlying mitral valve lesion may determine the preoperative and postoperative courses of these patients. Therefore, when tricuspid valve disease is being evaluated, we urge that patients be categorized by the nature of their underlying mitral or aortic valve lesions.     

Intraoperative transesophageal color-coded Doppler echocardiography for evaluation of residual regurgitation after mitral valve repair

Because mitral valve competence after mitral valve reconstruction is awkward to assess during this procedure, we evaluated in this respect transesophageal color-coded Doppler echocardiography in 23 patients undergoing mitral valve reconstruction for severe mitral regurgitation. Transesophageal echocardiographic examinations were performed after induction of anesthesia but before sternotomy (baseline), after mitral valve repair before decannulation, and at sternal closure, all at similar mean aortic pressure and echocardiographic instrument settings. The degree of mitral regurgitation by transesophageal color Doppler flow mapping was visually quantified on a 5-point scale (0 to 4), pending the left atrial extent of the regurgitant jet. This was compared with the degree of mitral regurgitation by left ventricular cineangiography performed within several weeks after operation and also visually quantified on a 5-point scale (0 to 4), with use of the right anterior oblique projection. There was good correlation between the two methods (r = 0.83; p less than 0.001). We conclude that residual mitral regurgitation, as assessed by transesophageal color flow mapping in the operating room, highly correlates with the ultimate mitral regurgitation by cineangiography. Therefore transesophageal echocardiography can be helpful for evaluation of mitral valve competence during mitral valve reconstruction, and hence, in case of repair failure, allow valve replacement in the same surgical session, thus avoiding reoperation.     

Successful repair of traumatic tricuspid valve regurgitation

Isolated traumatic tricuspid valve regurgitation is an uncommon complication of blunt chest trauma. Tricuspid valve replacement has been ordinarily managed for this lesion. Herein, we report two cases of successful repair for traumatic tricuspid valve regurgitation, 11 and 40 years following blunt chest trauma, respectively. Tricuspid valve repairs were performed using an artificial chordae implantation with expanded polytetrafluoroethylene (CV-5) sutures and ring annuloplasty. Postoperative echocardiography revealed that the tricuspid valve regurgitation improved to mild and trivial respectively in two patients. They are presently doing well, 4 and 2 years after the repair, respectively.     

Three-dimensional color Doppler for assessing mitral regurgitation during valvuloplasty.

OBJECTIVE: Transesophageal color Doppler (or 2D Doppler) is the most widely used technique for intraoperative assessment of mitral valve repair. However, the most severe mitral regurgitations produce eccentric jet flows which cannot be assessed by 2D imaging. Up to now the indications for surgical intervention and intraoperative decisions after valve repair have been based on 2D Doppler examinations. Aim of this study was to compare conventional 2D Doppler to three-dimensional (3D) Doppler for assessing residual regurgitation in patients after mitral valvuloplasty. METHODS: Twenty-four patients were referred to surgery for mitral valve repair. They underwent transesophageal echocardiography and 3D data acquisition during mitral valve reconstruction. Conventional assessment of mitral valve regurgitation, measured by color Doppler jet area, was compared to the volume of regurgitant jets obtained by 3D Doppler. Regurgitant volume and fraction were measured by pulsed Doppler and two-dimensional echocardiography. The 3D reconstructions of color Doppler data were accomplished by means of the 'Heidelberg Raytracing Algorithm' developed at our institution. RESULTS: The jet areas did not show any significant correlation to the regurgitant fraction (r = 45; P = NS) or regurgitant volumes (r = 0.40; P = NS). In contrast the jet volumes correlated significantly to regurgitant fraction (r = 0.71; P < 0.01) and regurgitant volume (r = 0.85; P < 0.01). The reproducibility analysis of repeated jet volume and jet area measurements also showed that the parameter jet volume has a lower variability and higher agreement of repeated measurements than jet area. CONCLUSIONS: Three-dimensional color Doppler flow imaging revealed the complex geometry of eccentric regurgitant jets and showed that the assessment of mitral regurgitation, based on conventional 2D Doppler, can be misleading. This new technique has a great potential for becoming a reference method for assessing mitral valve repair.     

Tricuspid valve surgery for functional tricuspid valve regurgitation associated with left-sided valvular disease.

OBJECTIVES: We have reviewed 260 patients who underwent initial tricuspid valve surgery for functional tricuspid valve regurgitation (TR) and analyzed independent predictors for early and late unfavorable results. MATERIALS AND METHODS: Between 1981 and 1998, 260 tricuspid valve operations were performed for functional TR. There were 94 males and 166 females with a mean age of 55 years. The tricuspid valve surgery procedures consisted of De Vega tricuspid annuloplasty in 240 patients, ring annuloplasty in four patients, and tricuspid valve replacement in 16 patients. The mean duration of follow-up was 7.8 years. RESULTS: Hospital mortality was 8.9% (23 patients). Late deaths occurred in 34 patients including cardiac-related late deaths in 26 patients. The survival rates were 83+/-2% at 5 years and 78+/-3% at 10 years. Late tricuspid valve reoperation was performed on 13 patients due to residual or recurrent TR in 12 patients and thrombosed tricuspid bileaflet mechanical valve in one patient. The tricuspid valve reoperation-free survival rate was 90+/-2% at 5 years and 84+/-3% at 10 years. The only predictor of hospital mortality was preoperative highly elevated right atrial pressure (P=0.01). Variables predictive of cardiac-related late death were preoperative New York Heart Association (NYHA) class IV (P=0.01) and poor left ventricular ejection fraction (LVEF) (P=0.02). Residual TR of more than grade 2+ early after tricuspid annuloplasty was a significant risk factor for late tricuspid valve reoperation (P=0.01). Preoperative TR of grade 4+ was predictive of early residual TR (P=0.04). CONCLUSIONS: Tricuspid valve surgery for functional TR can be performed with acceptable levels of early mortality. Cardiac-related late mortality after tricuspid surgery may be improved by earlier surgical treatment before NYHA class IV or deterioration of LVEF occurs. To prevent late tricuspid reoperation, it is important not to leave residual TR of grade 2+ or more after tricuspid annuloplasty.     

Surgical treatment of tricuspid insufficiency in patients undergoing mitral valve replacement

During the past eight years, 46 of the 106 patients who underwent mitral valve replacement were associated with tricuspid insufficiency. No surgical correction was performed (14 cases) in cases of slight tricuspid insufficiency. Tricuspid annuloplasty (11 cases) or valve replacement (21 cases) was employed according to the severity of insufficiency. In the non-repair group, the mortality rate was fairly low (21 per cent), but the postoperative status was the least satisfactory by the NYHA classification. Tricuspid insufficiency was significantly reduced only in two of these 14 cases after the mitral valve replacement. In the tricuspid annuloplasty group, although the technique of tricuspid annuloplasty did not always correct insufficiency completely, only one patient died of residual insufficiency. The cardiac output measured with Minnesota Impedance Cardiograph increased postoperatively in proportion to stress in this group. In the tricuspid valve replacement group, cardiac catheterization studies revealed hemodynamic improvement at rest in all, but cardiac output during exercise remained unchanged or decreased in some cases. Now we consider that tricuspid insufficiency with advanced mitral valve disease, even of a slight degree, should be surgically treated and that annuloplasty has more obvious hemodynamic benefits than valve replacement.     

Intraoperative evaluation of atrioventricular septal defect repair by color flow mapping echocardiography

Despite improving survival rates after repair of atrioventricular septal defect, many patients require reoperation because of postoperative heart failure. We used intraoperative color flow mapping echocardiography to assess the results of surgical repair of atrioventricular septal defect in 19 consecutive patients and compared those findings with results three to five days and 3 to 11 months after repair. There was close correlation between intraoperative and postoperative color flow mapping echocardiography in estimating the presence and severity of left atrioventricular valve regurgitation. All patients survived surgical repair, but in 4 (21%), postoperative congestive heart failure due to left atrioventricular valve regurgitation developed. The need for reoperation was significantly correlated with the severity of left atrioventricular valve regurgitation (r = 0.68) as estimated by intraoperative echocardiography and preoperative aberrancies in the atrioventricular valve (r = 0.68). Age, weight, additional congenital heart disease, preoperative pulmonary vascular resistance, preoperative atrioventricular valve regurgitation, and postoperative mean pulmonary arterial or left atrial pressure were not significantly correlated with the need for reoperation. Intraoperative color flow mapping echocardiography can accurately predict the development of early postoperative heart failure and subsequent reoperation after surgical repair of atrioventricular septal defect.     

Improved intraoperative evaluation of mitral valve operations utilizing two-dimensional contrast echocardiography

Whenever possible, precise mitral valve repair is preferable to valve replacement. Present methods for intraoperative detection of mitral regurgitation, primarily hemodynamic measurements and direct palpation, may underestimate or not detect the presence and severity of regurgitation. We have investigated two-dimensional contrast echocardiography as a means of improving our intraoperative assessment of mitral valve function both before and after repair or replacement. After exposure of the heart, a baseline two-dimensional echocardiogram (in modified long- and short-axis planes) is performed using a hand-held 5 mHz mechanical transducer. Five milliliters of agitated 5% dextrose in water is injected into the left ventricle through a transseptal needle to generate detectable microbubbles. In the absence of mitral regurgitation, virtually all microbubbles exit through the aorta; in the presence of regurgitation, a mass of microbubbles reflux into the left atrium. After repair of the mitral valve and immediately after bypass, the contrast echocardiogram is repeated and hemodynamic measurements are obtained. Forty-three patients (37 with mitral valve disease and six additional patients without mitral disease) undergoing cardiac operations were evaluated. Experience with intraoperative two-dimensional contrast echocardiography has accurately demonstrated relatively small degrees of mitral regurgitation when conventional techniques failed to do so and has allowed more precise repair of the residual regurgitation. Two commissurotomy and two annuloplasty patients who were thought to have satisfactory repairs underwent immediate second procedures because of significant residual mitral regurgitation demonstrated solely by this echocardiographic microbubble technique. No complications associated with this technique have developed. We conclude that intraoperative two-dimensional contrast echocardiography is a sensitive and safe technique that allows intraoperative detection of even small degrees of mitral regurgitation and provides a basis for precise repair of mitral valve lesions.     

Mitral stenosis after mitral valve repair for non-rheumatic mitral regurgitation

BACKGROUND: Mitral stenosis after mitral valve repair for non-rheumatic mitral regurgitation is rare. METHODS: From 1990 to 1999, 478 patients had mitral valve repair for myxomatous and 40 patients had mitral valve repair for ischemic mitral regurgitation. The Carpentier annuloplasty ring (Edwards Lifesciences, Irvine, CA) was used in 72 patients, the Duran ring (Medtronic, Minneapolis, MN) in 152, a posterior band in 221 and no ring or band in 73 patients. RESULTS: Four patients developed mitral stenosis late after mitral valve repair: 2 for myxomatous disease and 2 for ischemic mitral regurgitation. All 4 patients had Duran annuloplasty rings (sizes 25 to 31). The diagnosis of mitral stenosis was made by Doppler echocardiography. The mitral valve area in these 4 patients decreased from 2.7 cm2 (range, 2.3 to 3.2 cm2) early postoperatively to 0.85 cm2 (0.4 to 1.2 cm2) after a mean follow-up of 66 months (range, 38 to 110 months). Three patients had mitral valve replacement and the etiology of the mitral stenosis was the same in all patients (ie, pannus overgrowth on the annuloplasty ring with extension onto both leaflets rendering them stiff and immobile). The fourth patient had a mitral valve area of 1.2 cm2, which was mildly symptomatic with normal pulmonary artery pressure, and this patient has not had reoperation. CONCLUSIONS: Mitral stenosis may develop after mitral valve repair for myxomatous disease or ischemic mitral regurgitation when a Duran ring is used for annuloplasty. The stenosis is caused by pannus on the annuloplasty ring with extension onto the leaflets.     

Tricuspid valve repair for tricuspid valve endocarditis: tricuspid valve "recycling"

Tricuspid valve endocarditis traditionally has been treated with either valve excision or valve replacement. To avoid implantation of foreign material in an infected field, we have applied the principles of mitral valve repair to 4 patients with tricuspid valve endocarditis. On preoperative echocardiography, all patients had 3 to 4+ tricuspid regurgitation, evidence of progressive right ventricular enlargement, and mobile vegetations. In each case, up to three quarters of the anterior leaflet was excised en bloc with infected chordae and papillary muscle heads. Surgical procedures included standard quadrangular resection, conversion to a bicuspid valve, and pericardial patch replacement of the anterior leaflet with mobilization of basal chordae to replace resected marginal chordae. On postoperative echocardiography, tricuspid regurgitation and right ventricular dimensions were reduced in 2 of 4 patients in spite of loss of leaflet tissue. All excised valve tissue demonstrated bacteria on Gram stain or culture. Nonetheless, all repaired valves were successfully sterilized without recurrent infections. Tricuspid valve repair can allow eradication of infection with potential for improving valve competency in complicated tricuspid valve endocarditis.     

Tricuspid regurgitation. A comparison of nonoperative management, tricuspid annuloplasty, and tricuspid valve replacement.

The best means of managing tricuspid regurgitation associated with mitral or mitral and aortic valve disease is still to be determined. During the period 1972 to 1974, we treated 76 patients who had tricuspid regurgitation along with associated valvular dysfunction. Patients with mold regurgitation were treated conservatively, those with moderate regurgation underwent annuloplasty, and those with severe regurgitation had tricuspid valve replacement. We found the results to be less satisfactory in the group treated by annuloplasty than in the other two groups. We still manage conservatively those patients with mild regurgitation, but we believe it appropriate to replace the valve in an increasing number of subjects who have tricuspid regurgitation of moderate severity.