A novel technique for correction of severe tricuspid valve regurgitation due to complex lesions.

OBJECTIVES: Correction of tricuspid regurgitation due to complex lesions (not treatable with annuloplasty only) is associated with suboptimal results. To improve the efficacy of valve repair in this context, we developed a new surgical approach, which consists of stitching together the central part of the free edges of the leaflets producing a 'clover' shaped valve. Our preliminary experience with this novel technique is reported. METHODS: Between 2001 and 2003, 14 patients (mean age 57+/-17 years), with severe tricuspid regurgitation due to complex lesions, underwent valve repair with this novel approach in combination with annuloplasty. The aetiology of the disease was post-traumatic in five cases, degenerative in eight and secondary to dilated cardiomyopathy in one. Anterior leaflet prolapse/flail was present in most patients associated with posterior and/or septal leaflet prolapse or tethering. Annular and right ventricular dilatation was present in all cases. Mitral valve repair/replacement was concomitantly performed in nine patients. RESULTS: Hospital mortality was 7.1% (1/14). At follow-up extending to 22 months (mean 12+/-6.3), all survivors were asymptomatic. At the last echocardiogram tricuspid regurgitation was absent or mild in 13 patients and moderate in one. Mean tricuspid valve area and gradient were 4.2+/-0.4 cm(2) and 2.7+/-1.4 mmHg, respectively. CONCLUSIONS: Despite the short follow-up, this novel technique appears to be an easy, rapid and effective approach to correct severe tricuspid regurgitation due to complex lesions. Such a repair restored tricuspid valve competence, even in the presence of huge RV dilatation and pulmonary hypertension.     

Tighter tricuspid annuloplasty with DeVega technique for secondary tricuspid regurgitation

More effective surgical treatment of secondary tricuspid regurgitation was investigated on the basis of intraoperative assessment of tricuspid regurgitation (TR) and clinicopathological study of right ventricular muscle biopsy. From March 1986 to February 1989, more aggressive narrowing of tricuspid valve ring using DeVega's method was performed on 29 patients. They were 8 men and 21 women, with the age of 28 to 71 (mean 53.5). Tricuspid annular diameter before procedure ranged from 31 to 45 mm in size, with the mean of 36.9 mm. Tricuspid annuli were constricted to 27 mm in 20 patients, and to 25 mm in 9 patients. Intraoperative evaluation of TR was done by digital examination from right atrium, contrast echocardiography, and filling regurgitation test on arrested or rebeating heart. But these intraoperative assessment of regurgitation did not predict postoperative residual tricuspid regurgitation. There was no early mortality. Postoperative residual tricuspid regurgitation was observed in only two patients (8.7%) of total cases within a follow-up period of 12 months. Quantitative study of extent of diffuse interstitial fibrosis of the right ventricular wall and diameter of right ventricular myocardial cells obtained by open transmural biopsy were done. The degree of diffuse interstitial fibrosis was assessed by the point-counting method, and mean percentage fibrosis (%fibrosis) was noted as 27.9%. Mean diameter of right ventricular myocardial cells was 19.5 microns in size. The diameter of right ventricular myocardial cell was correlated with pulmonary arterial pressure (r = 0.56).(ABSTRACT TRUNCATED AT 250 WORDS)     

Reoperation for tricuspid regurgitation after total correction of tetralogy of Fallot.

BACKGROUND: The aim of this study is to review the outcome of reoperation for severe tricuspid regurgitation after repair of tetralogy of Fallot. METHODS: Between 1972 and 2000, 12 patients underwent reoperation on the tricuspid valve after total correction of tetralogy of Fallot. The mean age at the time of reoperation was 17 years (range, 1 to 39 years). The mean interval between the initial correction and the reoperation was 7.8 years (range, 10 days to 19 years). The functional class was New York Heart Association class II in 2 patients and class III or IV in 10. Six patients underwent tricuspid valve repair, and the others underwent tricuspid valve replacement. RESULTS: Hospital mortality was 16.7% (2/12). Three patients (30%, 3/10) required a second reoperation 1.6, 9.2, and 15.6 years after the most recent reoperation with no deaths. The reasons for second reoperation were failure of the tricuspid valve repair in two and a thrombosed valve in one. There were two late deaths. Mean overall event-free actuarial survival at 10 years was 46.3%. CONCLUSION: Reoperation for severe tricuspid regurgitation after total correction of tetralogy of Fallot was associated with a high operative mortality and disappointing long-term results. Tricuspid regurgitation after corrective surgery for tetralogy of Fallot must be diagnosed promptly and cured, as tolerance is poor because of postoperative right ventricular insufficiency.     

A new technique for tricuspid valve repair addressing the subvalvular apparatus in functional tricuspid regurgitation

Annular dilatation is the main mechanism for tricuspid regurgitation, but right ventricular dilatation often adds a restrictive mechanism, which may limit durability. We describe a subvalvular technique anchoring the chordal origins to the annuloplasty, with the aim to stabilize valve geometry and increase durability. A Goretex suture is attached to the anterior papillary muscle. One arm of the suture is stitched through the septal muscle and both arms are atrialized underneath the septal leaflet and tied to the annuloplasty band. In 12 patients (75 ± 6 years, EuroSCORE II 10 ± 9%), severe-torrential tricuspid regurgitation was successfully reduced to mild. Results were stable in all but one patient during follow-up (1–15 months). NYHA class and general health status was improved. This subvalvular technique is safe with the potential to generate a durable repair.     

Surgical results of high grade constriction of tricuspid annulus in DeVega technique for secondary tricuspid regurgitation

Sixty-six patients were operated on by our high degree constriction technique using DeVega tricuspid annuloplasty from 1985 to 1989. They were 20 men and 46 women, age distributed from 28 to 71 (mean 54.5). Preoperative tricuspid annular diameter ranged from 29 mm to 45 mm, average 36.3 mm. Those were constricted to 27 mm in 38 patients, and to 25 mm in 28 patients. Postoperative residual tricuspid regurgitation was observed in only 8.5% of total cases followed up 14 to 55 months. This results were comparable with other reports. We concluded that our tight constriction DeVega method is considered better to prevent postoperative tricuspid regurgitation than ordinary methods.     

Correction of traumatic tricuspid regurgitation using the double orifice technique

We present a case of acute traumatic tricuspid regurgitation in a 39-year-old man who was involved in a motor vehicle accident. A large ecchymotic region over the anterior chest wall prompted evaluation by both transthoracic and transesophageal echocardiography which confirmed the valvular injury. At surgery, valvular incompetence was found to be the result of a flail anterior leaflet due to papillary muscle rupture. The valve was successfully repaired using a single stitch double orifice technique in combination with a ring annuloplasty. The valve remains competent 18 months after surgery.     

Prevalence and risk factors of tricuspid regurgitation after correction of tetralogy of Fallot

Tricuspid regurgitation was evaluated in 133 patients with tetralogy of Fallot after corrective operations for a real-time Doppler flow imaging system. Moderate or severe tricuspid regurgitation was found in 15% (10/66) of patients in whom the ventricular septal defect was closed through the right atrium and tricuspid valve, 13% (2/15) through the pulmonary artery, and 25% (13/52) through the right ventricle. These differences were not significant. Right ventricular systolic pressure was significantly higher (66 +/- 27 mm Hg) in patients with moderate or severe tricuspid regurgitation (group A) than in patients with mild or no tricuspid regurgitation (group B) (41 +/- 13 mm Hg) (p less than 0.01). Right ventricular end-diastolic pressure was significantly higher in group A (7.7 +/- 2.2 mm Hg) than in group B (6.1 +/- 2.9 mm Hg) (p less than 0.01). Significant pulmonary regurgitation (angiographic grades 3/4 to 4/4) was more frequent in group A (8/18; 44%) than in group B (14/64; 22%) (p less than 0.05). Residual ventricular septal defect (pulmonary/systemic flow ratio greater than 1.3) was also more frequent in group A (5/18; 28%) than in group B (0/64; 0%) (p less than 0.01). Right ventricular end-diastolic volume was significantly higher in group A (202% +/- 79% of the normal right ventricle) than in group B (158% +/- 38% of normal) (p less than 0.01). Thus significant tricuspid regurgitation was associated with high right ventricular systolic pressure, high right ventricular end-diastolic pressure, and significant pulmonary regurgitation and residual ventricular septal defect, which increased the right ventricular end-diastolic volume. Operative procedure for closing the ventricular septal defect was not related to the development of significant tricuspid regurgitation.     

Cardiac perforation and tricuspid regurgitation as a complication of percutaneous vertebroplasty.

Percutaneous vertebroplasty is a minimally invasive technique that is used to treat vertebral fractures, tumors and osteolytic vertebral metastases. However, cement leakage to the venous system is a potential source of serious complications after percutaneous vertebroplasty. We report a 65-year-old female patient who demonstrated cardiac perforation, pulmonary cement embolism, and tricuspid regurgitation, and these were all caused by venous leakage of polymethylmethacrylate as a complication of the procedure.     

The double-orifice technique as a standardized approach to treat mitral regurgitation due to severe myxomatous disease: surgical technique.

OBJECTIVES: Mitral-valve repair in Barlow's disease is challenging; conventional techniques are difficult to perform, and there is a high risk of a postoperative suboptimal result. Double-orifice repair has been applied in a standardized approach to treat patients with severe mitral regurgitation and bileaflet prolapse due to Barlow's disease. METHODS: Since 1993, 82 patients with severe mitral regurgitation due to Barlow's disease underwent correction applying the edge-to-edge concept. They were submitted to double-orifice repair in a standardized fashion, suturing the middle portions of both leaflets. RESULTS: There were no hospital deaths. The repair was unsatisfactory in one patient who underwent valve replacement soon after the repair. The mean postoperative valve area was 3.7+/-0.79 cm(2) against a mean preoperative value of 9.2+/-2.1 cm(2). No or mild regurgitation was found in all but three patients who showed moderate residual regurgitation. There were no late deaths. Freedom from reoperation was 86+/-14% at 5 years. At the latest follow-up, all patient but one were New York Heart Association (NYHA) functional class I, and echo-Doppler assessment of valve reconstruction showed stable valve function in all patients. CONCLUSIONS: The double-orifice repair can be used as a standardized approach to treat valve regurgitation due to Barlow disease with low risk and good early and mid-term results.     

Sliding tricuspid valvuloplasty for severe tricuspid regurgitation after corrective surgery of a ventricular septal defect

We encountered a case of massive tricuspid regurgitation after corrective surgery for a ventricular septal defect. Fixation of the septal leaflet to the ventricular septum at the point where it was closed with a pericardial patch and marked annular dilatation were the lesions contributing to the severe tricuspid regurgitation. The posterior leaflet of the tricuspid valve was excised from the tricuspid annulus, slid to the adhering septal leaflet, and then reattached to a safe area of the septal leaflet to prevent conduction disturbance. The sliding repair was supported by annuloplasty with a Carpentier–Edwards ring, and a concomitant right-sided Maze procedure was conducted for atrial flutter.     

超声心动图对继发性三尖瓣反流术疗效的评价

【摘要】〓目的〓通过超声心动图比较继发性三尖瓣反流患者行三尖瓣缝线成形术和成形环成形术的早期和中期效果,评价两种三尖瓣成形方法的疗效。方法〓回顾性分析我院2008年1月~2013年6月行三尖瓣成形术治疗的,并能追踪到而且进行了随访的继发性三尖瓣反流患者 175 例,根据成形方法分成两组:缝线成形术组 143例(82%),使用成形环成形术组 32 例(18%),分别于术前、术后一个月、术后一年通过超声心动图测量左室射血分数(LVEF)、三尖瓣反流束面积(TRA)、三尖瓣反流分数(TRF)、右室前后径(RVD)、右房上下径(RAD1)及右房左右径(RAD2),比较术前、术后半个月及术后1年时各参数的变化。结果〓两组患者,与术前相比,所有患者术后一个月TRA、TRF及RVD、RAD1及RAD2均显著降低(P<0.05),LVEF无显著变化(P>0.05);术后1年,缝线成形术组的患者TRF较术后一个月显著增加(P<0.05),其余指标无明显变化(P>0.05);而使用成形环组术后一年,所有指标较术后一个月无显著变化(P>0.05)。结论〓三尖瓣成形环成形术治疗三尖瓣反流,在术后中期仍可维持良好的疗效。超声心动图对三尖瓣反流的程度可提供半定量信息,在术前及术后随访中有着重要的应用价值。