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.     

Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. I. Prevalence, diagnosis, and comparison of preoperative clinical and hemodynamic features in patients with and without tricuspid regurgitation

Most reports of clinical experiences with palliation of acquired tricuspid regurgitation have failed to address the issue of coexisting disease of the mitral or aortic valve, or both. To accurately determine the natural history and the effect of operative interventions, we studied patients with chronic, pure mitral regurgitation who had surgical treatment at the National Heart, Lung, and Blood Institute from 1968 to 1984. Forty-seven patients fulfilled the criteria of a documented history of mitral regurgitation for more than 1.5 years, minimal mitral diastolic gradient, severe mitral regurgitation by angiography, and no prior mitral or tricuspid operative procedure. Twenty-five of the 47 patients (53%) had evidence of tricuspid regurgitation. No statistical differences in age, sex, mean duration of symptoms of congestive heart failure, or functional class were found between those patients with and those without tricuspid regurgitation. However, patients with symptoms of congestive heart failure for more than 6 years were more likely to have tricuspid regurgitation. This increased prevalence also correlated with higher elevations of left ventricular end-diastolic, systolic pulmonary artery, and mean right atrial pressures. The severity of tricuspid regurgitation estimated preoperatively did not correlate statistically with that determined by digital palpation, although the presence of tricuspid regurgitation was reliably confirmed. These data demonstrate that tricuspid regurgitation is frequently present in patients with chronic, pure mitral regurgitation and is associated with prolonged symptoms of congestive heart failure and significant alterations in right heart dynamics.     

Tricuspid valve replacement in a patient with idiopathic tricuspid regurgitation]

Tricuspid regurgitation is often seen but is rarely categorized as "idiopathic". A 66-year-old man suspected of idiopathic tricuspid regurgitation underwent tricuspid valve replacement. With right heart failure over twenty years, his CTR increased to eighty six (86) per cent. During operation, no abnormal findings were observed except for the dilated tricuspid valve ring. Then a stented porcine xenograft (Carpentier-Edwards 33 mm) was inserted in the tricuspid valve annulus. Seven years after replacement, he died. Autopsy demonstrated myocardial hypertrophy of the right ventricle and dilatation of the right heart, supporting the diagnosis of idiopathic tricuspid regurgitation.     

Non-penetrating traumatic tricuspid regurgitation after mitral valve replacement

A case of traumatic rupture of the tricuspid chordae tendineae with severe regurgitation in a patient who previously had mitral valve replacement is presented. In this case, it is strongly suggested that a firm pericardial adhesion of the anterior right ventricular wall became a factor of the disruption of the tricuspid valve under a slight precordial blow.     

Tricuspid valve replacement for elderly patients with isolated tricuspid valve regurgitation; report of 2 cases

Isolated tricuspid valve regurgitation (TR) is a rare clinical entity. We report 2 patients, 80 and 74-year-old with isolated TR. They underwent valve replacement with the Carpentier-Edwards bioprosthesis because of resistance to medical treatment. The causes of insufficiency were suspected as congenital in case 1 and infective endocarditis in case 2, respectively. Postoperative course was free from major complications in both patients. Valvuloplasty and/or annuloplasty are recommended for TR, however, replacement of the tricuspid valve is sometimes necessary in isolated TR patients. The higher occurrence of thrombosis of mechanical prosthesis in the tricuspid position has been reported. The bioprosthesis in tricuspid position may reduce the rate of thromboembolism, thrombosis and structural dysfunction, therefore it may be an option for radical therapy in isolated TR especially in aged patients.     

Tricuspid regurgitation secondary to mitral valve disease: tricuspid annulus function as guide to tricuspid valve repair.

METHODS. A prospective analysis was performed on 50 patients (pts) with rheumatic mitral disease and associate secondary tricuspid insufficiency who underwent mitral valve replacement from January 1995 to December 1998. Surgical indication to tricuspid annuloplasty was considered in patients with echocardiographic tricuspid annulus diameter > 21 mm/m2, regardless semiquantitative evaluation of tricuspid insufficiency. De Vega annuloplasty was performed in 33 out of 50 patients. RESULTS: Hospital mortality was 2.0% (CL 0.3-3.6). The follow up of the discharged patients ranged from 3 to 48 months (mean 25 +/- 15.9). Three late deaths occurred (6.1% CL 2.8-9.2). Forty-two patients out of the 46 followed up (91.3% CL 84.9-93.8) were in I or II NYHA class. In eight patients (16.3% of discharged patients) the obtained result has been considered as 'negative late results': persisting moderate (three cases) or moderate-severe (five cases) TrI, together with congestive heart failure requiring a furosemide intake of > 25 mg/day. No patients had severe TrI at follow up. The statistics analysis demonstrated the 'preoperative fraction shortening of the tricuspid annulus' (P = 0.038) as factor predictive of late negative result. The incidence of late negative result was 57.1% among patients with fractional shortening lower than 25% and 0% among those patients with fractional shortening greater than 25% (P = 0.0001). CONCLUSIONS: The choice to treat the tricuspid insufficiency according to indexed tricuspid annulus dimension (> 21 mm/m2) has been effective in terms of clinical efficacy and of late functional result. Fractional shortening of the tricuspid annulus, expression of right ventricular cardiomyopathy in patients with poorest prognosis, affects the postoperative evolution of tricuspid insufficiency.     

Tricuspid valve replacement with a mitral homograft in children with rheumatic tricuspid valvulopathy

OBJECTIVE: Tricuspid valve replacement in children is associated with a nonnegligible complication rate because of specific disadvantages of mechanical or biologic prostheses. The objective of this study was to examine the midterm clinical outcomes of tricuspid valve replacement with a mitral homograft in 8 children with unreparable rheumatic tricuspid valve involvement. METHODS: Between 1993 and 2003, tricuspid valve replacement with a mitral homograft was performed in 8 patients (2 male and 6 female patients; mean age, 14.2 years) with rheumatic tricuspid valve disease. All patients were in New York Heart Association class III or IV. In all patients with rheumatic valve disease, conservative operations had previously been performed on the tricuspid valve during concomitant left-sided surgical intervention. Mean follow-up was 56 +/- 12 months and was complete. RESULTS: There were no operative or late deaths. All patients were alive at the most recent follow-up contact and were in New York Heart Association functional class I or II. None of the patients required homograft-related reoperation. At the most recent echocardiograhic examination, 6 patients had trivial residual tricuspid regurgitation, and 2 had mild tricuspid regurgitation. None of the patients had maximal transvalvular tricuspid gradients greater than 2 mm Hg during their yearly follow-up visits. CONCLUSION: On the basis of our midterm results, tricuspid valve replacement with a mitral homograft in children seems to be a valuable alternative surgical option.     

改良二尖瓣成形术治疗小儿二尖瓣反流

目的 总结改良二尖瓣成形术在小儿二尖瓣反流中的治疗经验。方法 1999年3月至2009年12月共收治小二尖瓣中、重度反流行改良二尖瓣成形术患儿106例。全组男69例,女37例;年龄0.4～8.5岁,平均(3.7±1.8)岁;体重6.6 ～52.0 kg,平均(10.0±3.5)kg。术前超声评估左心室功能。按年龄分为3组：＜6个月16例;6个月到2岁51例;2岁到8.5岁39例。另有7例合并二尖瓣狭窄,根据术前血流动力学、功能状况和解剖结构分别采用取不同的手术方法。结果 死亡3例(2.8％),其中2例为术后二尖瓣反流加重严重影响心功能,1例为合并难以纠治的肺高压。其他患儿恢复良好。结论 对于小儿二尖瓣反流行成形术可行,术后早期效果良好,瓣膜发育尚可,再手术率相对较低。对小儿二尖瓣反流早期干预可以减少瓣膜损害。     

Mitral valve replacement versus annuloplasty for treating severe functional mitral regurgitation

Objectives

To improve the clinical outcome of patients with severe functional mitral regurgitation (FMR) associated with ischemic cardiomyopathy (ICM), we compared the therapeutic efficacy of mitral annuloplasty (MAP) with that of mitral valve replacement (MVR).

Methods

In a retrospective observation 63 consecutive patients underwent mitral valve surgery for severe ICM–FMR from November 1999 to March 2012. All patients had severe FMR (regurgitant volume >60 ml/beat) with Carpentier type I and type IIIb disease. Mean RV was 74.0 ± 35.0 ml/beat and coaptation depth was 12.7 ± 3.0 mm. Twenty-six patients (41.3 %) were treated by MVR with sparing of the subvalvular apparatus and 37 (58.7 %) by MAP.

Results

Total in-hospital mortality was 6.3 %. Kaplan–Meier survival estimates at 1 and 5 years were 84.2 and 78.6 % in the MVR group and 82.6 and 71.6 % in the MAP group, with no significant difference between groups (p = 0.758). Freedom from major adverse cardiac and cerebrovascular events (MACCE) at 5 years was 66.9 % for patients treated by MVR and 64.1 % for those treated by MAP (p = 0.866). At the last follow-up visit, >grade II MR had recurred in 4 annuloplasty patients (10.8 %). In multivariate analysis, independent predictors of increased late death and MACCE were significantly associated with residual pulmonary hypertension (late death: odds ratio = 25.0, p = 0.0009; MACCE: odds ratio = 31.3, p = 0.0001).

Conclusions

Mitral valve replacement with sparing of the subvalvular apparatus is a safe and effective surgical alternative for patients with severe FMR.     

Tricuspid annuloplasty significantly reduces early tricuspid regurgitation after biatrial heart transplantation.

BACKGROUND: The incidence of tricuspid annuloplasty (TR) observed early after cardiac biatrial implantation is unpredictable and in our experience not infrequently problematic. Although the bicaval method of implant may reduce the incidence of TR, its benefit has not been conclusively documented. METHODS: In an attempt to reduce the incidence of TR observed early after cardiac transplantation, 25 consecutive patients undergoing cardiac transplantation received donor heart tricuspid annuloplasty (TA) with either a DeVega or Ring technique. Early transthoracic echocardiograms were analyzed and compared with an immediately prior and consecutive cohort of 25 patients undergoing transplantation without TA. The biatrial technique of cardiac transplantation with a Cabrol modification was used for donor heart implant in both groups. Echocardiograms obtained 5 days after cardiac transplantation were reviewed in blinded fashion. TR was scored 0 = none, 1 = mild, 2 = moderate, and 3 = severe. RESULTS: Donor and recipient characteristics were not different between groups. No hospital deaths occurred in either group. Patients undergoing transplantation without TA had a higher TR score, 1.3 (range 0-3), than did patients with TA, 0.7 (range 0-1.5, p = 0.002). Moderate or severe TR was present in 8 of 25 patients without TA compared with 0 of 25 patients with TA (p = 0.004). No patients required permanent pacemaker. CONCLUSIONS: TA can significantly reduce the incidence of early postoperative TR after biatrial cardiac transplant without adding to the complexity of operation.