Progression of isolated tricuspid regurgitation late after mitral valve surgery for rheumatic mitral valve disease

BACKGROUND AND AIMS OF THE STUDY: Severe tricuspid regurgitation (TR) may develop late after mitral valve surgery without significant mitral stenosis, regurgitation and other causes of left heart failure. The study aim was to investigate severe isolated TR late after mitral valve surgery for rheumatic mitral valve disease. METHODS: A total of 208 patients who underwent mitral valve surgery (valve replacement in 121, commissurotomy in 62, valvuloplasty in 25) was investigated. The mean (+/-SD) follow up was 13+/-6 years. Severe isolated TR was defined clinically by elevated venous pressure, and echocardiographically by grade 4+ TR without significant mitral stenosis, regurgitation, other causes of left heart failure, pulmonary hypertension or rheumatic tricuspid valve. RESULTS: Severe isolated TR was identified in 30 patients (14%) at four to 24 years after mitral valve surgery. All patients had atrial fibrillation. Of these patients, 23 had medical treatment and seven had tricuspid valve surgery. Three of the medically treated patients were in NYHA class IV and died from multiple organ failure at three to seven years after severe TR was diagnosed. Among surgically treated patients, four were in NYHA class IV and had postoperative complications (one early death, one late death), while three NYHA class II/III patients had very few postoperative complications. CONCLUSION: Severe isolated TR was detected in 14% of patients after mitral valve surgery. It is important to detect patients with progressive heart failure and to indicate earlier reoperation in order to prevent significant late mortality.     

左心瓣膜置换术后远期三尖瓣关闭不全的外科治疗

目的:评价左心瓣膜置换术后三尖瓣重度关闭不全外科治疗效果。方法:对25例左心瓣膜置换术后,人工瓣膜功能正常,三尖瓣重度关闭不全患者行三尖瓣成形术或三尖瓣置换术;首次手术二尖瓣置换术17例,二尖瓣加主动脉瓣置换术8例,在首次手术中10例曾行三尖瓣DeVega法成形术。结果:三尖瓣成形术13例;三尖瓣置换术12例。术后早期死亡4例,病死率16%。随访7个月～8年,平均(5.1±2.6)年,2例三尖瓣置换患者死于心血管事件,长期生存15例,心功能Ⅱ级8例,Ⅲ级4例,Ⅳ级3例,多数仍需强心、利尿药维持,临床症状明显改善。结论:对左心瓣膜置换术后三尖瓣重度关闭不全患者外科手术是一种合适的选择。合理掌握手术指征、手术时机和良好的围手术期治疗是手术成功的关键。     

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)     

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.     

Evolution of repaired and non-repaired tricuspid regurgitation in rheumatic mitral valve surgery without severe pulmonary hypertension

The aim of this study was to evaluate the usefulness of repairing significant tricuspid regurgitation (> or = grade 2) without severe pulmonary hypertension (< or = 50 mm Hg). Between 1993 and June 2001, 88 consecutive patients were operated on for rheumatic mitral valve disease associated with significant tricuspid regurgitation and without severe pulmonary hypertension. The severity of the tricuspid valve disease was assessed by echocardiography. Sixty-three patients had severe (> or = grade 3) tricuspid regurgitation (Group I), and 25 patients had moderate (grade 2) tricuspid regurgitation (Group II). There was no hospital mortality. six patients died during follow-up. The overall actuarial survival rate for 8 years was 92.1% +/- 3.1%. Cox proportional hazard regression analysis showed that age ( p = 0.006) and pulmonary complication ( p = 0.01) were associated with increased late mortality. Freedom from death was similar in both groups at 8 years (93.1% +/- 3.3% versus 88% +/- 8%, p = 0.7). Severe postoperative tricuspid regurgitation (> or = grade 3), caused by the failure of tricuspid repair or leaving the valve untouched, impaired long-term survival after surgery, and actuarial survival was 96.1% +/- 2.7% and 83% +/- 7.8% at 7 years ( p = 0.048), respectively. Severe tricuspid regurgitation, functional or organic, should be corrected at the time of mitral valve surgery, whereas untouched functional moderate tricuspid regurgitation improves after mitral valve surgery.     

左心瓣膜术后心房颤动与三尖瓣反流的关系

目的:研究左心瓣膜术后三尖瓣反流与术后心房颤动(房颤)的关系。方法:随访2002年3月至2008年11月接受主动脉瓣置换术或二尖瓣置换术,且未行三尖瓣成形术或三尖瓣置换术的患者374例,其中男性151例,女性223例,年龄23～79岁,平均(52±11)岁。所有患者均经过术前和术后彩色多普勒超声心动检查及心电图检查。单因素分析组间使用χ2检验。危险因素采用Logistic回归模型分析。结果:左心瓣膜术后房颤是术后发生三尖瓣反流的独立危险因素。Logistic多因素分析结果为:术后房颤、女性及术后左心房扩大,是术后三尖瓣反流的独立危险因素;术时年龄、术后左心室大小、术后右心室大小及术后射血分数这4项不是三尖瓣反流的危险因素。结论:左心瓣膜术后房颤是术后发生三尖瓣反流的独立危险因素。对于术后房颤应该引起重视,积极治疗。     

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.     

左心瓣膜置换术后孤立性三尖瓣关闭不全的外科治疗及危险因素

目的 明确左心瓣膜置换术后出现远期孤立性三尖瓣关闭不全（tricuspid regurgitation,TR）的外科治疗效果和危险因素.方法 分析2000年1月至2010年12月广东省人民医院因左心瓣膜术后发生远期孤立性重度TR而接受三尖瓣外科治疗的41例患者的资料.三尖瓣成形（tricuspid valve repair,TVP）7例,三尖瓣置换（tricuspid valve replacement,TVR）34例,比较两组的近、远期结果.并比较存活组与术后早期死亡组及术后远期死亡组的临床资料,分析手术早期及远期死亡的危险因素.结果 随访时间（6.3±3.4）年,随访率97％,死亡14例（34.1％）.TVP组术后死于右心功能衰竭1例（14.3％）,无远期死亡;因再发重度TR于术后3.5年行TVR1例.TVR组手术死亡8例,远期死亡5例,死亡率38.2％.因右心功能衰竭死亡9例,感染性心内膜炎、脑出血、猝死、结肠癌术后肝转移死亡各1例.TVP组死亡率有高于TVR组的趋势（P=0.43）.手术早期死亡组三尖瓣反流面积、肌酐值明显高于与存活组,差异有统计学意义（P＜0.05）;而术后远期死亡组右心室大小、肌酐值明显高于存活组,差异有统计学意义（P＜0.05）.结论 左心瓣膜置换术后远期孤立性TR的再次手术死亡率高,选择TVP将有助于降低死亡率.三尖瓣反流程度重、术前肌酐值升高是手术早期死亡的危险因素;右心室大小和术前肌酐值升高是术后远期死亡的危险因素.     

左心瓣膜置换术后三尖瓣关闭不全的外科治疗

目的 探讨左心房室瓣置换术后三尖瓣关闭不全的外科处理方法。 方法 回顾性分析2007年1月至2017年1月我院在左心瓣膜置换术后出现三尖瓣重度关闭不全再次手术42例患者的临床资料。 结果 手术患者42（男11，女31）例。年龄30～66（52±11）岁。18例（43%）为人工瓣膜功能正常，其余24例（57%）均并发不同程度的主动脉瓣和（或）二尖瓣瓣周漏。两次手术间隔1~19（11±4）年。采用三尖瓣成型环成形31例；采用三尖瓣置换11例，其中，3例为生物瓣膜，8例为双叶机械瓣膜。术后早期院内死亡6例，病死率为14%，其中三尖瓣成形2例，三尖瓣置换4例。致死原因，右心功能衰竭3例，多脏器功能衰竭2例，因凝血功能障碍，出血导致死亡1例。全组随访37例，随访率88%，随访时间6～120（73±31）个月，失访5例（失访率为12%）。随访病例中，5例三尖瓣人工瓣置换患者三尖瓣功能良好。26例三尖瓣成形患者中无或少量返流22例，中量以上返流4例。 结论 左心瓣膜置换术后出现三尖瓣重度关闭不全，行三尖瓣置换或三尖瓣成形术可达到满意疗效。术前心功能的调控及全身各脏器功能的评估是手术成功的保障。依据三尖瓣结构不同的病理改变，选择适合的手术方式也是确保手术成功的关键。     

Functional tricuspid regurgitation following replacement of the mitral valve.

In this series, the effect of replacement of the mitral valve was examined in 86/900 (9.6%) patients who had developed moderate functional tricuspid regurgitation, secondary to rheumatic mitral valvar disease. These patients were subdivided according to the severity of pulmonary hypertension and impairment of right ventricular function. Forty-six patients presented with severe pulmonary hypertension and 40 patients had moderate pulmonary hypertension (mean main pulmonary arterial pressure: 78 +/- 14 mmHg vs 41 +/- 6 mmHg; P less than 0.05). The latter had more advanced disease, greater impairment of right ventricular function and dilatation of the right heart chambers. Functional tricuspid regurgitation regressed in 38/42 survivors with severe pulmonary hypertension and persisted or progressed significantly in 22/34 survivors with impaired right ventricular function despite successful replacement of the mitral valve. The latter underwent replacement of the tricuspid valve (n = 16) or tricuspid annuloplasty (n = 6), at a mean interval of 44 +/- 4.4 months after replacement of the mitral valve, which resulted in 8/22 (23.5%) early deaths. Functional tricuspid regurgitation is more likely to persist in patients with advanced right ventricular failure. Tricuspid valvar competence should be restored in these patients at initial replacement of the mitral valve.     

Comparison of Doppler echocardiography and cardiac catheterization in patients requiring valve surgery: search for a 'gold standard'.

OBJECTIVE: To compare the sensitivities of Doppler echocardiography and cardiac catheterization in the diagnosis of severe valvular heart disease in patients requiring valve surgery. DESIGN: Retrospective analysis of Doppler echocardiograms and cardiac catheterizations. SETTING: Tertiary referral cardiovascular centre in a university setting. PATIENTS: Sixty-nine patients undergoing valve surgery between July 1988 and July 1990. RESULTS: The sensitivities of echocardiography and cardiac catheterization were 84 and 87%, respectively (P = 1.0) in 32 patients who underwent aortic valve surgery primarily for severe aortic stenosis; 83 and 67%, respectively (P = 1.0) in six patients with severe aortic regurgitation, and 100 and 85%, respectively (P = 1.0) in seven patients with combined severe aortic stenosis and regurgitation. The sensitivities of echocardiography and cardiac catheterization in 11 patients who underwent mitral valve surgery for severe mitral stenosis were 73 and 91%, respectively (P = 0.6) and 69 and 92%, respectively (P = 0.3) in 13 patients with severe mitral regurgitation. Sensitivities of echocardiography and cardiac catheterization in the diagnosis of severe tricuspid regurgitation in five patients who had tricuspid valve repair were 100 and 80%, respectively (P = 1.0). Two patients with severe aortic stenosis by echocardiography, but not by catheterization, did not undergo aortic valve replacement during valvular surgery; both required aortic valve replacement within two years of initial surgery because of heart failure. Four patients with severe tricuspid regurgitation identified by echocardiography did not have tricuspid repair; three had pulmonary hypertension and these patients had resolution of tricuspid regurgitation on follow-up. One patient with severe tricuspid regurgitation and absence of pulmonary hypertension required reoperation for tricuspid valve repair 10 months after initial operation. CONCLUSIONS: The sensitivity of echocardiography and cardiac catheterization in the detection of severe valvular lesions requiring surgery is similar. Discordant results should be reviewed carefully with knowledge of the inherent pitfalls of both techniques in order to ensure optimal patient outcome.     

Evidence for rheumatic valve disease in patients with severe tricuspid regurgitation long after mitral valve surgery: the role of 3D echo reconstruction

BACKGROUND AND AIM OF THE STUDY: Although severe tricuspid regurgitation (TR) is a well-recognized, long-term complication of rheumatic mitral valve replacement that impairs the functional results of surgery, its exact basis remains unclear and its management is unsatisfactory. The study aim was to obtain a detailed assessment of tricuspid valve morphology and function using 2D transesophageal echocardiography (TEE) with 3D reconstruction, and to determine long-term clinical outcome in patients after surgery for rheumatic mitral valve disease. METHODS: A total of 42 patients (mean age 50 +/- 10 years) was followed up; 39 patients had mitral replacement and three had valvotomy. Thirty patients had developed impaired exercise tolerance, fluid retention and echocardiographic evidence of severe TR at 8.2 +/- 2.6 years after surgery; the remainder had mild regurgitation. RESULTS: Follow up showed greater mortality in the severe TR group, with approximately 50% survival at 60 months after diagnosis compared with mild TR. None of the patients with severe TR had a dysfunctional mitral prosthesis. In these patients, transthoracic echo-Doppler showed enlarged right atrium and right ventricle, a mean transtricuspid retrograde pressure drop of 15 +/- 4 mmHg and apparently normal leaflet anatomy. Twenty patients (15 with severe TR) underwent a TEE and 3D reconstruction study for further evaluation. Abnormal leaflet anatomy was demonstrated in all patients with severe TR, with restricted leaflet motion in 10, leaflet shortening and thickening in the remainder, and dilatation of tricuspid valve annular insertion suggestive of rheumatic involvement. Although diastolic transtricuspid velocities were increased (peak flow 0.8 +/- 0.1 m/s) in these patients due to increased stroke volume, significant tricuspid stenosis was present in only two cases (mean gradient 4 and 3 mmHg respectively). Histopathology confirmed the presence of leaflet vascularization and extensive fibrosis in two patients who underwent tricuspid valve replacement. CONCLUSION: Rheumatic leaflet involvement contributes to severe TR occurring long after mitral valve replacement, though overt stenosis is uncommon. Knowledge of the structural basis of this condition may thus improve its long-term management, possibly with early tricuspid valve repair.     

Maintaining tricuspid valve competence in double discordance: a challenge for the paediatric cardiologist

Objectives—To establish the prevalence of tricuspid valve abnormalities in children with a double discordant heart (or congenitally corrected transposition of the great arteries); to study the influence of the loading conditions induced by various surgical interventions on the right and left ventricle in patients with double discordance and an abnormal tricuspid valve; and to propose a rational surgical approach.
Methods—Case notes were reviewed of 141 consecutive patients admitted in the first year of life with various types of double discordance (intact ventricular septum (group 1), ventricular septal defect (group 2), ventricular septal defect and pulmonary obstruction (group 3)). A study group of 62 patients with an abnormal tricuspid valve was selected by cross sectional echocardiography. These were followed up through palliative and open heart procedures with grading of tricuspid regurgitation.
Results—Tricuspid valve abnormalities were more common in groups 1 and 2 (60% and 56%) than in group 3 (31%). Preoperative tricuspid regurgitation was more common in group 2 (90%) than in groups 1 and 3 (38% and 36%). Ten patients in groups 1 and 2 died in the neonatal period with severe tricuspid regurgitation, associated with coarctation of the aorta in 60%. Eight patients in group 1 had no surgery and are doing well, with a competent tricuspid valve. Palliative procedures were undertaken in 28 patients: 14 had pulmonary artery banding, which resulted in a decrease in tricuspid regurgitation, 12 in group 2 by reducing the pulmonary blood flow and two in group 1 by changing the septal geometry; 14 in group 3 had an aortopulmonary shunt, which induced tricuspid regurgitation in two. Twenty patients are still alive after palliation, with stable tricuspid valve function. Repair of the tricuspid valve was unsuccessful in the three patients who underwent conventional surgery, leaving the right ventricle facing the systemic circulation. In two patients with a competent but abnormal tricuspid valve, conventional surgery induced severe tricuspid regurgitation. Of the 15 patients who underwent conventional surgery, only 10 survived (mortality 33%): eight with a tricuspid valve prosthesis and two with severe residual tricuspid regurgitation. However, tricuspid regurgitation decreased after anatomical correction (nine patients), restoring a systemic left ventricle and a subpulmonary right ventricle, even when the tricuspid valve was not repaired (five patients). Eight patients are doing well after anatomical correction (mortality 11%).
Conclusions—Tricuspid valve function in double discordance with an abnormal tricuspid valve depends on the loading conditions of both ventricles and on the septal geometry. Interventions that increase right ventricular volume or decrease left ventricular pressure are likely to induce tricuspid regurgitation, while those that decrease right ventricular volume or increase left ventricular pressure are likely to improve tricuspid valve function. Repair of the tricuspid valve always failed when the right ventricle was left in a systemic position and always succeeded when the right ventricle was placed in a subpulmonary position. These results should be taken in to account when dealing with patients with double discordance and an abnormal tricuspid valve.

Keywords: transposition of the great arteries;  double discordance;  double switch procedures;  tricuspid valve;  paediatric cardiology;  congenitally corrected transposition     

Mitral valve surgery in patients with poor left ventricular function

BACKGROUND: Mitral valve surgery for the correction of secondary mitral valve regurgitation (MR) in cardiomyopathy is associated with a poor outcome. Numerous studies have identified a severe left ventricular dysfunction as an indicator for a poor prognosis. The aim of the study was to asses the follow-up after mitral valve surgery and severe left ventricular dysfunction. METHODS: Between 1994 and 2000, 31 patients with mitral regurgitation and a left ventricular ejection fraction of below thirty percent undergoing isolated repair (n = 16) or replacement (n = 15) were investigated. All patients received maximal drug therapy. Twenty-one patients were New York Heart Association (NYHA) class III and 10 were class IV. Follow-up with echocardiography, ECG, and chest x-ray was performed in 87 % of the survivors. The mean duration of follow-up was 39 +/- 16 months. RESULTS: The mean duration of ICU and hospital stay was 3.6 +/- 2.1 days and 8.1 +/- 5.4 days, respectively. The 1-, 2-, and 5-year survival rates were 91 %, 84 %, and 77 %, respectively. NYHA class improved from 3.3 +/- 0.8 to 2.1 +/- 0.7 at follow-up (p < 0.01). The ejection fraction improved from 23.1 +/- 6.6 % to 36 +/- 6.8 % at follow-up (p < 0.02). Freedom from readmission for heart failure was 85 %, 79 %, and 68 % at 1-, 2-, and 5 years, respectively. CONCLUSIONS: Mitral valve surgery improves left ventricular function and reduces heart failure severity in patients with MR and cardiomyopathy. High-risk mitral valve surgery may be an alternative to heart transplantation in selected patients.     

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.     

Hypoplastic left heart syndrome: hemodynamic and angiographic assessment after initial reconstructive surgery and relevance to modified Fontan procedure

After undergoing initial reconstructive surgery for hypoplastic left heart syndrome performed between August 1985 and March 1989, 59 patients (age range 3 to 27 months, mean 13.8 +/- 4.5) underwent elective cardiac catheterization in anticipation of a modified Fontan procedure. Five important hemodynamic and anatomic features considered to be components of successful reconstructive surgery were specifically addressed. 1) Interatrial communication: Only two patients had a measured pressure difference of greater than 4 mm Hg across the atrial septum. 2) Tricuspid valve function: Angiography demonstrated significant tricuspid valve regurgitation in only five patients (moderate in two and severe in three). 3) Aortic arch: Pressure tracings from the right ventricle to the descending aorta revealed a gradient greater than 25 mm Hg in only two patients. 4) Pulmonary vasculature: Ten patients had a calculated pulmonary vascular resistance greater than 4 U.m2; 51 (86%) of the 59 patients had no evidence of distortion (stenosis or hypoplasia) of either the left or the right pulmonary artery. 5) Right ventricular function: Five patients had an end-diastolic pressure in the right ventricle greater than 12 mm Hg and two patients had qualitative assessment of decreased ventricular function. Comparison of catheterization data between survivors and nonsurvivors of the subsequent modified Fontan procedure showed that only significant tricuspid regurgitation is a possible predictor of poor outcome. After first stage reconstructive surgery for hypoplastic left heart syndrome, most survivors have favorable anatomy and hemodynamics at follow-up cardiac catheterization for a subsequent Fontan procedure.     

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.     

66例三尖瓣置换术近、中期临床效果分析

目的：分析三尖瓣置换术的近、中期临床疗效,总结三尖瓣置换的临床经验。方法：回顾分析2010年1月—2015年12月我院66例三尖瓣置换的临床资料。根据病因分类,风湿性心脏病35例（其中因风湿性心脏病术后再次行三尖瓣置换12例）,先天性心脏病8例,感染性心内膜炎5例,瓣膜退行性病变4例,胸部外伤1例,起搏器安置术后1例。术前心功能分级（NYHA)II级者12例,III级者37例,心功能IV级者17例,56例患者行生物瓣置换,10例行机械瓣置换。结果：66例患者中,住院期间死亡4例,其中2例死于严重心力衰竭,1例死于心律失常,1例死于多脏器功能衰竭,2例出现III度房室传导阻滞,予置入永久起搏器。术后随访3~60月,随访期间死亡1例,全组总死亡率：7.5%。术后心功能恢复至I级26例,II级35例,III级5例。结论：三尖瓣置换术早期死亡率较高,所以只有病变严重者才考虑行置换手术且须严格掌握三尖瓣置换指征。我院三尖瓣置换患者,近、中期效果是满意的,远期效果尚待观察。     

Significant tricuspid regurgitation is a marker for adverse outcome in patients undergoing percutaneous ballon mitral valvuloplasty

Objectives, This study examined the association between the presence of tricuspid regurgitation and immediate and late adverse outcomes in patients undergoing balloon mitral valvuloplasty.Background. Significant tricuspid regurgitation has an adverse impact on morbidity and mortality in patients undergoing mitral valve surgery for mitral stenosis.Methods. We studied 318 consecutive patients (mean [± SD] age 54 ± 15 years) who underwent ballon mitral valvuloplasty and had color Doppler ecnocardiographic studies before the procedure. Patients were classified into three groups: 221 with no or mild (69%), 60 with moderate (19%) and 37 with severe (12%) tricuspid regurgitation. Clinical follow-up ranged from 6 to 62 months.Results. Before mitral valvuloplasty, increasing degrees of tricuspid regurgitation were associated with a smaller initial mitral valve area (p < 0.05), higher echocardiographic score (p < 0.05), lower cardiac output (p < 0.01) and higher pulmonary vascular resistance (p < 0.01). Although the initial success rate did not differ significantly between groups, patients with a higher degree of tricuspid regurgitation had less optimal results, as reflected by a smaller absolute increase in mitral valve area (1.02 vs. 0.9 vs. 0.7 cm², p < 0.01). The estimated 4-year event-free survival rate (freedom from death, mitral valve surgery, repeat valvuloplasty and heart failure) was lower for the group with severe tricuspid regurgitation (68% vs. 58% vs. 35%, p < 0.0001). At 4 years, 94% of patients with mild tricuspid regurgitation were alive compared with 90% and 69%, respectively, of patients with moderate or severe tricuspid regurgitation (p < 0.0001). Cox proportional analysis identified tricuspid regurgitation as an independent predictor of late outcome (p < 0.001).Conclusions. Patients with mitral stenosis and severe tricuspid regurgitation undergoing mitral valvuloplasty have advanced mitral valve and pulmonary vascular disease, suboptimal immediate results and poor late outcome.     

Surgical management of a patient with combined heart pathologies and lung cancer. A simultaneous coronary artery bypass surgery,aortic valve replacement,tricuspid valve repair and pulmonary resection

Coexisting coronary artery disease and significant heart valve disease represent a considerable risk factor in patients undergoing pulmonary resection. The possibility to perform concomitant (simultaneous) heart and lung surgery could be a good option for many patients.In the presented case report, the intervention was performed on two valves, triple coronary artery bypass and pulmonary resection, which has not been published in literature to date.A 68-year-old woman with coronary artery disease, aortic valve stenosis, tricuspid valve regurgitation and pulmonary disease (malignant pathology) presented with triple vessel disease, moderate aortic valve stenosis, severe tricuspid regurgitation and tumorous infiltration in the upper lobe of the left lung. She underwent combined heart and pulmonary surgery-left upper lobectomy, aortic valve replacement, tricuspid valve repair and coronary artery bypass surgery. On the eight day of surgery, she was discharged. She continues to do well on follow-up.Simultaneous cardiac surgery and pulmonary resection for malignancy become almost standard treatment of patients who require heart and lung surgery. The most often approach is midline sternotomy that enables a comfortable cardiac intervention as well as an acceptable access to lungs. The left lower lobectomy remains an exception, in which pulmonary resection during extracorporeal circulation (ECC) is more often an option of left thoracotomy. If the use of ECC is inevitable, some authors prefer pulmonary resection before starting up ECC if the location of the neoplasm does not require resection during ECC.