Current applications of transcatheter edge-to-edge tricuspid valve repair / 中国介入心脏病学杂志

Tricuspid regurgitation(TR)is a common heart valve disease.According to the pathogenesis,TR can be divided into primary(organic)and secondary(functional)regurgitation,of which functional TR accounts for more than 90%.Patients with severe TR have poor prognosis and poor drug treatment,and surgery(valvuloplasty)is the main treatment.At present,transcatheter edge-to-edge tricuspid valve repair(T-TEER)has become an essential program of transcatheter treatment for TR,providing minimally invasive treatment for TR patients who cannot undergo surgery or are at high risk of surgery.T-TEER reduces the degree of regurgitation by clamping leaflets,and is currently in the early stage of research and development exploration and clinical validation,mainly for functional TR.T-TEER devices have also made significant progress(TriClip,PASCAL),and Chinese-made novel-designed T-TEER devices are also undergoing clinical trials(DragonFly-TTM,SQ-Kyrin-TTM,NeoBlazarTM).This paper reviews the current applications and research progress of T-TEER.

Cirugia de la insuficiencia tricuspidea

La valvulopatía tricuspídea es considerada frecuente y sobre todo en pacientes con afectación mitral, habiendo sido sostenidamente objeto de controversias, tanto en la selección de la correcta actuación terapéutica, como del momento apropiado de su ejecución. Aunque la válvula tricúspide es afectada por estenosis, predominantemente es asiento de lesión tipo insuficiencia, que significa paso retrógrado de sangre desde el ventrículo derecho (VD) a la aurícula derecha durante la sístole. Puede ser primaria (orgánica) o secundaria (funcional), relacionada a dilatación/disfunción ventricular derecha, dilatación anular, tracción de sus valvas e hipertensión arterial pulmonar. La ecocardiografía tridimensional (3D) y la resonancia magnética cardiaca al permitir cuantificar con mayor precisión el tamaño del VD y la función sistólica, han permitido actuaciones terapéuticas más tempranas y con mejores resultados, que incluyen la reparación valvular tricuspídea, sustitución valvular y diversas modalidades de técnicas transcatéter. Con estas consideraciones, presentamos a consideración de ustedes el estado actual de la cirugía en la insuficiencia tricuspídea.

Tricuspid valve disease is considered common and especially in patients with mitral involvement, having been the subject of sustained controversy, both in the selection of the correct therapeutic action and the appropriate moment of its execution. Although the tricuspid valve is affected by stenosis, it is predominantly the seat of an insufficiency-type lesion, which means retrograde passage of blood from the right ventricle (RV) to the right atrium during systole. It can be primary (organic) or secondary (functional), related to right ventricular dilation/dysfunction, annular dilation, traction of its leaflets and pulmonary arterial hypertension. Three- dimensional (3D) echocardiography and cardiac magnetic resonance, by allowing more precise quantification of RV size and systolic function, have allowed earlier therapeutic actions with better results, which include tricuspid valve repair, valve replacement and various modalities of transcatheter techniques. With these considerations, we present for your consideration the current state of surgery in tricuspid regurgitation.

Concomitant repair of moderate or less tricuspid regurgitation during mitral valve surgery improves early and mid-term prognosis of tricuspid valve and right heart function / 中国胸心血管外科临床杂志

@#Objective    To investigate the effect of concomitant tricuspid valve repair during mitral valve surgery on the early and mid-term prognosis of the tricuspid valve and right heart function in the patients with moderate or less tricuspid regurgitation. Methods    A retrospective study of 461 patients with mitral valve disease requiring cardiac surgery combined with moderate or less tricuspid regurgitation in our hospital from 2011 to 2014 was done. They were 309 males and 152 females with a median age of 53.00 (44.00, 60.00) years. According to whether they received tricuspid valve repair (Kay’s annuloplasty, DeVega’s annuloplasty or annular ring implantation), the patients were divided into a mitral valve surgery only group (a nTAP group, n=289) and a concomitant tricuspid valve repair group (a TAP group, n=172). At the same time, 43 patients whose tricuspid valve annulus diameter was less than 40 mm in the TAP group were analyzed in subgroups. Results    The median follow-up duration was 3.00 years (range from 0.10 to 9.30 years). There was no perioperative death. Three months after surgery, the anteroposterior diameter of the right ventricle in the TAP group was significantly improved compared with that in the nTAP group [–1.00 (–3.00, 1.00) mm vs. 0.00 (–0.20, 2.00) mm, P=0.048]. Three years after surgery, the improvement of right ventricular anteroposterior diameter in the TAP group was still significant compared with the nTAP group [–1.00 (–2.75, 2.00) mm vs. 2.00 (–0.75, 4.00) mm, P=0.014], and the patients in the TAP group were less likely to develop moderate or more tricuspid regurgitation (3.64% vs. 35.64%, P<0.001). Annuloplasty ring implantation was more effective in preventing regurgitation progression (P=0.044). For patients with a tricuspid annulus diameter less than 40 mm, concomitant tricuspid valve repair was still effective in improving the anteroposterior diameter of the right ventricle in the early follow-up (P=0.036). Conclusion     Concomitant tricuspid valve repair for patients with moderate or less tricuspid regurgitation during mitral valve surgery can effectively improve the tricuspid valve and right heart function in the early and mid-term after surgery. Annuloplasty ring implantation is more effective in preventing regurgitation progression. Patients whose tricuspid annulus diameter is less than 40 mm can also benefit from concomitant tricuspid repair.

Pharmaceutical care in a case of myocardial infarction complicated with antithrombotic therapy after tricuspid valve repair / 药学实践与服务

Objective To investigate the antithrombotic therapy for acute myocardial infarction patients after PCI stenting combined with tricuspid valve repair. Methods The risk of bleeding and embolization was evaluated, relevant data were reviewed, professional knowledges of pharmacy were utilized through the whole treatment process, individualized medication plan for patients was designed and used. Results A better therapeutic effect was achieved through the implementation of pharmaceutical care and medication education to the patients. Conclusion Clinical pharmacists carry out pharmaceutical care in antithrombotic drugs utilities，which could improve the safety level of drug use and provide basis for clinical rational drug use.

Repair versus replacement: a meta-analysis on the efficacy of isolated tricuspid valve surgery / 中华胸心血管外科杂志

Objective:We performed a meta-analysis examining outcomes of isolated tricuspid valve repair versus replacement.Methods:We searched PubMed, Embase, the Cochrane Library, Web of Science, CNKI, VIP database and WanFang database from the inception to September 30, 2021 for studies reporting outcomes of both isolated tricuspid valve repair and replacement, excluding congenital tricuspid aetiologies. Data were extracted and pooled using random-effects models and Review Manager 5.3 software.Results:A total of 18 articles were included, covering 10 023 patients, totalling 4 749 repairs and 5 274 replacements. Pooled operative mortality rates and odds ratios (95% confidence intervals) for isolated tricuspid repair and replacement surgery were 8.4% vs. 9.9%, OR=0.64(0.44, 0.93). Tricuspid repair was also associated with lower in-hospital acute renal failure 12.4% vs. 15.6%, OR=0.81(0.72, 0.92) and pacemaker implantation 7.9% vs. 26.4%, OR=0.24 (0.21, 0.30). There were no differences in rates of hospital stroke 14.4% vs. 10.3% , OR = 1.41 (0.98, 2.04) and late mortality rates 13.9% vs. 16.1%, OR=0.91(0.49, 1.69). Conclusion:Isolated tricuspid valve repair is associated with significantly reduced in-hospital mortality, renal failure and pacemaker implantation compared with replacement and is therefore recommended where feasible for isolated tricuspid valve disease.

Reoperative strategy and mid- to long-term surgical outcomes of Ebstein anomaly / 中国胸心血管外科临床杂志

@#Objective    To analyze the Ebstein anomaly's reoperative strategy and mid- to long-term results. Methods    We retrospectively reviewed the clinical data of 23 patients who diagnosed with Ebstein anomaly and underwent reoperation for tricuspid valve insufficiency between July 2002 and July 2017 in Fuwai Hospital. There were 9 (39.1%) males and 14 (60.9%) females, with a median age of 28.0 (19.0, 45.0) years. Results    Among the 23 patients, 8 (34.8%) underwent tricuspid valvuloplasty and 15 (65.2%) underwent tricuspid valve replacement. The rate of valvuloplasty was 16.7% before 2012, and 54.5% after 2012 (P=0.089) as Cone reconstruction procedure was used. In the valvuloplasty cohort, 3 (37.5%) patients were treated with Danielson or Carpentier technique, and 5 (62.5%) patients were treated with Cone reconstruction procedure. There was no operation-related death. Early complications occurred in 3 (37.5%) patients. The median follow-up was 6.9 years (range, 3.0-15.1 years), and no adverse cardiac events occurred. In the patients with valve replacement, 7 (46.7%) received mechanical prosthesis and 8 (53.3%) received bio-prosthesis. There was no operation-related death. And early complications were observed in 3 (20.0%) patients. The median follow-up was 6.5 years (range, 2.5-15.3 years). One (6.3%) patient died and 4 (26.7%) had long-term complications during the follow-up period. Conclusion    The mid- to long-term outcomes are convincing in patients who undergo the second operation due to recurrent tricuspid regurgitation of Ebstein anomaly. A low incidence of reoperation is observed. Cone reconstruction procedure provides possibilities of second tricuspid valvuloplasty, and this technique can reduce the rate of tricuspid valve replacement in the second operation. Tricuspid valve replacement is still an alternative method for the treatment of recurrent tricuspid regurgitation in patients with Ebstein anomaly. The bioprosthetic prosthesis may be a better choice than mechanical prosthesis.

Functional tricuspid regurgitation: Current understanding / 中国胸心血管外科临床杂志

@#Functional tricuspid regurgitation is referred to tricuspid regurgitation due to enlargement of right ventricular and dilation of tricuspid annulus. Patients with chronic progressive tricuspid regurgitation have poor prognosis, poor quality of life and heavy economic burden. This article provides a comprehensive review of functional tricuspid regurgitation in terms of anatomical basis, pathological stage, imaging assessment and surgical decision making.

Surgical Treatment with Fresh Autologous Pericardium for Tricuspid Valve Infective Endocarditis with Ventricle Septal Defect / 日本心臓血管外科学会雑誌

Right sided infective endocarditis (RSIE) is uncommon. Patients are traditionally treated with antibiotics alone, and indications for operation are not clearly established. A 23-years-old man who developed fever and general fatigue was referred to our hospital on the suspicion of RSIE. A ventricular septal defect (VSD) and untreated dental caries had been previously diagnosed. Transthoracic echocardiography revealed vegetation on the tricuspid valve and severe regurgitation. The tricuspid valve was repaired ; the anterosuperior leaflet was partially resected and repaired with fresh autologous pericardium and the use of synthetic chordae. Recurrence of infection and tricuspid valve regurgitation were not observed for 1 year after this operation.

A Case of Tricuspid Valve Repair with an Artificial Chordae for Juvenile Tricuspid Regurgitation due to Chordal Rupture and Cleft of the Anterior Leaflet / 日本心臓血管外科学会雑誌

A 34-year-old man was referred to our hospital for primary tricuspid regurgitation. An echocardiogram showed severe tricuspid regurgitation caused by the prolapse of the anterior leaflet due to chordal rupture and enlargement of the tricuspid annulus. A large cleft on the anterior leaflet and a divided leaflet near the septal leaflet with a ruptured chorda were observed during surgery. We attached an artificial chorda from the anterior papillary muscle of the right ventricle to the prolapsed leaflet. We then repaired the large cleft with interrupted 6-0 polypropylene sutures and performed tricuspid annuloplasty. The prolapse of the anterior leaflet disappeared, and an intraoperative transesophageal echocardiogram revealed improvement of tricuspid regurgitation. The technique of mitral valve repair can be used even for a complex pathology of congenital cleft, chordal rupture, and annular enlargement of the tricuspid valve.

Early and midterm results of Ebstein′s anomaly with the treatment:the cone reconstruction for the tricuspid valve / 实用医学杂志

Objective To evaluate the early and midterm effect by retrospective analysis of the cone reconstruction in Ebstein′s anomaly. Methods From January 2012 through June 2016,16 patients with Ebstein′s anomaly underwent the cone reconstruction in our hospital. There were 7 males and 9 females at mean age(28.21 ± 11.88)years,including 12 patients of Carpentier B type,4 patients of Carpentier C type. There were 9 patients in New York Heart Association(NYHA)functional class Ⅲ,5 patients in NYHA functional class Ⅳand the others in NYHA functional class Ⅱ. All patients had Tricuspid insufficiency ,including 2 patients with Grade 2 ,10 patients with Grade 3 and 4 patients with Grade 4. All patients were followed up over a period of 6 to 51 months (mean:24.36 ± 10.71). By comparing the details of pre-operation with post-operation and post-operation with current stage,we analyze the outcomes of early and midterm effects. Results All patients are well survived. There were one patient recovering from the low cardiac output syndrome with adding the strength of the positive inotropic drug in the first day after operation ,and one patient recovering from bigeminy of ventricular prematurebeat with the aid of amiodarone and lidocaine the third day after operation. The remaining patients recovered smoothly. Early post-operative echocardiograms showed good right ventricular morphology and reduction in tricuspid regurgitation grade from(3.13 ± 0.62)to(1.75 ± 0.45)(P<0.001)with the functional class improved from(3.19 ± 0.66)to(2.00 ± 0.52)(P<0.001). After mean follow-up of(24.36 ± 10.71)months,the situation is improving furtherly with the tricuspid regurgitation grade reducing to(1.31 ± 0.48)(P=0.016)and the functional class rising to(1.50 ± 0.52) (P = 0.031). Conclusions This surgical technique for Ebstein′s anomaly can improve the function of tricuspid valve and the right ventricular morphology. It showed a satisfactory performance in the early and midterm results by enhancing the Cardiac function and life quality. But indications should be strictly grasped and more experiences need to be accumulated. Long-term effect need to be furtherly explored.

Tricuspid annulus: A spatial and temporal analysis.

Background: Traditional two‑dimensional (2D) echocardiographic evaluation of tricuspid annulus (TA) dilation is based on single‑frame measurements of the septolateral (S‑L) dimension. This may not represent either the axis or the extent of dynamism through the entire cardiac cycle. In this study, we used real‑time 3D transesophageal echocardiography (TEE) to analyze geometric changes in multiple axes of the TA throughout the cardiac cycle in patients without right ventricular abnormalities. Materials and Methods: R‑wave‑gated 3D TEE images of the TA were acquired in 39 patients undergoing cardiovascular surgery. The patients with abnormal right ventricular/tricuspid structure or function were excluded from the study. For each patient, eight points along the TA were traced in the 3D dataset and used to reconstruct the TA at four stages of the cardiac cycle (end‑ and mid‑systole, end‑ and mid‑diastole). Statistical analyses were applied to determine whether TA area, perimeter, axes, and planarity changed significantly over each stage of the cardiac cycle. Results: TA area (P = 0.012) and perimeter (P = 0.024) both changed significantly over the cardiac cycle. Of all the axes, only the posterolateral‑anteroseptal demonstrated significant dynamism (P < 0.001). There was also a significant displacement in the vertical axis between the points and the regression plane in end‑systole (P < 0.001), mid‑diastole (P = 0.014), and mid‑systole (P < 0.001). Conclusions: The TA demonstrates selective dynamism over the cardiac cycle, and its axis of maximal dynamism is different from the axis (S‑L) that is routinely measured with 2D TEE.

Permanent Pacemaker Lead Induced Severe Tricuspid Regurgitation in Patient Undergoing Multiple Valve Surgery

Severe and permanent tricuspid regurgitation induced by pacemaker leads is rarely reported in the literature. The mechanism of pacemaker-induced tricuspid regurgitation has been identified, but its management has not been well established. Furthermore, debate still exists regarding the proper surgical approach. We present the case of a patient with severe tricuspid regurgitation induced by a pacemaker lead, accompanied by triple valve disease. The patient underwent double valve replacement and tricuspid valve repair without removal of the pre-existing pacemaker lead. The operation was successful and the surgical procedure is discussed in detail.

Post-traumatic tricuspid regurgitation with anterior papillary muscle rupture, corrected by papillary muscle reimplantation / 고신대학교의과대학학술지

A 60-year-old male patient with blunt chest trauma was transferred to our facility because of unstable vital signs and pericardial effusion. These conditions occurred after orthopedic surgery to repair multiple left finger fractures at a local medical center. Trans-thoracic echocardiography showed severe tricuspid regurgitation and he underwent papillary muscle reimplantation and tricuspid annuloplasty open heart surgery for post-traumatic tricuspid regurgitation with anterior papillary muscle rupture. We report early surgical traumatic valve disease correction without complications.

A Case of Tricuspid Valve Repair with Artificial Chordae after Resection of Tricuspid Valve Myxoma / 日本心臓血管外科学会雑誌

Tricuspid valve myxoma is extremely rare. A 33-year-old woman who had undergone clipping of a cerebral aneurysm, had a cardiac tumor pointed out incidentally while undergoing echocardiography. Echocardiography showed a mobile and solid round mass (14×12 mm) attached by a short stalk. We suspected a right ventricular tumor. Once the diagnosis of cardiac tumor has been established, prompt excision is essential to prevent complications, as well as syncope or collapse due to the transient occlusion of the tricuspid or pulmonary valves with embolization by the thrombus or fragments of the tumor tissue. Surgery was performed under cardiopulmonary bypass. The tumor was attached to the anterior papillary muscle and chordae of the tricuspid valve. The tumor was extirpated along with a piece of the papillary muscle and chordae. We performed tricuspid chordoplasty with artificial chordae. The histopathologic diagnosis was myxoma. The postoperative course was uneventful and the patient was discharged on the 15th day after the operation. While the patient has done well with no recurrence of the tumor during the five years that have passed since her operation, we will continue to observe her closely in the future because there have been some reports of recurrence after complete excision of cardiac myxoma and there are no long-term follow-up results of artificial chordae in the tricuspid position.

A Case of Tricuspid Leaflet Augmentation for Severe Secondary Tricuspid Regurgitation / 日本心臓血管外科学会雑誌

A 71-year old woman, who underwent direct closure of an atrial septal defect with mild tricuspid regurgitation (TR) 18 years previously, suffered terminal cardiac failure with extreme cardiomegaly, mitral regurgitation and severe TR. Medical treatment gradually became ineffectual and we decided to perform surgical therapy. Mitral annuloplasty with a prosthetic ring, tricuspid valve repair, plications of extended bilateral atrium walls and epicardial ventricular pacemaker implantation were performed. In tricuspid valve repair, anterior tricuspid leaflet was augmented by use of glutaraldehyde-preserved autologus pericardial patch and tricuspid annuloplasty with addition of a slightly larger prosthetic ring. Atrio-ventricular regurgitations disappeared and she was discharged 63 days after the operation. Valve extension is a very effective technique to treat severe secondary TR, and long term follow-up is necessary.

Tricuspid Valve Repair for Traumatic Tricuspid Valve Regurgitation over 30 Years after Causative Trauma / 日本心臓血管外科学会雑誌

A 28-year-old man was involved in a traffic accident that sandwiched his chest between a wall and a truck. Shortness of breath and other symptoms started to appear several years later. Echocardiography at that time showed severe tricuspid regurgitation due to a failed valve and ruptured chordae in the anterior leaflet. He was followed up with medication. Leg edema developed at the age of 62 years and worsening symptoms of heart failure over a period of 6 months indicated a need for surgery. Intraoperative findings revealed the ruptured chordae attached to the anterior leaflet and a scarred myocardium at the septomarginal trabeculation. The tricuspid valve was surgically repaired, the anterior leaflet chordae were surgically reconstructed, an annuloplasty ring was implanted to address the tricuspid regurgitation and atrial fibrillation was treated using the Maze procedure. Surgery 34 years after trauma has improved hemodynamic cardiac function and normalized the cardiac rhythm in this patient.

Continuous "Over and Over" Suture for Tricuspid Ring Annuloplasty

BACKGROUND: A ring implantation in the tricuspid annulus requires many interrupted mattress sutures for correction of tricuspid regurgitation (TR). In this study, tricuspid ring annuloplasty was performed by 2-0 polypropylene continuous suture instead of multiple interrupted 2-0 polyester mattress sutures, and the efficacy of the method was evaluated. MATERIALS AND METHODS: This study included 20 patients who underwent tricuspid ring annuloplasty by continuous suture between May 2009 and July 2010. Four of the patients had an isolated TR, and the rest had a left-sided cardiac lesion. The concomitant tricuspid annuloplasty was performed after the left-sided heart surgery was completed and a Duran flexible ring prosthesis was used. RESULTS: There was no perioperative mortality or conduction problem. More than a moderate degree of TR was improved to less than a mild degree after the procedure. After the ring annuloplasty, the right atrial volume decreased from 123.7+/-69.2 mL to 74.5+/-37.4 mL, and the mean right atrial pressure was lowered from 18.7+/-12.2 mmHg to 8.9+/-5.5 mmHg. CONCLUSION: The continuous "over and over" suture may be a useful procedure for fixing the ring to the annulus and making an intentional annular placation in performing tricuspid ring annuloplasty.

A Case of Tricuspid Valve Repair with Artificial Chordae after Resection of Tricuspid Valve Myxoma / 日本心臓血管外科学会雑誌

A 76-year-old-woman, who had undergone endoscopic resection of a gastric polyp 2 years previously, had a cardiac tumor incidentaly pointed out on an abdominal ultrasonographic image. Echocardiography showed a solid round mass (34×25 mm in diameter), attached by a short stalk and which was floating on the right ventricular outflow tract and prolapsing over the pulmonary valve during systole. We suspected right ventricular myxoma. Urgent surgery was performed under cardiopulmonary bypass. After aortic clamping, the trunk of the pulmonary artery was opened near the right ventricule. The tumor was found under the pulmonary valve, attached to the anterior papillary muscle and chordae of the tricuspid valve. The tumor was completely excised with a piece of the papillary muscle and chordae. After right atriotomy, mild tricuspid regurgitation was seen on a water test. After we performed tricuspid annuloplasty and chordplasty with artificial chordae, a second water test did not show any tricuspid regurgitation. The postoperative course was uneventful, and she was discharged on the 13th postoperative day.

A Case of Valve Repair for Active Infective Endocarditis Located in the Tricuspid Valve / 日本心臓血管外科学会雑誌

We report surgically treated case of tricuspid valve endocarditis in a non-drug addict. A 35-year-old man with no history of cardiac disease was admitted to our institution for persistent fever. His blood culture was positive for methicillin-sensitive <i>Staphylococcus aureus</i> (MSSA). Echocardiography showed friable vegetations attached to the tricuspid valve with moderate tricuspid regurgitation. No other valves were affected. Chest computed tomography revealed multiple septic pulmonary emboli in both lungs. The infection was uncontrollable, so despite 6 weeks' of appropriate intravenous antibiotics therapy, he required surgery. Infected lesions had extended to parts of the septal leaflet and the posterior leaflet of the tricuspid valve. Valve repair with the resection-suture technique was performed. Half of the septal leaflet and a part of the posterior leaflet were excised with the vegetations, and the remaining septal leaflet was sutured to the posterior leaflet after annular plication without implanting an artificial ring. The postoperative course was uneventful, without further tricuspid regurgitation or stenosis. He was discharged after additional antibiotic administration for 4 weeks postoperatively, and he has remained free from endocarditis for over 1 year.

Tricuspid Valve Repair for Active Infective Endocarditis Complicated by Vertebral Osteomyelitis and a Pancreatic Abscess / 日本心臓血管外科学会雑誌

A 65-year-old man was admitted with a high fever and back pain. Because magnetic resonance imaging revealed osteomyelitis in the lumbar spine, we started antibiotic therapy. Echocardiography revealed large vegetation on the tricuspid valve, and abdominal contrast computed tomography revealed a pancreatic abscess. As the vegetation increased in size and mobility it became non-responsive to medical treatment, and surgical removal of the vegetation with tricuspid valve repair were therefore performed. After additional antibiotic therapy, he was discharged 42 days after surgery. No further recurrence of endocarditis has been observed as of the time of writing.