Ex vivo hydrodynamics after central and paracommissural edge-to-edge technique: A further step toward transcatheter tricuspid repair?

OBJECTIVES: Transcatheter approaches in heart valve disease became tremendously important and are currently established in the aortic position, but transcatheter tricuspid repair is still in its beginning and remains challenging. Replicating the surgical edge-to-edge technique, for example, with the MitraClip System (Abbott Vascular, Santa Clara, Calif), represents a promising option and has been reported successfully in small numbers of cases. However, up to now, few data considering the edge-to-edge technique as a transcatheter approach are available. This study aims to determine the ex vivo hydrodynamics after the central and paracommissural edge-to-edge technique in different pathologies. METHODS: Because of basal or apical dislocation of papillary muscles, leaflet prolapse or tethering was simulated in porcine tricuspid valves mounted on a flexible holding device. Central and paracommissural edge-to-edge techniques were evaluated successively in these pathologies. Regurgitant volume and mean transvalvular gradient were determined in a pulse duplicator. RESULTS: In this ex vivo model, the isolated edge-to-edge technique reduced tricuspid regurgitation. In the prolapse model, regurgitant volume decreased significantly after central edge-to-edge technique (from 49.4 ± 13.6 mL/stroke to 39.3 ± 14.1 mL/stroke). In the tethering model, both the central and the paracommissural edge-to-edge techniques led to a significant decrease (from 48.7 ± 13.9 to 43.6 ± 15.6 and to 41.1 ± 13.8 mL/stroke). In all cases, the reduction of regurgitant volume was achieved at the cost of significantly increased mean transvalvular gradient. CONCLUSIONS: This study provides a reduction of tricuspid regurgitation after the edge-to-edge technique in the specific experimental setup. Whether this reduction is sufficient to treat tricuspid regurgitation successfully in clinical practice remains to be established. Transcatheter approaches need to be evaluated further, probably with regard to concomitant annuloplasty for higher reduction of tricuspid regurgitation.

[Valvular prolapse (clinical, echocardiographic, phonocardiographic and electrocardiographic features)]. / Prolapsy klapanov (klinicheskaia, ékhokardiograficheskaia, fonokardiograficheskaia i élektrokardiograficheskaia kharakteristiki).

Clinical, echoCG, PCG and ECG examinations were performed in 42 patients with primary isolated valve prolapses: mitral, aortal and tricuspid (32, 5 and 5 patients, respectively). It is shown that degree 1 regurgitation caused no hemodynamic disturbances, that of degree 2 and 3 brought about cardial complaints in more than half the patients, hemodynamic overstrain of the heart, sound symptoms similar to those of relevant valvular disease.

Systolic tricuspid leaflet prolapse in asymptomatic young men.

The degree of systolic movement of the tricuspid valve (TV) leaflets was measured in 100 consecutive apparently healthy men 18-20 years old at the time of maximum posterosuperior motion toward or into the right atrium. Backward bowing of greater than 0.20 mm2 of the anterior leaflet, and greater than 0.15 mm2 of either the posterior or septal leaflets beyond the plane of the tricuspid annulus was found in 5% or less of the cohort irrespective of the echocardiographic view in which it was recorded. The upper 5% of these young men had greater than 0.80 mm2 of backward bowing when the leaflet motion was summed from all three views. The anterior leaflet demonstrated more bowing than either the septal or posterior leaflets. The systolic TV prolapse area correlated highly with the degree of mitral leaflet prolapse (r = 0.654, p less than 0.001). We conclude that there is a wide continuous spectrum of tricuspid valve leaflet prolapse area in healthy young men. This quantitative approach may help standardize the echocardiographic evaluation of tricuspid leaflet motion.

Comparison of auscultation with two-dimensional and Doppler echocardiography in patients with suspected mitral valve prolapse.

Auscultation was compared to two-dimensional echocardiography (2D echo) and Doppler ultrasonography in 140 consecutive patients referred for evaluation for suspected mitral valve prolapse (MVP) to asses the precision of the two diagnostic methods. Ninety patients (64%) had midsystolic clicks, of which 42 (47%) had MVP by echocardiography; 6 patients (4%) had MVP by 2D echo but no click on examination. In 15 (17%) of the 90 patients, a click was heard only in the standing or squatting positions and 2D echo did not detect prolapse in the supine position in 10 (67%) of the 15. With auscultation as the reference standard for MVP, 2D echo has a sensitivity of 47% and a specificity of 89%. Of the 140 patients, 51 (36%) had systolic murmurs; Doppler detected mitral and/or tricuspid regurgitation in 26 (50%). In 23 (16%) patients, there was Doppler evidence of mitral or tricuspid regurgitation even though systolic murmurs were not heard. Auscultation shows a 53% sensitivity and 73% specificity for systolic murmurs, using Doppler ultrasonography as the reference standard. Of 48 patients with MVP by 2D echo, 15 (13%) had associated mitral regurgitation by Doppler. The results indicate that 2D echo and Doppler ultrasonography should be interpreted in concert with auscultation for the diagnosis of mitral valve prolapse and for therapeutic decision making.

Isolated prolapse of the tricuspid valve.

Tricuspid valve prolapse has remained a poorly defined entity. Some authors have stated that prolapse isolated to the tricuspid valve has not been documented. This report contains three cases of isolated tricuspid valve prolapse including the first pathologically confirmed case. A review of worldwide literature including all reported cases of isolated tricuspid valve prolapse is also presented. Although signs and symptoms are similar to those found with mitral valve prolapse, tricuspid valve prolapse may occasionally be differentiated by auscultation. The diagnostic criteria of tricuspid valve prolapse are thoroughly discussed for each of the presently available invasive and noninvasive techniques. Right heart catheterization can define such prolapse but is invasive and requires meticulous technique. Two-dimensional echocardiography supersedes M-mode because of the superior spatial evaluation of the tricuspid leaflets in relation to the right atrium and ventricle. Multiple views including a long-axis view of the right ventricular inflow are often required. This parasternal echocardiographic window is often the only one which permits adequate visualization of the posterior leaflet. The pathologic findings of tricuspid valve prolapse are similar to those of mitral valve prolapse. This report concludes with a description of associated conditions. Severe tricuspid regurgitation has not been noted with tricuspid valve prolapse in the absence of superimposed disease, yet much remains undefined concerning the clinical significance of this condition.

Echocardiographic findings of mitral and tricuspid valve prolapse in primary pulmonary hypertension.

Echocardiographic findings in six patients with primary pulmonary hypertension are presented. Four of six patients had abnormal septal motion with prolapse of mitral and tricuspid valves. The other two had none of the three echocardiographic abnormalities. It is possible that hemodynamic changes in ventricular pressure gradients across the interventricular septum cause an abnormal septal motion and secondary AV valve prolapse.

Late systolic click from isolated tricuspid valve prolapse simulating paradoxical splitting of the second heart sound.

A 72 year old woman was thought to have a paradoxically split second heart sound. Echocardiography with simultaneous phonocardiography revealed a late systolic click resulting from isolated tricuspid valve prolapse. Respiratory variation of the click in relation to the second heart sound resulted in an auscultatory phenomenon simulating paradoxical splitting of the second heart sound.

Mitral systolic honk in a case of congenitally corrected transposition of the great vessels.

A woman suffering from TCGV associated with steno-insufficiency with a prolapse of left atrioventricular valve (tricuspid) and an insufficiency with a prolapse of right atrioventricular valve (mitral) presented a systolic honk which was to be registered in all the precordial area. The increase of this noise at the end of inspiration and after amyl nitrite, in the absence of any relevant change as to the prolapse of both atrioventricular valves, demonstrated that the honk originated from the right atrioventricular valve more than from the left one.

[Echocardiographic abnormalities of the mitral valve in interatrial communication of the ostium secundum type]. / Anormalidades ecocardiográficas de la válvula mitral en la comunicación interauricular tipo ostium secundum.

Thirty one patients with atrial septal defect were studied by M-mode echocardiography. In sixteen patients (control group) there only findings suggesting right ventricular volume overload. The remaining fifteen patients, were divided into three groups. Group 1 consisted of five patients with mitral valve abnormalities related to the left ventricular pattern. The macroscopic aspect of the mitral valve in this group was reported by the surgeon to be rheumatic or myxomatous degeneration. In four patients (group II), there was prolapse of an atrioventricular valve, three mitral and one tricuspid. Group III consisted of six patients with an abnormal movement of the posterior mitral leaflet, related to a deformed left ventricle. The QP/QS ratio as well as the interatrial shunt was larger in groups I and III. These data suggest that there are abnormal mitral flow patterns and changes in the left ventricular geometry, related to right ventricular volume overload that cause altered mitral valve movement that can be detected by echocardiography.