Comparison of valvuloplasty and replacement for surgical treatment of tricuspid infective endocarditis.

BACKGROUND: Owing to the increase in both intravenous drug injections and intracardiac and vascular interventional treatments among drug users, the incidence of infective endocarditis (IE) involving the tricuspid valve, which sits between the two right heart chambers, has gradually increased. This study aimed to compare the clinical outcomes of different surgical procedures for tricuspid infective endocarditis (TIE). METHODS: We retrospectively analyzed fifty-six patients who underwent tricuspid valve surgery at our hospital from January 2006 to August 2019. All patients were diagnosed with TIE and indicated a need for surgery. Perioperative and follow-up data were collected to summarize and analyze the clinical outcomes of different surgical approaches, including tricuspid valvuloplasty (TVP) and tricuspid valve replacement (TVR) for TIE. RESULTS: Cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, postoperative mechanical ventilation time, and intensive care unit (ICU) stay time were shorter in the TVP group than in the TVR group. Additionally, the incidence of red blood cell transfusion and postoperative complications was lower in the TVP group than in the TVR group. The postoperative 30-day mortality rates were similar between both the groups. Fifty-two patients were followed up for an average of 5.50 ± 3.79 years. The postoperative 3-, 5-, and 7-year survival rates were 100%, 100%, and 95.5% in the TVP group and 96.7%, 96.7%, and 96.7% in the TVR group, respectively. The 5-year and 10-year reoperation rates were 0% and 0% in the TVP group and 6.7% and 20% in the TVR group, respectively. CONCLUSION: Both TVR and TVP for TIE significantly improved the functional status of the heart with satisfactory efficacy. TVP was found to be superior to TVR in reducing the need for postoperative blood transfusions, reducing the risk of postoperative complications, and reducing the need for long-term reoperations.

Right-to-left shunt via iatrogenic atrial septal defect requiring emergency surgical repair following cryoballoon atrial fibrillation ablation in a patient with arrhythmogenic right ventricular cardiomyopathy.

An 81-year-old woman with arrhythmogenic right ventricular cardiomyopathy underwent catheter ablation for atrial fibrillation and atrial flutter. Hypoxemia refractory to the administration of oxygen was seen after transseptal puncture. Transthoracic echocardiography revealed right to left shunt via an iatrogenic atrial septal defect (IASD) that was increased by tricuspid regurgitation flow. Her hypoxemia improved after IASD occlusion with the inflation of a venogram balloon catheter. Emergent surgical IASD closure was successfully performed. IASD after transseptal puncture for atrial fibrillation ablation infrequently causes severe complications that require emergent repair. Learning objective: Some cases requiring iatrogenic atrial septal defect (IASD) closure after atrial fibrillation (AF) ablation have been reported. We describe the case of an arrhythmogenic right ventricular cardiomyopathy patient with right to left shunt via an IASD which required emergent surgical repair after AF ablation. Right to left shunt after trans-septal puncture is rare, however it can be an emergent life-threatening complication. IASD occlusion with venogram balloon catheter is helpful for the diagnosis and the short-term solution.

The value of right atrial myocardial fibrosis in evaluating the prognosis of isolated tricuspid valve surgery after left heart valve surgery / 中国胸心血管外科临床杂志

@#Objective    To investigate the predictive value of right atrial myocardial fibrosis in the prognosis of isolated tricuspid regurgitation surgery after left heart valve surgery. Methods    The patients who underwent tricuspid valvuloplasty by the same operator in Guangdong Provincial People's Hospital from April 2016 to August 2021 due to long-term isolated severe tricuspid regurgitation after left heart valve surgery were included in the study. According to the degree of right atrial myocardial fibrosis, the patients were divided into three groups: a mild group, a moderate group, and a severe group. The clinical data of these patients were compared and analyzed. Results    A total of 75 patients were enrolled, including 16 males and 59 females with an average age of 57.0±8.4 years. There were 30 patients in the mild group, 29 patients in the moderate group and 16 patients in the severe group. In terms of the preoperative data, there were statistical differences in cardiac function grade, right atrial diameter, tricuspid incompetence area among the three groups (P<0.05). In terms of the postoperative data, there were statistical differences among the three groups in the cardiopulmonary bypass time, mechanical ventilation time, ICU monitoring time, complication rate and mortality (P<0.05). Further pairwise comparison showed that, compared with the mild group, the severe group had longer mechanical ventilation time (P=0.024), longer ICU monitoring time (P=0.003) and higher incidence of postoperative complications (P=0.024), while the moderate group had no statistical difference in all aspects (P>0.05); compared with the moderate group, the severe group had longer ICU monitoring time (P=0.021) and higher incidence of complications (P=0.006). Conclusion    The early outcome of tricuspid valvuloplasty in patients with isolated tricuspid regurgitation after left heart valve surgery with severe right atrial myocardial fibrosis is worse than that in the patients with mild and moderate fibrosis, suggesting that the degree of myocardial fibrosis in the right atrium can be a predictor of the effect of tricuspid regurgitation surgery and a judgement indicator of the surgery timing.

A Case of Neonatal Marfan Syndrome Requiring Double Atrioventricular Valve Replacement due to Rapid Exacerbation of the Repaired Valves / 日本心臓血管外科学会雑誌

Neonatal Marfan syndrome is the most severe form of Marfan syndrome usually showing critical cardio-respiratory symptoms from the neonatal period or early infancy. We report a boy with this syndrome who presented with heart failure at 3 months of age and was referred to our department at 6 months old after intense medical treatment. He had enophthalmos, funnel chest, arachnodactyly, and Steinberg's thumb sign, but had no family history of Marfan syndrome or other cardiac diseases. Left ventricular dilatation, severe mitral regurgitation and moderate tricuspid regurgitation were noted on echocardiography. Mitral valvuloplasty and tricuspid annuloplasty were performed, and the regurgitation improved to trivial and mild level, respectively. However, rapid exacerbation of mitral regurgitation occurred, and the patient fell into circulatory collapse which needed circulatory support with extracorporeal membrane oxygenator (ECMO) on 18th postoperative day. In the emergency operation, the previous surgical procedures on the mitral valve were intact and we thought that rapid progression of the mitral annular dilatation and valve expansion to be the cause of exacerbation. Mitral valve replacement (Regent® 21 mm aortic) was performed, and the cardiac function improved, but ECMO was still needed because of the depressed respiratory function. Furthermore, tricuspid regurgitation due to annular dilatation and valve expansion was aggravated rapidly which needed tricuspid valve replacement (ATS® 20 mm mitral) 9 days after the mitral valve replacement. ECMO was ceased on the 37th day and the patient was extubated on 71st day. He was discharged from the hospital 5 months after the first operation. One year has passed after discharge, and he is doing well with anticoagulation. In the treatment of neonatal Marfan syndrome, surgical procedure for valve repair is still controversial and it should be remembered that rapid exacerbation of the atrioventricular valve can occur even after satisfactory valve repair and there should be no hesitation regarding surgical intervention when needed.

Application effect of thoracoscopic tricuspid valvuloplasty in geriatric patients with tricuspid valve disease.

BACKGROUND: Thoracoscopic-assisted technology can ensure that doctors can implement minimally invasive treatment through the right intercostal incision or small incision of the lower sternum. This approach not only can achieve a cardiac correction effect equivalent to that of a thoracotomy but also has the benefit of a clear surgical field ensuring the safety of surgical treatment. AIM: To investigate the effect of thoracoscopic tricuspid valvuloplasty in patients with tricuspid valve disease. METHODS: A total of 41 patients with tricuspid valve disease underwent traditional thoracotomy treatment between January 2018 and June 2020. Forty-one patients with tricuspid valve disease who underwent thoracoscopic tricuspid valvuloplasty treatment between July 2020 and June 2021 in our hospital were selected as controls for our retrospective analysis. The study group underwent thoracoscopic tricuspid valvuloplasty, while traditional thoracotomy was performed in the control group. The operation conditions (the duration of extracorporeal circulation, aorta blocking, endotracheal intubation, and surgery), inflammatory response-related indices (C-reactive protein and white blood cell count) before and after surgery, parameters related to myocardial injury (myocardial troponin T, creatine kinase isoenzyme, creatine kinase, and lactate dehydrogenase), and the incidence of adverse events in the two groups was counted. RESULTS: The duration of extracorporeal circulation (109.35 ± 50.31 min), aortic occlusion (94.26 ± 59.61 min), endotracheal intubation (12.59 ± 3.54 h), and hospital stay (5.29 ± 2.34 d) in the study group were shorter than those in the control group (114.91 ± 46.98 min, 101.37 ± 61.44 min, 13.11 ± 4.01 h, 7.09 ± 3.11 d, respectively). The difference in hospital stay between the two groups was statistically significant (P < 0.05). Serum C-reactive protein level (4.69 ± 1.35 mg/L) and white blood cell count (6.21 ± 1.97 × 109/L) in the study group were found to be not significantly different than those in the control group (5.01 ± 1.18 mg/L, 5.98 ± 2.01 × 109/L, respectively; P > 0.05). Myocardial troponin T (0.04 ± 0.02 ng/mL), creatine kinase isoenzyme (4.02 ± 1.11 mg/mL), creatine kinase (91.35 ± 10.44 U/L), and lactate dehydrogenase (179.81 ± 60.04 U/L) in the study group were also not statistically significant different than those in the control group (0.05 ± 0.03 ng/mL, 3.97 ± 1.05 mg/mL, 89.69 ± 13.05 U/L, 186.35 ± 56.96 U/L; P > 0.05). After the operation, serum C-reactive protein level (7.89 ± 1.73 mg/L) and white blood cell count (10.76 ± 2.35 × 109/L) in the study group were significantly lower than those in the control group (9.96 ± 2.04 mg/L, 14.84 ± 3.07 × 109/L, respectively) (P < 0.05). In addition, myocardial troponin T (0.89 ± 0.32 ng/mL), creatine kinase isoenzyme (26.96 ± 4.95 mg/mL), creatine kinase (608.32 ± 202.33 U/L), and lactate dehydrogenase (282.56 ± 101.34 U/L) in the study group were lower than those in the control group (2.61 ± 0.69 ng/mL, 34.37 ± 6.87 mg/mL, 689.94 ± 214.64 U/L, 369.15 ± 114.46 U/L) (P < 0.05). The incidence of adverse events in the study group (4.88%) was lower than that in the control group (19.51%) (P < 0.05). CONCLUSION: Thoracoscopic tricuspid valvuloplasty can achieve good results in treating patients with tricuspid valve disease, reduce the risk of adverse events, and promote the rapid recovery of patients.

Electrical storm after correction of an uncomplicated congenital atrial septal defect in an adult: a case report.

BACKGROUND: There is a paucity of published literature describing electrical storm after the correction of uncomplicated atrial septal defect (ASD) in an adult. CASE PRESENTATION: We present a 49-year-old woman with a congenital ASD combined with mild tricuspid regurgitation who denied any history of arrhythmia or other medical history. She suffered from electrical storm (≥ 3 episodes of ventricular tachycardias or ventricular fibrillations) in the early stage after ASD repair with combined tricuspid valvuloplasty. During electrical storm, her electrolytes were within normal ranges and no ischemic electrocardiographic changes were detected, which suggested that retained air embolism or acute coronary thrombosis were unlikely. Additionally, echocardiographic findings and her central venous pressure (5-8 mmHg during the interval between attacks) failed to support the diagnosis of pericardial tamponade. After a thorough discussion, the surgeons conducted an emergent re-exploration and repeated closure of the ASD with combined DeVega's annuloplasty. Eventually, the patient recovered uneventfully, without reoccurring arrhythmias during follow-up. Although we fail to determine the definite cause, we speculate that the causes probably are iatrogenic injury of the conduction system due to a rare anatomic variation, poor intraoperative protection, latent coronary distortion during tricuspid valvuloplasty, or idiopathic or secondary abnormalities of the conduction system. CONCLUSIONS: For most surgeons, performing re-exploration without a known etiology is a difficult decision to make. This case illustrates that re-exploration could be an option when electrical storm occurs in the early stage postoperatively. Nevertheless, surgeons should assess the benefit-risk ratio when taking this unconventional measure.

Tricuspid valvuloplasty for isolated tricuspid regurgitation in children.

BACKGROUND: Isolated congenital tricuspid regurgitation other than Ebstein's anomaly was rare especially for children. The objective of this study was to investigate the clinical characteristics and to assess the results of tricuspid valvuloplasty for children with isolated tricuspid regurgitation. METHODS: From January 2010 to June 2019, 10 consecutive patients with isolated tricuspid regurgitation who were unresponsive to drug therapy underwent tricuspid valvuloplasty in our hospital. Patients' clinical data were analysed retrospectively. RESULTS: Mean age at operation was 48.5 ± 31.0 (range: 9-106) months and mean weight at operation was 16.1 ± 6.9 (range: 8.6-33.0) kg. All patients presented severe isolated tricuspid regurgitation. According to pathological lesions, the main causes accounted for chordae tendinea rupture (3/10), leaflet cleft (2/10), mal-connected chordal tendinea to leaflets (2/10), elongated chordae (1/10) and chordae absent (1/10), and severe anterior leaflet dysplasia (1/10). Individualised tricuspid valvuloplasty was adapted to all of them successfully. Post-operative echocardiography showed no tricuspid regurgitation in two patients and mild regurgitation in eight patients. The cardiothoracic ratios on their chest roentgenograms decreased from 0.59 ± 0.05 to 0.54 ± 0.05. At the latest follow-up (50.4 ± 47.2 months), echocardiography showed that mild to moderate tricuspid regurgitation in seven patients, moderate tricuspid regurgitation in three patients, and no patient with severe tricuspid regurgitation. All patients were in NYHA functional class I. CONCLUSIONS: For patients with isolated tricuspid regurgitation who were not well responsive to drug therapy, individualised tricuspid valve repair can achieve an excellent result.

Pulmonary and tricuspid valvuloplasty in carcinoid heart disease.

A 26-year-old female with carcinoid heart disease consisting of severe pulmonary and tricuspid valve stenosis was admitted with line associated sepsis. She recovered from sepsis with antibiotics and aggressive fluid resuscitation but became grossly volume overloaded with evidence of tense ascites and lower extremity edema. She developed worsening renal and hepatic function due to congestive nephropathy and hepatopathy, which did not respond to intravenous diuretics, and she was deemed too sick for surgical pulmonary and tricuspid valve replacement. Pulmonary and tricuspid valvuloplasty was performed as a rescue measure to alleviate her congestive symptoms and improve her candidacy for valve replacement. © 2016 Wiley Periodicals, Inc.

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.

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.

Successful Repair of Traumatic Tricuspid Regurgitation / 日本心臓血管外科学会雑誌

A 62-year-old man was referred to our hospital because of dyspnea. Electrocardiogram showed chronic atrial fibrillation and echocardiogram revealed severe tricuspid regurgitation. His history included a motorbike accident at age 17, and a heart murmur was pointed out in the following year. He developed paroxysmal atrial fibrillation when he was 45 years old. Heart failure was not controlled by medication and tricuspid valve repair was indicated. At surgery, the anterior leaflet of tricuspid valve was widely prolapsed due to chordal rupture. We performed chordal reconstruction with 4 expanded polytetrafluoroethylene (CV-5®) sutures, and ring annuloplasty. Furthermore, a small fenestration at the tricuspid annulus was noticed and was closed with a direct suture. The biatrial modified Maze procedure was performed subsequently. The patient is doing well without TR recurrence, and restored sinus rhythm is maintained. We report successful repair of traumatic tricuspid regurgitation.

Heart block following stage 1 palliation of hypoplastic left heart syndrome.

OBJECTIVES: Publicly available data from the Pediatric Heart Network's Single Ventricle Reconstruction Trial was analyzed to determine the prevalence, timing, risk factors for, and impact of second- and third-degree heart block (HB) on outcomes in patients who underwent stage 1 palliation (S1P) for hypoplastic left heart syndrome (HLHS). METHODS: The presence and date of onset of post-S1P HB occurring within the first year of life, potential risk factors for HB, and factors known to predict poor outcomes after S1P were extracted. Multivariable logistic and Cox regression analyses were performed to identify risk factors for HB and to determine the effect of HB on 3-year transplantation-free survival. RESULTS: Among the 549 patients in the cohort, 33 (6%) developed HB after S1P. The median interval between S1P and HB was 8 days (interquartile range, 0-133 days). Regression analysis showed that tricuspid valve repair during S1P and obstruction of pulmonary venous drainage requiring pre-S1P intervention were independently associated with HB (adjusted odds ratio [aOR], 11.6, 95% confidence interval [CI] 3.3-40; P < .001 and aOR, 5.1; 95% CI, 1.3-20.6; P = .02, respectively). Transplantation-free survival at 3 years was lower for those with HB (39% vs 65%; P = .004). HB remained associated with transplantation-free survival after controlling for known risk factors (adjusted hazard ratio, 3.1; 95% CI, 1.9-5.0; P < .001). Nine children (27%) had a pacemaker implanted, and 7 of these children (78%) died or underwent heart transplantation. CONCLUSIONS: HB after S1P is rare but heralds a poor outcome. Careful monitoring of these patients is recommended given their significantly increased risks of death and heart transplantation.

Successful Repair in Two Cases of Traumatic Tricuspid Regurgitation / 日本心臓血管外科学会雑誌

Traumatic tricuspid regurgitation is a rare cardiovascular event that can follow blunt chest trauma. We report 2 cases of successful repair of traumatic tricuspid regurgitation. Case 1 : a 22-year-old man. At 18 years of age, he was involved in a falling accident. At the age of 19, he had an abnormal electrocardiogram and a cardiac murmur pointed out on a medical examination in his university. Echocardiography revealed severe tricuspid regurgitation, and he was referred to our institution for surgery. The operative findings showed some fenestrations in the anterior leaflet of the tricuspid valve. The fenestrations were sutured directly and ring annuloplasty was performed. Case 2 : a 54-year-old man. At age 18, he was involved in a falling accident. At age 31, he complained of fatigue and dyspnea. Echocardiography revealed severe tricuspid regurgitation. At age 54, liver dysfunction was discovered. He was referred to our institution for surgical treatment. In the operative findings, the chordae tendineae of the anterior and septal leaflets of the tricuspid valve were ruptured. Tricuspid valvuloplasty was performed using chordal replacement with 2 expanded polytetrafluoroethylene (CV-52^®) sutures, edge-to-edge sutures and ring annuloplasty.