The relation of right ventricular outflow tract measurements with in-hospital clinical outcomes after tricuspid valve surgery

Right ventricular (RV) function is a determining factor for clinical outcomes in patients undergoing tricuspid valve surgery (TVS). Our aim was to investigate the importance of the function of the right ventricular outflow tract (RVOT), which is an important anatomical region of the RV, in patients underwent TVS. 104 patients who underwent TVS were analyzed retrospectively. Patients with previous cardiac surgery, congenital heart disease, or heart failure were excluded. The parasternal short-axis view at the level of the aortic root was used to measure RVOT dimensions and RVOT fractional shortening (RVOT-FS). The effect of RVOT diameter and function on major adverse cardiac events (MACE) after TVS was investigated. In our study, MACE, consisting of pacemaker implantation, acute kidney injury, postoperative atrial fibrillation and mortality, was developed at 44 (42.3%) patients.We compared the predictive performances of RVOT end-systolic (RVOTs) diameter, RVOT end-diastolic (RVOTd) diameter, RVOT-FS and RV diameters in prediction of MACE. The model including the RVOTs had higher AUC, R2 and likelihood ratio X2 values (0.775, 0.287 and 25.0, respectively) than RVOTd (0.770, 0.279 and 24.2, respectively) and RVOT-FS (0.750, 0.215 and 18.1, respectively). RVOT diameters showed better performance in predicting MACE than RV diameters. Moreover, there was statistically significant association between RVOTs, RVOTd and MACE (p value were 0.014 and 0.027, respectively), while no association between RVOT-FS and MACE (p value was 0.177). In summary, we determined that the RVOT diameters are important predictors for the in-hospital clinical outcomes of patients who underwent TVS.

Insight into tricuspid transcatheter edge-to-edge repair: no longer the forgotten valve

INTRODUCTION

Tricuspid regurgitation (TR) is one of the most prevalent types of valvular heart disease linked to poor prognosis in patients with heart failure and is usually ignored. TR has received considerable attention due to the progressive advancements in transcatheter therapies in recent years.

AREAS COVERED

With relatively solid data and rapid technological advancements, tricuspid transcatheter edge-to-edge repair (T-TEER) is the most frequently employed in a series of tricuspid transcatheter interventional treatments for TR. However, the efficacy and technical benefits of T-TEER are limited because of the unique anatomical characteristics and pathological mechanisms of the tricuspid valve. The aim of this review is to summarize reported data on current status of T-TEER and to provide an expert opinion regarding the challenges it is now experiencing and future development direction and approach.

EXPERT OPINION

T-TEER is a significant treatment for TR, but its effectiveness and technical promotion are limited due to the tricuspid valve unique anatomical characteristics and pathological mechanisms. The selection criteria for suitable patients, the choice of when to intervene, device innovation, the advancement of ultrasound technology, and the volume of evidence in evidence-based medicine all indicate that the disorder of TR will eventually be better treated and understood.

Differentiated impact of pulmonary hypertension on outcome after left ventricular assist device implantation and tricuspid valve repair

The present study aimed to investigate the impact of pulmonary hypertension (PH) on short-term survival after LVAD implantation with or without tricuspid annuloplasty valve repair (TVr) performed to treat regurgitation and avoid RV-failure post-LVAD insertion. Data of 24 patients receiving LVAD-implantation are assessed and compared. The primary outcome is in-hospital survival. Of 24 patients studied, 17 (70.8%) survived hospital stay: age (62.2 ± 12.3 vs 66.1 ± 8.5 years), preoperative LV-EF (15.9 ± 5.3% vs 13.6 ± 3.8%) vs. non-survivors, respectively. Survivors received preoperatively Impella (35.3% vs 0%, p = 0.037), had shorter intubation time (3.3 ± 3.5 vs 11.4 ± 11.1 days, p = 0.0053) and ICU stay (12.4 ± 9.8 vs 34.3 ± 34 days, p = 0.01) versus non-survivors. Non-survivors had more severe PH (37.0 ± 9.6 vs 29.8 ± 12.2 mmHg, p = 0.044) than survivors. Linear regression analysis revealed that cardiac operations performed concomitant with LVAD implantation increased mortality in patients with severe PH (p = 0.04), whereas isolated TVr performed concomitant with LVAD implantation did not increase mortality neither in the entire patient cohort (p = 0.569) nor in patients with severe PH (p = 0.433). LVAD with TVr improved survival in patients suffering from severe PH (vs. moderate PH), however this difference did not reach the level of significance due to the small number of patients (p = 0.08). LVAD-implantation alone improved survival of patients suffering from moderate PH (p = 0.045, vs. severe PH). Surgical correction of tricuspid regurgitation concomitant or before LVAD implantation improves early survival in patients suffering from severe PH when compared to LVAD implantation alone. Patients suffering from severe PH tend to benefit more from TVr than those suffering from moderate PH.

The role of elastin on the mechanical properties of the anterior leaflet in porcine tricuspid valves

Elastin is present in the extracellular matrix (ECM) of connective tissues, and its mechanical properties are well documented. In Marfan syndrome, however, the inability to properly code for the protein fibrillin-1 prematurely leads to the degradation and loss of elastin fiber integrity in the ECM. In this study, the role of elastin in the ECM of the anterior leaflet of the tricuspid valve was investigated by examining the biomechanical behavior of porcine leaflets before and after the application of the enzyme elastase. Five loading protocols were applied to the leaflet specimens in two groups (elastase-treated and control samples). The mechanical response following elastase application yielded a significantly stiffer material in both the radial and circumferential directions. At a physiological level of stress (85 kPa), the elastase group had an average strain of 26.21% and 6.32% in the radial and circumferential directions, respectively, at baseline prior to elastase application. Following elastase treatment, the average strain was 5.28% and 0.97% in the radial and circumferential directions, respectively. No statistically significant change was found in the control group following sham treatment with phosphate-buffered saline (PBS). Two-photon microscopy images confirmed that after the removal of elastin, the collagen fibers displayed a loss of undulation. With a significant reduction in radial compliance, the ability to withstand physiological loads may be compromised. As such, an extracellular matrix that is structurally deficient in elastin may hinder normal tricuspid valve function.

Impact of tricuspid regurgitation severity and repair on aortic valve replacement

BACKGROUND

Aortic stenosis is one of the most prevalent valve diseases but is rarely accompanied by tricuspid regurgitation. Our objective was to analyse the impact of tricuspid regurgitation severity and its surgical treatment on prognosis of patients undergoing aortic valve replacement.

METHODS

Retrospective cohort study including all patients presenting with aortic stenosis with some degree of tricuspid regurgitation between 2001 and 2018. Patients were divided into groups according to the degree of tricuspid regurgitation.

RESULTS

From a sample of 8,080 patients with aortic stenosis, 143 (1,8%) presented with more than trace tricuspid regurgitation. Among patients with mild, moderate, or severe tricuspid regurgitation, we observed no differences in 30-day (15,1 vs 14,8 vs 8,7%;p=0,727), 12-month (51,2 vs 56 vs 55%;p=0,892) or 5-year (64 vs 73,3 vs 66,7%;p=0,798) survival. Aortic valve replacement plus tricuspid annuloplasty, when compared with aortic valve replacement only was associated with longer ICU stay (9 vs 3 days;p=0,043) but not higher 30-day (0 vs 15,5%;p=0,112), 12-month (38,5 vs 54,3%;p=0,278) or 5-year mortality (57,1 vs 67.1%;p=0,594). Only history of liver disease and postoperative major morbidity were independent predictors of survival 30 days, 12 months and 5 years after surgery.

CONCLUSIONS

Severity of tricuspid regurgitation in patients with aortic stenosis was not associated with increased mortality. Tricuspid annuloplasty did not improve survival in this subset of patients but was associated with increased postoperative morbidity.

Strategies for tricuspid valve repair

Tricuspid valve repair is in many ways more challenging than mitral valve repair, especially since tricuspid valve anatomy is more complex with three leaflets, a saddle-shaped dynamic annulus and a complex subvalvular apparatus. The late referral of patients for tricuspid valve surgery adds to this challenge and contributes to poor prognosis. Nevertheless, studies have shown that the presence of moderate or greater tricuspid valve regurgitation leads to poor survival. Consequently, tricuspid valve surgery is now being performed more often, in order to improve the quality of life and survival. Tricuspid valve disease can be broadly classified into congenital and acquired tricuspid valve pathologies. Various repair techniques besides simple annular reduction maneuvers are used which are primarily aimed at restoring the complex interplay of various anatomical components. This review is a summary of the various operative techniques which provide successful reproducible results and achieve a competent and durable tricuspid valve repair with satisfactory late outcomes.

Anatomic Relationship of the Complex Tricuspid Valve, Right Ventricle, and Pulmonary Vasculature: A Review

Importance

Severe functional or secondary tricuspid regurgitation (TR) is associated with poor long-term outcomes in natural history studies as well as specific disease states. An understanding of the physiologic causes of the TR is lacking precluding a systematic approach to treatment.

Observations

The complex anatomic relationship between the tricuspid valve apparatus and structure of the right side of the heart lends insight into the functional changes seen with secondary TR. The association of these changes with changes in pulmonary vascular hemodynamics can lead to a cascade of events that result in disease progression.

Conclusions and Relevance

Appreciating the role of pulmonary vascular hemodynamics on right ventricular and tricuspid valve morphology and function improves our understanding of the pathophysiology of secondary TR. The limitations of current therapeutic approaches for secondary TR have stimulated interest in improving outcomes with this morbid disease. Changes in timing or approach to intervention require a more comprehensive understanding of the pathophysiology.

A detailed mechanical and microstructural analysis of ovine tricuspid valve leaflets

The tricuspid valve ensures unidirectional blood flow from the right atrium to the right ventricle. The three tricuspid leaflets operate within a dynamic stress environment of shear, bending, tensile, and compressive forces, which is cyclically repeated nearly three billion times in a lifetime. Ostensibly, the microstructural and mechanical properties of the tricuspid leaflets have mechanobiologically evolved to optimally support their function under those forces. Yet, how the tricuspid leaflet microstructure determines its mechanical properties and whether this relationship differs between the three leaflets is unknown. Here we perform a microstructural and mechanical analysis in matched ovine tricuspid leaflet samples. We found that the microstructure and mechanical properties vary among the three tricuspid leaflets in sheep. Specifically, we found that tricuspid leaflet composition, collagen orientation, and valve cell nuclear morphology are spatially heterogeneous and vary across leaflet type. Furthermore, under biaxial tension, the leaflets' mechanical behaviors exhibited unequal degrees of mechanical anisotropy. Most importantly, we found that the septal leaflet was stiffer in the radial direction and not the circumferential direction as with the other two leaflets. The differences we observed in leaflet microstructure coincide with the varying biaxial mechanics among leaflets. Our results demonstrate the structure-function relationship for each leaflet in the tricuspid valve. We anticipate our results to be vital toward developing more accurate, leaflet-specific tricuspid valve computational models. Furthermore, our results may be clinically important, informing differential surgical treatments of the tricuspid valve leaflets. Finally, the identified structure-function relationships may provide insight into the homeostatic and remodeling potential of valvular cells in altered mechanical environments, such as in diseased or repaired tricuspid valves. STATEMENT OF SIGNIFICANCE: Our work is significant as we investigated the structure-function relationship of ovine tricuspid valve leaflets. This is important as tricuspid valves fail frequently and our current approach to repairing them is suboptimal. Specifically, we related the distribution of structural and cellular elements, such as collagen, glycosaminoglycans, and cell nuclei, to each leaflet's mechanical properties. We found that leaflets have different structures and that their mechanics differ. This may, in the future, inform leaflet-specific treatment strategies and help optimize surgical outcomes.

The effects of -80 °C short-term storage on the mechanical response of tricuspid valve leaflets

Mechanical testing of soft tissues would ideally rely on using fresh specimens. In the event that fresh tissues are not readily available, alternative measures, such as storing fresh specimens at -80 °C, could be considered. Previous studies have shown that changes in the mechanical properties of the tissues due to freezing could be tissue-dependent. Prior to our study, however, such information was not available for the tricuspid valve leaflets. As such, for the first time, we examined whether fresh porcine specimens tested in a biaxial tensile machine would offer comparable results after being frozen at -80 °C. The stress-strain response of the tricuspid valve leaflets displayed no major deviation of the post-frozen leaflets as compared to fresh leaflets. We further compared the radial and circumferential strains as an indicator of deformation at similar stress states in fresh and thawed tissues, and we did not find any significant differences. Ice formation within the extra cellular matrix may modify the collagen fiber configuration, resulting in a slight change in the mechanical response. Nevertheless, our results indicated such a small deviation was negligible, thus enabling the possibility of using frozen porcine tricuspid valve specimens for future research.

Pacemaker lead as an iatrogenic cause of right heart failure: Case report

Technical advances in health care have improved patient survival and quality of life, but are not devoid of complications. We present the case of a 74-year-old woman with a history of hypertensive heart disease with preserved systolic function, atrial fibrillation and dyslipidemia. She had a DDDR pacemaker implanted in 2005 due to symptomatic complete atrioventricular block. The patient reported progressive fatigue, weakness, ascites with abdominal discomfort, and lower limb edema, accompanied by non-specific hepatic cholestasis on biochemical testing. Abdominal ultrasound revealed homogeneous hepatomegaly and dilatation of the inferior vena cava and upper hepatic veins, suggestive of congestive hepatopathy. Echocardiography revealed tricuspid regurgitation progressively worsening over the previous four years and dilatation and progressive dysfunction of the right ventricle, with preserved left ventricular function. The transesophageal echocardiogram revealed severe tricuspid regurgitation with flail septal leaflet and marked dilatation of the tricuspid annulus due to mechanical interference of the pacemaker lead, which was adhering to the septal leaflet. Minimally invasive surgical treatment was performed with partial resection of the leaflet, placement of a tricuspid annuloplasty ring and replacement of the pacemaker lead. Regression of the congestive symptoms was observed, and the postoperative echocardiogram showed the tricuspid annuloplasty ring with no evidence of stenosis and only slightly dilated right chambers with moderate pulmonary hypertension. Six months after the procedure, the patient suffered an acute neurological event and died.

Biomechanics of the Tricuspid Annulus: A Review of the Annulus' In Vivo Dynamics With Emphasis on Ovine Data

The tricuspid annulus forms the boundary between the tricuspid valve leaflets and their surrounding perivalvular tissue of the right atrioventricular junction. Its shape changes throughout the cardiac cycle in response to the forces from the contracting right heart myocardium and the blood-valve interaction. Alterations to annular shape and dynamics in disease lead to valvular dysfunctions such as tricuspid regurgitation from which millions of patients suffer. Successful treatment of such dysfunction requires an in-depth understanding of the normal shape and dynamics of the tricuspid annulus and of the changes following disease and subsequent repair. In this manuscript we review what we know about the shape and dynamics of the normal tricuspid annulus and about the effects of both disease and repair based on non-invasive imaging studies and invasive fiduciary marker-based studies. We further show, by means of ovine data, that detailed engineering analyses of the tricuspid annulus provide regionally-resolved insight into the kinematics of the annulus which would remain hidden if limiting analyses to simple geometric metrics.

Tricuspid valve leaflet strains in the beating ovine heart

The tricuspid leaflets coapt during systole to facilitate proper valve function and, thus, ensure efficient transport of deoxygenated blood to the lungs. Between their open state and closed state, the leaflets undergo large deformations. Quantification of these deformations is important for our basic scientific understanding of tricuspid valve function and for diagnostic or prognostic purposes. To date, tricuspid valve leaflet strains have never been directly quantified in vivo. To fill this gap in our knowledge, we implanted four sonomicrometry crystals per tricuspid leaflet and six crystals along the tricuspid annulus in a total of five sheep. In the beating ovine hearts, we recorded crystal coordinates alongside hemodynamic data. Once recorded, we used a finite strain kinematic framework to compute the temporal evolutions of area strain, radial strain, and circumferential strain for each leaflet. We found that leaflet strains were larger in the anterior leaflet than the posterior and septal leaflets. Additionally, we found that radial strains were larger than circumferential strains. Area strains were as large as 97% in the anterior leaflet, 31% in the posterior leaflet, and 31% in the septal leaflet. These data suggest that tricuspid valve leaflet strains are significantly larger than those in the mitral valve. Should our findings be confirmed they could suggest either that the mechanobiological equilibrium of tricuspid valve resident cells is different than that of mitral valve resident cells or that the mechanotransductive apparatus between the two varies. Either phenomenon may have important implications for the development of tricuspid valve-specific surgical techniques and medical devices.

Tricuspid annular diameter and right ventricular volume on preoperative cardiac CT can predict postoperative right ventricular dysfunction in patients who undergo tricuspid valve surgery

BACKGROUND

We investigated the predictive value of preoperative computed tomography (CT)-derived tricuspid annular and right ventricular (RV) parameters for postoperative RV dysfunction in patients undergoing tricuspid valve (TV) surgery.

METHODS

We retrospectively reviewed clinical, transthoracic echocardiography (TTE), and CT data of 100 consecutive patients who underwent cardiac CT and subsequently received TV surgery. Preoperative cardiac CT and TTE parameters were analyzed, including TV annulus diameter and RV size. Univariate and multivariate logistic regression analyses were performed to identify significant predictors for postoperative RV dysfunction, both in the entire study population and in the subgroup of patients without preoperative RV dysfunction.

RESULTS

Postoperative RV dysfunction occurred in 46% of all patients. In the multivariate logistic regression analysis, longer TV annulus diameter (>29.3 mm/m² on four-chamber view; (odds ratio [OR] 3.56, 95% confidence interval [CI] 1.13-11.24), larger RV volume (RV end-diastolic volume/body surface area > 128.8 ml/m²) on CT (OR 3.85, 95% CI 1.24-11.98) and presence of preoperative RV dysfunction on TTE (OR 11.96, 95% CI 2.8-50.99) were independent predictors for postoperative RV dysfunction in the entire study population (P < 0.05). Among patients without preoperative RV dysfunction, longer TV annulus diameter (OR 4.02, 95% CI 1.20-13.41) and larger RV volume on CT (OR 6.09, 95% CI 1.87-19.80) were independent predictors for postoperative RV dysfunction (P < 0.05).

CONCLUSIONS

Preoperative assessment of cardiac CT imaging-based TV annular diameter and RV volume can provide independent information for predicting postoperative RV dysfunction in patients undergoing TV surgery.

Pressure-induced microstructural changes in porcine tricuspid valve leaflets

Quantifying mechanically-induced changes in the tricuspid valve extracellular matrix (ECM) structural components, e.g. collagen fiber spread and distribution, is important as it determines the overall macro-scale tissue responses and subsequently its function/malfunction in physiological/pathophysiological states. For example, functional tricuspid regurgitation, a common tricuspid valve disorder, could be caused by elevated right ventricular pressure due to pulmonary hypertension. In such patients, the geometry and the normal function of valve leaflets alter due to chronic pressure overload, which could cause remodeling responses in the ECM and change its structural components. To understand such a relation, we developed an experimental setup and measured alteration of leaflet microstructure in response to pressure increase in porcine tricuspid valves using the small angle light scattering technique. The anisotropy index, a measure of the fiber spread and distribution, was obtained and averaged for each region of the anterior, posterior, and septal leaflet using four averaging methods. The average anisotropy indices (mean ± standard error) in the belly region of the anterior, posterior, and septal leaflets of non-pressurized valves were found to be 12 ± 2%, 21 ± 3% and 12 ± 1%, respectively. For the pressurized valve, the average values of the anisotropy index in the belly region of the anterior, posterior, and septal leaflets were 56 ± 5%, 39 ± 7% and 32 ± 5%, respectively. Overall, the average anisotropy index was found to be higher for all leaflets in the pressurized valves as compared to the non-pressurized valves, indicating that the ECM fibers became more aligned in response to an increased ventricular pressure.

STATEMENT OF SIGNIFICANCE

Mechanics plays a critical role in development, regeneration, and remodeling of tissues. In the current study, we have conducted experiments to examine how increasing the ventricular pressure leads to realignment of protein fibers comprising the extracellular matrix (ECM) of the tricuspid valve leaflets. Like many other tissues, in cardiac valves, cell-matrix interactions and gene expressions are heavily influenced by changes in the mechanical microenvironment at the ECM/cellular level. We believe that our study will help us better understand how abnormal increases in the right ventricular pressure (due to pulmonary hypertension) could change the structural architecture of tricuspid valve leaflets and subsequently the mechanical microenvironment at the ECM/cellular level.

Presence of ´isolated´ tricuspid regurgitation should prompt the suspicion of heart failure with preserved ejection fraction

Background

Diastolic dysfunction of the left ventricle is common but frequently under-diagnosed. Particularly in advanced stages affected patients may present with significant functional tricuspid regurgitation (TR) as the most prominent sign on echocardiography. The underlying left ventricular pathology may eventually be missed and symptoms of heart failure are attributed to TR, with respective therapeutic consequences.

The aim of the present study was to determine prevalence and mechanisms underlying TR evolution in heart failure with preserved ejection fraction (HFpEF).

Methods and results

Consecutive HFpEF patients were enrolled in this prospective, observational study. Confirmatory diagnostic tests including echocardiography and invasive hemodynamic assessments were performed.

Of the 175 patients registered between 2010 and 2014, 51% had significant (moderate or severe) TR without structural abnormalities of the tricuspid valve. Significant hemodynamic differences between patients with and without relevant TR were encountered. These included elevated pulmonary vascular resistance (p = 0.038), reduced pulmonary arterial compliance (PAC, p = 0.005), and elevated left ventricular filling pressures (p = 0.039) in the TR group. Multivariable binary logistic regression analysis revealed diastolic pulmonary artery pressure (p = 0.029) and PAC (p = 0.048) as independent determinants of TR.

Patients were followed for 18.1±14.1 months, during which 32% had a cardiac event. While TR was associated with outcome in the univariable analysis, it failed to predict event-free survival in the multivariable model.

Conclusions

The presence of ´isolated´ functional TR should prompt the suspicion of HFpEF. Our data show that significant TR is a marker of advanced HFpEF but neither an isolated entity nor independently associated with event-free survival.

Revisit of Functional Tricuspid Regurgitation; Current Trends in the Diagnosis and Management

Current knowledge of functional tricuspid regurgitation (FTR) as a progressive entity, worsening the prognosis of patients irrespective of its aetiology, has led to renewed interest in the pathophysiology and assessment of FTR. For the proper management of FTR, not only its severity, but also the mechanisms, the mode of leaflet coaptation, the degree of tricuspid annulus enlargement and leaflet tenting, and the haemodynamic consequences for right atrial and right ventricular morphology and function have to be taken into account. A better assessment of the anatomy and function of tricuspid apparatus and tricuspid regurgitation severity should help with the appropriate selection of patients who will benefit from either surgical tricuspid valve repair/replacement or a percutaneous procedure, especially among patients who are to undergo or have undergone primary left-sided valvular surgery. In this article, we review the anatomy, pathophysiology and the use of imaging techniques to assess patients with FTR, as well as the various treatment options for FTR, including emerging transcatheter procedures. The limitations affecting the current approach to FTR patients and the unmet clinical needs for their management have also been discussed.

Prognostic Impact of Tricuspid Regurgitation in Patients Undergoing Aortic Valve Surgery for Aortic Stenosis

BACKGROUND

The prognostic significance of tricuspid regurgitation (TR) and right ventricular (RV) function in patients undergoing aortic valve replacement (AVR) for severe aortic stenosis (AS) is unknown. The aim of the present study was to evaluate the impact of TR and RV systolic dysfunction on early and late mortality in this setting.

METHODS

This was a prospective single-center observational study. 465 consecutive patients who were referred to AVR for severe AS were investigated. Significant TR was defined as TR≥moderate by transthoracic echocardiography.

RESULTS

At baseline, significant TR was present in 26 (5.6%) patients. Patients with TR presented with a higher EuroSCORE I (p = 0.001), a higher incidence of previous cardiac surgery (p<0.001), pulmonary hypertension (p = 0.003), more dilated RVs (p = 0.001), and more frequent RV dysfunction (p = 0.001). Patients were followed for an average of 5.2 (±2.8 SD) years. By multivariable Cox regression analysis TR (p = 0.014), RV dysfunction (p = 0.046), age (p = 0.001) and concomitant coronary artery bypass graft surgery (CABG, p = 0.003) were independently associated with overall mortality. By Kaplan-Meier analysis, survival rates were significantly worse in patients with significant than with non-significant TR (log rank p = 0.001).

CONCLUSIONS

TR, RV dysfunction, age, and concomitant CABG are associated with outcome in patients undergoing AVR for severe AS. This finding underlines the importance of a thorough echocardiographic evaluation with particular consideration of the right heart in these patients.

Repairing the tricuspid valve in congenital heart diseases other than Ebstein's

The tricuspid valve is being increasingly recognised as an important safeguard to the heart with congenital heart disease. Both structural anomalies of the valve and functional burdens from other malformations of the right heart can lead to major haemodynamic consequences both upstream and downstream. The indications to surgically intervene on the tricuspid valve are evolving and vary depending on the malformation. The extant surgical techniques and their applications to corresponding frequent congenital anomalies of the tricuspid valve are reviewed.

Efficiency of different annuloplasty in treating functional tricuspid regurgitation and risk factors for recurrence

Background

Functional tricuspid regurgitation (FTR) is frequent in patients with mitral valve disease. Untreated tricuspid regurgitation (TR) may cause poor clinical outcomes. The surgical factors involved in annuloplasty for FTR remain controversial. Our objective was to compare effectiveness of different tricuspid annuloplasty (TVP), and reveal the risk factors of recurrence.

Methods

We analyzed the clinical details of 399 consecutive patients who underwent mitral surgery with concomitant TVP, from 2006 to 2011, in two Chinese single-centers. Three methods were used for TVP: De Vega surgery was completed in 242 patients; annuloplasty using a flexible band was completed in 98 patients; and surgery with a rigid ring was performed in 59 patients.

Results

The operative mortality rate was 2.3%. After surgery, the TR grade of all patients decreased significantly. At three years postoperatively, 13.7% of patients were diagnosed with recurrent FTR. At the three year time point, severe TR in the De Vega group was 18%, which was higher than those in the flexible (8.4%) and rigid planner ring groups (5.2%). During follow-up, the recurrent rates in the rigid group were significantly lower than in the flexible group. Multivariate analysis revealed that pre-operative atrial fibrillation, severe TR, large left atrial, ejection fraction (EF) < 40%, De Vega annuloplasty, and postoperative permanent pacemaker installation were independent risk factors for severe recurrent TR.

Conclusions

Rigid ring annuloplasty efficaciously improved post-operative tricuspid valve function in patients with FTR. Atrial fibrillation, a large left atrium, low EF and postoperative permanent pacemaker installation were independent risk factors for severe recurrent TR.