Duplication of the tricuspid valve

The concept of cone creation to treat isolated tricuspid valve dysplasia and the case of a double-orifice tricuspid valve

OBJECTIVES

Isolated tricuspid valve dysplasia is a rare disease characterized by a wide spectrum of possible anomalies. We describe the use of the Cone concept to treat a patient with a double-orifice tricuspid valve with massive regurgitation and severe deficit of coaptation.

METHODS

Three adult patients with congenital non-Ebstein tricuspid valve anomaly characterized by severe coaptation deficiency underwent tricuspid valve repair applying the Cone technique. In particular, we describe the case of a symptomatic 21-year-old woman with a double-orifice tricuspid valve, with massive regurgitation and severe right ventricular dilatation. The tricuspid valve was transformed from a double-orifice valve into a single-orifice valve. The most superior orifice was opened, and the tissue surrounding the orifice was used to extend the leaflet of the inferior orifice. A Cone was created, and a ring annuloplasty was used to stabilize the result.

RESULTS

The patient was discharged home after 7 days with trivial residual tricuspid regurgitation and no significant antegrade gradient. The final coaptation height was 2.8 cm. The cardiothoracic ratio decreased from 0.77 to 0.59 after 2 months, and symptoms promptly improved.

CONCLUSIONS

Over the past 2 years, we have applied the Cone creation concept to patients with a severely dysplastic tricuspid valve with excellent early results. One patient had a double-orifice tricuspid valve, and a Cone repair concept was adopted anyway. One orifice was sacrificed, and surrounding tissue was used to augment the leaflets of the other orifice. A Cone was created to improve central coaptation with a good initial result.

Double-Orifice Tricuspid Valve in an Infant with Multiple Noncardiac Anomalies

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DOTV can be seen in patients with noncardiac anomalies.

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Subcostal windows allow an en face echocardiographic assessment of the tricuspid valve.

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DOTV is rare, with a little known natural history warranting long-term follow-up.

Canine infantile left ventricular noncompaction

Background

Left ventricular noncompaction (LVNC) is a rare form of cardiomyopathy currently described in humans and cats. It consists of a spongy myocardium characterized by prominent trabeculation and deep recesses involving more than 50% of the ventricular thickness. We describe the clinical and pathological features of LVNC combined with tricuspid valve dysplasia, double-orifice tricuspid valve and severe pulmonary stenosis in a puppy. In addition, we briefly review the LVNC causes, pathogenesis, forms and current diagnostic criteria.

Case presentation

A seven-week-old intact German Shorthaired Pointer-cross male was presented with a poor body condition, exercise intolerance and dyspnea. Clinical exam identified a bilateral systolic murmur (grade IV/VI over the right heart base and grade III/VI over the left heart base). Echocardiography identified tricuspid valve dysplasia, mild mitral regurgitation, and severe pulmonic stenosis with a trans-valvar systolic pressure gradient of 106 mmHg. Left ventricular noncompaction was diagnosed by necropsy and further confirmed histopathologically by the presence of two distinct myocardial layers: an inner noncompacted zone covering more than 50% of ventricular thickness containing prominent trabeculation and deep recesses, and an outer zone of compact myocardium.

Conclusions

This is the first case describing LVNC in a canine patient, supporting the introduction of this form of heart disease as a differential diagnosis for cardiomyopathies in juvenile and adult dogs.

Utility of three-dimensional echocardiography and magnetic resonance imaging in the diagnosis of double-orifice tricuspid valve

Duplication of atrioventricular valves involves the mitral valve more often than the tricuspid valve and is often associated with other cardiac defects. Double-orifice tricuspid valve (DOTV) is often identified in surgery or autopsy and missed on echocardiography, as the two orifices are orthogonal to the imaging plane. If suspected on echocardiography, it masquerades as mild tricuspid hypoplasia. Three-dimensional echocardiography and magnetic resonance imaging of a DOTV are presented.

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.

An unusual example of isolated double-orifice tricuspid valve

Double-orifice tricuspid valve (DOTV) is a very rare congenital cardiac anomaly. We report an unusual example of DOTV where one orifice was committed to the left ventricle. This was identified preoperatively and managed surgically.

The clinical experience of double-orifice tricuspid valve

BACKGROUND AND AIM OF THE STUDY

Double-orifice tricuspid valve (DOTV) is an extremely rare congenital anomaly. By analysing the feature of its diagnosis and surgical treatment, we want to summarise the clinical experience of treating DOTV.

MATERIALS AND METHODS

Review two cases of DOTV treated by us between August 2009 and December 2011. One case was diagnosed as partial atrioventricular septum defect, and the other was tetralogy of Fallot. The defects were both identified during the operation for other congenital cardiac malformations and both accessory orifices were normal. But one of them was sutured because of its possible effect in future.

RESULTS

Cardiac colour Doppler echocardiogram was made at three to five days after operation and all results were normal. No operative complication or late deaths occurred. The time of follow-up were one month, three months, six months, one year and two years after operation, and all examinations were normal.

CONCLUSIONS

The accessory orifice of DOTV patients has its own independent chordae tendinea and mastoid muscle. So the gap of tricuspid valve should be excluded and the classification should be amended according to it. It should be surgically treated, when there is of dysfunction with it or potential harmful effect in sequent treatment.

A double-orifice tricuspid valve associated with a divided right atrium

Right atrioventricular valve duplication is a rare congenital anomaly with only isolated cases of a double-orifice tricuspid valve having been described. This article presents a case of the surgical repair of a double-orifice tricuspid valve associated with a divided right atrium, a ventricular septal defect, and Wolff-Parkinson-White syndrome.

Double-orifice tricuspid valve: a rare entity

Duplication of the atrioventricular valves is a rare anomaly and is more commonly seen in the mitral position. We report the case of a 14-year old child with a large inlet muscular ventricular septal defect, who had a double-orifice tricuspid valve, which was detected incidentally during surgery.

Double orifice tricuspid valve in an infant with tetralogy of Fallot

Atrioventricular valve duplication, also known as double orifice valve, is an excitingly rare anomaly that can involve either the mitral or more uncommonly the tricuspid valve. Herein we describe a case of a double orifice tricuspid valve that prejudiced the complete repair in a symptomatic infant with tetralogy of Fallot.

Double-orifice mitral valve with intact atrioventricular septum: an echocardiographic study with anatomic and functional considerations

We identified 18 patients with double-orifice mitral valve (DOMV) and intact atrioventricular (AV) septum out of 40,179 echocardiographic studies performed between 1997 and 2002 at Children's Hospital, Denver, CO. In this study we describe (1) the anatomic characteristics of the DOMV in the absence of AV septal defect, (2) the function of the mitral valve by spectral and color Doppler flow mapping, and (3) associated lesions. The topographic location of the orifices in the leaflets suggests possible embryologic mechanisms of DOMV. In this series, DOMV was most commonly associated with left-sided obstructive lesions (in 39% of patients). Spectral and color Doppler interrogation demonstrated a normal flow profile in most cases; only 2 patients had significant mitral regurgitation or stenosis. Therefore, due to the uncertain natural history of this lesion and the potential need for endocarditis prophylaxis, careful imaging of the mitral valve is recommended, particularly in the presence of left-sided obstructive lesions.

Duplication of the tension apparatus of the tricuspid valve

We report an infant with a large perimembranous ventricular septal defect, who had two separate orifices in the tricuspid valve, each supported by separate cordal apparatus, detected incidentally during surgery.

A case report of double-orifice tricuspid valve

A heart specimen with double-orifice tricuspid valve is described. The tricuspid valve was divided into the anterior and posterior orifices by a bridge of leaflet tissue. The valve was stenotic because of the arcade deformity of the anterior papillary muscle to which the bridging leaflet tissue had short chordal insertions. The anterior orifice was regurgitant as a result of a deficient septal leaflet. Clinical correlation was obtained by magnetic resonance imaging of the specimen. The functional significance of the malformed valve was assessed by three-dimensional reconstruction of the two-dimensional magnetic resonance images.

The transesophageal echocardiographic features of double-orifice left atrioventricular valve

Three adult patients with a double-orifice left atrioventricular valve (AV) were studied by both precordial and transesophageal ultrasound imaging, (two transverse plane and one biplane studies) to compare and contrast the information obtained by either imaging modality. In two patients, this pathologic condition was associated with other congenital heart malformations--a muscular inlet ventricular septal defect in the first, atrioventricular and ventriculoarterial discordance and an unrestrictive ventricular septal defect in the second. In the third patient, the double-orifice left AV valve existed as an isolated lesion. In the first and second case, both orifices were of similar size; in the third the additional orifice was of diminutive size and was demonstrated only by transesophageal longitudinal plane scanning. In summary, in this adult patient group, transesophageal echocardiography with color flow mapping was superior to precordial scanning in the assessment of both the morphology and functional status of a double-orifice left AV.

Duplication of the right atrioventricular orifice in a patient with common atrium and mitral cleft

The following case involved duplication of the right atrioventricular valve in a patient with a common atrium. The accessory orifice, formed by two fine leaflets, connected the right atrium with the right ventricular outflow tract and had no subvalvular apparatus. Successful surgical correction was accomplished under standard cardiopulmonary bypass.

Two-dimensional echocardiographic findings in double orifice mitral valve

Between December 1981 and April 1984, five children ranging in age from 1 month to 5 1/2 years examined by two-dimensional echocardiography appeared to have a double orifice mitral valve. The diagnosis was verified in one patient at surgery, one patient by angiography and one patient by necropsy. Associated malformations included mitral stenosis and regurgitation, coarctation of the aorta, ostium primum and secundum atrial septal defect, ventricular septal defect and hypoplastic left heart syndrome. Three varieties of double orifice mitral valve were observed: an incomplete bridge type (one patient), in which a small strand of tissue connected the anterior and posterior leaflets at the leaflet edge level; a complete bridge type (three patients), in which a fibrous bridge divided the atrioventricular orifice completely into equal or unequal parts and a hole type (one patient), in which an additional orifice with subvalvular apparatus occurred in the posterior commissure of the mitral valve. These three types could be distinguished by sweeping the transducer in cross-sectional view from the apex toward the base of the heart. Both orifices could be seen throughout the scan in the complete bridge type while in the incomplete bridge type the two orifices could be seen only at the level of the papillary muscles. In the hole type, the second orifice was seen at about midleaflet level. In all three types, the chordae surrounding each orifice attached to only one papillary muscle. Congenital mitral stenosis or regurgitation was evident in three patients. The type of the double orifice mitral valve did not predict the presence or severity of symptoms.

Duplication of the tricuspid valve

Duplication of the atrioventricular (AV) valves is a rare anomaly, more commonly seen in the mitral position. Only 13 cases have been reported in the literature.(1-10) The case described here represents an unusual variant of this anomaly and provides an opportunity to review the pathology and embryologic genesis of duplication deformities of the AV valves.