Non-functional tricuspid valve disease

Case Report: unexpected cause of cyanosis in an infant after acute exposure to high altitude-severe tricuspid regurgitation secondary to tricuspid valve prolapse

Background

Severe tricuspid regurgitation (TR) causing cyanosis with patent foramen ovale (PFO) and right-to-left atrial shunting requires a precise diagnosis for optimal therapy. Tricuspid valve prolapse (TVP) can lead to TR and is sometimes overlooked, especially in complex cases with factors like pulmonary hypertension (PH). We present an infant with cyanosis and profound TR after high-altitude exposure, initially misattributed to PH but found to be primarily due to spontaneous chordae tendineae rupture and TVP. This case underscores the challenges in diagnosing TR-induced cyanosis.

Case presentation

The 3-month-old infant rapidly developed cyanosis, hypoxemia, right atrial enlargement, severe tricuspid regurgitation (TR), and patent foramen ovale (PFO) shunting after high-altitude exposure. Although echocardiography revealed tricuspid valve prolapse (TVP), initial consideration linked TR and right-to-left shunting to pulmonary hypertension (PH) due to the temporal correlation with rapid altitude exposure. Despite hemodynamic stability and the absence of respiratory distress after respiratory support and combined PH medication therapy, the persistent hypoxemia did not reverse as expected. This treatment outcome and repeated echocardiograms reminded us that TR was primarily caused by TVP rather than PH alone. Intraoperative exploration confirmed that TVP was caused by a rupture of TV chordae tendineae and anterior papillary muscle head, and the chordae tendineae/papillary muscle connection was reconstructed. After surgery, this patient was noncyanotic with an excellent long-term prognosis, a trivial TR with normal TV function being observed echocardiographically.

Conclusions

TR-induced cyanosis can be not only a consequence of PH and right-sided heart dilation but also a primary condition. Repetitive reassessment should be undertaken with caution, particularly when patients are not improving on therapy in the setting of conditions known to predisposition to secondary TR. Since TVP caused by rupture of the chordae or papillary muscles is rare but fatal in children, early diagnosis is clinically substantial to proper management and satisfactory long-term outcomes.

Safety and efficacy of total thoracoscopic surgery for patients with tricuspid regurgitation and reduced right ventricular function after left heart valves replacement: a retrospective comparative study

BACKGROUND

Tricuspid valve surgery is the standard treatment for tricuspid valve disease refractory to pharmacologic therapy. However, patients with tricuspid regurgitation after previous left heart valves replacement with reduced right ventricular (RV) function are at greater risk of surgery. We compared the clinical outcomes of tricuspid valve replacement in this subgroup of patients through mini-thoracotomy and conventional full-sternotomy approach.

METHODS

We identified 44 patients at our institution with tricuspid regurgitation and reduced right ventricular function after left heart valves replacement who underwent either total thoracoscopic tricuspid valve replacement (T-TVR) or conventional tricuspid valve replacement (C-TVR) from December 2014 and May 2021. Patient clinical characteristics, hospital course, and postoperative changes in RV function were retrospectively reviewed and analyzed.

RESULTS

Baseline characteristics between T-TVR (n = 25) and C-TVR (n = 19) were comparable including a high incidence of liver dysfunction and renal insufficiency. There were no statistically differences between the two groups in terms of hospital mortality (8.0% vs. 21.1%, P = .211). Patients in the T-TVR group had less total drainage volume (201.60 ± 77.05 ml vs. 614.74 ± 182.31 ml, p < .001), required fewer postoperative blood product transfusions, and had a lower total length of hospital stay (15(15-16) vs. 16(14-17) days, P = .019) compared to the C-TVR group. T-TVR was associated with better and faster recovery of tricuspid annular plane systolic excursion (TAPSE) and right ventricle fractional area change (RVFAC) (adjusted β = 0.154, 95% CI: 0.037 to 0.271, p = .010 and adjusted β = 0.003, 95% CI: 0.000 to 0.005, p = .024; respectively) within the first 3 months postoperatively compared with C-TVR.

CONCLUSIONS

T-TVR represents a viable alternative to current surgical strategies as a potentially sicker cohort demonstrated similar hospital mortality compared to conventional surgery, with reduced length of hospital stay, fewer blood transfusions, and more favorable in promoting RV functional recovery in the early period. Future prospective, randomized-controlled trials with longer follow-up durations are needed to validate these findings.

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.

A comparative study on the results of beating and arrested heart isolated tricuspid valve surgery: A cross-sectional study

Background and Aims

The isolated tricuspid valve surgery is performed using beating or arrested heart surgery. The present study aimed to evaluate and compare the results of patients who underwent isolated tricuspid valve surgery using the beating and arrested heart techniques.

Methods

In this retrospective observational study, all patients undergoing isolated tricuspid valve surgery between 2011 and 2018 were included. The patient's demographic information, echocardiographic, surgery, and hospitalization results were collected, and the EuroSCORE was calculated from the patient's medical records.

Results

Fifty-three patients were included in the study of which 21 (39.63%) and 32 (60.37%) underwent a beating heart and arrested heart surgeries, respectively. There were no significant differences between the two studied groups in the echocardiographic results before and after the surgery, total hospitalization days (p = 0.56), and the mortality in the first 30 days after the surgery (p = 0.152). However, the duration of surgery (p < 0.001), EuroSCORE (p = 0.005), and patients who underwent lateral thoracotomy (p = 0.007) were notably lower in the arrested heart than in the beating heart group. In contrast, the duration of cardiopulmonary bypass and hospitalization in an intensive care unit after the surgery was remarkably lower in the beating heart than in the arrested heart group (p < 0.001 for both cases).

Conclusion

Although there were some significant differences between the two kinds of surgery techniques, it seems superficial that made a particular decision to consider each method's superiority. Therefore, further studies with larger populations and meta-analyses are required to recommend the preferred method for the surgeons certainly.

Tricuspid Valve Percutaneous Therapies

PURPOSE OF REVIEW

In this review, we have focused on the currently available transcatheter tricuspid valve therapies, device selection, as well as role and management of tricuspid regurgitation (TR) in the setting of other transcatheter valvular procedures.

RECENT FINDINGS

In this review, we have enlisted the recently finished as well as ongoing trials in the percutaneous tricuspid valve therapies. TR is highly prevalent yet remains underrecognized and is often untreated. TR has traditionally been managed conservatively with medical therapies including diuretics for volume management, whereas surgical therapies are reserved for those undergoing left-sided valvular surgery. Although the transcatheter devices for tricuspid repair and replacement are in clinical trials, the experience to date for their effectiveness and safety has been reassuring.

Transcatheter tricuspid valve intervention techniques and procedural steps for the treatment of tricuspid regurgitation: a review of the literature

Severe tricuspid regurgitation (TR) is an undertreated common pathology associated with significant morbidity and mortality. Classically, surgical repair or valve replacement were the only therapeutic options and are associated with up to 10% postprocedural mortality. Transcatheter tricuspid valve interventions are a novel and effective therapeutic option for the treatment of significant TR. Several devices have been developed with different mechanisms of action. They are classified as annuloplasty devices, replacement devices, caval valve implantation and coaptation devices. In this review, we provide a step-by-step description of the procedural steps and techniques of every device along with video support.

Severe Functional Tricuspid Valve Regurgitation: Predictors of Mortality After Initial Diagnosis

BACKGROUND

Severe functional tricuspid regurgitation (fTR) is associated with adverse clinical outcomes and remains under-treated. There is recent interest in this disease due to emerging tricuspid valve therapies. However, the timing and selection of patients who may benefit from treatment is uncertain. Risk factors associated with mortality after diagnosis of severe fTR may help guide treatment.

AIM

We studied patients with severe fTR to assess predictors of mortality.

METHODS

We retrospectively identified consecutive patients who had severe fTR diagnosed on transthoracic echocardiography in a single academic tertiary hospital. These were categorised into atrial fibrillation (AF)- and non-AF-related groups. Patient characteristics and echocardiographic parameters were collected. We then analysed the collected parameters on their impact on occurrence of mortality and also on the time to mortality.

RESULTS

A total of 635 patients with severe fTR were studied (41.6 % male, mean age of 68.6±15.4 years). There were 130 (20.5%) in the AF-related group and 505 (79.5%) in the non-AF related-group. Median follow-up duration was 774 days, during which 154 (24.3%) deaths occurred within the first year. Older age on diagnosis, reduced left ventricular ejection fraction (LVEF) (<50%), high pulmonary systolic pressure (PASP) (>50 mmHg) and a prior history of heart failure admissions were associated with occurrence of mortality. Older age on diagnosis, reduced LVEF, and high PASP were also found to be associated with time to mortality.

CONCLUSIONS

For patients diagnosed with severe fTR, advanced age on diagnosis, prior heart failure admission, LVEF <50%, and PASP >50 mmHg are associated with mortality. These factors could form the basis of future studies that determine the timing and decision to intervene in patients with severe fTR.

Tricuspid valve repair via partial sternotomy for traumatic valve insufficiency

Tricuspid valve insufficiency rarely follows a blunt chest trauma. When the tricuspid valve is solely injured, the cardiac trauma may stay asymptomatic and tolerable, which often makes it difficult to determine the indication for surgery. We report a case of a patient with tricuspid regurgitation secondary to trauma due to a motorcycle accident. The patient was initially asymptomatic, but shortness of breath emerged two years after the accident. He underwent the tricuspid valve repair with chordae reconstruction and annuloplasty via lower partial sternotomy. We advocate that early surgical intervention prevents right heart failure, atrial fibrillation, and valve replacement.

Echocardiographic assessment of the tricuspid and pulmonary valves: a practical guideline from the British Society of Echocardiography

Transthoracic echocardiography is the first-line imaging modality in the assessment of right-sided valve disease. The principle objectives of the echocardiographic study are to determine the aetiology, mechanism and severity of valvular dysfunction, as well as consequences on right heart remodelling and estimations of pulmonary artery pressure. Echocardiographic data must be integrated with symptoms, to inform optimal timing and technique of interventions. The most common tricuspid valve abnormality is regurgitation secondary to annular dilatation in the context of atrial fibrillation or left-sided heart disease. Significant pulmonary valve disease is most commonly seen in congenital heart abnormalities. The aetiology and mechanism of tricuspid and pulmonary valve disease can usually be identified by 2D assessment of leaflet morphology and motion. Colour flow and spectral Doppler are required for assessment of severity, which must integrate data from multiple imaging planes and modalities. Transoesophageal echo is used when transthoracic data is incomplete, although the anterior position of the right heart means that transthoracic imaging is often superior. Three-dimensional echocardiography is a pivotal tool for accurate quantification of right ventricular volumes and regurgitant lesion severity, anatomical characterisation of valve morphology and remodelling pattern, and procedural guidance for catheter-based interventions. Exercise echocardiography may be used to elucidate symptom status and demonstrate functional reserve. Cardiac magnetic resonance and CT should be considered for complimentary data including right ventricular volume quantification, and precise cardiac and extracardiac anatomy. This British Society of Echocardiography guideline aims to give practical advice on the standardised acquisition and interpretation of echocardiographic data relating to the pulmonary and tricuspid valves.

Transcatheter therapies for severe tricuspid regurgitation. Quo vadis?

Moderate-to-severe tricuspid regurgitation (TR) is common and is associated with a poor prognosis. To date, most patients are undertreated; therefore, transcatheter options could be clinically impactful in those who are denied surgery. Several transcatheter solutions have been developed that address the problem via leaflet enhancement, annuloplasty, or heterotopic implantation of self-expandable or balloon-expandable valves in the caval veins. A comprehensive patient evaluation, based on multimodality imaging techniques for a better understanding of the valvular pathology and TR mechanism, remains paramount for an appropriate device selection. To date, several trials have shown the feasibility and safety of a multitude of devices in this setting, but data from randomized clinical trials regarding clinical benefit based on hard endpoints are still lacking. Although the optimal patient profile and timing of intervention remain under investigation, data from available studies indicate that an earlier treatment referral, before onset of irreversible right ventricular remodeling, could be beneficial. This review discusses the present landscape and future implications of transcatheter therapies for severe TR.

Traumatic tricuspid valve regurgitation: A challenging case report

Traumatic tricuspid regurgitation (TR) is a rare cause of acute right ventricular dysfunction. The surgical technique could be complex and the reparative gesture has a lower success rate when compared with functional TR. We present the case of a 26-year-old male patient with traumatic TR who underwent tricuspid valve repair, with an initial satisfactory result. Later, the onset of acute severe residual TR was observed and the valve needed to be replaced. Surgery is the mainstay of treatment for traumatic TR, either in the form of repair or replacement. It requires an early diagnosis and concomitant treatment of injuries.

Mid-term outcome of severe tricuspid regurgitation: are there any differences according to mechanism and severity?

Aims

Patients with significant tricuspid regurgitation (TR) addressed according the new classification in torrential TR may have different prognosis compared with just severe TR patients. We sought to determine distribution and mechanism of consecutive severe TR patients, in accordance with aetiology and severity by applying the new proposed classification scheme and their long-term outcomes.

Methods and results

Between January and December 2013, 249 patients with significant TR referred to the cardiac imaging unit (mean age 79.9 ± 10.2 years; 29.8% female) were included. Patients were divided according to aetiology in six groups, and TR severity was reclassified into severe, massive, and torrential TR. The follow-up period was of 313 ± 103 days. When considering cardiovascular mortality, patients in the massive/torrential group showed the highest number of events (P < 0.007). Patients with TR due to pulmonary diseases had the worst prognosis according to different aetiology. Noteworthy, the best predictors for the combined endpoint [cardiovascular mortality and readmission admission for heart failure (HF)] were TR severity according to the new classification [hazard ratio (HR) 2.48, 95% confidence interval (CI) 1.25–4.93] and clinical scores such as New York Heart Association classification and congestive status (HR 1.78, 95% CI 1.28–2.49; HR 2.08, 95% CI 1.06–4.06, respectively).

Conclusion

Patients with massive/torrential TR and patients with comorbidities, especially pulmonary disease, were identified as populations at higher risk of death and readmission for HF. New classification scheme and clinical assessment may establish who may benefit the most of intensive therapeutic treatments and intervention on the tricuspid valve.