Predictors of long term tricuspid regurgitation after pulmonary valve replacement: a single center study on the cohort of significant preoperative tricuspid regurgitation

Background

Almost one-third of repaired tetralogy of Fallot (TOF) and pulmonary stenosis (PS) patients referred for pulmonary valve replacement (PVR) have at least moderate tricuspid regurgitation (TR). Predictors of long term TR in this population are not well defined and the role of Tricuspid Annuloplasty (TA) in addition to PVR in this setting is controversial.

Purpose

Patients with preoperative severe TR or moderate TR with dilated tricuspid annulus (>40mm) undergo TA at the time of PVR as per protocol in our instititution. The aim of this observational study was to evaluate the long term results of this approach and to identify predictors of significant TR at the end of follow-up.

Material and methods

We retrospectively reviewed 35 repaired TOF and PS patients who underwent surgical PVR with (n=17, group 1) or without (n=18, group 2) TA in a single tertiary hospital between June-2009 and June-2021. Pre- and postoperative echocardiographic and cardiac magnetic resonance data were assessed for TR severity and right ventricle size and systolic function. Baseline and clinical follow up data were collected. Uni- and multivariable tests were used to analyze predictors of at least moderate TR after PVR.

Results

Mean age at PVR and baseline image parameters were comparable between groups, except for TR grade (p 0.006), tricuspid annulus size (p 0.018) and right ventricle outflow tract diameter (p 0.04) which were greater in group 1. TA did not confer and increased risk of surgical and peroperative complications. Intensive care unit (p 0.94) and total hospital admission days (p 0.59) did not differ among groups. At one year, TR grade significantly improved regardless of TA. At the end of follow-up (5.29±2.9 years), the degree of TR increased in both groups with no differences between groups (p 0.38) (see table 1). In univariable analysis, two independent predictors of at least moderate TR at end of follow-up were identified; mixed TR mechanism (OR 12.5, p 0.006) and severe preoperative TR grade (OR 10.21, p 0.003). Mixed TR mechanism (OR 15.78, p 0.01) and a right ventricle ejection fraction below 45% (OR 1.47, p 0.01) were identified as risk factors of significant TR in multivariable analysis (see Table 2).

Conclusions

TA seems a reasonable approach at the time of PVR in patients with severe TR or moderate TR with dilated annulus. Mixed TR mechanism and a worse right ventricular function have been identified as independent predictors factors of long term significant postoperative TR in our study cohort.

Funding Acknowledgement

Type of funding sources: None.

P921Feasibility of multipoint, high-definition mapping with grid cathether of SVTs in patients with D-Transposition of the great arteries treated with atrial switch surgery

Introduction

 Patients with D-transposition of the great arteries (TGA) treated with Senning or Mustard surgery develop supraventricular tachycardias (SVTs) that require treatment with ablation. The use of multipoint, high-density, wavefront-activation-orientation independent mapping catheters hasn’t been reported in literature.

Purpose

To describe the feasibility of using a specific mapping catheter in SVTs in this set of patients.

Methods

Prospective observational study in patients with history of SVT and atrial switch surgery, that underwent EP study and electroanatomic (EA) mapping with a new 8Fr deflectable, multipoint (16 equidistant electrodes along 4 splines), with magnetic sensor, wavefront-activation-orientation independent catheter, in a third level hospital since April 2018 until May 2019, with medium-term follow-up. 

Results

A total of 8 EPS (electrophysiologic studies) were performed in 7 patients (clinical data in Table 1). One patient had a tachycardia recurrence, accounting for a second EPS. The pulmonary venous atrium (PVA) was mapped in all procedures, whereas the systemic venous atrium (SVA) was mapped only in 75% of them, A total of 15 EA maps were obtained, with a ratio of 1.9 maps/patient, and an average of 20 375 ± 13 045 total points per patient. In all cases, PVA mapping was performed via retrograde transaortic approach, without transbaffle puncture. Tachycardia was induced in 5 out of 8 procedures, obtaining 6 different tachycardias (4 CTI dependent macro-reentry: 3 w/anticlockwise activation; 1 localized re-entry in SVA; 1 focal AT in SVA).  No arrhythmia was induced in the other 3 procedures, however, in a patient with a previous CTI ablation, evidence of a gap in the ablation line on the voltage map was found. Ablation was performed with an irrigated, contact force, 3.5 mm catheter in 6 of the 8 procedures (75%). A retrograde transaortic approach was used in 3 of CTI dependent macro-reentries (75%). In one patient (who underwent two procedures) ablation was performed through a baffle leak. We report an acute success rate of ablation of 100%, and a recurrence rate of 20% on medium-term follow up. There were no major complications; nonetheless, one patient with history of morbid obesity had a minor vascular complication on the femoral puncture site treated medically.

Conclusions

it’s feasible and safe to use this new mapping catheter in patients with history of atrial switch surgery, both via retrograde and anterograde approach on the PVA and SVA respectively. The most frequent tachycardia observed in this study was anticlockwise CTI-dependent atrial flutter.

Abstract Figure. Patient characteristics