Development and web deployment of prediction model for pulmonary arterial pressure in chronic thromboembolic pulmonary hypertension using machine learning

BACKGROUND AND PURPOSE

Mean pulmonary artery pressure (mPAP) is a key index for chronic thromboembolic pulmonary hypertension (CTEPH). Using machine learning, we attempted to construct an accurate prediction model for mPAP in patients with CTEPH.

METHODS

A total of 136 patients diagnosed with CTEPH were included, for whom mPAP was measured. The following patient data were used as explanatory variables in the model: basic patient information (age and sex), blood tests (brain natriuretic peptide (BNP)), echocardiography (tricuspid valve pressure gradient (TRPG)), and chest radiography (cardiothoracic ratio (CTR), right second arc ratio, and presence of avascular area). Seven machine learning methods including linear regression were used for the multivariable prediction models. Additionally, prediction models were constructed using the AutoML software. Among the 136 patients, 2/3 and 1/3 were used as training and validation sets, respectively. The average of R squared was obtained from 10 different data splittings of the training and validation sets.

RESULTS

The optimal machine learning model was linear regression (averaged R squared, 0.360). The optimal combination of explanatory variables with linear regression was age, BNP level, TRPG level, and CTR (averaged R squared, 0.388). The R squared of the optimal multivariable linear regression model was higher than that of the univariable linear regression model with only TRPG.

CONCLUSION

We constructed a more accurate prediction model for mPAP in patients with CTEPH than a model of TRPG only. The prediction performance of our model was improved by selecting the optimal machine learning method and combination of explanatory variables.

Leaflet remodeling reduces tricuspid valve function in a computational model

Tricuspid valve leaflets have historically been considered "passive flaps". However, we have recently shown that tricuspid leaflets actively remodel in sheep with functional tricuspid regurgitation. We hypothesize that these remodeling-induced changes reduce leaflet coaptation and, therefore, contribute to valvular dysfunction. To test this, we simulated the impact of remodeling-induced changes on valve mechanics in a reverse-engineered computer model of the human tricuspid valve. To this end, we combined right-heart pressures and tricuspid annular dynamics recorded in an ex vivo beating heart, with subject-matched in vitro measurements of valve geometry and material properties, to build a subject-specific finite element model. Next, we modified the annular geometry and boundary conditions to mimic changes seen in patients with pulmonary hypertension. In this model, we then increased leaflet thickness and stiffness and reduced the stretch at which leaflets stiffen, which we call "transition-λ." Subsequently, we quantified mean leaflet stresses, leaflet systolic angles, and coaptation area as measures of valve function. We found that leaflet stresses, leaflet systolic angle, and coaptation area are sensitive to independent changes in stiffness, thickness, and transition-λ. When combining thickening, stiffening, and changes in transition-λ, we found that anterior and posterior leaflet stresses decreased by 26% and 28%, respectively. Furthermore, systolic angles increased by 43%, and coaptation area decreased by 66%; thereby impeding valve function. While only a computational study, we provide the first evidence that remodeling-induced leaflet thickening and stiffening may contribute to valvular dysfunction. Targeted suppression of such changes in diseased valves could restore normal valve mechanics and promote leaflet coaptation.

A tissue-silicone integrated simulator for right ventricular pulsatile circulation with severe functional tricuspid regurgitation

There is a great demand for development of a functional tricuspid regurgitation (FTR) model for accelerating development and preclinical study of tricuspid interventional repair devices. This study aimed to develop a severe FTR model by creating a tissue-silicone integrated right ventricular pulsatile circulatory simulator. The simulator incorporates the porcine tricuspid annulus, valve leaflets, chordae tendineae, papillary muscles, and right ventricular wall as one continuous piece of tissue, thereby preserving essential anatomical relationships of the tricuspid valve (TV) complex. We dilated the TV annulus with collagenolytic enzymes under applying stepwise dilation, and successfully achieved a severe FTR model with a regurgitant volume of 45 ± 9 mL/beat and a flow jet area of 15.8 ± 2.3 cm2 (n = 6). Compared to a normal model, the severe FTR model exhibited a larger annular circumference (133.1 ± 8.2 mm vs. 115.7 ± 5.5 mm; p = 0.009) and lower coaptation height (6.6 ± 1.0 mm vs. 17.7 ± 1.3 mm; p = 0.003). Following the De-Vega annular augmentation procedure to the severe FTR model, a significant reduction in regurgitant volume and flow jet area were observed. This severe FTR model may open new avenues for the development and evaluation of transcatheter TV devices.

Prognostic value of right ventricular free-wall longitudinal strain in patients with pulmonary hypertension: systematic review and meta-analyses

BACKGROUND

Right ventricular (RV) dysfunction is associated with adverse outcomes in patients with pulmonary hypertension (PH). This systematic review and meta-analysis evaluated the prognostic value of RV free-wall longitudinal strain (RVfwLS), compared with other RV parameters in PH.

METHODS

We searched for articles presenting the HR of two-dimensional RVfwLS in PH. HRs were standardised using the within-study SD. The ratio of HRs of a 1 SD change in RVfwLS versus systolic pulmonary arterial pressure (SPAP), systolic tricuspid annular velocities (s'-TV), RV fractional area change (FAC) or tricuspid annular plane systolic excursion (TAPSE) was calculated for each study, after which we conducted a random model meta-analysis. Subgroup analysis regarding the type of outcome, aetiology of PH and software vendor was also performed.

RESULTS

Twenty articles totalling 2790 subjects were included. The pooled HR of a 1 SD decrease of RVfwLS was 1.80 (95% CI: 1.62 to 2.00, p<0.001), and there was a significant association with all-cause death (ACD) and composite endpoints (CEs). The ratio of HR analysis revealed that RVfwLS has a significant, strong association with ACD and CE per 1 SD change, compared with corresponding values of SPAP, s'-TV, RVFAC or TAPSE. RVfwLS was a significant prognostic factor regardless of the aetiology of PH. However, significant superiority of RVfwLS versus other parameters was not observed in group 1 PH.

CONCLUSIONS

The prognostic value of RVfwLS in patients with PH was confirmed, and RVfwLS is better than other RV parameters and SPAP. Further accumulation of evidence is needed to perform a detailed subgroup analysis for each type of PH.

TRIAL REGISTRATION NUMBER

UMIN Clinical Trials Registry (UMIN000052679).

Word of caution: silent late device embolisation after perimembranous ventricular septal defect closure in a 6-Kg infant

We report on a 6-month-old infant (6 Kg/ 64 cm) with perimembranous ventricular septal defect (absent sub-aortic rim, 10 mm left ventricular entry, and 4 and 6 mm right ventricular exists) and successful retrograde closure using an 8x6 mm KONAR-MF™ VSD occluder (Lifetech, China). Immediate and 48 hours post-procedure ultrasounds showed an accurately positioned device and two jets of mild-to-moderate residual shunts. At the 2-week follow-up, the device did not change position and the shunt was stable and intra-prosthetic. The scheduled 3-month follow-up was skipped for familial reasons. The patient came back without alarming symptoms for the regular 6-month follow-up, and the device was found embolised to the left pulmonary artery. The device was retrieved surgically, and the defect was patch-closed with excellent outcomes. There was a pseudoaneurysm involving the tricuspid valve chordae and the device was endothelialized partially on one edge suggesting that embolization occurred somewhere between 3 months and 6 months post-operative. Defects with compromised anatomies should be closed surgically to avoid suboptimal results, especially in small infants.

Revisiting the anatomy of the right ventricle in the light of knowledge of its development

Controversies continue regarding several aspects of the anatomy of the morphologically right ventricle. There is disagreement as to whether the ventricle should be assessed in bipartite or tripartite fashion, and the number of leaflets to be found in the tricuspid valve. In particular, there is no agreement as to whether a muscular outlet septum is present in the normally constructed heart, nor how many septal components are to be found during normal development. Resolving these issues is of potential significance to those investigating and treating children with congenitally malformed hearts. With all these issues in mind, we have revisited our own experience in investigating the development and morphology of the normal right ventricle. To assess development, we have examined a large number of datasets, prepared by both standard and episcopic microscopy, from human and murine embryos. In terms of gross anatomy, we have compared dissections of normal autopsied hearts with virtual dissections of datasets prepared using computed tomography. Our developmental and postnatal studies, taken together, confirm that the ventricle is best assessed in tripartite fashion, with the three parts representing its inlet, apical trabecular, and outlet components. The ventricular septum, however, has only muscular and membranous components. The muscular part incorporates a small component derived from the muscularised fused proximal outflow cushions, but this part cannot be distinguished from the much larger part that is incorporated within the free-standing muscular infundibular sleeve. We confirm that the tricuspid valve itself has three components, which are located inferiorly, septally, and antero-superiorly.

Treatment of cardiac implantable electronic device endocarditis in pacemaker-dependent patients utilizing a percutaneous aspiration system

With the increasing use of cardiac implantable electronic devices, the number of patients with cardiac implantable electronic device-related endocarditis is also rising. The treatment of this type of endocarditis is a challenging clinical task, in particular if device removal is required in patients who are pacemaker dependent. This video tutorial describes a treatment strategy for cardiac implantable electronic device-related endocarditis involving the tricuspid valve in pacemaker-dependent patients. The proposed treatment strategy consists of implanting an epicardial pacemaker via a minimally invasive subxiphoid approach, percutaneous aspiration of tricuspid valve vegetations and complete transvenous explantation of the infected cardiac implantable electronic device system using advanced lead extraction tools.

Refining accuracy of RV-PA coupling in patients undergoing transcatheter tricuspid valve treatment

BACKGROUND

Assessing right ventricular (RV) function is paramount for risk stratification, which remains challenging in patients with tricuspid regurgitation (TR). We assessed RV-pulmonary artery (PA) coupling and its predictability of outcomes after transcatheter tricuspid valve repair (TTVR).

METHODS

Study participants comprised patients undergoing transcatheter tricuspid valve repair to treat symptomatic TR from June 2015 to July 2021. We calculated an RV-PA coupling ratio using a formula, which is dividing tricuspid annular plane systolic excursion (TAPSE) by echocardiographically estimated (ePASP) or invasively measured PASP (iPASP) at baseline. The primary outcome was all-cause mortality or heart failure rehospitalization within one year.

RESULTS

The study participants (n = 206) were at high surgical risk (EuroSCORE II: 7.4 ± 4.8%). The primary outcome occurred in 57 patients within one year. The c-statistics for the outcome were 0.565 (95% CI 0.488-0.643) for TAPSE/ePASP and 0.695 (95% CI 0.631-0.759) for TAPSE/iPASP. The correlation between the ePASP and iPASP was attenuated in patients with massive/torrential TR compared to those with severe TR (interaction p = 0.01). In the multivariable Cox proportional model, TAPSE/iPASP was inversely associated with the risk of the primary outcome (per 0.1-point increase: adjusted-HR 0.67, 95% CI 0.56-0.82, p < 0.001), independent of baseline demographics. According to the TAPSE/iPASP quartiles (i.e., ≤ 0.316; 0.317-0.407; 0.408-0.526; ≥ 0.527), the event-free survival was 43.4%, 48.3%, 77.9%, and 85.4% at one year after TTVR.

CONCLUSION

RV-PA coupling predicts one-year mortality and heart failure rehospitalization after TTVR in patients with TR. The predictability is improved if invasively-measured PA pressure is included.

A rare Serratia marcescens-associated acute endocarditis of a tricuspid valve in an intravenous drug user : A case report and literature review

Serratia marcescens is a gram-negative bacillus that is an opportunistic agent in respiratory tract infections, urinary tract infections, and septicemia. It is rarely also a cause of infective endocarditis which follows a rapid and devastating course, typically in persons with history of intravenous drug use (IDU). This article reports a fatal case of a 27-year-old patient with a known history of IDU, who presented with clinical symptoms concerning right-sided endocarditis as well as signs of acute respiratory distress syndrome. Finally, a detailed review of the literature is provided concerning the acute endocarditis of a tricuspid valve, especially associated with Serratia marcescens infection.

A computer model of the effect of venous-arterial-venous extracorporeal membrane oxygenation venous return of oxygenated blood on right atrial recirculation and tricuspid valve blood oxygen saturation

OBJECTIVE

Venous-arterial venous extracorporeal membrane oxygenation (V-AV ECMO), as a new clinical application of ECMO, showed great clinical application potential in the treatment of patients with combined cardiopulmonary failure. Given the complicated cannulation strategy of V-AV ECMO, its influence on the hemodynamics of the human circulatory system remained unclear.

METHODS

In this paper, a fluid-structure interaction was used to study the effect of V-AV ECMO oxygenated blood shunt ratio on right atrial recirculation and tricuspid valve (TV) blood oxygen saturation. In this study, the right atrium, superior vena cava supplying cannulae and inferior vena cava draining cannulae model of a specific patient was constructed. Seven cases with shunt ratio of 12.50%, 18.75%, 25.00%, 31.25%, 37.50%, 43.75% and 50.00% were designed.

RESULTS

The streamline diagram and velocity contour of oxygenated blood, recirculation fraction (RF), correlation of three variables (shunt ratio, RF, and oxygen saturation), and the oxygen saturation of blood at the TV were extracted for the study. Study results showed that, first, as the shunt ratio increased, the RF of the seven cases was 14.64%, 29.87%, 33.85%, 40.12%, 40.40%, 40.02%, and 38.09%. Second, with the increase of the shunt ratio, oxygen saturation of blood at the TV in seven cases was 82.1%, 82.5%, 83.3%, 83.3%, 84.0%, 84.6%, and 85.3%.

CONCLUSIONS

In this study, the shunt ratio had a strong correlation with the RF and oxygen saturation of blood at the TV. As the shunt ratio increased, the RF initially increased and then stabilized. However, oxygen saturation of blood at the TV would increase with the increase of the shunt ratio, but the degree of increase was small. This research provided useful information for surgeons and operators using V-AV ECMO.

Identification of immune-related signatures and pathogenesis differences between thoracic aortic aneurysm patients with bicuspid versus tricuspid valves via weighted gene co-expression network analysis

BACKGROUND

Thoracic aortic aneurysm (TAA) occurs due to pathological aortal dilation, and both individuals with normal tricuspid aortic valves (TAV) or abnormal bicuspid aortic valves (BAV), the latter being a congenital condition, are at risk. However, some differences are present between TAA/BAV and TAA/TAV with respect to their pathophysiological processes and molecular mechanisms, but their exact nature is still mostly unknown. Therefore, it is necessary to elucidate TAA developmental differences among BAV vs. TAV patients.

METHODS

Publically-available gene expression datasets, aortic tissue derived from TAA/BAV and TAA/TAV individuals, were analyzed by weighted gene co-expression network analysis (WGCNA) to identify gene modules associated with those conditions. Gene Ontology (GO) enrichment analysis was performed on those modules to identify the enriched genes within those modules, which were verified by Gene Set Variation Analysis (GSVA) on a dataset derived from aortic smooth muscle cell gene expression between TAA/TAV and TAV/BAV patients. Immune cell infiltration patterns were then analyzed by CIBERSORT, and a protein-protein interaction (PPI) network was constructed based on WGCNA and enrichment analysis results to identify hub genes, followed by validation via stepwise regression analysis. Three signatures most strongly associated with TAA/TAV were confirmed by receiver operating characteristic (ROC) and decision curve analyses (DCA) between prior-established training and testing gene sets.

RESULTS

WGCNA delineated 2 gene modules being associated with TAA/TAV vs. TAA/BAV; both were enriched for immune-associated genes, such as those relating to immune responses, etc., under enrichment analysis. TAA/TAV and TAA/BAV tissues also had differing infiltrating immune cell proportions, particularly with respect to dendritic, mast and CD4 memory T cells. Identified three signatures, CD86, integrin beta 2 (ITGB2) and alpha M (ITGAM), as yielding the strongest associations with TAA/TAV onset, which was verified by areas under the curve (AUC) at levels approximating 0.8 or above under ROC analysis, indicating their predictive value for TAA/TAV onset. However, we did not examine possible confounding variables, so there are many alternative explanations for this association.

CONCLUSIONS

TAA/TAV pathogenesis was found to be more associated with immune-related gene expression compared to TAA/BAV, and the identification of three strongly-associated genes could facilitate their usage as future biomarkers for diagnosing the likelihood of TAA/TAV onset vs. TAA/BAV, as well as for developing future treatments.

Heterozygous nonsense variants in laminin subunit 3α resulting in Ebstein's anomaly

Ebstein's anomaly is a rare congenital heart disease characterized by tricuspid valve downward displacement and is associated with additional cardiac phenotypes such as left ventricle non-compaction. The genetic basis of Ebstein's anomaly has yet to be fully elucidated, although several genes (e.g., NKX2-5, MYH7, TPM1, and FLNA) may contribute to Ebstein's anomaly. Here, in two Ebstein's anomaly families (a three-generation family and a trio), we identified independent heterozygous nonsense variants in laminin subunit 3 α (LAMA3), cosegregated with phenotypes in families with reduced penetrance. Furthermore, knocking out Lama3 in mice revealed that haploinsufficiency of Lama3 led to Ebstein's malformation of the tricuspid valve and an abnormal basement membrane structure. In conclusion, we identified a novel gene-disease association of LAMA3 implicated in Ebstein's anomaly, and the findings extended our understanding of the role of the extracellular matrix in Ebstein's anomaly etiology.

Right Atrial Function Role in Tricuspid Regurgitation-Related Systemic Venous Congestion

Tricuspid regurgitation (TR) is a frequent valvular pathology and when significant, may cause systemic venous congestion (SC). The right atrium (RA) is an intermediate structure between the tricuspid valve and the venous system and its role in SC is not yet defined. A total of 116 patients with a measurable TR effective regurgitant orifice area (EROA) and regurgitant volume (RVol) were selected from 2020 to 2022. SC was estimated by echocardiography using inferior vena cava diameter and estimated right atrial pressure (eRAP) and by clinical congestive features. TR grade was mild in 23 patients (20%), moderate in 53 patients (46%), and severe in 40 patients (34%). There was a significant decrease in RA function measured by strain with increasing TR severity (p <0.001). There was a marked difference in RA strain between the groups with eRAP >10 and ≤10 mm Hg (25 ± 11% vs 11 ± 7%, p <0.0001). Variables independently associated with inferior vena cava diameter were RA strain (β -0.532, p <0.001), RA volume indexed (β 0.249, p = 0.002), RVol (β 0.229, p = 0.005) and EROA (β 0.185, p = 0.016), and independently associated with eRAP >10 mm Hg were EROA (odds ratio [OR] 1.024, 95% confidence interval [CI] 1.002 to 1.046), RVol (OR 1.039, 95% CI 1.007 to 1.072) and RA strain (OR 0.863, 95% CI 0.794 to 0.940). The addition of RA strain to models containing EROA or RVol significantly improved the power of the model. RA strain was independently associated with the presence of 3 or more congestive features. In conclusion, echocardiographic and clinical signs of SC are frequent in higher degrees of TR, and RA function seems to play a key role in modulating the downstream effect of TR.

The impact of annuloplasty ring or band implantation on post-repair mitral valve haemodynamic performance

OBJECTIVES

The clinical importance of optimal post-repair mitral valve diastolic performance is increasingly being recognized. The haemodynamic effect of a partial annuloplasty band implantation, in comparison to a full ring, remains insufficiently explored.

METHODS

Patients undergoing mitral valve repair for pure degenerative disease between 2011 and 2019 at 2 experienced heart valve centres were eligible for inclusion. Exclusion criteria were concomitant procedures other than tricuspid valve repair and ablation procedures for atrial fibrillation. Pre-discharge and follow-up echocardiograms (1-4 years after surgery) were analysed to assess haemodynamic mitral valve performance.

RESULTS

Of 535 patients meeting the inclusion criteria, 364 (68.0%) patients underwent full annuloplasty ring and 171 (31.0%) partial band implantation. On predischarge echocardiogram, post-repair mitral valve gradient and area did not differ between groups [2.89 mmHg (IQR 2.26-3.72) vs 2.60 mmHg (IQR 1.91-3.55), P = 0.19 and 1.98 cm2 (IQR 1.66-2.46) vs 2.03 cm2 (IQR 1.55-3.06), P = 0.15]. However, multivariable linear regression analysis demonstrated band annuloplasty as a determinant of larger valve area (coefficient 0.467 cm2, standard error 0.105, P < 0.001). On multivariable analysis, no significant impact on post-repair gradient was observed (-0.370 mmHg, standard error 0.167, P = 0.36). At follow-up, the differences between groups disappeared and multivariable regression analysis failed to demonstrate a significant impact of annuloplasty device type on mitral valve gradient (coefficient -0.095 mmHg, standard error 0.171, P = 1.00) or area (coefficient -0.085 cm2, standard error 0.120, P = 1.00). These results were confirmed with a linear mixed model analysis.

CONCLUSIONS

Partial band annuloplasty was related to an improved haemodynamic profile directly after valve repair for degenerative disease but the effect was short-lived. Our results suggest that the type of annuloplasty device has no durable impact on diastolic valve performance.

The Academic Impact of Congenital Heart Surgeons' Society (CHSS) Studies

PURPOSE

We reviewed all 64 articles ever published by The Congenital Heart Surgeons' Society (CHSS) Data Center to estimate the academic impact of these peer-reviewed articles.

MATERIALS AND METHODS

The Congenital Heart Surgeons' Society has performed research based on 12 Diagnostic Inception Cohorts. The first cohort (Transposition) began enrolling patients on January 1, 1985. We queried PubMed to determine the number of publications that referenced each of the 64 journal articles generated by the datasets of the 12 Diagnostic Inception Cohorts that comprise the CHSS Database. Descriptive summaries of the data were tabulated using mean with standard deviation and median with range.

RESULTS

Sixty-four peer-reviewed papers have been published based on the CHSS Database. Fifty-nine peer-reviewed articles have been published based on the 12 Diagnostic Inception Cohorts, and five additional articles have been published based on Data Science. Excluding the recently established Diagnostic Inception Cohort for patients with Ebstein malformation of tricuspid valve, the number of papers published per cohort ranged from 1 for coarctation to 11 for transposition of the great arteries. The 11 articles generated from the CHSS Transposition Cohort were referenced by a total of 111 articles (median number of references per journal article = 9 [range = 0-22, mean = 10.1]). Overall, individual articles were cited by an average of 11 (mean), and a maximum of 41 PubMed-listed publications. Overall, these 64 peer-reviewed articles based on the CHSS Database were cited 692 times in PubMed-listed publications. The first CHSS peer-reviewed article was published in 1987, and during the 35 years from 1987 to 2022, inclusive, the annual number of CHSS publications has ranged from 0 to 7, with a mean of 1.8 publications per year (median = 1, mode = 1).

CONCLUSION

Congenital Heart Surgeons' Society studies are widely referenced in the pediatric cardiac surgical literature, with over 10 citations per published article. These cohorts provide unique information unavailable in other sources of data. A tool to access this analysis is available at: [https://data-center.chss.org/multimedia/files/2022/CAI.pdf].

Transcatheter systemic atrioventricular valve-in-valve implantation in a congenitally corrected transposition of the great arteries patient

We present an asymptomatic pregnant patient with congenitally corrected transposition of the great arteries and severe atrioventricular bioprosthesis regurgitation - with increased maternal and fetal risk due to volume overload. She was considered high risk for reintervention and was submitted to an off-label post-partum transcatheter valve-in-valve implantation with a Sapiens 3 valve. The procedure was successful, and she remains asymptomatic 30 months after - and even went through another successful pregnancy.

VA-ECMO Cardiac Support During Liver Transplant: A Case Report

Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for cardiovascular collapse during and after liver transplantation (LT). According to the most recent guidelines, patients with severe cardiomyopathy are excluded from LT because of high-mortality risk during surgery. Intraoperative ECMO support could give these patients the opportunity to undergo LT by reducing the risk of heart failure and reperfusion syndrome. In this case report, we present a case of veno-arterial ECMO (VA-ECMO) support started before LT surgery in a patient with severe pulmonary hypertension, mitral valve steno-insufficiency, and right heart dysfunction. The presence of severe heart disease would have contraindicated LT, but simultaneous liver cirrhosis contraindicated mitral valve surgery, leaving the patient locked in a "Catch-22" state. The best solution was to perform LT with VA-ECMO support before, during, and after the surgery to reduce cardiac load and possible heart failure. LT was performed with good hemodynamic stability and the patient was successfully weaned from ECMO a few hours after surgery. At the 6 month follow-up, normal liver and kidney functions were recorded as well as an overall improvement of heart function; the patient successfully underwent mitral valve replacement and tricuspid annuloplasty 10 months after transplant and is now in good condition.

Lead-related tricuspid regurgitation and ventricle dysfunction: Current management and future perspectives

The implantation of cardiac implantable electronic devices (CIEDs) may result in or worsen previously existing tricuspid regurgitation (TR). The prevelence of lead-related tricuspid regurgitation (LRTR) in patients with CIEDs is between 7.2% and 44.7% when the degree of worsening TR is not reported, or from 9.8% and 38% when it is diagnosed as worsening of TR severity by at least 2 grades after a CIED has been implanted. It has been suggested that a CIED lead positioned over or pinning a leaflet may be the main cause of TR in this patient population. The septal and posterior leaflets of the tricuspid valve have been reported to be the most affected by CIED leads. Severe LRTR is related to the development of heart failure (HF) or worsening of previously existing dysfunction; it is also associated with elevated mortality. However, there are no definitive predictors of LRTR development or standardized methods of treatment. Some studies have suggested that imaging-guided lead placement can reduce the occurrence of LRTR. This review summarizes current knowledge concerning the development, evaluation, consequences, and management of LRTR.

Heart transplantation in neonatal Marfan syndrome: Saving life in a rare and fatal condition

BACKGROUND

Neonatal Marfan syndrome is a rare disease with mortality in the first year of life reported as high as 95% predominantly due to progressive heart failure from valvar regurgitation and cardiomyopathy. Multisystem involvement and uncertain prognosis have historically precluded transplant candidacy, and current management options are of limited success.

CASE REPORT

We present a baby girl with a postnatal diagnosis of neonatal Marfan syndrome who at 1 year of age underwent mitral valve and tricuspid valve repair with postoperative profound left ventricular and moderate right ventricular dysfunction necessitating biventricular assist device (BiVAD) support and subsequent heart transplant. A number of noncardiac issues persisted in our patient; however, she enjoyed a good quality of life for the initial 3 years posttransplant. Unfortunately, she subsequently developed rapidly progressive coronary allograft vasculopathy (CAV) with progressive deterioration in function and cardiac arrest.

CONCLUSION

To our best knowledge, this is only the second case of neonatal Marfan syndrome to undergo heart transplant reported in the literature and the first with BiVAD support as a bridge to candidacy. This is also the first case of neonatal Marfan syndrome associated with intragenic duplication. This case though demonstrating that earlier listing, ventricular assist device (VAD) support and even primary transplant as treatment in neonatal Marfan syndrome should all be considered viable options but also portends a cautionary tale given the spectrum of comorbidities in this rare and severe disorder.

Novel Use of the Penumbra CAT 12 Lightning Aspiration System for the Treatment of a Complex Thrombus

Debulking procedures using aspiration devices have been previously described in the literature to treat vegetations or thrombi on intracardiac structures such as the tricuspid valve. Transcatheter therapy has also been shown to be an effective alternative to surgical treatment for managing high risk or non-surgical patients. Furthermore, aspiration procedures can help identify the unique etiologies of intracardiac masses which can greatly impact differing treatment modalities. Utilization of aspiration devices combined with blood-loss limiting technologies have led to an increased interest in using aspiration systems to address a wider array of clinical situations that can occur. Herein we describe our experience in using the Penumbra CAT 12 Lightning Aspiration System in addressing and treating a mobile mass attached to the lead of an implantable cardiac device.

Permutations in pacer wire implantation in patients evaluated for transcatheter tricuspid valve interventions

Pacer wire induced tricuspid regurgitation is not well-understood. The mechanisms behind pacer wired induced tricuspid regurgitation have not been clearly defined. This clinical vignette sets to identify different technical mechanisms behind cardiac lead induced tricuspid regurgitation to help optimize cardiac lead implantation strategies for future device implantation.

Early and severe tricuspid valve dysplasia in a fetus with cardiospondylocarpofacial syndrome due to a variant c.616T>G p.(Tyr206Asp) in MAP3K7

Cardiospondylocarpofacial syndrome (CSCF; MIM#157800) is a rare condition caused by monoallelic variants in the MAP3K7 gene. The characteristic features of CSCF include growth retardation, facial dysmorphism, carpal-tarsal fusion, dorsal spine synostosis, deafness, inner ear malformation, cardiac septal defect and valve dysplasia. We present here a 20-week-old fetus with cardiospondylocarpofacial syndrome arising from a de novo variant c.616T>G p.(Tyr206Asp) in the MAP3K7 (NM_145331.3) gene with early and severe tricuspid valve dysplasia as a prenatal manifestation. Fetal echocardiography revealed tricuspid regurgitation with valve prolapse. Fetus had facial dysmorphism and dilated right atrium and right ventricle with tricuspid valve dysplasia on perinatal evaluation. To the best of our knowledge, this is the first report mentioning the prenatal manifestation of cardiospondylocarpofacial syndrome.

Dysplastic Pulmonary Valve Infective Endocarditis With an Atrial Septal Defect-A Black Swan Event: When Rarity Brings Clarity

ABSTRACT

A case of infective endocarditis of a dysplastic pulmonic valve along with atrial septal defect has been described. Right-sided endocarditis has now increased in frequency because of cardiac invasive procedures and intravenous drug abuse. Although the tricuspid valve usually bears the brunt of right-sided endocarditis, there have now been increasing reports of pulmonary valve infective endocarditis.

Moyamoya Disease Complicating Ebstein's Anomaly

Ebstein's anomaly is an uncommon congenital disorder affecting the tricuspid valve. We herein report a 38-year-old woman who experienced consciousness and sensory disturbance during treatment for heart failure caused by Ebstein's anomaly. Urgent magnetic resonance imaging and cerebral angiography demonstrated acute cerebral infarction and internal carotid artery obstruction with the development of collateral arteries. We diagnosed her with multiple cerebral infarctions due to moyamoya disease. Ebstein's anomaly concomitant with moyamoya disease is extremely rare. However, we should consider the possibility of this rare but important concurrence when treating patients with heart failure due to Ebstein's anomaly to avoid excessive diuresis and vasodilation and irreversible brain injury.

A Physics-Guided Neural Operator Learning Approach to Model Biological Tissues From Digital Image Correlation Measurements

We present a data-driven workflow to biological tissue modeling, which aims to predict the displacement field based on digital image correlation (DIC) measurements under unseen loading scenarios, without postulating a specific constitutive model form nor possessing knowledge of the material microstructure. To this end, a material database is constructed from the DIC displacement tracking measurements of multiple biaxial stretching protocols on a porcine tricuspid valve anterior leaflet, with which we build a neural operator learning model. The material response is modeled as a solution operator from the loading to the resultant displacement field, with the material microstructure properties learned implicitly from the data and naturally embedded in the network parameters. Using various combinations of loading protocols, we compare the predictivity of this framework with finite element analysis based on three conventional constitutive models. From in-distribution tests, the predictivity of our approach presents good generalizability to different loading conditions and outperforms the conventional constitutive modeling at approximately one order of magnitude. When tested on out-of-distribution loading ratios, the neural operator learning approach becomes less effective. To improve the generalizability of our framework, we propose a physics-guided neural operator learning model via imposing partial physics knowledge. This method is shown to improve the model's extrapolative performance in the small-deformation regime. Our results demonstrate that with sufficient data coverage and/or guidance from partial physics constraints, the data-driven approach can be a more effective method for modeling biological materials than the traditional constitutive modeling.

Native heart valve thrombosis associated with COVID-19 - a report of 4 cases

Native heart valve thrombosis (NHVT) is a rare valvular pathology, usually associated with prothrombotic state or disturbed intracardiac blood flow related to structural valve abnormalities. While different venous and arterial thromboembolic complications of COVID-19 have been widely described, so far NHVT has not been reported in the context of the disease. The authors describe 4 cases of NHVT associated with COVID-19, revealed on aortic, mitral (2 patients) and tricuspid valve. In a 29-yearold male with mild pneumonia, large thrombus developed on bicuspid aortic valve (BAV), which resulted in fatal brain emboli. In a 76-yearold male with a history of rheumatoid arthritis (RA) being in a recovery period after COVID-19, central retinal artery occlusion (CRAO) was the first sign of mitral valve thrombus, which disappeared after 3 weeks, during apixaban use. Such therapy was also successful in a 46-yearold female with multiple cardiovascular risk factors in whom mitral valve thrombus was found in a routine echocardiography after she got COVID-19 the third time. In a 75-year-old man with moderate COVID-19 pneumonia and bacterial coinfection, coexistent transient focal LV dysfunction and tricuspid valve thrombus were observed. The patient was treated with apixaban as well; however, in this case only reduction in the thrombus size was seen after 4 months therapy. The authors indicate that in patients with COVID-19 and NHVT, other prothrombotic conditions can usually be found. This complication may involve different valves and occur irrespective of COVID-19 severity. Interdisciplinary evaluation of such patients is necessary.

The Association of Pulmonary Flow Characteristics With Cardiac Function in Tricuspid Valve Malformation Fetuses: Study With Two-Dimensional Speckle Tracking Echocardiography

OBJECTIVES

To explore the relationship between cardiac function and pulmonary flow characteristics in tricuspid valve malformation (TVM) fetuses by conventional and speckle tracking echocardiography.

METHODS

Eighty-eight TVM fetuses were retrospectively included and compared with 80 normal controls. TVM fetuses in each trimester were divided into two subgroups according to pulmonary flow characteristics: those with normal pulmonary flow (TVM-N) and those with reduced or absent pulmonary flow (TVM-R/A). Cardiac measurements, Celermajer index, and Simpson-Andrews-Sharland (SAS) score were obtained. Speckle tracking echocardiography was used to compute ventricular deformation parameters.

RESULTS

TVM fetuses demonstrated significantly lower global longitudinal strain (GLS) and strain rate for both ventricles than controls (all P < .05). When compared with TVM-N, left ventricular (LV) ejection fraction, LV fractional area change, right ventricular (RV) fractional area change, LVGLS, and RVGLS were significantly reduced (all P < .05), while the RV diameter Z-score, RV/LV diameter, SAS score, and Celermajer index were obviously increased in TVM-R/A in both trimesters (all P < .05). Both LVGLS and RVGLS correlated with cardiothoracic circumference ratio, RV diameter Z-score, RV/LV diameter, Celermajer index, and SAS score (all P < .01). There was a slow decline for LVGLS and RVGLS in TVM-N fetuses throughout the gestation. Conversely, these two parameters worsened rapidly in TVM-R/A group.

CONCLUSIONS

TVM fetuses present biventricular dysfunction by deformation analysis in the second and third trimester of pregnancy. TVM fetuses with reduced or absent pulmonary flow exhibit significantly greater impairment and more rapid deterioration of cardiac function, which may contribute to poor outcomes.

Pediatric aortic valve neocuspidization

Treatment of pediatric aortic valve disease is controversial. In this regard, interest is growing in the neocuspidization of the aortic valve according to Ozaki. In this video tutorial, we illustrate briefly the entire reconstruction technique of a neoaortic valve with pretreated autologous pericardium used in our institution in pediatric patients by describing a case of an incompetent native tricuspid aortic valve.

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.

[Cunninghamella bertholletiae-infective endocarditis complicated by tricuspid valve giant vegetation in a patient with aplastic anemia]

A 62-year-old female was presented to the hospital of the current study for pancytopenia and was diagnosed with severe aplastic anemia. She was treated with a combination therapy of antithymocyte globulin, cyclosporine A, and eltrombopag. The patient also presented with febrile neutropenia after commencement of the treatment and did not respond to the various antibiotics and antifungal agents. Echocardiography showed a giant vegetation attached to the tricuspid valve on Day 78 of the immunosuppressive therapy, and the tricuspid valve replacement was performed. The vegetation was formed by Cunninghamella bertholletiae, a mucor type, and was treated with high-dose liposomal amphotericin B (L-AMB), which was terminated after six weeks due to decreased renal function. In addition, mucormycosis was controlled by posttreatment with posaconazole (PSCZ). This is a rare case of mucormycosis that developed into a giant vegetation during the immunosuppressive therapy for aplastic anemia. It was believed to be a valuable case to consider in future mucormycosis treatment, including the success of the treatment by switching from L-AMB to PSCZ.

Patient-Specific Quantification of Normal and Bicuspid Aortic Valve Leaflet Deformations from Clinically Derived Images

The clinical benefit of patient-specific modeling of heart valve disease remains an unrealized goal, often a result of our limited understanding of the in vivo milieu. This is particularly true in assessing bicuspid aortic valve (BAV) disease, the most common cardiac congenital defect in humans, which leads to premature and severe aortic stenosis or insufficiency (AS/AI). However, assessment of BAV risk for AS/AI on a patient-specific basis is hampered by the substantial degree of anatomic and functional variations that remain largely unknown. The present study was undertaken to utilize a noninvasive computational pipeline ( https://doi.org/10.1002/cnm.3142 ) that directly yields local heart valve leaflet deformation information using patient-specific real-time three-dimensional echocardiographic imaging (rt-3DE) data. Imaging data was collected for patients with normal tricuspid aortic valve (TAV, [Formula: see text]) and those with BAV ([Formula: see text] with fused left and right coronary leaflets and [Formula: see text] with fused right and non-coronary leaflets), from which the medial surface of each leaflet was extracted. The resulting deformation analysis resulted in, for the first time, quantified differences between the in vivo functional deformations of the TAV and BAV leaflets. Our approach was able to capture the complex, heterogeneous surface deformation fields in both TAV and BAV leaflets. We were able to identify and quantify differences in stretch patterns between leaflet types, and found in particular that stretches experienced by BAV leaflets during closure differ from those of TAV leaflets in terms of both heterogeneity as well as overall magnitude. Deformation is a key parameter in the clinical assessment of valvular function, and serves as a direct means to determine regional variations in structure and function. This study is an essential step toward patient-specific assessment of BAV based on correlating leaflet deformation and AS/AI progression, as it provides a means for assessing patient-specific stretch patterns.

3D Holographic Virtual Surgical Planning for a Single Right Ventricle Fontan Patient Needing Heartmate III Placement

A 15 year old female with hypoplastic left heart syndrome status post Norwood with Sano modification, bidirectional Glenn and extracardiac conduit Fontan developed severe right ventricular (RV) systolic dysfunction. Due to symptomatic heart failure, she underwent assessment for ventricular assist device (VAD) placement as a bridge-to-cardiac transplantation strategy. To evaluate her atypical anatomy, a chest computed tomography (CT) was uploaded into an EchoPixel True3D (Santa Clara, CA) view portal along with an accurately scaled 3D surface model of the HeartMate III (HM3) device. The surgeon then manipulated the position of the HM3 to evaluate multiple potential device positions in relation to anatomic features such as the intraventricular septum, tricuspid valve annulus, and RV muscle bundles. The patient was taken to the operating room and the HM3 device was placed just anterior to the RV apex as virtually planned. She had an uneventful postoperative course, underwent cardiac transplantation on postoperative day (POD) 63 and is doing well now 19 months post-transplantation.

[Surgery for Recurrent Common Atrioventricular Regurgitation]

Patients with common atrioventricular valve( CAVV) regurgitation are at increased risk of mortality and adverse outcomes during single ventricle palliation. CAVV repair is one of the most challenging techniques in pediatric cardiac surgery. Especially in patients who require CAVV repair before Glenn operation have the complicated valve anatomy and sometimes need repeat valve surgery. Several techniques of CAVV repair include annuloplasty, commissuroplasty, cleft closure, edge-to-edge repair, and bivalvation. Prosthetic valve replacement for uncontrollable CAVV regurgitation in patients with single ventricular physiology is the last available option entailing a moderately high risk of death, valve dysfunction, and redo valve replacement.

Analysis of Risk Factors for Major Complications of 1500 Transvenous Lead Extraction Procedures with Especial Attention to Tricuspid Valve Damage

Background: Transvenous lead extraction (TLE) is a relatively safe procedure, but it may cause severe complications such as cardiac/vascular wall tear (CVWT) and tricuspid valve damage (TVD). Methods: The risk factors for CVWT and TVD were examined based on an analysis of data of 1500 extraction procedures performed in two high-volume centers. Results: The total number of major complications was 33 (2.2%) and included 22 (1.5%) CVWT and 12 (0.8%) TVD (with one case of combined complication). Patients with hemorrhagic complications were younger, more often women, less often presenting low left ventricular ejection fraction (LVEF) and those who received their first cardiac implantable electronic device (CIED) earlier than the control group. A typical patient with CVWT was a pacemaker carrier, having more leads (including abandoned leads and excessive loops) with long implant duration and a history of multiple CIED-related procedures. The risk factors for TVD were similar to those for CVWT, but the patients were older and received their CIED about nine years earlier. Any form of tissue scar and technical problems were much more common in the two groups of patients with major complications. Conclusions: The risk factors for CVWT and TVD are similar, and the most important ones are related to long lead dwell time and its consequences for the heart (various forms of fibrotic scarring). The occurrence of procedural complications does not affect long-term survival in patients undergoing lead extraction.

Transcatheter valve-in-valve-in-valve replacement in tricuspid position in a patient with pre-existing permanent dual-chamber pacemaker

Graphic abstract

Innovation in surgical training: Simulating prosthetic heart valves and annuloplasty rings using pacifiers for cardiac surgery wet-labs in a resource limited setting

Conducting a hands-on cardiac wet-lab on valvular surgeries in a resource-limited setting is restricted by the lack of prosthetic heart valves and annuloplasty rings for developing cognitive and technical skills required to understand and protect the three-dimensional cardiac anatomy. In recent times, simulation is regarded as an effective tool in surgical education and has proven to improve the technical skills of trainees. The current short report presents a novel simulator to mimic heart valve replacement surgeries by using a pacifier as a prosthetic valve and annuloplasty ring. Considering resource-constraints in the local context, pacifier-based valve simulators can be usedful as they are cost-effective, readily available, easy to assemble, sturdy to use and have been remarkably helpful in teaching heart valve surgeries to residents and junior surgeons.

Virtually All Complications of Active Infective Endocarditis Occurring in a Single Patient

Described herein is a 49-year-old black man with advanced polycystic renal disease, on hemodialysis for 6 years, who during his last 12 days of life had his vegetations on the aortic valve extend to the mitral and tricuspid valves, through the aortic wall to produce diffuse pericarditis, to the atrioventricular node to produce complete heart block, and embolize to cerebral arteries producing multiple brain infarcts, to a branch on the left circumflex coronary artery producing acute myocardial infarction, and to mesenteric arteries producing bowel infarction.

[Tricuspid Valve Replacement Preserving the Leaflets in a Congenitally Corrected Transposition of the Great Arteries;Report of a Case]

In patients with a congenitally corrected transposition of the great arteries (ccTGA), the regurgitation of the systemic atrioventricular valve (SAVV) increases and anatomical right ventricular (ARV) dysfunction often progressively develops. A low systemic ventricular ejection fraction( SVEF) is a risk factor for mortality. However, in patients with a low ejection fraction of ARV, it is unclear how to best perform valve replacement for patients with regurgitation of SAVV. A 70-year-old female with respirator discomfort was admitted to our hospital and diagnosed to have situs solitus ccTGA, severe SAVV regurgitation, and ARV dysfunction. Her ARV ejection fraction was 25% and she was therefore dependent on inotropic agents. We successfully performed a tricuspid valve replacement while preserving the leaflets, the chorda tendineae's, and papillary muscles, and placing the lead for cardiac resynchronization therapy on the ARV. Her postoperative course was uneventful. Thereafter, she was discharged 6 weeks after surgery.

A review of heart valve disease research in Malaysia

INTRODUCTION

Heart valve disease comprises a cluster of conditions affecting the aortic, mitral, pulmonary and tricuspid valves. This paper reviews all the research on heart valve disease in Malaysia published between the years 2000- 2016.

METHODS

The methodology was based on the search process described in the paper, "Bibliography of clinical research in Malaysia: methods and brief results". The search databases included PubMed, Scopus and several Malaysian journals such as MyJurnal and UKM Journal Repository, by using the following keywords: (heart valve disease OR infective endocarditis OR rheumatic heart disease) and (Malaysia).

RESULTS

In all 94 papers were identified of which 39 papers were selected and reviewed on the basis of their relevance. The local studies contributed to the knowledge and understanding of the epidemiology, aetiology, pathophysiology, clinical presentations, investigations, treatment, and outcomes of heart valve disease in the country.

DISCUSSION

The clinical relevance of the studies performed in the country is discussed along with recommendations for future research.

[A Giant Papillary Fibroelastoma in the Right Ventricle]

Papillary fibroelastoma (PFE) accounts for approximately 8% of benign primary cardiac tumors. PFE frequently develops in the left heart system, such as the aortic valve and the mitral valve. We report a case of a giant PFE in the right ventricle. The patient was an 83-year-old woman with a history of chronic atrial fibrillation, diabetes, and hypertension. She had experienced palpitation and shortness of breath for several years. A giant mobile tumor was observed in the right ventricle by transthoracic echocardiography, and its extirpation was performed. Intraoperatively, a giant tumor of 3 cm in diameter was observed on the right ventricular side of the posterior tricuspid leaflet. As the tumor strongly adhered to the tendinous cords, it was unavoidable to resect the tendinous cords. Thus, a tricuspid valve repair was performed in addition to the tumor extirpation. The patient was diagnosed with papillary fibroelastoma by pathological examination.

[Surgical Repair without Ventriculotomy for Double-chambered Right Ventricle in a 61-year-old Man;Report of a Case]

A 61-year-old man with double-chambered right ventricle( DCRV) was operated on successfully without ventriculotomy. The patient presented with cardiac murmur and electrocardiogram abnormality with exertional dyspnea. Echocardiography demonstrated double-chambered right ventricle with severe tricuspid valve regurgitation. Cardiac catheterization data revealed a 110 mmHg peak-to-peak pressure gradient in the right ventricular cavity with normal pulmonary pressure. The tricuspid valve was repaired with an annuloplasty ring, and the abnormal muscle bands in right ventricular outflow tract were resected through both right atrium and pulmonary artery. No major complications occurred after surgery. Postoperative echocardiography demonstrated a pressure gradient of 18 mmHg between the pulmonary artery and right ventricle without tricuspid regurgitation, and his clinical symptoms were improved. Surgical repair without right ventriculotomy combined with tricuspid annuloplasty was effective and feasible for DCRV in an adult patient.