[Pulmonary heart: A review].

The review on the problem of the pulmonary heart pursues two goals: firstly, to restore historical justice and to show the priority studies of doctor Dmitry D. Pletnev on such problems as diagnosis of right ventricular myocardial infarction, clinical characteristics of congestive heart failure of the right ventricle; secondly, to outline the modern concept of the pulmonary heart. The review provides an analysis of the pathogenetic mechanisms of the development of heart failure in the pulmonary heart. Much attention is paid to echo cardiography data and biological markers are emphasized in assessing the function of the right atrium, right ventricle, tricuspid valve regurgitation, pulmonary artery pressure. Prognostically unfavorable signs of the course of the pulmonary heart have been identified, which include a high degree of tricuspid valve regurgitation, the amplitude of movement of the fibrous valve ring (TAPSE) and atrial fibrillation developing with dilation of the right atrium.

Different Causes of Functional Tricuspid Valve Regurgitation Are Linked to Differences in Tricuspid Valve and Right-Sided Heart Geometry and Function: 3D Echocardiography Study.

Background and Objectives: The aim of this study was to clarify the tricuspid valve (TV) and right ventricular (RV) geometry and function characteristics using 3D echocardiography-based analysis and to identify echocardiographic predictors for severe tricuspid regurgitation (TR) in different etiologies of functional TR (fTR). Methods and Results: The prospective study included 128 patients (median age 64 years, 57% females): 109 patients with moderate or severe fTR (69-caused by dominant left-sided valvular pathology (LSVP), 40 due to precapillary pulmonary hypertension (PH)), and 19 healthy controls. The 2D and 3D-transthoracic echocardiography analysis included TV, right atrium, RV geometry, and functional parameters. All the RV geometry parameters as well as 3D TV parameters were increased in both fTR groups when compared to controls. Higher RV diameters, length, areas, volumes, and more impaired RV function were in PH group compared to LSVP group. PH was associated with larger leaflet tenting height, volume, and more increased indices of septal-lateral and major axis tricuspid annulus (TA) diameters. LVSP etiology was associated with higher anterior-posterior TA diameter and sphericity index. Univariate and multivariate logistic regression and ROC analyses revealed that different fTR etiologies were associated with various 2D and 3D echocardiographic parameters to predict severe TR: major axis TA diameter and TA perimeter, the leaflet tenting volume had the highest predictive value in PH group, septal-lateral systolic TA diameter-in LSVP group. The 3D TA analysis provided more reliable prediction for severe fTR. Conclusions: TV and RV geometry vary in different etiologies of functional TR. Precapillary PH is related to more severe RV remodeling and dysfunction and changes of TV geometry, when compared to LSVP group. The 3D echocardiography helps to determine echocardiographic predictors of severe TR in different fTR etiologies.

A percutaneous approach to create tricuspid regurgitation in swine: a model for transcatheter tricuspid valve therapy assessment.

PURPOSE: The purpose of this study was to develop a simple and effective percutaneous approach to create tricuspid regurgitation in swine. METHODS: Eleven pigs (71.68 ± 7.70 kg, 3 male) were involved in this study. A grasping forceps was introduced into the right ventricle through a steerable sheath under fluoroscopic guidance and used to disrupt the tricuspid valve apparatus by avulsing leaflet or chordae tendineae repeatedly. Transthoracic echocardiography and right ventricular angiography were used to evaluate the degree of tricuspid regurgitation created. RESULTS: Ten of the 11 pigs (90.91%) achieved severe tricuspid regurgitation and 1 (9.09%) obtained moderate tricuspid regurgitation immediately after the procedure. Heart rate of the pigs significantly increased immediately after tricuspid regurgitation creation compared to baseline (88.64 ± 23.24 vs. 76.00 ± 15.30 bpm, P = 0.02), but recovered to normal level at one month follow-up (77.09 ± 11.97 bpm, P = 0.85). The right atrium, tricuspid valve annulus, and right ventricle dilated obviously one month after tricuspid regurgitation creation (dimension changes: 3.01 ± 0.35 vs. 3.56 ± 0.40 cm, P = 0.02; 2.92 ± 0.36 vs. 3.37 ± 0.39 cm, P = 0.01; 3.06 ± 0.42 vs. 3.60 ± 0.47 cm, P = 0.03 respectively). Autopsy findings showed that rupture of leaflet and/or chordae tendineae finally led to the tricuspid regurgitation. CONCLUSIONS: Severe tricuspid regurgitation can be created by a simple and effective percutaneous approach with a grasping forceps in swine model and right heart dilation can be observed consistently at one-month follow-up. This model will be valuable in pre-clinical studies for developing new tricuspid valve repair or replacement technique to treat severe tricuspid regurgitation.

Mechanical and Structural Evaluation of Tricuspid Bicuspidization in a Porcine Model.

INTRODUCTION: Tricuspid regurgitation (TR) affects approximately 1.6 million Americans and is associated with just a 63.9% 1-year survival rate in its moderate to severe forms due to its asymptomatic nature and late diagnosis and surgical referral. As a result, industrial fervor has begun to broach this topic, with several percutaneous treatment devices currently under development. As much remains unknown about the tricuspid apparatus, the mechanics of these procedures remain unquantified. In this study, a testing apparatus and technique for the evaluation of percutaneous tricuspid valve (TV) bicuspidization were developed for the evaluation of these parameters in twelve porcine hearts. METHODS: The passive relaxed myocardial state and the active contracted state were each induced in six porcine hearts and the bicuspidization experiment was run twice, the second time after induction of TR. TV annular area, cinching force, static leakage through the TV annulus, and annular ellipticity were quantified and compared among the groups. RESULTS: The use of phenol was effective to induce functional TR by increased annular area. Cinching force was not found to differ between any of the testing states, but the bicuspidization experiment was able to reduce the TR annular area to that of its healthy counterpart in addition to reducing static leakage through the TV annulus. Despite appropriately reducing the area, bicuspidization was found to induce a more circular TV annular shape. CONCLUSION: Taken together, these results provide a first mechanical analysis of the TV bicuspidization mechanism and may serve as a point of reference for future clinical animal studies.

Three-dimensional echocardiography investigation of the mechanisms of tricuspid annular dilatation.

Tricuspid annular (TA) size, assessed by 2D transthoracic echocardiography (TTE), has a well-established prognostic value in patients undergoing mitral valve surgery, with TA dilatation triggering simultaneous tricuspid annuloplasty. While TA dilatation is common in patients with dilated atria secondary to atrial fibrillation, little is known about the mechanisms of TA dilatation in patients with sinus rhythm (SR). This study aimed to identify echocardiographic parameters most closely related to the TA size as a potential tool for identification of patients prone to developing TA enlargement. 120 patients with SR underwent clinically indicated TTE, including 30 patients with normal hearts and 90 patients diagnosed with at least one right heart abnormality, defined as: right ventricular (RV) or right atrial (RA) dilatation, ≥ moderate tricuspid regurgitation (TR) and elevated systolic pulmonary artery pressure (sPAP). RA and RV end-diastolic and end-systolic volumes (EDV, ESV) and function were measured using commercial 3D software (TomTec). 3D RV long and short axes were used as surrogate indices of RV shape. Degrees of TR and sPAP were estimated by 2D TTE. 3D TA sizing was performed at end-diastole using 3D custom software. Linear regression analysis was used to identify variables best correlated with TA size, followed by multivariate analysis to identify independent associations. The highest correlations were found between TA area and: RA ESV (r = 0.73; p < 0.01), RV EDV (r = 0.58; p < 0.01), RV end-diastolic long and short axes (r = 0.53, 0.42; both p < 0.01), TR degree (r = 0.40; p < 0.01) and sPAP (r = 0.32; p < 0.01). Multivariate analysis revealed that RA ESV was the only parameter independently associated with TA area (p < 0.05, r = 0.85). In conclusion, RA volume plays an important role in TA dilatation even in patients with normal SR. Understanding of annular remodeling mechanisms could aid in identifying patients at higher risk for TA dilatation, especially those scheduled for mitral valve surgery.

Contemporary Etiologies, Mechanisms, and Surgical Approaches in Pure Native Aortic Regurgitation.

OBJECTIVE: To study contemporary etiologies, mechanisms, and corresponding surgical approaches in isolated aortic regurgitation (AR). PATIENTS AND METHODS: Consecutive patients undergoing surgery for moderately severe and severe AR were retrospectively identified from January 1, 2006, through October 20, 2017. Intraoperative echocardiograms, surgical reports, and pathology reports were reviewed. RESULTS: Of 382 patients (54±16 years, 82% men), there were 207 (54%) tricuspid (TAV), 167 (44%) bicuspid (BAV), 5 quadricuspid, and 3 unicuspid aortic valves. Isolated AR mechanisms (n=116, 30%) included cusp prolapse (n=44, 11%), restriction/retraction (n=33, 9%), aortic root dilatation (n=33, 9%), perforation (n=5, 1%), and fenestration (<1%); mixed mechanisms were present in 266 (70%). The most common mixed mechanism was root dilatation and prolapse (27% BAV vs 16% TAV, P=.01). Valve repair (AVr) was performed in 31% BAV and 23% TAV (P=.06). Aortic surgery was more common in BAV (37% vs 27%, P<.001). Overall, root dilatation was associated with AVr. In TAV, cusp prolapse and restriction/retraction were associated with replacement; in BAV, prolapse was associated with AVr. AR etiology was idiopathic in 43% TAV patients, 47% of whom had root dilatation. CONCLUSIONS: BAV accounted for 44% of surgical referrals for AR and, compared with TAV, was more often associated with prolapse, root dilatation, and mixed mechanisms of AR. Because mechanisms affected the choice of AVr differently in BAV and TAV, comprehensive mechanistic description of surgical AR is critical.

Intraoperative Implantation of Temporary Endocardial Pacing Catheter During Thoracoscopic Redo Tricuspid Surgery.

BACKGROUND: The placement of a temporary epicardial pacing wire is a challenge during a minimally invasive redo cardiac operation. The aim of this study is to assess the application of temporary endocardial pacing in patients who underwent minimally invasive redo tricuspid surgery. METHODS: Perioperative data of consecutive patients who underwent thoracoscopic redo tricuspid surgery were collected. All the tricuspid surgeries and combined procedures were performed under peripheral cardiopulmonary bypass without aortic cross-clamping. A sheath was introduced into the right jugular vein beside the percutaneous superior vena cava cannula and a temporary endocardial pacing catheter was guided into the right ventricle via the sheath prior to the right atrial closure. The pacemaker was connected and run as needed during or after operation. RESULTS: A total of 33 patients who underwent thoracoscopic redo tricuspid surgery were enrolled. Symptomatic tricuspid valve regurgitation (93.9%) and tricuspid valvular prosthesis obstruction (6.1%) after previous cardiac operations were noted as indications for a redo surgery. The mean time from previous cardiac operation to this time redo surgery was 13.3±6.4years. Isolated tricuspid valve replacement was performed in 18 patients (54.5%) and tricuspid valve plasty combined with or without mitral valve replacement was performed in 15 patients (45.5%). A temporary endocardial pacing catheter was successfully placed in the right ventricle for all patients with good sensing and pacing. No temporary pacing related complications occurred from insertion to removal of pacing catheter in the patients. CONCLUSIONS: This application of temporary endocardial pacing provided a safe and effective substitute for epicardial pacing in patients who underwent minimally invasive redo tricuspid surgery.

Is hepatojugular reflux a good predictor of heart failure with preserved ejection fraction?

Hypertension may occur with left ventricular (LV) diastolic dysfunction, and the consequence may be symptoms and signs of heart failure (HF). Hepatojugular reflux (HJR), described as a sign of regurgitation of the tricuspid valve, may reflect structural and functional changes of the LV in the hypertensive patient. The signal may be present in the presence of HF. Case: male, 49 years old with uncontrolled blood pressure. Physical examination showed jugular turgescence, HJR, and elevated blood pressure. Complementary exams showed signs of atrial and left ventricular overload in the electrocardiogram and, the echocardiogram showed left atrium volume increase, concentric LV hypertrophy and signs of grade I diastolic dysfunction. DISCUSSIO: The HJR present correlates with pulmonary artery pressure and probably reflect the increase in central blood volume.

Specific Anatomic Considerations for Tricuspid Interventions.

PURPOSE OF REVIEW: This review discusses the normal anatomy and pathology of the tricuspid valve (TV) and right side of the heart. Emphasis is on those anatomic and pathologic features relevant to interventions intended to restore normal function to the TV in disease states. RECENT FINDINGS: TV pathology is less common than aortic and mitral valve pathology, and treatment and outcomes for interventions face considerable hurdles. New innovations and early data showing safety and efficacy in transcatheter interventions have transformed TV interventions into the next frontier in cardiac valve disease treatment. Certain features of the TV and right heart have presented themselves as potential targets, as well as impediments, for TV intervention. The causes of TV pathology and the anatomy of the TV and right heart bring unique challenges to intervention. Approaches to intervention will continue to progress and change the way we view and treat TV pathology.

Atrial functional tricuspid regurgitation: An underappreciated cause of secondary tricuspid regurgitation.

Secondary tricuspid regurgitation (TR) caused by right ventricular enlargement in the setting of left heart disease/pulmonary hypertension has been well described. In contrast, that associated with right atrial enlargement-atrial functional TR (AF-TR)-remains largely underappreciated. AF-TR most often occurs in the setting of lone atrial fibrillation, although it is also seen in its absence (idiopathic AF-TR). Several recent studies have found that the prevalence, hemodynamic significance, and prognosis of AF-TR are not inconsequential, suggesting increased physician awareness of this novel clinical entity is warranted. This article discusses the pathogenesis, echocardiographic findings, and treatment of this underappreciated cause of secondary TR.

Modified band annuloplasty technique for functional tricuspid regurgitation repair in patients with grossly dilated annuli: The three-suture junctional continuous suture band annuloplasty technique.

Functional tricuspid regurgitation (FTR) is the most common of all tricuspid dysfunctions. Ring annuloplasty is an effective treatment strategy for FTR. Currently, the most commonly used suture method for tricuspid ring annuloplasty is the interrupted U-shaped suture method. However, when tricuspid annuli are grossly dilated (septal segments > 60 mm), interrupted sutures are insufficient in avoiding the folding over of the annulus or the tearing of sutures. Therefore, we recommend a new band suture technique; namely, the three-suture junctional continuous suture band annuloplasty technique.

Severe tricuspid valve destruction secondary to previous non-appropriately treated endocarditis.

Tricuspid valve(TV) destruction with a remote history of endocarditis without known risk factors (ie, HIV, intravenous drug use, neoplasm, trauma) is rare. We describe the case of a TVs destruction in a 12-year-old non-HIV boy, with a 4-year history of endocarditis without known risk factors nor evidence regarding previous appropriately management.

Right Atrioventricular Valve Leaflet Morphology Redefined: Implications for Transcatheter Repair Procedures.

OBJECTIVES: The authors aimed to comprehensively detail the right atrioventricular valve functional leaflet anatomies. BACKGROUND: The rapid development of both surgical and percutaneous repair techniques for tricuspid regurgitation has renewed interest in variations in the morphology of the right atrioventricular valve. METHODS: The functioning right atrioventricular valves of 40 reanimated human hearts were imaged using Visible Heart methodologies. Hearts were then perfusion-fixed and dissected, uniquely allowing for the comparative assessments of functional versus fixed valve anatomies from the same set of donor hearts. RESULTS: The right atrioventricular valves have "3-leaflet" configurations in 57.5% and "4-leaflet" configurations in the remaining hearts. For 4-leaflet valves, extra leaflets were commonly observed in the most inferior regions of the annuli. No difference in valve perimeters between 2 valve types were observed (112.2 vs. 117.1 mm; p = 0.14). In 3-leaflet valves, septal, mural, and superior leaflets occupied 32.2 ± 6.5%, 15.9 ± 5.5%, and 25.5 ± 6.2% of the annulus, respectively, whereas in the 4-leaflet arrangements, these values were 27.0 ± 5.8% (septal), 12.0 ± 4.5% (inferior), 13.7 ± 9.4% (mural), and 19.8 ± 6.1% (superior). The muroseptal/inferoseptal commissures were usually located in the cavotricuspid regions, whereas the inferomural and superomural commissures were in the right atrial appendage vestibule area. CONCLUSIONS: The right atrioventricular valve has 4 functional leaflets in more than 40% of cases. The authors found that the inferomural region is the most variable area of the valve and believe that anatomic variation is an important consideration for planned interventions.

Clinical and epidemiological features of Heart-Hand Syndrome: a hospital-based study in China.

Heart-hand syndrome (HHS) is a clinically and genetically heterogeneous disorder characterized by the co-occurrence of a congenital cardiac disease and an upper limb malformation. This study revealed the clinical and epidemiological features of HHS in China. The study was based on patients with congenital upper limb malformation treated in Beijing Ji Shui Tan hospital from October 1st, 2013 to October 1st, 2016. We reviewed the patients' medical records and identified patients with abnormal ultrasonic cardiogram and/or electrocardiogram (ECG). A total of 1462 patients (910 male and 552 female) were identified to be treated for congenital upper limb malformation. Among them, 172 (11.8%) had abnormal ultrasonic cardiogram and/or ECG. Abnormal heart structure were discovered in 121 patients and 51 patients had abnormal ECG. The most common type of abnormal heart structure was tricuspid regurgitation (53/121, 43.8%), while the most common abnormal ECG was wave patterns (22/51, 43.1%). This hospital-based study suggests that the rate of congenital heart disease is high in patients treated for congenital upper extremity malformation in China. Surgeons and anesthetists should be aware of the comorbidity and preoperational examination of congenital heart diseases is highly needed to avoid complications during operation.

Effect of tricuspid annuloplasty concomitant with left heart surgery on right heart geometry and function.

OBJECTIVES: To elucidate the effect of tricuspid annuloplasty concomitant with left-sided valve surgery on the right heart in patients with mild or more tricuspid regurgitation (TR). METHODS: We enrolled 78 patients with mild or more TR who underwent left-sided valve surgery. Forty-three patients underwent only left-sided valve surgery (group non-T) and 35 underwent concomitant tricuspid annuloplasty (group T). Echocardiographic changes between the preoperative and 1-year follow-up periods were compared. Propensity score matching was used to obtain risk-adjusted outcome comparisons (16 pairs). RESULTS: In group non-T, there were more operations for aortic stenosis and concomitant coronary artery bypass grafting, and fewer operations for mitral regurgitation. The prevalence of atrial fibrillation was higher in group T. In preoperative echocardiography, there were no significant differences in left ventricular and right ventricular (RV) dimensions and functions. Tricuspid valve annular diameter and TR-related parameters were significantly larger in group T. Left ventricular dimensions and TR-related parameters significantly improved in both groups 1 year after operation. RV diameter was significantly reduced in only group T. In analysis of variance, RV diameter in systole and diastole showed significant interaction, whereas left heart dimensions and function, tricuspid valve tethering height, and RV fractional area change did not show interaction. These results were not attenuated even after propensity-matching analyses. CONCLUSIONS: Among patients with mild or more TR, RV reverse remodeling was not obtained with left-sided valve surgery alone. Additional use of tricuspid annuloplasty might potentially achieve favorable TR regulation as well as RV reverse remodeling.