Severe tricuspid regurgitation with chordae tendinae rupture in CABG surgery.

A 58-year-old male patient was admitted with chest pain and was diagnosed with coronary heart disease. He was scheduled for coronary artery bypass grafting (CABG) under cardiopulmonary bypass (CPB). Intraoperative real-time transesophageal echocardiography (TEE) showed that the tricuspid valves were well-aligned and subtle regurgitation. Real-time TEE after separation from CPB showed severe tricuspid regurgitation and prolapsed chordae tendineae. The tricuspid chordae tendineae rupture due to a right atrial venous return cannula. The use of negative pressure to improve venous drainage during CPB may result in the tricuspid valve being adsorbed to the cannula, increasing the likelihood of injury to the tricuspid valve.

Mid-Term Follow-Up of Neonatal Neochordal Reconstruction of Tricuspid Valve for Perinatal Chordal Rupture Causing Severe Tricuspid Valve Regurgitation.

BACKGROUND: Papillary muscle rupture in the perinatal period is a rare event that leads to severe mitral or tricuspid insufficiency due to a flail leaflet. Neonatal tricuspid chordal reconstruction for this condition is rarely reported. Early recognition and treatment have the potential to be lifesaving. We present our surgical experience with five such patients, along with their midterm follow-up. METHODS: Between August 2010 and November 2012, five neonates (aged 1-30 days) underwent surgery for severe atrioventricular valve regurgitation. All neonates had severe tricuspid regurgitation due to ruptured chordae. In addition, two had moderate mitral regurgitation; one due to ruptured chordae of the posterior mitral leaflet and the other due to prolapse of the anterior mitral leaflet. All underwent emergent surgery where the ruptured chordae to the anterior tricuspid leaflet were replaced with neochordae made with expanded polytetrafluoroethylene (ePTFE) suture. The mitral valve was repaired in two patients. RESULTS: All patients survived surgery without the need for postoperative mechanical circulatory assist. Predischarge echocardiograms showed good coaptation of tricuspid and mitral leaflets with minimal regurgitation in all. At follow-up between 75 months to 102 months, four patients had excellent outcomes with less than mild tricuspid regurgitation. One child with flail tricuspid and mitral leaflets developed progressive tricuspid and mitral regurgitation requiring surgical re-repair at 20 months following the initial surgery. CONCLUSION: Repair of chordal rupture of the tricuspid valve in neonates using ePTFE neo-chordae can provide acute salvage and gratifying midterm results in the management of this potentially fatal condition.

A novel emerin gene mutation in Emery Dreifuss muscular dystrophy patient with spontaneous chordae tendinae rupture.

Emery Dreifuss muscular dystrophy (EDMD) is an inherited myopathy characterized by early contractures, slow progressive muscle weakness and cardiac involvement. To date at least seven genes have been associated to EDMD with different inheritance patterns, being emerin gene responsible for the X-linked form of the disease. We report a 40-year-old man who was referred for severe gait difficulty. At age 6 years the patient presented with a waddling gate, lumbar lordosis and heel contractures. Both electrophysiology and muscle biopsy were consistent with a neurogenic disorder and he received a diagnosis of spinal muscular atrophy type 3. At the age of 30 the patient developed heart involvement with junctional escape rhythm and, eight years later, had a spontaneous chordae tendinae rupture. A new clinical examination showed severe muscular weakness and atrophy in scapulohumeroperoneal pattern with significant involvement of the lower facial and intrinsic hand muscles and on a second muscle biopsy emerin was absent by immunohistochemistry and by immunoblot analysis. Sequence analysis of EMD gene revealed the presence of a novel mutation represented by an out-of-frame deletion spanning from the beginning of exon 1 to the half of intron 2 (p.Asp6Glyfs*27). Our study expands the clinical and molecular spectrum of X-linked EDMD.

Lesión postraumática de la válvula tricúspide / Post-traumatic injury of tricuspid valve

Resumen Se presenta el caso de un adulto con insuficiencia de la válvula tricúspide de origen traumático, debido a ruptura del músculo papilar de la valva anterior en relación a trauma de tórax cerrado, se realizó el diagnóstico mediante ecocardiografía transesofágica. La válvula se reemplazó mediante bioprótesis con resultados clínicos favorables. Este caso enfatiza la necesidad de una alta sospecha de lesión valvular por parte del clínico en los pacientes con trauma torácico cerrado. (Acta Med Colomb 2016; 41: 202-205).

Abstract The case of an adult with traumatic tricuspid valve insufficiency due to papillary muscle rupture of the anterior leaflet in relation to closed chest trauma is presented. Diagnosis was made by trans-esophageal echocardiography. The valve was replaceded by bioprosthesis with favorable clinical outcome. This case emphasizes the need for a high suspicion of valvular lesion by the clinician in patients with blunt chest trauma. (Acta Med Colomb 2016; 41: 202-205).

A Case of Iatrogenic Chordal Rupture after Transcatheter Aortic Valve Implantation Procedure Requiring a Second Valve.

Transcatheter aortic valve implantation (TAVI) has emerged as a therapeutic option for high-risk aortic stenosis. Malposition of the prosthesis and severe residual aortic regurgitation are known complications of the procedure, which might require a second valve implantation. Although the implantation of a second valve seems to be an effective method, very few data are available describing this technique. Herein is reported a case of iatrogenic chordal rupture in a TAVI procedure which required a second valve implantation due to dislodgment of the first prosthesis.

Ruptura de cordoalha mitral associada a crise tireotóxica: uma avaliação por ecocardiograma 3D / Mitral chordae rupture associated with thyrotoxic crisis: an assessment by 3D echocardiography

Relatamos o caso de ruptura de cordoalha mitral em um paciente adulto jovem, com apresentação clínica de febre, novo sopro cardíaco e disfunção respiratória, condição em que a hipótese de endocardite infecciosa é mandatória. Entretanto, o curso clínico, com ausência de critérios maiores para endocardite, a presença concomitante de crise tireotóxica e uma válvula mitral sem outras alterações estrututurais ecocardiográficas, reforça a hipótese alternativa de rutura de cordoalha associada ao estado hiperdinânimo. Os achados foram apropriadamente documentados e confirmados por ecocardiograma 3D. A revisão da literatura existente descreve que, embora a presença de regurgitação mitral leve a moderada seja altamente prevalente na tireotoxicose, a ruptura mitral na ausência de outras anormalidades estruturais é um achado raro e inesperado.

We report a case of a mitral chordaea rupture in a young adult patient presenting with fever, new cardiac murmur and respiratory distress, where the hypothesis of infective endocarditis was primarily selected as the main clinical concern. However, the clinical course in the absence of major criteria for endocarditis, the concomitant presence of a thyrotoxic state and no other echocardiographic detected structural alterations, strengthened the alternative hypothesis of primary rupture due to the hyperkinetic state. These findings were thoroughly documented and confirmed by 3D-echocardiography. The literature review describes that, although mild to moderate mitral regurgitation is highly prevalent in thyrotoxicosis, mitral rupture, in the absence of a previous structural abnormality, is a rare unexpected finding.

Correção da ruptura de cordas tendíneas na insuficiência mitral degenerativa pelo emprego de cordas padronizadas de pericárdio bovino / Surgical repair of chordae tendineae rupture after degenerative valvular regurgitation using standardized bovine pericardium

OBJETIVO: Avaliar, clinicamente e pelo ecodopplercardiograma, o funcionamento da valva mitral em 22 pacientes submetidos à correção do refluxo valvar com substituição das cordas tendíneas nativas por cordas padronizadas de pericárdio bovino. MÉTODOS: Os pacientes apresentavam insuficiência mitral degenerativa. Quatorze (63,6%) pacientes eram do gênero masculino e a idade variou de 19 a 76 anos (média 56,8±13,8 anos). As cordas de pericárdio bovino foram tratadas com glutaraldeído, com reforço de suas extremidades transversais formando um trapézio. RESULTADOS: Um (4,5%) paciente faleceu no pós-operatório imediato em síndrome de baixo débito cardíaco e três (13,6%) no pós-operatório tardio. Uma (4,5%) paciente foi reoperada. As curvas atuariais de sobrevivência livre de óbitos por causa cardiovascular e livres de reoperações para os pacientes que deixaram o hospital (21) demonstraram taxas de 82,0±9,8% e 83,9±10,4%, aos 70 meses de pós-operatório, respectivamente. Dezessete (77,3%) pacientes estão vivos com a própria valva. Dos 17 pacientes vivos com a própria valva 16 (94,1%) estão em classe funcional I. O ecodoppler pós-operatório (média de 41 meses; 4 a 70 meses) demonstrou ausência de regurgitação mitral em 11 (64,7%) pacientes e regurgitação discreta em cinco (29,4%). CONCLUSÃO: A técnica de implante de cordas padronizadas de pericárdio bovino para substituição de cordas tendíneas da valva mitral em pacientes com insuficiência mitral degenerativa demonstrou resultados bastante satisfatórios.

OBJECTIVE: To evaluate clinically and by Doppler Echocardiography 22 patients submitted to mitral valve repair after valvular regurgitation using standardized bovine pericardium chordae. METHODS: The patients had degenerative mitral regurgitation. Fourteen (63.6%) patients were male and the age ranged from 19 to 76 years (mean 56.8 ± 13.8 years). The strings of bovine pericardium treated with glutaraldehyde were reinforced in its transverse ends forming a trapezoid. RESULTS: One patient (4.5%) died in the immediate postoperative period with in low cardiac output syndrome and three (13.6%) in the late postoperative period. One patient (4.5%) was reoperated. The actuarial curves for survival free of death from cardiovascular causes and free from reoperation for patients who left the hospital (21), showed rates of 82.0 ± 9.8% and 83.9 ± 10.4% at 70 months postoperatively, respectively. Seventeen patients (77.3%) are alive with native valves. Of the 17 patients alive with native valves 16 (94.1%) were in functional class I. The Doppler Echocardiography postoperatively (mean 41 months, 4-70 months), showed no mitral regurgitation in 11 (64.7%) patients and mild regurgitation in five (29.4%). CONCLUSION: The technique of standard cords of bovine pericardium implantation to replace chordae tendineae of the mitral valve in patients with degenerative mitral regurgitation showed satisfactory results.

[Severe tricuspid valve injury following blunt chest trauma--case report]. / Ciezkie uszkodzenie zastawki trójdzielnej po tepym urazie klatki piersiowe--opis przypadku.

Tricuspid valve (TV) injury is a rare complication of blunt chest trauma, most commonly as a result of a traffic collision. The authors describe a case of massive TV regurgitation due to a rupture of the chorde tendinae to the anterior and septal leaflets in a 21-year-old man, the victim of a car crash. Concomitant organ injuries included, among others, multiple rib fractures, pulmonary contusion, open femoral fracture. TV annuloplasty with Medtronic Duran ring implantation was performed one year after the accident because of right ventricular function worsening and occurrence of right heart failure symptoms. Three years after surgery only trivial TV regurgitation is detectable. The patient manifest good physical efficiency and continues occupational activity.

Comparison of the diagnostic power of transthoracic and transesophageal echocardiography to detect ruptured chordae tendineae.

Preoperative information concerning the severity and etiology of MR is very important for selecting the most appropriate surgical strategy. Ruptured chordae tendineae (RCT) are one of the most important preoperative findings. We compared the diagnostic power of transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) to detect RCT in patients with MR. We studied 61 patients with MR (30 men, 31 women; mean age, 61 ± 12 years) who underwent mitral valve repair or replacement. Both TTE and TEE were performed before the operations, and the sensitivity and specificity of TTE and TEE to detect RCT were determined. In addition, other factors that influenced the detection of RCT by these two methods were investigated. At the time of an operation, RCT was confirmed in 39 of 61 cases. Transesophageal echocardiography had a higher sensitivity than TTE (74% versus 44%; P = 0.006) to detect RCT, although the specificity was not significantly different. In patients with a body mass index (BMI) > 22 (P = 0.023) or MR grade 4 (P = 0.026), TEE had a significantly higher diagnostic sensitivity than TTE, although there was no significant difference in patients with BMI < 22 or MR grade ≤ 3. In the lateral and medial segments of the mitral valve, TEE had a significantly higher diagnostic sensitivity to detect RCT than TTE (P = 0.0012), although there was no significant difference in the middle segments. There was no significant difference between TTE and TEE with respect to the sensitivity to detect RCT in myxomatous mitral valves. Although the sensitivity of TEE was higher than that of TTE to detect RCT, it was affected by BMI, MR grade, the RCT-presenting segments, and the etiology of MR.

Detection of valve malfunction after mechanical MVR using digital phonocardiography.

We present the case of a 63-year-old female patient who developed severe chronic dyspnea two years after mechanical mitral valve replacement (MVR). Conventional cardiac diagnostics including echocardiography, fluoroscopy, right and left heart catheterization could not detect any malfunction. Only digital phonocardiography was able to show alterations of the typical acoustic signal. Based on the symptoms, the clinical history and these abnormal findings the decision was taken to reoperate. Intraoperatively, a ruptured tendinous chord was found, impeding the inferior leaflet. Redo MVR was performed.

Isolated latent tricuspid regurgitation caused by blunt trauma.

Isolated tricuspid regurgitation with rupture of the chordae tendinae caused by blunt trauma is uncommon. We present a 20-year-old man who was asymptomatic for four months after a traffic accident, but then developed severe tricuspid regurgitation, caused by rupture of the chordae tendinae. We performed minimally invasive tricuspid valve repair with chordal reconstruction and annuloplasty. We discuss the optimal treatment of traumatic valve insufficiency in a young patient and review the literature.

Surgical repair of mitral and tricuspid valves after cardiac transplantation.

A 43-year-old man underwent mitral valve repair for mitral valve insufficiency due to infective endocarditis, and tricuspid valve repair for iatrogenic chordal rupture due to multiple endomyocardial biopsies after orthotopic cardiac transplantation. Valve repair using no artificial material is feasible, instead of valve replacement, to decrease the risk of recurrent infective endocarditis and enable further biopsies.

Current status of surgery for degenerative mitral valve disease.

Degenerative mitral valve (MV) disease refers to a collection of ill-defined pathologies of the MV which manifest as mitral regurgitation (MR). Untreated MR may progress to heart failure and death. Recent advances in the surgical technique of MV repair have improved long-term surgical results to the extent that early surgery is advocated in most patients with severe MR even when asymptomatic to restore normal functional capacity and life expectancy. This article reviews the pathophysiology, evaluation, treatment, and results of surgical intervention for degenerative MR.

Clinical significance of mitral leaflet flail.

BACKGROUND: There has been scant academic consideration paid to investigations of mitral leaflet flail in terms of clinical profile, surgical strategy, and surgical outcome. METHODS: One hundred consecutive patients with mitral leaflet flail referred for surgical treatment in the past 4(2/3) years were included in this study. RESULTS: The most common reasons leading to mitral leaflet flail were chord rupture (38%), myxomatous degeneration (23%), and combined chord rupture and myxomatous degeneration (12%). Mitral leaflet flail was predominantly characterized by independent P(2) flail, followed by P(2,3) flail and independent A(2) flail. Chord rupture occurred in 54 patients, and the most commonly involved segments were P(2), P(2,3), and P(3). The most common risk factors for mitral valve replacement were papillary muscle rupture, extensive myxomatous degeneration, extensive chord rupture, and severely dilated mitral valve annulus. Multivariate regression analyses demonstrated that the development of mitral leaflet flail was significantly associated with the pertinent variables tested, especially correlated with insertion of the prosthetic ring, number of artificial chord, and presence of carotid stenosis. CONCLUSIONS: Mitral leaflet flail may affect patients of any age, but is more prevalent among males and younger patients. Mitral chord rupture was the leading cause for mitral leaflet flail. Myxomatous degeneration, infective endocarditis, mitral annulus calcification, and papillary muscle rupture were the next most common causes. An increased incidence of mitral leaflet flail was closely related to the chords of the posterior leaflet and the middle scallop. Due to the progressive disappointing prognosis of mitral leaflet flail, surgery should be performed at an early stage.

[Central venous catheterization complication by a guide wire].

Central venous catheterization using the Seldinger technique is a well known and often used method. On the other hand, there are also well known complications by needle puncture or by indwelling catheter, there are few reports about a guide wire which got hung up around the tricuspid valve. We report a case in which a guide wire got hung up to the chordae tendineae of the tricuspid valve. To insert the AVA 3Xi (Edwards life science Co. Iervine) from the right internal jugular vein, we inserted a guide wire without ease. Resistance appeared when we tried to remove the wire for 20 cm from the inserted state. The X-ray and the transesophageal echocardiography, showed the guide wire in the right ventricle. As actions to be taken, we advanced the central vein catheter of the EXCV catheter kit (Nippon Sherwood Medical Industries Co., Ltd.) to the tip, and a the guide wire was easily removed. There are many reports of the complication by the central venepuncture, but there are few reports about the guide wire which was entrapped in the vicinity of a tricuspid valve. The tip of the guide wire in this case was bent excessively, but the cause of the damage did not become clear by investigation. When a guide wire became hard to withdraw, we should never withdraw a guide wire blindly, but should search a cause and we should use the material which was matched with the cause.

Ventricular fibrillation in acute mitral valve insufficiency caused by chordae tendineae rupture: report of a surgically corrected case.

In this report, we present the case of a previously healthy 80-year-old woman who was referred to surgery after a cardiac arrest due to ventricular fibrillation successfully resuscitated; the following evaluation revealed acute mitral regurgitation due to chordae tendineae rupture. After mitral valve repair, a single-chamber cardioverter-defibrillator was implanted for secondary prevention of sudden cardiac death. After 16 months of follow-up, the patient is asymptomatic without any further episodes of ventricular arrhythmias reported, underlying the pivotal role of mitral valve repair in the prevention of potentially lethal ventricular arrhythmias.