Surgical management of tricuspid regurgitation: a new algorithm to minimise recurrent tricuspid regurgitation.

INTRODUCTION: Recurrent tricuspid regurgitation (TR) is frequently observed after cardiac surgery; however, the correct approach remains controversial. We developed an algorithm for action on the tricuspid valve (TV) and conducted a 1-year follow-up study. The aim was to assess the efficacy of the algorithm to minimise residual TR after TV surgery. The hypothesis was that the TR rate at 1 year would be reduced by selecting the surgical approach in accordance with a set of preoperative clinical and echocardiographic variables. METHODS: A prospective, observational, single-centre study was performed in 76 consecutive patients with TV involvement. A protocol was designed for their inclusion, and data on their clinical and echocardiographic characteristics were gathered at 3 months and 1-year postsurgery. The treatment of patients depended on the degree of TR. Surgery was performed in all patients with severe or moderate-to-severe TR and in those with mild or moderate TR alongside the presence of certain clinical or echocardiographic factors. They underwent annuloplasty or extended valve repair when the TV was distorted. If repair techniques were not feasible, a prosthesis was implanted. Residual TR rates were compared with published reports, and predictors of early/late mortality and residual TR were evaluated. RESULTS: TR was functional in 69.9% of patients. Rigid ring annuloplasty was performed in 35.7% of patients, De Vega annuloplasty in 27.1%, extended repair in 11.4% and prosthetic replacement in 25.7%. TR was moderate or worse in 8.19% of patients (severe in 3.27%) at 1 year postintervention. No clinical, surgical or epidemiological variables were significantly associated with residual TR persistence, although annulus diameter showed a close-to-significant association. Total mortality was 12.85% for all causes and 10% for cardiovascular causes. In multivariate analysis, left ventricular ejection fraction was related to both early and late mortality. CONCLUSIONS: Severe residual TR was significantly less frequent than reported in other series, being observed in less than 4% of patients at 1-year postsurgery.

Echocardiography-guided Cardiac Implantable Electronic Device Implantation to Reduce Device Related Tricuspid Regurgitation: A Prospective Controlled Study.

BACKGROUND: Endocardial leads of permanent pacemakers (PPM) and implantable defibrillators (ICD) across the tricuspid valve (TV) can lead to tricuspid regurgitation (TR) or can worsen existing TR with subsequent severe morbidity and mortality. OBJECTIVES: To evaluate prospectively the efficacy of intraprocedural 2-dimentional-transthoracic echocardiography (2DTTE) in reducing/preventing lead-associated TR. METHODS: We conducted a prospective randomized controlled study comparing echocardiographic results in patients undergoing de-novo PPM/ICD implantation with intraprocedural echo-guided right ventricular (RV) lead placement (Group 1, n=56) versus non-echo guided implantation (Group 2, n=55). Lead position was changed if TR grade was more than baseline in Group 1. Cohort patients underwent 2DTTE at baseline and 3 and/or 6 months after implantation. Excluded were patients with baseline TR > moderate or baseline ≥ moderate RV dysfunction. RESULTS: The study comprised 111 patients (74.14 ± 11 years of age, 58.6% male, 19% ICD, 42% active leads). In 98 patients there was at least one follow-up echo. Two patients from Group 1 (3.6%) needed intraprocedural RV electrode repositioning. Four patients (3.5%, 2 from each group, all dual chamber PPM, 3 atrial fibrillation, 2 RV pacing > 40%, none with intraprocedural reposition) had TR deterioration during 6 months follow-up. One patient from Group 2 with baseline mild-moderate aortic regurgitation (AR) had worsening TR and AR within 3 months and underwent aortic valve replacement and TV repair. CONCLUSIONS: The rate of mechanically induced lead-associated TR is low; thus, a routine intraprocedural 2DTTE does not have a significant role in reducing/preventing it.

Impact of tricuspid regurgitation on late right ventricular failure in left ventricular assist device patients ~can prophylactic tricuspid annuloplasty prevent late right ventricular failure? ~.

BACKGROUND: In this study, we evaluated the prevalence of tricuspid regurgitation (TR) worsening in patients with left ventricular assist devices (LVADs) and its impact on late right ventricular (RV) failure. METHODS: We enrolled 147 patients of the 184 patients who underwent continuous-flow LVAD implantations from 2005 to March 2018. The prevalence of postoperative TR worsening and late RV failure were retrospectively evaluated. RESULTS: Concomitant tricuspid annuloplasty (TAP) was performed in 28 of 41 patients (68%) with preoperative TR greater than or equal to moderate (TR group) and in 23 of 106 patients (22%) with preoperative TR less than or equal to mild (non-TR group). Regarding the TR-free rates, despite receiving or not receiving concomitant TAP, there was no significant difference between the 2 groups (TR group: p = 0.37; non-TR group: p = 0.42). Of the 9 patients with postoperative TR greater than or equal to moderate, late RV failure developed in 3 patients, with TR worsening after RV failure in each case. During follow-up, 16 patients (11%) had late RV failure. As for the late RV failure-free rates, despite receiving or not receiving concomitant TAP, there was no significant difference between the 2 groups (TR group: p = 0.37; non-TR group: p = 0.96). CONCLUSIONS: TR prognosis was preferable regardless of a patient receiving concomitant TAP; however, the presence of postoperative TR seemed to unrelated to late RV failure. Prophylactic TAP might not be necessary to prevent late RV failure.

A hybrid endocardial-epicardial biventricular implantable cardioverter-defibrillator to circumvent the tricuspid valve.

The development of pacing and defibrillator systems that do not involve hardware traversing the tricuspid annulus can be desirable in order to minimize lead-related complications such as tricuspid regurgitation. Occasionally, primary tricuspid valve pathology (ie, infectious endocarditis, nonbacterial thrombotic endocarditis, and carcinoid disease) or congenital heart disease prohibits use of transvenous leads and alternative strategies are required to provide pacing or defibrillation. We describe such a case in which a biventricular implantable cardioverter defibrillator was implanted using a hybrid system involving endocardial and epicardial components.

Impact of additional annuloplasty on tricuspid valve and cardiac functions after atrial septal defect closure in adults.

BACKGROUND: Surgical indications for moderate to severe tricuspid regurgitation (TR) during atrial septal defect (ASD) closure are still unclear. Additional tricuspid valve annuloplasty (TVP) can be beneficial to avoid postoperative persistent TR. Therefore, we compared the results of surgical ASD closure with or without additional TVP in patients who presented with moderate-to-severe TR. METHODS: Between November 2009 and June 2016, 103 patients with ASD and moderate-to-severe TR underwent surgical ASD closure without (n = 76, group 1) and with additional TVP (n = 27, group 2). Clinical outcomes and echocardiographic data were analyzed. RESULTS: There was no mortality. Postoperative outcomes were similar despite significantly longer aortic clamping time in group 2 (P = .003). Mean TR grade, right atrial diameter, right ventricular end-diastolic diameter, pulmonary artery pressure, and Qp/Qs ratio decreased significantly in both groups (P < .05). Mean follow-up time was 5.3 months (range: 1 month-6.2 years) in group 1 and 6.1 months (range: 1 month-4.1 years) in group 2 (P = .66). Echocardiography results showed significant decrease in TR grade in both groups (P = .93). The incidence of persistent moderate to severe TR was higher in isolated ASD closure group (14.4% vs 3.7%, P = .086). Additional TVP provided greater regression in TR grade (-1.49 ± 0.9 vs -1.89 ± 0.8, P = .041). CONCLUSION: Despite TVP being associated with longer ischemic time, postoperative outcomes were comparable to ASD closure alone. Both approach demonstrated an effective decrease in TR, but TVP provided greater regression and lower incidence of persistent TR. Therefore, additional TVP should be considered in patients undergoing ASD closure with moderate-to-severe TR.

SAPIEN S3 valve deployment in the pulmonary position using the gore DrySeal sheath to protect the tricuspid valve.

BACKGROUND: Tricuspid valve injury can occur during implantation of a SAPIEN valve in the pulmonary position. We describe our experience using a long Gore DrySeal (GDS) sheath to protect the tricuspid valve during advancement of the Commander delivery system. METHODS: Retrospective single center review of all patients who underwent placement of a SAPIEN valve in the right ventricular outflow tract between January 2016 and April 2020. Patients were divided into two groups: delivery of the valve using standard technique (Group I), and with the use of a GDS (Group II), for comparison. RESULTS: There were 48 patients in total: 25 in Group I and 23 in Group II. In Group II, the first 10 patients had a 29 mm S3 placed through a 26 French (Fr), 65 cm GDS. We then performed additional crimping of the S3 onto the balloon after the balloon catheter was withdrawn to position the valve on the balloon outside the body. Subsequently, seven had a 29 mm S3 placed through a 24 Fr GDS, and four had a 26 mm S3 placed through a 22 Fr GDS including one weighing 16 kg. Two had a 23 mm S3 placed through a 22Fr GDS as the 20Fr GDS was not available in our lab. Severe tricuspid valve injury occurred in 2/25 (8%) of Group I patients and 0/23 of Group II patients. CONCLUSION: Use of a long GDS may protect the tricuspid valve from injury during implantation of the S3 valve in the pulmonary position, and is technically feasible in smaller patients.

Leadless pacemaker implantation: A feasible and reasonable option in transcatheter heart valve replacement patients.

BACKGROUND: Leadless pacemakers (LPMs) have been shown to have lower postoperative complications than traditional permanent pacemakers but there have been no studies on the outcomes of LPMs in patients with transcatheter heart valve replacements (THVRs). This study determined outcomes of LPMs compared to transvenous single-chamber pacemakers (SCPs) post-THVR. METHODS: This is a retrospective single-center study including 10 patients who received LPMs post-THVR between February 2017 and August 2018 and a comparison group of 23 patients who received SCP post-THVR between July 2008 and August 2018. LPM or SCP was implanted at the discretion of electrophysiologists for atrial fibrillation with slow ventricular response or sinus node dysfunction with need for single-chamber pacing only. RESULTS: LPMs were associated with decreased tricuspid regurgitation (P = 0.04) and decreased blood loss during implantation (7.5 ± 2.5 cc for LPMs vs 16.8 ± 3.2 cc for SCPs, P = 0.03). Five LPM patients had devices positioned in the right ventricular septum as seen on transthoracic echocardiogram. Frequency of ventricular pacing was similar between LPM and SCP groups. In the LPM group, one case was complicated by a pseudoaneurysm and one death was due to noncardiac causes. There was one pneumothorax and one pocket infection in the SCP group. CONCLUSIONS: In this small retrospective study, LPMs were feasible post-THVR and found to perform as well as SCPs, had less intraprocedural blood loss, and were associated with less tricuspid regurgitation. Further, larger studies are required to follow longer-term outcomes and complications.

Mid-term results of a randomized trial of tricuspid annuloplasty for less-than-severe functional tricuspid regurgitation at the time of mitral valve surgery†.

OBJECTIVES: The optimal management of functional tricuspid regurgitation (FTR) in the setting of mitral valve operations remains controversial. The current practice is both centre specific and surgeon specific with guidelines based on non-randomized data. A prospective randomized trial was performed to evaluate the worth of less-than-severe FTR repair during mitral valve procedures. METHODS: A single-centre randomized study was designed to allocate patients with less-than-severe FTR undergoing mitral valve surgery to be prophylactically treated with or without tricuspid valve annuloplasty (TVP- or TVP+). These patients were analysed using longitudinal cardiopulmonary exercise capacity, echocardiographic follow-up and cardiac magnetic resonance. The primary outcome was freedom from more than or equal to moderate tricuspid regurgitation with vena contracta ≥4 mm. Secondary outcomes were maximal oxygen uptake and right ventricular (RV) dimension and function. RESULTS: A total of 53 patients were allocated to receive concomitant TVP+, and 53 patients were treated conservatively (TVP-). At 5 years, tricuspid regurgitation was observed to be greater than mild in 10 patients in the TVP- group and no patients in the TVP+ group (P < 0.01). Maximal oxygen uptake, RV basal diameter, end-diastolic diameter and end-systolic diameter and fractional area changes were similar in both groups. Cardiac magnetic resonance confirmed no differences in RV end-diastolic volume, RV end-systolic volume and RV ejection fraction. CONCLUSIONS: This single-centre prospective randomized trial demonstrated that prophylactic tricuspid annuloplasty irrespective of annular dilatation at the time of mitral surgery reduced the recurrence of moderate or severe FTR at 5-year follow-up and reduced the pulmonary pressure. Nevertheless, the functional capacity, the RV function and the RV dimension remained similar.

Shoulder Point Fitting Method as a New Universal Tricuspid Annuloplasty.

Approximately half of all tricuspid valves consist of four or more leaflets; however, no previous reports have discussed how to implant an annuloplasty ring in these multi-leaflet valves. We herein define the shoulder point of the tricuspid annulus and the annuloplasty ring and advocate a simple and universal fitting method to avoid deforming the tricuspid valve after ring implantation.

Change in biventricular function after cone reconstruction of Ebstein's anomaly: an echocardiographic study.

Aims: The Cone reconstruction in Ebstein's anomaly (EA) aims to reduce tricuspid valve regurgitation (TR) and reposition the valve to the anatomic annulus, but post-operative progress of ventricular function is poorly understood. This study evaluated biventricular function after Cone reconstruction using echocardiographic techniques. Methods and results: A retrospective study assessing longitudinal change was conducted from 2009 to 2014. All symptomatic patients with EA and severe TR undergoing surgery were included. Transthoracic advanced echocardiography was performed pre- and post-operatively (at short-term (<30 days) and mid-term). Conventional and longitudinal 2D strain parameters were measured for left ventricle (LV) and right ventricle (RV). Paired analyses were compared using Wilcoxon Matched-pairs signed rank test. From the 38 patients operated for EA, the echocardiographic data of 17 patients, aged 15 (1-57 years) at operation could be analysed. Median follow up was 6 months (8 days-54 months). The tricuspid annular plane systolic excursion (26.42 ± 5.79 mm vs. 8.75 ± 3.18 mm, P < 0.001), RV fractional area change (FAC) (45.00 ± 8.13% vs. 35.46 ± 5.76%, P = 0.038) and LV 2D peak systolic strain were significantly reduced post-operatively (-20.49 ± 2.79 vs. -17.73 ± 2.76, P = 0.041), with a trend to later recovery for LV 2D strain. There was no evidence of systolic mechanical dys-synchrony before or after operation. Conclusion: Although clinical outcome of Cone reconstruction for EA remains excellent, acute post-operative changes leads to reduction of myocardial function of both ventricles, with a trend to later recovery for LV. Continuing impairment of RV function is multifactorial but may reflect intrinsic myocardial deficiency.

Renin-angiotensin system blockade promotes a cardio-renal protection in albuminuric homozygous sickle cell patients.

The management of sickle cell nephropathy (SCN) at an early stage is an important issue to prevent renal and cardiovascular morbidity and mortality. This study aimed to evaluate in this population, whether angiotensin converting enzyme inhibitors (ACEIs) treatment could exert a cardio-renal protection in a SCN cohort. Forty-two SCN patients (urine albumin:creatinine ratio (ACR) > 10 mg/mmol) were treated with ACEIs for 6 months, then evaluated for ACR, measured glomerular filtration rate (mGFR) together with haematological and cardiovascular parameters. A 1-month washout was also performed in order to differentiate short- and long-term ACEIs effects. A decrease in ACR baseline value (>30%) was detected in 62% of cases (mean ACR: 46·4 ± 7·6 and 26·4 ± 3·9 mg/mmol at baseline and 6 months respectively; P = 0·002), whereas mGFR values were unchanged. ACR decrease was detected at 1 month following ACEI initiation (32·9 ± 6·9, P = 0·02) with a persistent trend after withdrawal (P = 0·08). ACEIs also decreased diastolic blood pressure (P = 0·007), pulse wave velocity (P = 0·01), tricuspid regurgitation velocity (TRV; P = 0·04), asymmetric dimethyl arginine (ADMA: P = 0·001) and haemoglobin (P = 0·01) while conventional haemolytic biomarkers were unchanged. Our data suggest that ACEIs are safe and effective at decreasing albuminuria in sickle cell patients with a beneficial effect on specific mortality risk factors, such as TRV and asymmetric dimethyl arginine.

Extraction of looped transvenous pacing leads to reduce tricuspid regurgitation.

Transvenous leads are a known source of iatrogenic tricuspid regurgitation. It is commonly held that extraction of chronic pacing and defibrillator leads will not reduce this, due to the inevitable trauma to the valve associated with the procedure. We demonstrate three cases of clinically significant reductions in tricuspid regurgitation after extraction of leads that were looped across the tricuspid valve.

Determinants of recurrent tricuspid regurgitation following tricuspid valve annuloplasty during mitral valve surgery.

BACKGROUND: The purpose of this study was to determine risk predictors for recurrent tricuspid regurgitation (TR) following tricuspid valve annuloplasty during mitral valve surgery. METHODS: Ninety-eight consecutive patients underwent tricuspid valve annuloplasty concomitant with mitral valve repair (71 patients), replacement (16 patients), or other procedures over a 10-year period. Fifty-seven patients underwent surgery with a flexible band and 41 with a rigid ring. RESULTS: Late TR progression (≥2/4) occurred in eight (14.0%) of flexible band patients, and in nine (22.0%) rigid ring patients. Multivariate analysis did not identify the superiority of one annuloplasty device over the other to prevent recurrent TR. Multivariate risk predictors of late TR progression were late atrial fibrillation (hazard ratio [HR]: 3.78; 95% confidence interval [CI]: 1.19-12.0), and recurrent mitral regurgitation; HR; 4.46; 95%CI; 1.52-13.1). Freedom from TR progression at 5 years was 89.2% in atrial fibrillation-free patients compared to 56.8% in those with atrial fibrillation (log-rank, P = 0.018), and 89.8% in mitral regurgitation-free patients compared to 55.3% in those with recurrent mitral regurgitation (log-rank, P = 0.003). CONCLUSIONS: A durable mitral valve repair and preservation of sinus rhythm are the keys to preventing late TR progression.

The modified cone reconstruction in the treatment of Ebstein's anomaly: Case reports.

RATIONALE: To investigate the early and mid-term clinical outcomes of the modified cone reconstruction in the treatment of Ebstein's anomaly (EA) which provide appropriate surgical treatment for clinical and reduce the incidence of re-operation and valve replacement. PATIENT CONCERNS: Clinical data of 18 consecutive patients with EA in our hospital between May 2008 and August 2015 were analyzed retrospectively. All patients were diagnosed by echocardiography. Among these patients, according to New York Heart Association functional grade, there were 12 patients with grade II cardiac function and 6 patients with grade III. All patients had severe tricuspid regurgitation grade. DIAGNOSES: All patients were diagnosed EA. One case was with acute arterial embolism and amputation of left lower extremity caused by paradoxical embolism of combined secundum atrial septal defect. INTERVENTIONS: The modified cone reconstruction in the treatment of EA of the tricuspid valve uses its own tissues to form not only central bloodstream, but also the coaption between 2 leaflets. For those patients whose anterior leaflet developed poor and smaller, the valve leaflet was widened by using autologous pericardial. For all patients, tricuspid annulus were reinforced by autologous pericardial. One case was combined with double-orifice technique due to postoperative poor closure of the tricuspid valve. OUTCOMES: There were 2 cases with arrhythmia, and they returned to normal after medication. The rest patients recovered smoothly with no death. Review of echocardiography: 1 patient with moderate regurgitation, the rest of patients' leaflets coapted well and had no tricuspid stenosis. All cases were followed up postoperatively for 9 to 38 months, and there were 14 patients with grade I cardiac function and 4 patients with grade II. LESSONS: The early and mid-term clinical outcomes of the modified cone reconstruction in the treatment of EA were which can make leaflets coapt and had a strong antiregurgitation ability, reducing the incidence of re-operation, valve replacement, and postoperative mortality.

Impact of baseline tricuspid regurgitation on long-term clinical outcomes and survival after interventional edge-to-edge repair for mitral regurgitation.

AIMS: Tricuspid regurgitation (TR) in patients with mitral valve disease is associated with poor outcome and mortality. Only limited data on the impact of TR on functional outcome and survival in patients undergoing MitraClip procedures are available. METHODS AND RESULTS: 261 patients (mean age 76.6 ± 10, EuroScore 15.9 ± 15.1%) with symptomatic mitral regurgitation (MR) (75.2% functional MR) undergoing MitraClip procedure were included and followed for 721 ± 19.4 days. At baseline 54.7% presented with TR grade 0/I, 29.5% with grade II, 13.4% with grade III and 2.3% with grade IV. When dividing groups according to baseline TR grades, follow-up (FU)-NYHA class was significantly improved only in patients with TR ≤ II (p = 0.05). FU-6-min walking distance increased significantly in the overall cohort (p = 0.05), in patients with TR ≤ II (p = 0.007), but not in patients with TR > II (p = 0.4). Moreover, FU-NT-pro-BNP levels were higher in patients with TR > II (p = 0.05), compared to patients with TR ≤ II. There was a higher mortality according to baseline TR > II and multivariate Cox regression revealed TR > II as the strongest independent predictor for mortality (hazard ratio 2.04). CONCLUSIONS: Concomitant TR at baseline negatively influences functional outcome and mortality in patients undergoing MitraClip procedures. Our results underline the need for dedicated interventional strategies for the treatment of TR in patients with symptomatic MR.

Impact of Right Ventricular Dysfunction and Tricuspid Regurgitation on Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: Right ventricular (RV) dysfunction and tricuspid regurgitation (TR) may coexist with aortic stenosis. The aim of this study was to assess the association between RV dysfunction, TR, associated comorbidities, and outcomes following transcatheter aortic valve replacement (TAVR). METHODS: A retrospective analysis was conducted of baseline and 6-month clinical and echocardiographic parameters, including TR grade, RV size (grade, end-diastolic and end-systolic areas, annular diameter), and function (grade, tricuspid annular plane systolic excursion [TAPSE], fractional area change, Tei index), in 519 consecutive TAVR patients. RESULTS: The prevalence of moderate or greater TR was 11% (n = 59). Although TR was associated with increased mortality (P = .02) in unadjusted analysis, it did not demonstrate an independent association with outcome when adjusted for RV dysfunction (TAPSE; P = .30) or multiple clinical parameters (P ≥ .20). RV parameters associated with poor outcomes included TAPSE (P = .006) and Tei index (P = .005). TAPSE was associated with lower survival even when adjusted for TR (P = .009) and all clinical parameters (P = .01). Persistence of moderate or greater TR 6 months after TAVR seemed to be associated with lower survival (P = .02), even when adjusted for clinical and RV parameters (P = .07). CONCLUSIONS: TR in association with aortic stenosis is frequently progressive despite TAVR but is not independently associated with outcomes. RV function is a stronger driver of adverse outcomes compared with TR itself, and RV quantitative rather than qualitative evaluation is the key to stratify these patients.

Severe tricuspid regurgitation after mitral valve surgery: the risk factors and results of the aggressive application of prophylactic tricuspid valve repair.

PURPOSE: This study aimed to examine the risk factors for severe postoperative tricuspid regurgitation (TR) in patients undergoing mitral valve surgery. We also studied the effects of prophylactic tricuspid valve repair (TVR) on severe postoperative TR. METHODS: We retrospectively studied 125 patients without severe TR who underwent mitral valve surgery from 1987 to 2006. Patients did not undergo TVR before 1998 (the early period, n = 54). In 1998 (the late period, n = 71), patients with a preoperative tricuspid annular diameter of ≥35 mm underwent TVR using an annuloplasty ring (n = 52). RESULTS: In the analysis of the early period, the rates of freedom from severe TR at 10 and 20 years after surgery were 76 and 59 %, respectively. A multivariate analysis identified moderate preoperative TR as a significant risk factor for severe TR. In the late period, none of the 52 patients who underwent TVR developed severe TR. However, 4/19 patients who did not undergo TVR developed severe TR, and all of these four patients had a preoperative tricuspid annular diameter of ≤35 mm. CONCLUSIONS: Moderate preoperative TR is a significant risk factor for severe postoperative TR in patients undergoing mitral valve surgery. The aggressive application of TVR can prevent severe postoperative TR; however, tricuspid annular dilatation might not be a good indicator for TVR.

Should Tricuspid Annuloplasty be Performed With Pulmonary Valve Replacement for Pulmonary Regurgitation in Repaired Tetralogy of Fallot?

Indications for prophylactic tricuspid annuloplasty in patients with pulmonary regurgitation (PR) after tetralogy of Fallot (TOF) repair are unclear and often extrapolated from acquired functional tricuspid regurgitation (TR) data in adults, where despite correction of primary left heart pathology, progressive tricuspid annular dilation is noted beyond a threshold diameter >4 cm (21 mm/m(2)). We hypothesized that unlike in adult functional TR, in pure volume-overload conditions such as patients with PR after TOF, the tricuspid valve size is likely to regress after pulmonary valve replacement (PVR). A total of 43 consecutive patients who underwent PVR from 2005 until 2012 at a single institution were retrospectively reviewed. Absolute and indexed tricuspid annulus diameters (TADs), tricuspid annulus Z-scores, grade of TR along with right ventricular size, and function indices were recorded before and after PVR. Preoperative and postoperative echocardiographic data were available in all patients. A higher tricuspid valve Z-score correlated with greater TR both preoperatively (P = 0.005) and postoperatively (P = 0.02). Overall reductions in the absolute and indexed TAD and tricuspid valve Z-scores were seen postoperatively, with greater absolute as well as percentage reduction seen with larger preoperative TAD index (P = 0.007) and higher tricuspid annulus Z-scores (P = 0.06). In pure volume-overload conditions such as patients with PR after TOF, reduction in the tricuspid valve size is seen after PVR. Concomitant tricuspid annuloplasty should not be considered based on tricuspid annular dilation alone.

The effects of right ventricular apical pacing with transvenous pacemaker and implantable cardioverter defibrillator on mitral and tricuspid regurgitation.

BACKGROUND: The incidence of new or worsening tricuspid regurgitation (TR) or mitral regurgitation (MR) after permanent pacemaker (PPM) or implantable cardioverter defibrillator (ICD) lead placement has not been well investigated. We studied the effect of transvenous leads implantation and right ventricular (RV) pacing on tricuspid and mitral valve regurgitations. METHODS: We reviewed the charts of all patients undergoing PPM or ICD lead placement in our electrophysiology laboratory from December 2001 to December 2006. RESULTS: A total of 206 patients (120 with PPM and 86 with ICD) had baseline echocardiography within 6months before, and a follow up study at least 6months after lead insertion. The mean age was 74±14years; 56% were men. The follow-up period was 29±19months. TR worsened by at least one grade after lead insertion in 44.7% patients (P<0.001). Pre- and post-implant changes in TR severity did not differ with respect to lead type (ICD vs. PPM) or degree of RV pacing dependence. As for MR; patients with high frequency of RV pacing (>40%) had a higher incidence of worsening MR when compared to those with low frequency of RV pacing (44% vs. 19%; P<0.001). CONCLUSION: PPM or ICD lead implantation worsens TR; that effect is probably induced by mechanical interferences with the TV closure and was consistent regardless the lead type or degree of RV Pacing. MR was noted to increase in patients with high frequency of RV pacing frequency; this is probably caused by the mechanical dyssynchrony induced by RV pacing.

Effect of the septal adjustment technique for tricuspid annuloplasty with an MC3 ring.

OBJECTIVES: Functional tricuspid regurgitation (FTR) is a significant negative prospective factor for long-term survival in patients with mitral valve disease. Tricuspid annuloplasty (TAP) for FTR is recommended as a concomitant procedure during left-sided valvular surgery. The MC3 annuloplasty ring is designed to restore the dilated tricuspid annulus to its natural three-dimensional shape, but selection of the optimal ring size during TAP is sometimes difficult. One solution is the septal adjustment technique (SAT), in which the point of fixation of the septal portion to the septal annulus is adjusted under confirmation with the water test. Here, we evaluated early outcomes with this new technique. METHODS: Between January 2008 and September 2014, 56 patients (mean age 67.6 ± 9.0 years, male/female 28/28) with FTR underwent TAP with an MC3 ring. We retrospectively compared early outcomes, including mortality, morbidity and postoperative residual tricuspid regurgitation (TR), between patients undergoing TAP with the SAT (n = 19, Group A) and those undergoing TAP with the conventional technique (n = 37, Group C). RESULTS: Although preoperative TR grade was significantly higher in Group A than Group C (3.2 ± 0.6 vs. 2.8 ± 0.6, p = 0.032), postoperative TR grade was significantly lower in Group A than Group C (0.9 ± 0.6 vs. 1.4 ± 0.8, p = 0.039), and TR grade was significantly decreased in Group A compared to Group C (2.2 ± 0.9 vs. 1.4 ± 0.8, p = 0.004). TR area reduction was significantly larger in Group A than in Group C (5.21 ± 2.34 vs. 2.85 ± 3.09, p = 0.006). CONCLUSIONS: The SAT for TAP with an MC3 ring provided better control of postoperative TR than the conventional technique.