A giant atrial septal aneurysm causing tricuspid valvular obstruction.

Atrial septal aneurysm (ASA) is a rare congenital malformation consisting of redundant atrial septal tissue that bulges into either the right or the left atrium. Here, we report the case of a 45-year-old man with a giant ASA prolapsing into the tricuspid orifice and leading to tricuspid valvular obstruction. He was treated successfully by resection of the ASA and repair of the resulting atrial septal defect. Our case indicates the utility of transthoracic, contrast, and transesophageal echocardiography to characterize a huge ASA causing tricuspid valvular obstruction.

A Rare Case of Rheumatic Heart Disease with Stenosis and Incompetence of Three Valves in a Nigerian Woman.

BACKGROUND: Though valve disease resulting from rheumatic heart disease is common, triple valve involvement is uncommon; with a bleak survival outlook Objective: To report a 38-year-old patient with both stenosis and incompetence of 3 valves, who lived till adulthood and went into heart failure after child-birth. No such report has come from Nigeria Methods: Case report of a Nigerian woman who lived with multiple valve disease up to adulthood when after delivery she developed hypertension and went into heart failure. Recurrent atrial fibrillation kept her in and out of heart failure. Three of her valves: mitral, aortic and tricuspid were both stenosed and incompetent. The consequent pulmonary hypertension and later development of arterial hypertension and atrial fibrillation worsened her morbidity till surgical intervention. CONCLUSION: Mixed triple valve disease of rheumatic origin tough rare, can occur; and is amenable to specialist surgical intervention.

Anesthetic Management of a Patient With a Giant Right Atrial Myxoma.

Cardiac myxomas account for 50% of all benign primary cardiac tumors. Rarely, these tumors occur in the right atrium (RA; 10% to 20%), with a stalk frequently attached to the interatrial septum. Right atrial myxomas can lead to RA enlargement, arrhythmias, functional tricuspid stenosis, right heart failure, and catastophic pulmonary embolization resulting in sudden cardiac death. Anesthetic management of patients with RA myxomas can be complicated by the mass effect of the myxoma, preload limitations, and the potential for cardiovascular collapse. Multimodal cardiac imaging inclusive of echocardiography, computed tomography, and magnetic resonance imaging helps with the diagnosis, preoperative optimization, and formulation of anesthetic and surgical plans. We present a case report highlighting the importance of multimodal imaging, adequate preoperative patient optimization, and the anesthetic considerations in the successful management of a patient with a giant 8.3 × 4.7 cm RA myxoma.

Right atrial myxoma mimicking tricuspid stenosis.

A 62-year-old man presented to the cardiology clinic with symptoms of fatigue, shortness of breath and swelling in the abdomen and legs. A pedunculated mobile mass with a short stalk in the right atrium was found to originate from the inferior vena caval opening and prolapse into the right ventricle through a tricuspid valve during diastole in echocardiography. The patient was referred to our department and surgery was planned for right atrial myxomas diagnosis. The mass with surrounding tissue was surgically removed using the cardiopulmonary bypass method. No postoperative complications were seen in the currently asymptomatic patient who is still under our follow-up schedule.

Right-sided valve disease.

In this review, we discuss right-sided heart valve disease, namely tricuspid regurgitation (TR), tricuspid stenosis, pulmonary regurgitation, pulmonary stenosis and right-sided endocarditis. These are frequently seen in conjunction with other diseases, making assessment of their significance more difficult, but it has become increasingly clear that moderate or severe right-sided heart valve disease, in particular TR, is associated with worse prognosis. There remain large gaps in our knowledge of medical and interventional treatment, but in this article we outline what is known about the causes, presentation and management of these commonly seen conditions.

[Practical approach of cardiac valvulopathies]. / Approche des valvutlopathies cardiaques par le praticien. Investigations diagnostiques et place du traitement médicamenteux.

In the light of the recommendations published in 2012 by the European Society of Cardiology, the present article provides a review of the assessment, diagnosis and drug therapy of frequent cardiac valvular disease in adults. Congenital valvular heart disease, as well as pathology of the pulmonary valve and tricuspid stenosis, which are less frequent, will not be discussed here.

Measurement of the ascending aorta diameter in patients with severe bicuspid and tricuspid aortic valve stenosis using dual-source computed tomography coronary angiography.

We aimed to evaluate the diagnostic performance of dual-source computed tomography coronary angiography (DSCT-CA) in the measurement of the ascending aorta (AA) diameter and compare the AA diameter in patients with severe bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) stenosis. Eighty-eight consecutive patients (50 men, mean age 60.3 ± 13 year) with severe aortic stenosis (AS) underwent DSCT-CA before aortic valve surgery. Seventy-four of the 88 patients underwent cardiovascular magnetic resonance (CMR). The internal diameter of AA was measured from early-systole with DSCT-CA and CMR by 2 radiologists independently at 4 levels (aortic annulus, sinuses of Valsalva, sinotubular junction, and tubular portion at the right pulmonary artery). The patients were divided in to 2 groups (BAV [n = 53]; TAV [n = 35]) according to operative findings. Patients with BAV were significantly younger than those with TAV (P = 0.0035). Inter-observer agreement of AA diameters at 4 levels with DSCT-CA and CMR was excellent (intraclass correlation coefficient = 0.89-0.97). Also, the DSCT-CA and CMR measurements of the AA diameter strongly correlated (r = 0.871-0.976). Mean diameter of the AA by DSCT-CA was significantly larger in patients with BAV (34.4 ± 8.2 mm) as compared to those with TAV (30.6 ± 5.5 mm). The diameters at the sinuses of Valsalva, sinotubular junction, and tubular portion were significantly larger in BAV than in TAV. Twenty-two of 53 (41.5%) patients with BAV and 2 of 35 (5.7%) patients with TAV had AA dilatation > 45 mm. DSCT-CA allows accurate assessment of the AA diameters in patients with severe AS. Patients with severe BAV stenosis had larger AA diameters and higher prevalence of AA dilatation > 45 mm as compared to those with severe TAV stenosis.

Live/real time three-dimensional transthoracic echocardiographic assessment of tricuspid valve pathology: incremental value over the two-dimensional technique.

Twenty-nine patients with different tricuspid valve (TV) pathologies were studied by both two-dimensional transthoracic (2DTTE) and live/real time three-dimensional transthoracic echocardiography (3DTTE). A major contribution of 3DTTE over 2DTTE was the en face visualization of all three leaflets of the TV in all patients. This allowed accurate assessment of TV orifice area in patients with TV stenosis and carcinoid disease. Loss of TV leaflet tissue, defects in TV leaflets and size of TV systolic non-coaptation could also be delineated and resulted in identifying the mechanism of tricuspid regurgitation (TR) in patients with Ebstein's anomaly and rheumatic heart disease. Prolapse of TV leaflets could also be well visualized and enabled us to develop a schema for systematic assessment of individual segment prolapse which could help in surgical planning. The exact sites of chordae rupture in patients with flail TV as well as right ventricular papillary muscle rupture could be well seen by 3DTTE. 3DTTE also permitted sectioning of various TV masses for more specific diagnosis of their nature. In addition, color Doppler 3DTTE provided an estimate of quantitative evaluation of TR severity, since the exact shape and size of the vena contracta could be accurately assessed. In conclusion, our preliminary experience with 3DTTE has demonstrated substantial incremental value over 2DTTE in the assessment of various TV pathologies.

Aortic stenosis severity is not a risk factor for poststenotic dilatation of the ascending aorta.

BACKGROUND: Dilatation of the ascending aorta in aortic stenosis may be partly explained by intrinsic wall structure changes, but the relative contribution of altered hemodynamics is unclear. The aim of this study was to assess the association between ascending aortic dimensions and valve stenosis severity. METHODS AND RESULTS: An analysis of echocardiographic examinations was conducted in 296 patients with aortic stenosis (179 males, mean age 71 years), 57 with bicuspid and 239 with tricuspid aortic valve, mean transaortic gradient 43+/-20 mmHg, and not more than moderate aortic regurgitation. Aortic dimensions at the level of annulus, sinuses of Valsalva, sinotubular junction and proximal ascending aorta were measured. Only height (p<0.001), degree of aortic regurgitation (p<0.01) and presence of bicuspid aortic valve (p<0.001) were independent predictors of ascending aortic dimensions. CONCLUSIONS: An independent association between aortic pressure gradients and proximal ascending aortic dimensions was not observed in patients with bicuspid or tricuspid aortic valve stenosis. Therefore, the poststenotic dilatation of the ascending aorta is not explained by aortic stenosis severity itself. Possible nonhemodynamic causes deserve detailed study at the time of diagnosis.

Histological evaluation of autophagic cell death in calcified aortic valve stenosis.

BACKGROUND AND AIM OF THE STUDY: Calcification in aortic valves is the most common valvular lesion in western populations. This event is correlated with cellular degeneration in the valvular cusps, although there is no exact evidence how these cells die: this requires further exploration. METHODS: Twelve human severely calcified aortic valves obtained during cardiac surgery were studied by semi-quantitative analysis, and results compared with data from 12 human control aortic valves obtained during autopsy. Tissue analysis was by hematoxylin and eosin and Alcian blue staining. Detection of neurons was by immunohistochemical staining of PGP9.5 and neurofilament. In order to detect autophagy, an immunohistochemical staining for ubiquitin was used. The TUNEL technique was used to detect apoptosis. Co-localization of Alizarin red with ubiquitin labeling was performed on non-decalcified aortic valves. RESULTS: Hematoxylin and eosin staining showed moderate to severe mineralization in 10 of 12 patients in the surgical group, but in only one of 12 in the autopsy group. No significant observations were made with regard to PGP9.5 and neurofilament staining. Moderate to severe ubiquitin labeling was found initially in the majority of the surgical resection group (9/12) compared to a minority in the autopsy group (1/12). TUNEL-positive labeling was very rare and found mostly at the endothelial layer of the valvular cusps. CONCLUSION: Immunohistochemical methods showed the main cell death mechanism involved in the calcification of aortic leaflets to be autophagy rather than apoptosis. These findings suggest that autophagic cell death might play a role in the release of matrix vesicles in early degenerative aortic valves, thereby attracting inflammatory cells, and this could eventually lead to mineralization.

[Tricuspid valve stenosis. A prospective study of 35 cases]. / La sténose de la valve tricuspide: a propos de 35 cas.

Authors report the results of prospective and longitudinal study. The aims of this study were to evaluate among 35 patients, prevalence, diagnosis and treatment aspects of tricuspid stenosis (TS), as well as evolution and pronostical factors. The prevalence of TS was about 4.2%. The main clinical signs were: dyspnoea (94.2%), jugular veinus pulses (42.8%), superior cave syndrom (68.8%), diastolic rumble (74.3%). ECG showed sinus rhythm (51.4%), a right atrial hypertrophy (48.5%). Echocardiography showed tricuspid leaflets thickened (82.8%), a right atrial hypertrophy (48.5%), a mean gradient between right atrial and right ventricle: 8.6 +/- 3.14 mmHg (65.7%) and mean tricuspid area about 1.41 +/- 0.83 cm2 (continuous equation); about 1.74 +/- 1.29 cm2 (Hatle formula) and 1.11 0.84 cm2 (simplified Hatle formula). Aetiology was only rheumatic fever. After a follow-up of 8.53 +/- 6.06 months, the mortality rate was 28.5%. Complications were irreducible heart failure (24 cases), liver failure (2 cases) and stroke (3 cases). Factors associated with mortality were: severity of tricuspid stenosis and pulmonary hypertension, importance of dyspnea and heart failure (p < 0.041).

A cross between truncus arteriosus communis and aortopulmonary septal defect: a hitherto undescribed entity.

Case history and necropsy findings of a 5-month-old infant with a unique heart defect with features of truncus arteriosus communis and aortopulmonary defect in combination with severe tricuspid stenosis are presented. There is a wide spectrum of remarkable heart defects between truncus arteriosus communis and aortopulmonary septal defect.

Absent pulmonary valve with tricuspid atresia or severe tricuspid stenosis: report of three cases and review of the literature.

Absence of the pulmonary valve occurs usually in association with tetralogy of Fallot and occasionally with an atrial septal defect or as an isolated lesion. Very rarely it occurs with tricuspid atresia, intact ventricular septum, and dysplasia of the right ventricular free wall and of the ventricular septum. We present the clinical, anatomic, and histologic findings of a new case, and for the first time, the data from two patients with absent pulmonary valve and severe tricuspid stenosis, who exhibited similar histologic findings. We also reviewed the clinical and anatomic data of 24 previously published cases and compared them with the new cases. In all three new cases, the myocardium of the right ventricle was very abnormal. In the two cases with tricuspid stenosis, large segments of myocardium were replaced with sinusoids and fibrous tissue. In the case with tricuspid atresia, the right ventricular free wall contained only fibroelastic tissue. The ventricular septum in all three patients showed asymmetric hypertrophy and in two of the three patients, multiple sinusoids had replaced large segments of myocardial cells. The left ventricular free wall myocardium and the walls of the great arteries were unremarkable. Our data indicate that myocardial depletion involving the right ventricular free wall and the ventricular septum and its replacement by sinusoids and fibroelastic tissue occur not only in cases of absent pulmonary valve with tricuspid atresia but also in cases of absent pulmonary valve with tricuspid stenosis. The degree of myocardial depletion varies and is more severe when the tricuspid valve is atretic.