Insertion of prosthetic tricuspid valve two years after the tricuspid valvulectomy

A case of a 14-year-old boy who underwent a prosthetic tricuspid valve insertion two years after the tricuspid valvulectomy due to intractable right-sided active endocarditis is presented. At the initial operation, the tricuspid valve was thoroughly resected because of marked destruction and attachment of vegetations, and a concomitant ventricular septal defect was directly closed. When a prosthetic valve was placed in the tricuspid portion, a semicircular Dacron patch was attached to the right side of the interventricular septum in a fashion of up-chord and down-arc to cover the bundle of His. The straight edge of the patch was located near the AV node and was not sutured to the tricuspid valve annulus. A 31 mm of CarboMedics prosthetic valve was sutured to the tricuspid valve annulus and to the free edge of the patch at the position near the AV node to prevent AV block. Postoperative course was uneventful and ECG showed regular sinus rhythm.     

Successful repair of tricuspid regurgitation due to blunt trauma

A 19-year-old man developed paralysis of the left arm as a result of left brachial plexus injury by a traffic accident. He underwent operation for the brachial plexus paralysis, and then severe heart failure developed postoperatively. Echocardiography revealed severe tricuspid valve regurgitation. Tricuspid valve plasty was performed 14 months after the traffic accident. The anterior leaflet of the tricuspid valve was torn and the chordae attached there were torn as well. The torn anterior leaflet was sutured directly, and the prolapsed portion of this leaflet was collected by transfer of the elongated chordae. Annuloplasty (DeVega technique) was then added. Postoperative echocardiography revealed trivial regurgitation of the tricuspid valve. Only 9 cases of successful repair of traumatic tricuspid regurgitation have been reported in Japan.     

A case report on a reconstructive operation of a traumatic tricuspid regurgitation with a congenital defect of the left pericardium

We reported a successful tricuspid valve replacement in a 58-years old man, who had easy fatiguability after 14 years of a blunt chest trauma. The preoperative examination revealed a marked cardiomegaly with deformation of both ventricles and grade 4 tricuspid regurgitation caused by the prolapse of the anterior leaflet. The operative inspection revealed a left pericardial defect with a diameter of 10 cm and a torn anterior papillary muscle. Since a usual plastic procedure did not improve the regurgitation, a Carpentier-Edward bioprosthetic valve was implanted in the supra annular position. Atrioventricular conduction was preserved. The tricuspid valve was not resected to preserve the ventricular function. The patient recovered his own activity.     

A case of congenital tricuspid regurgitation associated with atrial septal defect and peripheral pulmonary stenosis

This report describes a 5-year-old girl with congenital tricuspid regurgitation associated with an atrial septal defect and peripheral pulmonary stenosis. The girl was diagnosed with the heart murmur at birth and recently developed the cardiomegaly. Cardiac echocardiography and catheterization showed severe tricuspid regurgitation, an atrial septal defect of the secundum type and peripheral pulmonary stenosis. In the operative findings, the tricuspid annulus was dilated to 33 mm in diameter, and leaflets were attached normally to the antomic annulus. There was a large cleft of the anterior leaflet of the tricuspid valve. Suture of the cleft and annuloplasty of the tricuspid valve, suture closure of the atrial septal defect and patch dilatation of peripheral pulmonary stenosis were successfully performed. Including this case, 19 other cases with congenital tricuspid regurgitation undergoing surgery were reported to date.     

Case of MPO-ANCA positive interstitial pneumonitis and necrotizing, crescentic glomerulonephritis

A 56-year-old female who was diagnosed incomplete endocardial cushion defect, underwent closure of ostium primum defect and repair of mitral cleft 2 years ago. Mitral and tricuspid ring annuloplasty was done 9 months after the first operation because of an increment of mitral and tricuspid valve regurgitation. The Third operation, mitral valve replacement by mechanical valve and tricuspid valve replacement by bioprosthetic valve, was performed because of the gradually increased mitral stenosis and tricuspid regurgitation. Post-operative course was uneventful. Resected anterior cusp of mitral and tricuspid valve revealed hypertrophy and shortness macroscopically, and revealed fibrosis and calcification histopathologically. It was considered that remarkable regurgitation was due to secondary change of both valves. We concluded that valve replacement should be performed for case of secondary change of atrioventricular valve in adult patient.     

Valve repair with chordal replacement for traumatic tricuspid regurgitation

A 70-year-old woman who had fatiguability due to right heart failure seven years after receiving blunt chest trauma in a road traffic accident presented to our hospital. Preoperative echocardiography revealed severe tricuspid regurgitation resulting from prolapse of the anterior leaflet. The valve was repaired by chordal replacement with expanded polytetrafluoroethylene sutures and DeVega annuloplasty. At three months after surgery, the patient is in good clinical condition, and repeat echocardiography revealed only mild tricuspid regurgitation.     

Traumatic tricuspid valve regurgitation and cerebral emboli

We report a case of traumatic tricuspid valve regurgitation and late presentation with transient ischemic attacks caused by the presence of a right-to-left shunt through a small atrial septal defect.     

Monocusp homograft VSD patch in atrioventricular canal with tetralogy of Fallot

A monocusp aortic homograft was used to compensate for deficient right atrioventricular valve tissue during repair of complete atrioventricular canal defect with tetralogy of Fallot. The homograft was used to produce a comma-shaped ventricular septal defect patch together with the septal leaflet of the right atrioventricular valve, thus committing native leaflet tissue to left atrioventricular valve reconstruction. One year postoperatively the child is in New York Heart Association class I with no tricuspid regurgitation.     

Vanishing De Vega annuloplasty for functional tricuspid regurgitation

Annuloplasty is performed for significant functional tricuspid regurgitation even if it is presumed that in some cases the regurgitation will regress spontaneously after correction of the left-sided lesion. In an attempt to avoid the drawbacks of a permanent annuloplasty, we used a reabsorbable De Vega annuloplasty in a selected group of patients. Of 73 patients with functional tricuspid regurgitation operated on between May 1989 and May 1991, 25 with pulmonary arteriolar resistance below 400 dyne.sec.cm-5 underwent a De Vega annuloplasty with 2-0 polydioxanone suture. The diagnosis of significant functional tricuspid regurgitation (mean 2.74 +/- 1.05) was established by transthoracic color Doppler echocardiography in all patients. The degree of functional tricuspid regurgitation and pulmonary arteriolar resistance were measured with the patients anesthetized. In 16 patients the regurgitation remained severe (3+ to 4+) and in 9 it was moderate (2+). Twenty-three patients had mitral (12 repairs, 11 replacements) and 9 had aortic (4 repairs, 5 replacements) valve operations. The immediate postbypass residual functional tricuspid regurgitation was 0 to 1+ in 23 and 0 in 2. There was 1 (4%) operative death. The maximum follow-up period was 24 months (mean 13.9 months). There were 2 (8.3%) late deaths. Six patients underwent reoperation because of mitral dysfunction. Four of them who were reoperated on between 2 and 5 weeks after the initial procedure showed no recurrence of functional tricuspid regurgitation. The other 2, reoperated on at 5 and 10 months after the first operation, had recurrence of functional tricuspid regurgitation. Visual inspection of these two tricuspid valves showed a dilated anulus with otherwise normal valves. All surviving patients are in New York Heart Association functional class I or II without significant functional tricuspid regurgitation (mean 0.78 +/- 0.56). We concluded that functional tricuspid regurgitation in patients with low pulmonary arteriolar resistance can be adequately treated by a vanishing De Vega annuloplasty, which will stent the tricuspid anulus for about 4 months.     

Adjustable tricuspid valve annuloplasty assisted by intraoperative transesophageal color Doppler echocardiography

Intraoperative transesophageal echocardiography (TEE) can play a major role in active guidance of cardiac surgery. This study describes a new application of TEE for assisting tricuspid suture annuloplasty. Twenty-five patients (aged 52 +/- 11 years) who underwent mitral valve replacement and tricuspid valve annuloplasty were studied intraoperatively by TEE. After cardiopulmonary bypass, the suture annuloplasty was adjusted on the beating heart until palpable regurgitation was eliminated. Further adjustment of the suture was performed under echocardiographic guidance until color Doppler flow imaging showed the most adequate correction of tricuspid regurgitation (TR). A significant decrease in the semiquantitative grade of TR, of regurgitant jet area and of the ratio jet area/right atrial area was obtained when the suture was adjusted under echocardiographic guidance. The peak inflow velocity and the gradient across the tricuspid valve did not show significant changes throughout the procedures. The results showed that the tricuspid suture annuloplasty guided by TEE enables a substantial reduction in residual TR without creating valve stenosis.     

Biopsy-induced tricuspid regurgitation after cardiac transplantation

Transvenous endomyocardial biopsy is now well-established as the gold standard for evaluation of possible rejection episodes after cardiac transplantation. From 1985 to August 1992, 1990 patients have undergone 193 cardiac transplantations at Barnes Hospital. One hundred eighty-three patients survived their initial hospitalization and serve as the study group. Their records were reviewed for the purposes of identifying those with tricuspid regurgitation as a complication of right ventricular endomyocardial biopsy. These patients have undergone a total of 2,960 biopsies for an average of 16.2 biopsies per patient. Over a mean follow-up period of 4.22 years, all patients have been evaluated with standard two-dimensional echocardiograms. Mild to moderate tricuspid regurgitation was very common, but was thought to be biopsy-induced only if severe and accompanied by flail components of the tricuspid valve. Twelve patients were identified with this entity at our institution. Of these, 5 had no symptoms and were receiving no diuretics, 3 had mild symptoms consisting of lower extremity edema and continued to receive diuretics, 2 had moderate symptoms, and 2 had right heart failure and anasarca refractory to medical therapy. Both of the severely affected patients subsequently required tricuspid valve replacement. We conclude that the tricuspid valve apparatus is at significant risk of injury during endomyocardial biopsy, that most patients will be minimally symptomatic due to tricuspid regurgitation when this injury occurs, and that when the injury is accompanied by severe symptoms, the likelihood of improvement with medical therapy is small.     

Cardiac metastatic melanoma investigated by magnetic resonance imaging

A case of tricuspid valve regurgitation due to a non-penetrating chest trauma was presented. This case involves a 20-year-old man, who was admitted to a nearby hospital because of rib fracture, mandibular fracture, and hemorrhage of the left hemopneumothorax, caused by a traffic accident. Palpitation and chest discomfort were observed at admission time, but there was no follow-up. Tricuspid regurgitation was pointed out during surgery for the mandibular fracture, and he continued follow up treatment at an outpatient clinic. However his palpitation and chest discomfort worsened, and he was admitted to our department 8 month after injury. During surgery to repair the tricuspid valve, a papillary muscle rupture, valve cusp laceration, and anulus dilatation were found. We performed a papillary muscle repair (chorda tendineae reconstruction), valve cusp suture, and annuloplasty. Absence of the left pericardium was observed during the operation. We reported valve repair of traumatic tricuspid regurgitation which with papillary muscle rupture. Due to its rarity and the fact that there has been no reported cases of papillary muscle repair for traumatic tricuspid regurgitation in Japan, we used researched information on the subject.     

Surgical treatment of traumatic rupture of the aortic valve with dove-coo murmur--case report

Aortic regurgitation due to traumatic rupture of the aortic valve with dove-coo murmur is rare. A 71-year-old man was admitted for cardiac failure due to aortic regurgitation with dove-coo murmur, 4 years after the traffic accident. The aortic valve replacement was performed and his postoperative course was good. The aortic valve was tricuspid valve with the tear in the left side of right coronary cusp, and the size of the tear was 7 mm. The aortic valve was not recognized the findings of inflammatory or rheumatic change in the pathological study.     

Suspension of straddling tricuspid valve chordae into the appropriate ventricle

In 2 children with an inlet ventricular septal defect and straddling chordae tendineae of the septal leaflet of the tricuspid valve to the posteromedial papillary muscle of the mitral valve and to an accessory papillary muscle in the left ventricle, the straddling chordae were excised with a wedge of posteromedial papillary muscle and with the top segment of the accessory papillary muscle, respectively. After patch closure of the ventricular septal defect, the papillary muscle segment with its group of chordae was anchored to the right ventricular septum with resulting competence of the tricuspid valve. In contrast to the traditional repair technique, the reported modification is applicable when the straddling chordae insert into a papillary muscle of the mitral valve. In addition, various disadvantages related to the construction of a complex baffle in the inappropriate ventricle are avoided.     

Tricuspid regurgitation and acute myocardial infarction

A 71-year-old man had a right ventricular infarct complicated with hypotension and transient complete atrioventricular block. The patient was found to have tricuspid regurgitation, which was corrected with a prosthetic tricuspid valve. After correction, there was dramatic improvement in his clinical status, with correction of persistent hypotension and weakness and early discharge home to full activity. Tricuspid regurgitation is a mechanical defect of acute myocardial infarction that benefits greatly from surgical correction. This therapy should be considered in any individual in whom tricuspid regurgitation complicates acute right ventricular infarction.     

A modified repair technique for tricuspid incompetence in Ebstein's anomaly

OBJECTIVE: A modified technique for tricuspid valve repair in Ebstein's anomaly restructures the valve mechanism at the level of the true tricuspid anulus by using the most mobile leaflet for valve closure without plication of the atrialized chamber. Midterm results of this therapeutic approach for patients with Ebstein's anomaly and tricuspid valve incompetence are reported. METHODS: Between October 1988 and April 1997, the incompetent tricuspid valve was repaired with our technique in 19 patients (12 female, 7 male; 2 to 54 years, mean 21 years). The indication for operation was congestive heart failure of various degrees in all patients. Tricuspid incompetence was grade II in two patients, grade III in 14, and grade IV in three. Associated congenital malformations were simultaneously repaired (interatrial communication in 18, ventricular septal defect in two, pulmonary stenosis in two, mitral valve prolapse in one). Follow-up ranged between 10 and 103 months (median 28 months) and was complete for all patients. RESULTS: There were no operative deaths. One patient with active endocarditis and pulmonary abscess died 2 months after the operation of recurrent sepsis; there were no late deaths. During follow-up, New York Heart Association functional class improved from 2.8 before the operation to 1.9 without recurrent cyanosis, and tricuspid incompetence decreased from a mean grade of 3.1 to one of 0.9, without any echocardiographic deterioration of the tricuspid valve function or right ventricular dilation. CONCLUSIONS: Our technique allows tricuspid valve repair in patients with Ebstein's anomaly, even in cases usually reserved for primary valve replacement, without late functional deterioration.     

Hypoproteinemia caused by tricuspid regurgitation: report of a case

A case of tricuspid regurgitation (TR) complicated by severe hypoproteinemia is presented herein. A 68-year-old man who had undergone coronary artery bypass grafting (CABG) for postinfarction angina suffered repeated inferior myocardial infarction due to obstruction of the proximal right coronary artery, 3 years after which he developed systemic edema. Investigations revealed TR associated with hypoproteinemia; however, treatment consisting of aggressive diuretic therapy and albumin administration proved ineffective. The hypoproteinemia manifested as protein-losing enteropathy clinically, and the tricuspid valve was replaced to eliminate high venous pressure. The serum protein levels became normalized after the operation. Although TR is generally well tolerated in the absence of pulmonary hypertension, surgical management is recommended for patients with severe protein deficiency resistant to medical treatment.     

Ebstein's anomaly of the tricuspid valve: a case report

A case of Ebstein's malformation of the tricuspid valve with a complicating ventricular septal defect in a 3-year-old Black child is presented. A pre-operative diagnosis of an atrioventricular canal was made, and only at operation was it discovered to be an Ebstein's anomaly of the tricuspid valve. The clinical picture and diagnoses are reviewed, and the problem of a correct pre-operative diagnosis is discussed. The operative treatment and postoperative result in our patient is described.     

Pulsatile total cavopulmonary shunt for hypoplastic right heart syndrome with abnormal systemic venous return--a case report

A pulsatile total cavopulmonary shunt was successfully performed on a 5-year-old girl with hypoplastic right heart syndrome associated with abnormal systemic venous return; at the same time, modified mitral valve replacement was performed for mitral regurgitation. The right atrium, tricuspid valve and right ventricle were all extremely dimunitive. The diameter of the tricuspid valve was 50% of normal and the volume of the right ventricle was 8.6% of normal. In addition, there were severe subpumonary stenosis, a restrictive ventricular septal defect (VSD) and an atrial septal defect (ASD). The bilateral superior venae cavae (SVCs) and the hepatic vein drained to the left atrium, and the inferior vena cava was infrahepatically interrupted with a hemiazygos connection to the left superior vena cava. At the operation, each SVC was anastomosed end-to-side to each branch of the pulmonary artery (PA). The restrictive ventricular septal defect and stenotic subpulmonary lesion were left. The diameter of the ASD was reduced from 12 mm to 7 mm. The main PA was neither divided nor banded. The pulsatile blood flow from the left heart to the PA was regurated by a native restrictive VSD and stenotic subpulmonary lesion, and that from the right heart via the ASD was limited by reducing the size of the ASD. These described anatomic arrangements produced adequate antegrade pulsatile flow in the PA, which might prevent the development of pulmonary arteriovenous fistulae and, besides permit transfer of drainage of the hepatic vein from the left to the right atrium via the ASD in future.     

Evaluation of tricuspid regurgitation by the ultrasonic pulsed Doppler technique from a transcutaneous approach (author's transl)

Severity of tricuspid regurgitation was assessed by using a combined system of the ultrasonic pulsed Doppler technique and two-dimensional echocardiography from a transcutaneous approach. The study group comprised 47 patients with various heart diseases, who were clinically presumed to have tricuspid regurgitation, and 10 healthy subjects. 1) Pansystolic abnormal flow signal was detected in an area from the tricuspid valve into the right atrial cavity in 43 patients including 8 patients without definitive signs of tricuspid regurgitation. Such abnormal flow had never been detected in healthy subjects and was considered to represent tricuspid regurgitant flow. Tricuspid regurgitant flow usually exhibited a wide band spectrum of velocity component indicating a disturbed flow. In 4 patients with clinical signs of severe tricuspid regurgitation, a laminar flow was detected in the right atrial cavity, which was considered to indicate a regurgitant jet in the central part of tricuspid regurgitant flow. 2) The area where tricuspid regurgitant flow was detected was interpreted as revealing the main direction and spread of tricuspid regurgitant flow. Based on this finding, severity of TR was classified into 4 grades by the assessment on the basis of the distance reached by tricuspid regurgitant flow in the right atrium. Severity of tricuspid regurgitation was also classified into 4 grades by right ventriculography. The grade of tricuspid regurgitation assessed by Doppler technique was nearly consistent with that assessed by right ventriculography. Severity of tricuspid regurgitation was also classified into 4 grades on the basis of the extent of the area where the regurgitant flow spread, and nearly the same results were obtained as those described above. 3) Thus, the combined use of Doppler flowmetry and two-dimensional echocardiography proved to be useful for detecting tricuspid regurgitant flow and assessing the severity of tricuspid regurgitation.