As the indications for transcatheter aortic valve replacement (TAVR) expand, multi-valve lesions are becoming more common in clinical practice. Moderate to severe atrioventricular regurgitation, particularly when persistent after TAVR, significantly increases the risk of adverse events. Therefore, many studies have evaluated factors that contribute to the improvement of atrioventricular regurgitation. However, this field remains controversial due to the heterogeneity of retrospective studies and the lack of randomized controlled trials. Despite advances in atrioventricular valve intervention techniques, evidence for atrioventricular regurgitation intervention after TAVR is still scarce. The management decision for atrioventricular regurgitation in patients who underwent TAVR is complex and must take into account the severity of valve disease, anatomical characteristics, quality of life, and procedural complexity. We conducted a review of atrioventricular regurgitation in patients who have received TAVR in hope that it will help decision-making in clinical practice.
Abstract： Surgical repair of functional tricuspid regurgitation (FTR) is often carried out concomitantly with other leftsided heart valve procedures. Though diseases of both left heart valve and tricuspid were treated during the surgery, postoperative residual or recurrent tricuspid regurgitation has been clearly associated with progressive heart failure and worsened longterm survival. To date, surgical interventions mainly address FTR at three anatomic levels: commissure, annulus and leaflets. However, a certain mid and longterm failure rate after operation still exists. High surgical mortality rates have been reported in patients with recurrent tricuspid regurgitation requiring complex reoperations. With a better understanding of tricuspid anatomical complex and valvuloplasty, significant improvements have been made in FTR surgical indications and techniques. This review article will focus on the development of surgical indications in tricuspid valve repair, while the repair techniques and their impact on longterm clinical outcome will also be compared.
With the prevalence of atrial fibrillation and the increasing use of intracardiac pacemakers, the incidence of isolated tricuspid regurgitation is gradually increasing. Severe isolated tricuspid regurgitation has a seriously negative effect on the survival rate and life quality of patients. As the major invasive therapy, surgery is not routinely carried out due to high perioperative mortality. This article attempts to summarize the etiology, natural course and adverse consequences of isolated tricuspid regurgitation, current treatment strategies, surgical indications and techniques, efficacy evaluation, prognostic factors and transcatheter treatment progress of isolated tricuspid regurgitation, aiming to provide references for cardiologists and further researches.
ObjectiveTo investigate the effect of concomitant tricuspid valve repair during mitral valve surgery on the early and mid-term prognosis of the tricuspid valve and right heart function in the patients with moderate or less tricuspid regurgitation. MethodsA retrospective study of 461 patients with mitral valve disease requiring cardiac surgery combined with moderate or less tricuspid regurgitation in our hospital from 2011 to 2014 was done. They were 309 males and 152 females with a median age of 53.00 (44.00, 60.00) years. According to whether they received tricuspid valve repair (Kay’s annuloplasty, DeVega’s annuloplasty or annular ring implantation), the patients were divided into a mitral valve surgery only group (a nTAP group, n=289) and a concomitant tricuspid valve repair group (a TAP group, n=172). At the same time, 43 patients whose tricuspid valve annulus diameter was less than 40 mm in the TAP group were analyzed in subgroups. ResultsThe median follow-up duration was 3.00 years (range from 0.10 to 9.30 years). There was no perioperative death. Three months after surgery, the anteroposterior diameter of the right ventricle in the TAP group was significantly improved compared with that in the nTAP group [–1.00 (–3.00, 1.00) mm vs. 0.00 (–0.20, 2.00) mm, P=0.048]. Three years after surgery, the improvement of right ventricular anteroposterior diameter in the TAP group was still significant compared with the nTAP group [–1.00 (–2.75, 2.00) mm vs. 2.00 (–0.75, 4.00) mm, P=0.014], and the patients in the TAP group were less likely to develop moderate or more tricuspid regurgitation (3.64% vs. 35.64%, P<0.001). Annuloplasty ring implantation was more effective in preventing regurgitation progression (P=0.044). For patients with a tricuspid annulus diameter less than 40 mm, concomitant tricuspid valve repair was still effective in improving the anteroposterior diameter of the right ventricle in the early follow-up (P=0.036). Conclusion Concomitant tricuspid valve repair for patients with moderate or less tricuspid regurgitation during mitral valve surgery can effectively improve the tricuspid valve and right heart function in the early and mid-term after surgery. Annuloplasty ring implantation is more effective in preventing regurgitation progression. Patients whose tricuspid annulus diameter is less than 40 mm can also benefit from concomitant tricuspid repair.
ObjectiveTo analyze the assessment and maintenance of 125 donor hearts from brain death donation and explore the use of marginal donor hearts.MethodsA retrospective analysis was conducted on the evaluation, maintenance, operation and follow-up results of 125 donor hearts from April 2016 to August 2019. There were 98 males and 27 females at age of 6-50 (36.0±2.4) years.ResultsTwelve donor hearts were discarded due to unqualified evaluation after heart harvest. 113 patients of heart transplantation were performed with a double lumen venous anastomosis manner. The mean time of cold ischemia was 220.1±6.7 min. Four patients died within 30 days after operation. Postoperative right ventricular assist circulation was performed in 4 patients, intra-aortic balloon counterattack (IABP) in 12 patients and extracorporeal membrane oxygenation (ECMO) in 12 patients. Marginal donors included 15 hepatitis B antigen positive donor hearts, 2 tricuspid regurgitation, 1 mitral regurgitation, 5 coronary calcification, 4 myocardial stunning and 2 severe weight mismatch. The results of follow-up (2 years) after marginal donor heart transplantation were satisfactory.ConclusionImproving the assessment and maintenance of donor hearts can improve the utilization rate of the heart, and the marginal donor heart transplantation needs long-term follow-up.
Preoperative evaluation is crucial for heart valvular surgery. This article discusses some issues that need to be emphasized: the impact of hypertension on the severity of aortic valve lesions, and how to improve the accuracy of clinical assessment; the identification of functional tricuspid regurgitation, in order to choose the appropriate surgical technique; the need for right ventricular function testing, and the use of risk scoring models, to better grasp surgical timing and indications and improve efficacy; and the importance of evaluating atrial mitral and/or tricuspid regurgitation complications in chronic atrial fibrillation, and making rational choices for interventional and surgical treatment.
摘要:目的:探讨改良De Vega环缩术与经典De Vega环缩术相比对于治疗重度三尖瓣返流是否具有更好的成形效果。方法: 2007年12月至2009年3月对29例重度三尖瓣返流的患者行De Vega环缩术。其中16例行改良De Vega环缩术,13例行经典De Vega环缩术,随访比较两组患者三尖瓣返流程度,右心室舒张期末内径,EF值及心功能分级。以秩和检验分析研究两组患者三尖瓣返流程度和心功能分级的差异,以t检验研究两组患者右心室舒张末期内径及EF值变化。结果:术前两组患者一般指标无显著差异。两组患者随访时间无显著差异。随访经典De Vega组重度返流1例,中度返流5例,轻度返流5例,微量及无返流2例;改良De Vega组无中、重度返流,轻度返流8例,微量及无返流8例。经分析显示两组患者三尖瓣返流程度结果差异有统计学意义(Plt;0.05)。经典De Vega组心功能分级I级5例,II级7例,III级1例;改良De Vega组I级7例,II级8例,III级1例,两组患者心功能差异无统计学意义(Pgt;0.05)。两组患者右室舒张期末内径及EF值组内比较随访与术前差异均有统计学意义(Plt;0.05),随访时组间比较差异有统计学意义(Plt;0.05), 改良De Vega环缩术随访时右室舒张期末内径缩小更显著,射血分数改善更明显。结论:改良De Vega环缩术治疗重度三尖瓣返流效果优于经典De Vega环缩术。Abstract: Objective: To compare the efficacy of one kind of modified De Vega technique and traditional De Vega technique for the correction of severe tricuspid regurgitation. Methods: From December 2007 to March 2009, 29 patients were treated with tricuspid valve annuloplasty. These were 16 patients in modified De Vega annuloplasty group and the others (13 patients) in traditional De Vega annuloplasty group. The grade of tricuspid regurgitation、New York Heart Association (NYHA) functional class、ejection fraction (EF) and the right ventricular enddiastolic dimension of two groups were followed and reviewed. Results: There was no statistically difference between two groups about preoperative characteristics and followup time. There was 1 patient with severe TR, 5 patients with moderate TR, 5 patients with mild TR and 2 patients without TR in traditional De Vega annuloplasty group after the operations. In modified De Vega annuloplasty group, no patient was observed with severe or moderate TR, 8 patients with mild TR, and 8 patients without TR. At interval time, there was significant difference in the grade of tricuspid regurgitation between two groups (Plt;0. 05). Both tricuspid valve plasty techniques could reduce the right ventricular enddiastolic dimension and improve ejection fraction significantly (Plt; 0. 05), and there was significant difference in the right ventricular enddiastolic dimension and ejection fraction at interval time between two groups (Plt;0.05). Conclusions: The outcome of modified tricuspid De Vega technique is superior to that of traditional De Vega technique in correcting severe tricuspid regurgitation.
A 23-year-old male patient was diagnosed with congenitally corrected transposition of the great arteries (ccTGA) at the age of 3 during a routine physical examination. Due to the absence of significant symptoms, the patient was managed conservatively with follow-up without surgical treatment. He developed chest tightness one year prior to admission, with symptom exacerbation in the recent month. Echocardiography demonstrated significantly worsened morphological tricuspid regurgitation. The patient presented to Guangdong Provincial People’s Hospital for surgical evaluation. Given the patient’s age and clinical presentation, a totally thoracoscopic morphological tricuspid valve replacement was performed. Postoperative assessment showed good prosthetic valve function, with no regurgitation or paravalvular leakage; the electrocardiogram confirmed sinus rhythm without atrioventricular block. Extubation occurred within 12 hours postoperatively, and the patient was transferred from the intensive care unit (ICU) on postoperative day 2. At the three-month follow-up, the patient was asymptomatic and had resumed normal activities. This report describes the first case of a totally thoracoscopic morphological tricuspid valve replacement in a ccTGA patient in China. This initial experience suggests that the totally thoracoscopic approach for morphological tricuspid valve replacement in ccTGA patients is a feasible, safe, and effective minimally invasive option associated with rapid recovery.
Objective To summarize the clinical characteristics and management experiences of patients with severe tricuspid regurgitation (TR) after mitral valve surgery. Methods Thirty patients were followed up and reviewed for this report. There were 1 male and 29 female patients whose ages ranged from 32 to 65 years (47.1±92 years). A total of 28 patients had atrial fibrillation and 2 patients were in sinus rhythm. There were 13 patients of mild TR, 10 patients of moderate TR and 7 patients of severe TR at the first mitral valve surgery. Five patients received the tricuspid annuloplasty of De Vega procedure at the same time, 2 patients received Kay procedure. The predominant presentation of patients included: abdominal discomfort (93.3%, 28/30), edema (66.7%,20/30), palpitation (56.7%, 17/30), and ascites (20%, 6/30). Results Nine patients underwent the secondary surgery for severe TR. The secondary surgery included tricuspid valve replacement (6 cases), mitral and tricuspid valve replacement (2 cases) and Kay procedure (1 case). Eight patients were recovered and discharged and 1 patient died from the bleeding of right atrial incision and low output syndrome. Twentyone patients received medical management and were followed up. One case was lost during followup. Conclusion Surgery or medical management should be based on the clinical characteristics of patients with severe TR after mitral valve surgery. It should be based on the features of tricuspid valve and the clinical experience of surgeon to perform tricuspid annuloplasty or replacement.
ObjectiveTo compare the efficacy of additional tricuspid valve annuloplasty (TVP) and isolated closure for atrial septal defect (ASD) with moderate to severe tricuspid regurgitation (TR). MethodsClinical data of the patients diagnosed with ASD combined with secondary moderate to severe TR and treated in our hospital from January 2009 to June 2020 were retrospectively analyzed. Patients were divided into a TVP group and a non-TVP group based on whether TVP was performed simultaneously. The baseline data of two groups were matched with a ratio of 1∶1 propensity score. ResultsA total of 32 pairs from 257 patients were successfully matched. In the TVP group, there were 24 females and 8 males with an average age of 44.0±13.1 years. In the non-TVP group, there were 28 females and 4 males with an average age of 44.5±11.6 years. The TR area and estimated pulmonary artery pressure in the two groups were significantly decreased compared with preoperation (all P<0.001). The TR area (P=0.001) and the estimated pulmonary artery pressure (P=0.002) were decreased more significantly in the TVP group than those in the non-TVP group. Linear regression analysis showed that age and preoperative TR area had a positive correlation with TR area at follow-up (β=0.045 and 0.259, respectively, both P<0.05), while additional TVP had a negative correlation (β=–1.542, P=0.001). ConclusionAdditional TVP can significantly reduce the TR area and pulmonary artery pressure, and elderly patients with severe TR before surgery should actively receive TVP.