Pulmonary and tricuspid regurgitation after Tetralogy of Fallot repair: A case report

BACKGROUND Tetralogy of Fallot(TOF)is one of the most common congenital heart defects,and surgery is the primary treatment.There are no precise guidelines on the treatment protocol for tricuspid regurgitation(TR)as a common complication of TOF repair.The timing for treatment in patients presenting with valve regurgitation after TOF repair is often difficult to determine.Here,we report the first case of sequential treatment of pulmonary and TR using interventional therapy.CASE SUMMARY We present the case of a 52-year-old female patient,who had a history of TOF repair at a young age.A few years later,the patient presented with pulmonary and tricuspid regurgitation.The symptoms persisted and TR worsened following percutaneous pulmonary valve implantation.Preoperative testing revealed that the patient’s disease had advanced to an intermediate to advanced stage and that her general health was precarious.Because open-heart surgery was not an option for the patient,transcatheter tricuspid valve replacement was suggested.This procedure was successful,and the patient recovered fully without any adverse effects.This case report may serve as a useful resource for planning future treatments.CONCLUSION Treatment of both valves should be considered in patients with tricuspid and pulmonary regurgitations following TOF repair.The interventional strategy could be an alternative for patients with poor general health.

Importance of concomitant functional mitral regurgitation on survival in severe aortic stenosis patients undergoing aortic valve replacement

BACKGROUND Mitral regurgitation(MR)is commonly seen in patients with severe aortic stenosis(AS)undergoing aortic valve replacement(AVR).But the long-term implications of MR in AS are unknown.AIM To investigate MR’s impact on survival of patients undergoing surgical AVR for severe AS.METHODS Of the 740 consecutive patients with severe AS evaluated between 1993 and 2003,287 underwent AVR forming the study cohort.They were followed up to death or till the end of 2019.Chart reviews were performed for clinical,echocardiographic,and therapeutic data.MR was graded on a 1-4 scale.Mortality data was obtained from chart review and the Social Security Death Index.Survival was analyzed as a function of degree of MR.RESULTS The mean age of the severe AS patients who had AVR(n=287)was 72±13 years,46%women.Over up to 26 years of follow up,there were 201(70%)deaths,giving deep insights into the determinants of survival of severe AS who had AVR.The 5,10 and 20 years survival rates were 75%,45%and 25%respectively.Presence of MR was associated with higher mortality in a graded fashion(P=0.0003).MR was significantly associated with lower left ventricular(LV)ejection fraction and larger LV size.Impact of MR on mortality was partially mediated through lower LV ejection fraction and larger LV size.By Cox regression,MR,lower ejection fraction(EF)and larger LV end-systolic dimension were independent predictors of higher mortality(χ^(2)=33.2).CONCLUSION Presence of greater than 2+MR in patients with severe AS is independently associated with reduced survival in surgically managed patients,an effect incremental to reduced EF and larger LV size.We suggest that aortic valve intervention should be considered in severe AS patients when>2+MR occurs irrespective of EF or symptoms.

Isolated Tricuspid Valve Repair and Right Atrial Plication Performed Using a Beating-Heart Technique for Atrial Functional Tricuspid Valve Regurgitation

Background: Isolated tricuspid valve disease remains a controversial indication for surgical intervention. Many patients referred for surgery already have a poor clinical condition and an advanced New York Heart Association functional class. There is no consensus on the optimal surgical technique for this condition, including on whether to perform the procedure on a beating or an arrested heart and whether to perform valve repair or replacement. Methods: We analyzed four case series between 2015 and 2022 in which patients with secondary tricuspid regurgitation (TR) underwent valve repair on a beating heart and right atrial plication for a dilated right atrium. The TRI-SCORE was calculated for each patient. Results: All patients experienced a favorable postoperative course with significant improvements in heart failure symptoms. TR was markedly reduced;however, in one patient with concomitant mitral regurgitation (MR) and a high TRI-SCORE, MR worsened postoperatively. This patient later died from unknown causes due to multiple comorbidities in the late phase. Conclusions: Tricuspid valve repair on a beating heart was effective for improving the cardiac function, and the TRI-SCORE proved useful as a preoperative risk assessment tool. The underlying mechanism by which TR exacerbates MR requires further investigation.

Predictors of persistence of functional mitral regurgitation after cardiac resynchronization therapy:Review of literature

Functional mitral regurgitation is a common finding among heart failure patients with ischemic and non-ischemic dilated cardiomyopathies.The presence of moderate or severe mitral regurgitation is associated with higher morbidity and mortality.Heart failure patients meeting electrocardiogram and left ventricle function criteria are good candidates for cardiac resynchronization therapy,which may reduce the degree of functional mitral regurgitation in the short and long term,specifically targeting myocardial dyssynchrony and inducing left ventricle reverse remodeling.In this article,we analyze data from the literature about predictors of mitral regurgitation improvement after cardiac resynchronization therapy implantation.

Transcatheter closure of ventricular septal defect in patients with aortic valve prolapse and mild aortic regurgitation:feasibility and preliminary outcome

Objective:To evaluate the feasibility,safety and efficacy of transcathcter closure of ventricular septal defect(VSD)in patients with aortic valve prolapse(AVP)and mild aortic regurgitation(AR).Methods:Between January 2008 and July 2014,transcatheter closure of VSD was attempted in 65 patients.Results:The total intermediate closure successful rate in all subjects was 96.9%.During the perioperative period,no death,major bleeding,pericardial tamponade,occluder dislodgement,residual shunt or hemolysis occurred.Two procedures had been forced to suspend due to significant aggregation of device related aortic regurgitation,three cases of transient complete left bundle branch block occurred but did not sustain.At 1-year followup,no patients had residual shunts and complications.Furthermore,grade of residual AR were relieved in 61.9%(39/63)cases and degree of AVP were ameliorated in 36.5%(23/63)patients;Conclusions:Transcatheter closure VSD in selected patients with AVP and mild AR is technically feasible and highly effective.Long term safety and efficacy needs to be assessed.

Clinical features and treatment options for mitral regurgitation in elderly inpatients

Objective To summarize clinical characteristics and treatment strategy of Chinese elderly mitral regurgitation （MR） inpatients under the current guidelines, and to identify factors related to treatment options in them. Methods A single center retrospective study was conducted in which patients hospitalized in Fuwai hospital from May ist of 2014 to April 30 of 2015 with moderate to severe MR assessed by transthoraeic echocardiography were enrolled consecutively （n = 1741）. Patients 〉 60 years old were grouped as elderly group （n = 680） and patients 〈 60 years were grouped as control group （n = 1061）. The elderly group was categorized into two subgroups based on surgical status. Results The mean age of the elderly group was 66.98 i 5.94 years. The most common reason of MR in elderly group was degenerative MR （41.18%）. Atherosclerotic risk factors such as hypertension, diabetes or hyperlipidaemia were more commonly observed in elderly group than the control group （45.44% vs. 25.17%, P 〈 0.001; 19.56% vs. 8.48%, P 〈 0.001; 35.29% vs. 19.51%, P 〈 0.001）. Elderly group had higher Enroscore Ⅱ score （5.54 ± 2.42 vs. 3.15 ± 1.66）, greater left ventricular end diastolic diameter （LVEDD） （57.72±12.3 vs. 57.33 ± 10.19 ram） and a lower surgery rate （54.71% vs. 63.91%）; P 〈 0.05. Age, left ventricular ejection fraction （LVEF）, regurgitation grade, Eu- roScore-Ⅱ high risk stratification and having diabetes were identified as factors associated with therapy decisions in elderly MR patients. Conclusions Valve surgery was denied in 45.29% of elderly MR inpatients. Older age, impaired LVEF, lower regurgitation grade, Euro- Score-Ⅱ high risk stratification, and having diabetes were factors most significantly associated with surgery denial among elderly Chinese inpatients with MR.

Clinically unrecognized mitral regurgitation is prevalent in lone atrial fibrillation

AIM:To investigate the prevalence of clinically unrecognized mitral regurgitation(MR) in lone atrial fibrillation(AF).METHODS:We studied the prevalence and severity of MR by transesophageal echocardiography(TEE) in patients with "lone" AF as compared to a matched cohort of patients in normal sinus rhythm(NSR) undergoing TEE for other indications besides recognized valvular heart disease.RESULTS:A total of 157 subjects(57 in the AF group and 100 in the NSR group) with structurally normal cardiac valves were included in the study.In the AF group,moderate MR or more was noted in 66% of thepatients,mild MR in 18%,trace or no MR in 16%.In the control group,moderate MR was noted in 6% of patients,mild MR 31%,trace or no MR in 63 % of patients.Moderate MR or greater was significantly more prevalent in the AF group compared to the NSR group(66% vs 6%,P < 0.0001).CONCLUSION:Clinically unrecognized moderate MR is prevalent in "lone" AF-either as an etiologic factor leading to "lone" AF or developing after onset of AF.

Chronic ischemic mitral valve regurgitation and surgical perspectives

Chronic ischemic mitral valve regurgitation is a result of disturbed left ventricular geometry secondary to myocardial ischemia in the absence of intrinsic mitral valve pathology. It is a common complication after myocardial infarction, and patients who have ischemic mitral regurgitation(IMR) have a worse prognosis compared to patients who have ischemic heart disease alone, and this is directly related to the severity of IMR. Medical therapy has limited efficacy, and surgical options including various repair techniques and valve replacement had been tried with variable success. Still there is intense debate among surgeons whether to interfere with moderate degree IMR at the time of coronary artery revascularization.

Mechanical dyssynchrony and deformation imaging in patients with functional mitral regurgitation

Chronic functional mitral regurgitation(FMR) is a frequent finding of ischemic heart disease and dilated cardiomyopathy(DCM), associated with unfavourable prognosis. Several pathophysiologic mechanisms are involved in FMR, such as annular dilatation and dysfunction, left ventricle(LV) remodeling, dysfunction and dyssynchrony, papillary muscles displacement and dyssynchrony. The best therapeutic choice for FMR is still debated. When optimal medical treatment has already been set, a further option for cardiac resynchronization therapy(CRT) and/or surgical correction should be considered. CRT is able to contrast most of the pathophysiologic determinants of FMR by minimizing LV dyssynchrony through different mechanisms: Increasing closing forces, reducing tethering forces, reshaping annular geometry and function, correcting diastolic MR. Deformation imaging in terms of two-dimensional speckle tracking has been validated for LV dyssynchrony assessment. Radial speckle tracking and three-dimensional strain analysis appear to be the best methods to quantify intraventricular delay and to predict CRT-responders. Speckle-tracking echocardiography in patients with mitral valve regurgitation has been usually proposed for the assessment of LV and left atrial function. However it has also revealed a fundamental role of intraventricular dyssynchrony in determining FMR especially in DCM, rather than in ischemic cardiomyopathy in which MR severity seems to be more related to mitral valve deformation indexes. Furthermore speckle tracking allows the assessment of papillary muscle dyssynchrony. Therefore this technique can help to identify optimal candidates to CRT that will probably demonstrate a reduction in FMR degree and thus will experience a better outcome.

Real-time Three-Dimensional Color Doppler Flow Imaging： An Improved Technique for Quantitative Analysis of Aortic Regurgitation

The recently introduced real-time three-dimensional color Doppler flow imaging （RT-3D CDFI） technique provides a quick and accurate calculation of regurgitant jet volume （RJV） and fraction. In order to evaluate RT-3D CDFI in the noninvasive assessment of aortic RJV and regurgitant jet fraction （RJF） in patients with isolated aortic regurgitation, real-time three-dimensional echocardiographic studies were performed on 23 patients with isolated aortic regurgitation to obtain LV end-diastolic volumes （LVEDV）, end-systolic volumes （LVESV） and RJV, and then RJF could be calculated. The regurgitant volume （RV） and regurgitant fraction （RF） calculated by two-dimensional pulsed Doppler （2D-PD） method served as reference values. The results showed that aortic RJV measured by the RT-3D CDFI method showed a good correlation with the 2D-PD measurements （r= 0.93, Y=0.89X＋ 3.9, SEE= 8.6 mL, P〈0.001 ）; the mean （SD） difference between the two methods was - 1.5 （9.8） mL. % RJF estimated by the RT-3D CDFI method was also correlated well with the values obtained by the 2D-PD method （r=0.88, Y=0.71X＋ 14.8, SEE= 6.4 %, P〈0. 001）; the mean （SD） difference between the two methods was -1.2 （7.9） %. It was suggested that the newly developed RT-3D CDFI technique was feasible in the majority of patients. In patients with eccentric aortic regurgitation, this new modality provides additional information to that obtained from the two-dimensional examination, which overcomes the inherent limitations of two-dimensional echocardiography by depicting the full extent of the jet trajectory. In addition, the RT-3D CDFI method is quick and accurate in calculating RJV and RJF.

Percutaneous coronary intervention for acute myocardial infarction with mitral regurgitation

Ischemic mitral regurgitation （IMR） is a common complication of acute myocardial infarction （AMI）. Current evidences suggest that revascularization of the culprit vessels with percutaneous coronary artery intervention （PCI） or coronary artery bypass grafting can be beneficial for relieving IMR. A 2.5-year follow-up data of a 61-year-old male patient with ST-segment elevation AMI complicated with IMR showed that mitral regurgitation area increased five days after PCI, and decreased to lower steady level three months after PCI. This finding suggest that three months after PCI might be a suitable time point for evaluating the possibility oflMR recovery and the necessity of surgical intervention of the mitral valve for AMI patient.

Transcatheter interventions for severe tricuspid regurgitation:a literature review

The prevalence of tricuspid regurgitation(TR)increases with age,affecting 65%-85%of adults.Primary TR is caused by a congenital or acquired abnormality of the tricuspid valve apparatus(leaflets,chordae,papillary muscles,or annulus).Secondary TR is due to insufficient coaptation from dilation of tricuspid valve annulus due to the right ventricle(RV)or right at-rium(RA)remodeling and increased RV pressures.Isolated TR is without increased RV pressures and is associated with atrial fibrillation.Mild TR is a benign disease.Moderate to severe tricuspid regurgitation has independently been associated with in-creased mortality.Most of these patients are treated medically due to poor outcomes with surgical repair of isolated TR.The in-hospital mortality rate is 8.8%,and the median length of stay in hospital is 11 days resulting in higher healthcare costs.Even if the patients undergo surgical repair or replacement,available data do not show improvement in survival.With a more detailed un-derstanding of the complex anatomy and physiology of the tricuspid valve and significant complications from untreated tricusp-id valve disease,the approach to the management of TR has shifted from a conservative approach to a process of prevention and intervention.In the past decade,transcatheter tricuspid valve interventions and tricuspid annuloplasty rings have been de-veloped,contributing to decreased mortality from surgical repair.Transcatheter tricuspid valve intervention techniques have im-proved survival,quality of life,and reduced heart failure rehospitalization.This review summarizes normal anatomy,types of TR,etiology and different mechanisms of TR,echocardiographic assessment of the severe TR,and highlights various percu-taneous transcatheter techniques for tricuspid valve repair.

Transient severe mitral regurgitation after paroxysmal supraventricular tachycardia in patient with WPW syndrome

A 65-year-old woman was presented with acute ab- dominal pain. The initial heart rate was 170 beats/min and the ECG showed supraventricular tachycardia （Figure IA）. After intra-venous adenosine administered, it recovered to sinus rhythm and the follow-up ECG showed WPW pattern （Figure 1B）. The echocardiography revealed mitral valve prolapse of mid portion of anteromedial valve leaflet （A2） with severe mitral regurgitation （MR） （Figure 2）.

Transfemoral aortic valve implantation in the case of pre-existing mitral prosthesis and pure aortic regurgitation: A case report

BACKGROUND Transcatheter aortic valve replacement(TAVR)is recommended in patients with severe aortic stenosis who have high surgical risk.However,in the pre-existing mechanical mitral valve prosthesis and natural pure aortic regurgitation,TAVR is relatively contraindicated.In this report,we described one case of TAVR with native aortic regurgitation in the presence of mechanical mitral valve prosthesis.CASE SUMMARY A 64-year-old man with a medical history of mitral valve replacement had severe dyspnea and was symptomatic even at rest for 3 mo.His echocardiography showed severe native pure aortic regurgitation.His euroscore was 15.A TAVR procedure with an evolut R was planned.A 34 mm evolut R was placed by transesophageal echocardiography.The mitral prosthesis was functioning normally,and mild-moderate paravalvular leakage was evident by transesophageal echocardiography.The patient recovered without any complication.At 1 mo follow up,the patient was well,and no paravalvular leakage was noted.CONCLUSION TAVR for pure aortic regurgitation in the presence of prosthetic mitral valve can be a safe procedure.

Establishment of mitral regurgitation swine model and study the change of hydrogen sulfide system

Objective To establish the mitral regurgitation swine model and study the change of hydrogen sulfide(H2S)system in chronic heart failure model.Methods Miniature pigs were randomly divided into two groups,the control group(n=6)and mitral regurgitation group(n=6).Chronic heart failure models were established by pulling mitral chordal through a small incision extracorporeal.

Catheter-based intervention for symptomatic patient with severe mitral regurgitation and very poor left ventricular systolic function-Safe but no room for complacency

Many patients with left ventricular systolic dysfunction have concomitant mitral regurgitation(MR). Their symptoms and prognosis worsen with increasing severity of MR. Percutaneous Mitra Clip&#174; can be used safely to reduce the severity of MR even in patients with advanced heart failure and is associated with improved symptoms, quality of life and exercise tolerance. However, a few patients with very poor left ventricular systolic function may experience significant haemodynamic disturbance in the peri-procedural period. We present three such patients, highlighting some of the potential problems encountered and discuss their possible pathophysiological mechanisms and safety measures.

Association between cardiovascular implantable electronic devices and tricuspid regurgitation: a case- control study

Cardiovascular implantable electronic devices(CIEDs)are widely used in the modern era.Every year,about 730,000 permanent pacemakers and 330,000 CIEDs are implanted worldwide.CIEDs have been known to increase the life expectancy of millions of people and improve their quality of life by controlling the heart rate and atrioventricular and interventricular synchronization and preventing sudden cardiac death.[1]The tricuspid valve consists of the annulus,leaflets,chordae tendineae,and papillary muscles.Interaction between the endocardial lead and any component of this structure can lead to tricuspid valve dysfunction,thereby resulting in tricuspid regurgitation(TR).[2]CIED-related TR has been shown to be an independent predictor of hospitalization for heart failure.[3,4]

Ischemic Mitral Regurgitation

A 57-year-old man reported experiencing dyspnea after walking 100 feet that has been progressing despite medical therapy.He has two-pillow orthopnea and occasional nighttime dyspnea but no angina.He had an anterior myocardial infarction 5 years previously but did not seek medical care until 2 days after the event.Viability studies demonstrated only limited anterior wall viability.– Electrocardiogram:sinus rhythm with left bundle branch block.– Medications:furosemide,120 mg twice daily;metolazone,5 mg every other day;carvedilol,25 mg twice daily;lisinopril,40 mg daily;spironolactone,25 mg daily.

Functional Tricuspid Regurgitation and Ring Annuloplasty Repair

Functional tricuspid regurgitation(TR)primarily arises from asymmetric dilation of the tricuspid annulus in the setting of right ventricular dysfunction and enlargement in response to left-sided myocardial and valvular abnormalities.Even if the TR is not severe at the time of mitral valve surgery,it can worsen and even appear late after successful mitral valve surgery,which portends a poor prognosis.Despite data demonstrating inferior outcomes in the presence of residual TR,surgical repair for functional TR remains underused.Acceptance of TR,in the presence of tricuspid annular dilation,may be unacceptable.Surgical repair should consist of placement of a rigid or semirigid annular ring,which has been shown to provide superior durability as compared with suture and flexible band techniques.Finally,percutaneous annuloplasty for correction of functional TR may allow treatment of patients with recurrent TR at high risk of reoperation.

Management of Mitral Regurgitation in a Patient Contemplating Pregnancy

Management of rheumatic mitral regurgitation in a woman contemplating pregnancy presents unique challenges for the clinician.When tasked with taking care of this type of patient,attention needs to be paid to the patient’s functional status to determine if symptoms are present.In addition to this clinical assessment,transthoracic echocardiography is also critical.It provides insight into the etiology of the mitral regurgitation,assesses for the presence of concomitant mitral stenosis or other valvular abnormalities,characterizes the severity of mitral regurgitation through an integrative approach and identifi es high risk findings including progressive left ventricular(LV)dilation and LV dysfunction.Surgical intervention is recommended for symptomatic patients and in asymptomatic patients with evidence of progressive LV dilation and a LV ejection fraction of less than 60%.While the presence of pulmonary hypertension and atrial fi brillation have been shown to be risk factors in degenerative mitral regurgitation,the same has not been demonstrated in rheumatic mitral valve disease.While mitral regurgitation may be reasonably well tolerated during pregnancy,symptomatic patients are at higher risk for adverse maternal and fetal outcomes,and therefore,it is recommended that mitral valve surgery be performed prior to pregnancy.Once the decision has been made to proceed to surgery,mitral repair,performed at a Heart Valve Center of Excellence is recommended if possible due to improved outcomes.Mitral valve repair is possible in>80%cases of rheumatic mitral regurgitation.If repair is not possible,replacement with either a bioprosthetic or mechanical valve are reasonable options.There are advantages and disadvantages to each approach and the choice of prosthesis should be a shared decision between the patient and her treatment team.