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PubMed1992

Surgical implications of juxtaposed atrial appendages and the associated anomalies.

Juxtaposition of the atrial appendages (JAA) is an uncommon anomaly of the heart that is frequently associated with other cardiac abnormalities, such as transposition of the great arteries and tricuspid atresia. We encountered 7 patients with JAA from July 1984 to July 1989 at National Taiwan University Hospital. The JAA was right-sided in 1 patient and left-sided in 6. The patients' ages ranged from 10 months to 12 years. The cardiac anomalies in the patient with right JAA were double-outlet right ventricle and ventricular septal defect, which was repaired with a patch. Of the 6 patients with left JAA, 5 had transposition of the great arteries, and in 3 of them obstructive tricuspid lesions (tricuspid stenosis in 1, tricuspid atresia in 2) were noted. Three patients with left JAA and normal tricuspid valve underwent total correction (one Senning operation and two Rastelli operations). The other 3 patients with tricuspid obstruction underwent total cavopulmonary connection (2) and Fontan operation (1). We concluded that, first, left JAA was more frequently seen and associated with more morbid anatomy than right JAA. Second, if left JAA is discovered in planning biventricular repair for transposition of the great arteries, the tricuspid valve should be inspected carefully to rule out tricuspid obstruction.

Child↗
PubMedDate not supplied

Creation of a one-way interatrial communication in the treatment of critical pulmonary stenosis with intact ventricular septum: a case report.

BACKGROUND: In biventricular repair of pulmonary outflow tract obstruction with intact ventricular septum, the right ventricle is loaded with total pulmonary blood flow acutely as the right-to-left shunt is abolished by closure of the atrial septal defect (ASD). METHODS: We designed a one-way interatrial communication by creation of an atrial septal flap to reduce the excessive volume load of the right ventricle. RESULTS: This procedure was successfully performed in a 3-year-old girl undergoing definitive biventricular repair for critical pulmonary stenosis associated with tricuspid stenosis and a small right ventricle. CONCLUSIONS: We believe that creation of a one-way interatrial communication might be a good alternative to adjustable ASD and/or bidirectional Glenn shunt in biventricular repair of critical pulmonary stenosis or pulmonary atresia with intact ventricular septum.

Child, Preschool↗
PubMed1977

Congenital pulmonary atresia with tricuspid insufficiency: morphologic study.

In an anatomic study of 21 cases of pulmonary atresia with tricuspid insufficiency (pulmonary atresia with intact ventricular septum, type II), the morphologic features of the tricuspid valve and the right ventricle were found to differ greatly from those seen in pulmonary atresia with tricuspid stenosis (pulmonary atresia with intact ventricular septum, type I). Morphologically, pulmonary atresia with tricuspid insufficiency (type II) has a greater resemblance to Ebstein's disease with pulmonary atresia than to type I pulmonary atresia. The anomaly may be more amenable to surgery than pulmonary atresia with tricuspid stenosis because the right ventricle in the former may be converted into a functional chamber by a valvotomy combined with a shunting procedure and atrial septostomy.

Female↗
PubMed1994

[Application of extended transseptal approach for a patient with chronic atrial fibrillation caused by mitral stenosis and tricuspid regurgitation].

A 45-year-old female of mitral valvular disease with chronic atrial fibrillation was referred to our hospital. She had received previous closed mitral commissurotomy (12 years ago) and open mitral commissurotomy combined with aortic valve replacement (6 years ago). An echocardiogram showed restenosis and regurgitation of the mitral valve (valve area 1.2 cm2 by B-mode) and severe regurgitation of the tricuspid valve. She also complained of chronic atrial fibrillation since 35 years old. Mitral valve replacement with CarboMedics bileaflet valve (25 mm) and tricuspid annuloplasty by DeVega procedure was undergone via an extended transseptal approach and cryoablastion was added to the posterior wall of the left atrium along the rim of the left pulmonary veins and around the left atrial appendage for ablation of chronic atrial fibrillation. After completion of surgery, atrial fibrillation disappeared. Post operative echocardiogram showed apparent atrial kick of both atriumns in the inflow pattern of both ventricles. The patient continues to be well with normal sinus rhythm for 6 months after surgery. An extended transseptal approach is useful in mitral reoperation, in addition, it can be applicable for the surgery of chronic atrial fibrillation.

Atrial Fibrillation↗
PubMed1991

Percutaneous triple-valve balloon valvuloplasty in a pregnant woman.

A 22-yr-old pregnant woman with mitral, aortic, and tricuspid stenosis presented with accelerating dyspnea and shortness of breath at the end of her first trimester. She subsequently underwent percutaneous triple-valve balloon valvuloplasty at 22 weeks of gestation without complications and achieved marked clinical improvement. We conclude that percutaneous triple-valve balloon valvuloplasty represents an alternative treatment for mitral, aortic, and tricuspid stenosis in pregnant women with compromised cardiovascular status who do not wish to terminate their pregnancy.

Adult↗
PubMed1992

The Inoue balloon for dilatation of the tricuspid valve: a modified over-the-wire approach.

The Inoue balloon was used for dilatation of tricuspid stenosis in a 74 year old woman. The valve was reached by an over-the-wire approach with a 0.025 exchange length guide wire. The Inoue stylet would not reach the tricuspid orifice because the right atrium was so large. The Inoue balloon's special dilatation characteristics allowed good positioning at the tricuspid orifice. After dilatation to 27.5 mm, the pressure drop across the valve was reduced from 12 to 5 mm Hg. Further dilatation at 30 mm, however, created moderately severe tricuspid reflux without a further reduction of gradient. The Inoue balloon is suitable for dilatation of tricuspid stenosis but small increments in dilatation size may be required for optimal reduction in gradient without creating significant reflux.

Aged↗
PubMed1984

Two-dimensional echocardiography in the diagnosis of carcinoid heart disease.

Tricuspid valve disease accounts for significant morbidity and mortality in the carcinoid syndrome, but M-mode echocardiography is often insensitive in completely defining the tricuspid valve. We performed two-dimensional echocardiography (2DE) in seven patients with proven carcinoid syndrome. There were five males and two females whose ages ranged from 53 to 79 years. The carcinoid syndrome had been present by symptoms for 12 to 84 months and by 5-HIAA levels for 6 to 84 months prior to 2DE. Short, thickened, immobile tricuspid valve leaflets, fixed in a partially open position, were visualized in two patients and confirmed in one patient at surgery. Tricuspid regurgitation was demonstrated angiographically in one and by contrast 2DE in the other. A third patient had clinical evidence of tricuspid stenosis with a doming tricuspid valve on 2DE. The motion of the tricuspid value viewed in real time was clearly distinct in these two situations. Four patients had both normal M-mode and 2DE studies despite the fact that clinical and biochemical evidence of carcinoid disease had been present for equally long periods of time. The tricuspid valve was best visualized in the parasternal right ventricular long-axis and short-axis views. The apical four-chamber view was less helpful. Thus, 2DE demonstrated specific tricuspid valve abnormalities in the carcinoid syndrome with thickening, shortening, and immobility of the leaflets when valvular regurgitation was present and thickening and doming when the valve was stenotic. 2DE should be a useful method in the diagnosis and sequential evaluation of patients with carcinoid heart disease.

Aged↗
PubMed1994

[Percutaneous tricuspid valvuloplasty].

The authors herein describe the case of a 44 year old woman, who 14 years ago underwent surgical intervention after a rheumatic disease. A double mitral-aortic valvular implantation and a tricuspid commissurotomy was carried out. The patient come under our observation for severe congestive heart failure, while both mechanical prostheses were working well. Furthermore, the Doppler echocardiography showed a severe tricuspid stenosis (mean gradient = 8.6 mm Hg) and a concurrent mild to moderate valvular regurgitation. Because of her poor clinical condition and due to the high surgical risk it was decided to perform a balloon valvuloplasty of the tricuspid stenosis. The procedure, using the percutaneous femoral approach, was carried out with a TRIAD-TWIN AT (diameter = 18 + 18 mm; length = 4 cm; Mansfield) catheter and an Amplatz guide wire was advanced up to the apex of the right ventricle. Both balloons were inflated simultaneously on three occasions to a maximum pressure of 3.5 atmospheres for 60". At the end of the procedure there was the complete disappearance of telediastolic gradient, the valvular regurgitation remained unchanged (when compared to the pre-valvuloplasty control) and the mean trans-tricuspid gradient reduced to 4 mm Hg. Immediately following the procedure there was a remarkable, rapid hemodynamic improvement of the patient and at three months her condition is constant. In conclusion tricuspid valvuloplasty even using the percutaneous femoral approach can be performed and considered a simple and effective treatment.

Adult↗
PubMed1993

[The results of the surgical treatment of recurrent mitral stenosis under artificial circulation].

A total of 533 operations for recurrent mitral stenosis have been performed since 1987. Two hundred and twenty-six patients were operated on under extracorporeal circulation. Indications for open correction of the abnormality as an alternative to transventricular commissurotomy were defined by echocardiographic studies. In 86 patients, mitral restenosis was accompanied by involvement of other valves: aortic, tricuspid. Mitral prosthesis was required in 216 cases. Valve-preserving operations were made in 10 cases. The hospital mortality was 12.8%, it decreased from 17.5 for the first 126 operations to 7% for the last 100 operations. In isolated restenosis, the hospital mortality rate was 7.8%, it has reduced by 1.8% in the past 2 years. The hospital mortality was 2.4% for 327 transventricular recommissurotomies. There were 20.9% fatal outcomes in restenosis concurrent with other valvular diseases. In mitral-tricuspid stenosis, deaths reduced from 23.8% to 9.5%. The mortality rates decreased from 35.7 to 15.4% in mitral-aortic stenosis and from 33.3% to 18.2% in tricuspid stenosis. High mortality rates in restenosis concurrent with involvement of other valves are mainly related to the baseline status of the patients operated on.

Adult↗
PubMed1993

Concurrent percutaneous balloon valvotomy for combined rheumatic tricuspid and aortic stenosis.

Concurrent percutaneous balloon valvotomy of aortic and tricuspid valve was successfully performed in a 20-year-old male with severe rheumatic aortic and tricuspid stenosis. Balloon valvotomy was done using a 18-mm single balloon for aortic and 20 + 20-mm double balloon for the tricuspid valve. Immediately after valvotomy the peak transaortic systolic gradient decreased from 120 to 32 mmHg and the aortic valve area increased from 0.27 to 1.1 cm2, the mean and end-diastolic trans-tricuspid gradient decreased from 14 and 18 to 1.5 and 2 mmHg, respectively, the tricuspid valve area increased from 0.8 to 3.6 cm2 and the cardiac-index increased from 2 to 2.9 l/mt/m2. At 1 year of follow-up the clinical (NYHA class 1) and hemodynamic improvement was maintained.

Adult↗
PubMed1978

[Hemodynamic results after tricuspid valvuloplasty (author's transl)].

Postoperative hemodynamic studies were conducted at rest and during exercise in 24 patients who, in addition to mitral and/or aortic valve surgery, had De Vega's tricuspid anuloplasty. To determine the degree of tricuspid insufficiency (TI), right atrial pressure (PRA) tracings, biplane right ventricular cineangiograms, and ultrasonic Doppler flow patterns were obtained. 20 patients had postoperative by a mild to moderate TI, but after operation the TI had improved by one or more degrees in 14 cases. In addition, a mild to moderate tricuspid stenosis with pressure gradients from 2.0 to 7.8 mm Hg were found in 12 patients. There was no significant change in mean right atrial pressure (PRA) with 8.0 +/- 4.5 mm Hg preoperatively and 7.5 +/- 3.5 mmHg postoperatively at rest. During exercise PRA rose to 17.0 +/- 6.5 mmHg. This pressure increase is in part due to the persistent elevation of left atrial and pulmonary artery pressure, in part to the TI and the tricuspid stenosis. De Vega's anuloplasty does not answer the tricuspid challenge, since the results are unpredictable.

Adolescent↗
PubMed1991

[A case report of controlled aortic root reperfusion (CARP) following global myocardial ischemia during surgery for severe mitral stenosis with tricuspid regurgitation].

The use of controlled aortic root reperfusion (CARP) as additional myocardial protection in cardiac surgery has been employed at University of Alabama at Birmingham Since 1986. This technique has been applied to a patient in Japan undergoing mitral valve replacement and tricuspid annuloplasty and favorable results were obtained. The CARP method consists of two consecutive procedures following global myocardial ischemia, that is, terminal warm blood cardioplegic reperfusion and selective controlled coronary perfusion. When the repair was almost completed, the CARP technique was initiated with warm blood (37 degrees C) from an oxygenator, and the initial phase was hyperkalemic (K+ 20 mEq/1, 3 min). [Terminal warm blood cardioplegic reperfusion] This was followed by normokalemic warm blood (without interruption) from the pump oxygenator infused through a cardioplegic needle into the isolated aortic root with the aortic cross-clamp still in place (10 to 20 min). [Selective controlled coronary perfusion] Terminal warm blood cardioplegic reperfusion induced electromechanical quiescence initially which allowed rapid repletion of adenosine triphosphate and improved cardiac function. Selective controlled coronary perfusion with normokalemic warm blood permits necessary and sufficient coronary blood flow following global ischemia even when systemic arterial pressure fell and coronary vascular resistance rose. On considering these two points, we consider that the CARP technique offers excellent myocardial protection in accelerating the recovery of myocardial function following global ischemic damage. The CARP method offers useful assistance in cardiac surgery particularly for patients who have abnormal preoperative cardiac function and who have experienced long periods of global myocardial ischemia.

Aorta↗
PubMed1976

Anatomic variations in underdeveloped right ventricle related to tricuspid atresia and stenosis.

In the anatomy of 416 hearts, the seat of tricuspid stenosis or atresia is examined, with special reference to Fontan-like surgical procedures. A classification is offered which includes cases with and without regular or inverted transposition, and with decreased or increased pulmonary flow. The size and thickness of the right atrium, the size and architecture of the right ventricle, the size of the pulmonary tree, the types of atrial and ventricular septal defects, the condition of the mitral valve, and the size and thickness of the left atrium and left ventricle are analyzed. In addition the various intracardiac and extracardiac abnormalities are enumerated. Reference is also made to the tendency of the aorta and pulmonary trunk to override the septum, in some cases producing double-outlet left ventricle. It is considered that many cases of tricuspid valve atresia and stenosis with or without transposition may be amenable to Fontan-like procedures in the proper age group. All the above anatomic considerations have a bearing on the suitability and type of operative tricuspid bypass procedures, and they may influence the prognosis of surgical therapy.

Abnormalities, Multiple↗
PubMed1995

Enhancement of ventricular mechanics following bidirectional superior cavopulmonary anastomosis in patients with single ventricle.

Seventeen consecutive patients undergoing bidirectional cavopulmonary anastomosis (BDCPA) using normothermic, noncardioplegic, cardiopulmonary bypass were studied preoperatively and early postoperatively (12.2 days) using transthoracic echocardiographic techniques. The purpose of the study was to assess the changes in left ventricular mechanics associated with the change in blood flow related to the BDCPA. Of the 17 patients, pulmonary atresia and tricuspid stenosis was present in 7, tricuspid atresia in 6, double inlet left ventricle in 3, and severe pulmonic stenosis with straddling of the tricuspid valve in 1. All other forms of single ventricle type anatomy and other patients undergoing BDCPA were excluded for the purposes of this study. The mean left ventricular end-diastolic volume index fell from 120 mL/m2 to 91.1 mL/m2 (p < 0.05). Similarly the left ventricular end-systolic volume index fell from 55.8 mL/m2 to 42.3 mL/m2, respectively (p < 0.05). The stroke volume index also fell from 64.5 mL/m2 to 48.8 mL/m2. Left ventricular ejection fraction was preserved and was unchanged in every patient. It was concluded that BDCPA, performed as described above, preserves left ventricular function and that the systolic and diastolic volumes as well as the stroke volume are significantly decreased as evidence of improvement of left ventricular mechanics. The continued use of the BDCPA either as a definitive procedure or as a staged procedure in preparation for total cavopulmonary connection is therefore endorsed.

Anastomosis, Surgical↗
PubMed1999

Surgical assessment of tricuspid valve replacement for severe tricuspid regurgitation without stenosis.

Eight patients undergoing tricuspid valve replacement (TVR) for severe tricuspid regurgitation (TR) without stenosis were subjected to the study. Four patients had primary TR due to trauma, infective endocarditis, or Ebstein's anomaly, and the other 4 had secondary TR associated with mitral valve lesions. The right heart pressure as well as clinical manifestations due to right heart failure showed deteriorated values in both the primary and secondary TR groups, though pulmonary arterial pressure was higher in the latter group. In 2 patients, initial annuloplasty procedures could not reduce TR sufficiently and were instantly abandoned for TVR. These 2 patients, one with congenital and one with secondary TR, died of intractable right heart failure early postoperatively, while the remaining 6 patients are alive to date, in the New York Heart Association (NYHA) functional class I, during the follow-up period of 6-192 (mean, 104) months. The 2 patients who died had shown a longer morbid duration and a lower preoperative right ventricular systolic function indicated by stroke work to pulmonary artery resistance. This paper might suggest that an earlier surgical intervention in severe TR is recommended before the right ventricular function deteriorates.

Adolescent↗