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1.  Maintaining tricuspid valve competence in double discordance: a challenge for the paediatric cardiologist 
Heart  1998;80(5):479-483.
Objectives—To establish the prevalence of tricuspid valve abnormalities in children with a double discordant heart (or congenitally corrected transposition of the great arteries); to study the influence of the loading conditions induced by various surgical interventions on the right and left ventricle in patients with double discordance and an abnormal tricuspid valve; and to propose a rational surgical approach.
Methods—Case notes were reviewed of 141 consecutive patients admitted in the first year of life with various types of double discordance (intact ventricular septum (group 1), ventricular septal defect (group 2), ventricular septal defect and pulmonary obstruction (group 3)). A study group of 62 patients with an abnormal tricuspid valve was selected by cross sectional echocardiography. These were followed up through palliative and open heart procedures with grading of tricuspid regurgitation.
Results—Tricuspid valve abnormalities were more common in groups 1 and 2 (60% and 56%) than in group 3 (31%). Preoperative tricuspid regurgitation was more common in group 2 (90%) than in groups 1 and 3 (38% and 36%). Ten patients in groups 1 and 2 died in the neonatal period with severe tricuspid regurgitation, associated with coarctation of the aorta in 60%. Eight patients in group 1 had no surgery and are doing well, with a competent tricuspid valve. Palliative procedures were undertaken in 28 patients: 14 had pulmonary artery banding, which resulted in a decrease in tricuspid regurgitation, 12 in group 2 by reducing the pulmonary blood flow and two in group 1 by changing the septal geometry; 14 in group 3 had an aortopulmonary shunt, which induced tricuspid regurgitation in two. Twenty patients are still alive after palliation, with stable tricuspid valve function. Repair of the tricuspid valve was unsuccessful in the three patients who underwent conventional surgery, leaving the right ventricle facing the systemic circulation. In two patients with a competent but abnormal tricuspid valve, conventional surgery induced severe tricuspid regurgitation. Of the 15 patients who underwent conventional surgery, only 10 survived (mortality 33%): eight with a tricuspid valve prosthesis and two with severe residual tricuspid regurgitation. However, tricuspid regurgitation decreased after anatomical correction (nine patients), restoring a systemic left ventricle and a subpulmonary right ventricle, even when the tricuspid valve was not repaired (five patients). Eight patients are doing well after anatomical correction (mortality 11%).
Conclusions—Tricuspid valve function in double discordance with an abnormal tricuspid valve depends on the loading conditions of both ventricles and on the septal geometry. Interventions that increase right ventricular volume or decrease left ventricular pressure are likely to induce tricuspid regurgitation, while those that decrease right ventricular volume or increase left ventricular pressure are likely to improve tricuspid valve function. Repair of the tricuspid valve always failed when the right ventricle was left in a systemic position and always succeeded when the right ventricle was placed in a subpulmonary position. These results should be taken in to account when dealing with patients with double discordance and an abnormal tricuspid valve.

 Keywords: transposition of the great arteries;  double discordance;  double switch procedures;  tricuspid valve;  paediatric cardiology;  congenitally corrected transposition
PMCID: PMC1728855  PMID: 9930048
2.  Mechanical Valve Dysfunction in Yemen 
Rheumatic heart disease is the most common cardiac disease in Yemen. It is associated with high morbidity and mortality. Valve replacement is the most common open heart surgery procedure in our cardiac center. The use of mechanical valves remains burdened with serious complications such as thrombosis. Valve thrombosis is still associated with high mortality] The reported mortality rate of the redo operation ranges from 8 to 20% and up to 37-54% in critically ill patients.
The aim of the present study was to investigate mechanical valve obstruction among Yemeni patients.
Patients and Methods:
Between January 2003 and April 2007, 2794 patients underwent prosthetic valve replacement in our center, Al-Thawra Hospital. Of those patients, 129 (4.6%) underwent reoperation for te obstructive mechanical valve. Patients with clinical suspicion of prosthetic valve obstruction (PVO) were admitted emergently to the CCU and the diagnosis was confirmed with echocardiography. All patients had heart failure; 95% of them were in NYHA class IV. All were transferred directly from the CCU to the operating room. The mean age was 34.8 ± 13.4 years. Two patients received preoperative thrombolytic therapy that was not successful. Obstruction involved the mitral valve prosthesis in 47 (36.4%); the aortic prosthesis in 16 (12.4%) patients; both valves in 21 (16.3%) patients; mitral valve replacement with tricuspid valve repair in 22(17%); double valve replacement with tricuspid valve repair in 1 (0.8%); redo mitral valve replacement with aortic valve cleaning in 7 (5.4%) cases; aortic valve cleaning in 5 (3.9%) patients; mitral valve cleaning in 5 (3.9%); and 5 (3.9%) patients had redo mitral with aortic replacement.
The operations were performed urgently. The etiology of the obstruction was thrombus in 111 (86%), pannus formation in 4 (3%), pannus and thrombus in 6 (4.8%), vegetation in 7 (5.4%) patients, and interposition of suturing materials in 1 (0.8%) patient. The in- hospital mortality was 23/129 (17.8%).
The incidence of prosthetic valve obstruction remains high in Yemen. The vast majority of the patients who are referred to our hospital come from remote provinces in the country where regular INR measurement is not readily available. For those who are living in areas without good medical care, certain measures are necessary to avoid this disastrous complication: (1) good patient education, (2) free INR testing and free anticoagulant drugs such as warfarin; and (3) use of tissue rather than mechanical valves.
PMCID: PMC3000911  PMID: 21187996
Mechanical valve; pannus; prosthetic valve obstruction; thrombus
3.  Surgical treatment of tricuspid regurgitation after mitral valve surgery: a retrospective study in China 
Functional tricuspid regurgitation (TR) occurs in patients with rheumatic mitral valve disease even after mitral valve surgery. The aim of this study was to analyze surgical results of TR after previous successful mitral valve surgery.
From September 1996 to September 2008, 45 patients with TR after previous mitral valve replacement underwent second operation for TR. In those, 43 patients (95.6%) had right heart failure symptoms (edema of lower extremities, ascites, hepatic congestion, etc.) and 40 patients (88.9%) had atrial fibrillation. Twenty-six patients (57.8%) were in New York Heart Association (NYHA) functional class III, and 19 (42.2%) in class IV. Previous operations included: 41 for mechanical mitral valve replacement (91.1%), 4 for bioprosthetic mitral valve replacement (8.9%), and 7 for tricuspid annuloplasty (15.6%).
The tricuspid valves were repaired with Kay's (7 cases, 15.6%) or De Vega technique (4 cases, 8.9%). Tricuspid valve replacement was performed in 34 cases (75.6%). One patient (2.2%) died. Postoperative low cardiac output (LCO) occurred in 5 patients and treated successfully. Postoperative echocardiography showed obvious reduction of right atrium and ventricle. The anterioposterior diameter of the right ventricle decreased to 25.5 ± 7.1 mm from 33.7 ± 6.2 mm preoperatively (P < 0. 05).
TR after mitral valve replacement in rheumatic heart disease is a serious clinical problem. If it occurs or progresses late after mitral valve surgery, tricuspid valve annuloplasty or replacement may be performed with satisfactory results. Due to the serious consequence of untreated TR, aggressive treatment of existing TR during mitral valve surgery is recommended.
PMCID: PMC3348082  PMID: 22490269
Tricuspid regurgitation; Annuloplasty; Tricuspid valve replacement; Mitral valve surgery; Rheumatic heart disease
4.  Pulmonary valve endocarditis caused by right ventricular outflow obstruction in association with sinus of valsalva aneurysm: a case report 
Right-sided infective endocarditis is uncommon. This is primarily seen in patients with intravenous drug use, pacemaker or central venous lines, or congenital heart disease. The vast majority of cases involve the tricuspid valve. Isolated pulmonary valve endocarditis is extremely rare. We report the first case of a pulmonary valve nonbacterial thrombotic endocarditis caused by right ventricular outlflow tract (RVOT) obstruction in association with a large sinus of Valsalva aneurysm.
Case presentation
A 60-year-old man with a six-week history of fever, initially treated as pneumonia and sinusitis with levofloxacin, was admitted to the hospital with a new onset of a heart murmur. An echocardiogram showed thickening of the pulmonary valve suggestive of valve vegetation. A dilated aortic root and sinus of Valsalva aneurysm measuring at least 6.4 cm were also identified. The patient was empirically treated for infective endocarditis with vancomycin and gentamycin for 28 days. Four months later, the patient underwent resection of a large aortic root aneurysm and exploration of the pulmonary valve. During the surgery, vegetation of the pulmonary valve was confirmed. Microscopic pathological examination revealed fibrinous debris with acute inflammation and organizing fibrosis with chronic inflammation, compatible with a vegetation. Special stains were negative for bacteria and fungi.
This is the first case report of a pulmonary valve nonbacterial endocarditis caused by RVOT obstruction in association with a sinus of Valsalva aneurysm. We speculate that jets created by the RVOT obstruction and large sinus of Valsalva aneurysm hitting against endothelium of the pulmonary valve is the etiology of this rare nonbacterial thrombotic endocarditis.
PMCID: PMC2491616  PMID: 18627635
5.  Prosthetic Tricuspid Valve Thrombosis: Three Case Reports and Literature Review 
A common complication of prosthetic heart valves is thrombosis. Although the incidence of prosthetic valve thrombosis (PVT) in the tricuspid position is high, there are not enough data on the management of it, in contrast to left-sided PVT. Here, we describe three cases of tricuspid PVT with three different management approaches: thrombolytic therapy; close observation with oral anticoagulants; and surgery. The first case was a woman who suffered from recurrent PVT, for which we successfully used Tenecteplase for second and third episodes. We employed Tenecteplase in this case for the first time in the therapy of tricuspid PVT. The second case had fixed leaflets in open position while being symptomless. At six months' follow-up, with the patient having taken oral anticoagulants, the motion of the leaflets was restricted and she was symptomfree. The last case was a woman who had a large thrombus in the right atrium immediately after mitral and tricuspid valvular replacement. The patient underwent re-replacement surgery and a new biological valve was implanted in the tricuspid position. Also, we review the literature on the pathology, signs and symptoms, diagnosis, and management of tricuspid PVT.
PMCID: PMC3537206  PMID: 23323074
Tricuspid valve; Thrombosis; Thrombolytic therapy; Anticoagulants; Surgical procedures; operative
6.  Asymptomatic large left-atrial ball thrombus. Secondary to mitral stenosis. 
Texas Heart Institute Journal  1997;24(4):376-378.
We describe the very unusual case of a patient with a large, free-floating left-atrial thrombus secondary to severe mitral stenosis, in whom the peculiar symptoms and complications of a ball thrombus were absent. The patient's only symptom before the episode reported here was mild dyspnea, which was attributed to mitral stenosis. She experienced neither embolism nor syncope. While even her clinical signs did not indicate a left-atrial ball thrombus, both echocardiography and angiography showed a free-floating thrombus. Because of the risk of stroke and acute obstruction of the mitral valve, emergency surgery was performed upon diagnosis of the ball thrombus. The surgery, which consisted of removing the thrombus and replacing the mitral valve with a mechanical prosthesis, was uneventful. A computed tomographic brain scan prior to discharge did not detect any cerebral infarction.
PMCID: PMC325486  PMID: 9456496
7.  Intermediate Term Evaluation of Starr-Edwards Ball Valves in the Mitral Position 
Texas Heart Institute Journal  1985;12(1):43-47.
The Model 6120 ball valve prosthesis introduced in 1965 is still strongly supported as a mitral valve substitute in many centers around the world. A current reassessment of the performance of this prosthesis is therefore pertinent to current medical practice.
In this institution since 1974, 227 Starr-Edwards caged ball valves have been implanted in the mitral position during isolated valve replacement. Two models of caged ball valves were used concurrently: the silastic ball valve in 108 patients (48%) and the composite strut “tract” valve in 119 (52%).
Hospital mortality was 7%, and 8-year survival (standard error) was 74 (6%), with 100% follow-up, documenting 752 total patient-years. No late deaths were known to be valve related, and there were no cases of prosthetic thrombosis. The actuarial estimate of patients free from thromboembolism at 8 years was 89 (4%) with a linearized rate of 1.3% per year. At the most recent follow-up, 95% of the patients were in the New York Heart Association (NYHA) Classes I or II. These good results were partly due to an awareness at operation of ventricular outflow tract size requirements and to strict control of postoperative anticoagulation.
We conclude that the Starr-Edwards ball valve is the mitral valve of choice in the young patient who is able to take anticoagulation drugs and has a left ventricular outflow tract of satisfactory size.
PMCID: PMC341791  PMID: 15227040
8.  Prosthetic valve endocarditis caused by Staphylococcus capitis: report of 4 cases 
Although Staphylococcus capitis is considered to be a rare causative organism for prosthetic valve endocarditis, we report 4 such cases that were encountered at our hospital over the past 2 years. Case 1 was a 79-year-old woman who underwent aortic valve replacement with a bioprosthetic valve and presented with fever 24 days later. Transesophageal echocardiography revealed an annular abscess in the aorto-mitral continuity and mild perivalvular regurgitation. We performed emergency surgery 5 days after the diagnosis of prosthetic valve endocarditis was made. Case 2 was a 79-year-old woman presenting with fever 40 days after aortic valve replacement with a bioprosthesis. Transesophageal echocardiography showed vegetation on the valve, and she underwent urgent surgery 2 days after prosthetic valve endocarditis was diagnosed. In case 3, a 76-year-old man presented with fever 53 days after aortic valve replacement with a bioprosthesis. Vegetation on the prosthetic leaflet could be seen by transesophageal echocardiography. He underwent emergency surgery 2 days after the diagnosis of prosthetic valve endocarditis was made. Case 4 was a 68-year-old woman who collapsed at her home 106 days after aortic and mitral valve replacement with bioprosthetic valves. Percutaneous cardiopulmonary support was started immediately after massive mitral regurgitation due to prosthetic valve detachment was revealed by transesophageal echocardiography. She was transferred to our hospital by helicopter and received surgery immediately on arrival. In all cases, we re-implanted another bioprosthesis after removal of the infected valve and annular debridement. All patients recovered without severe complications after 2 months of antibiotic treatment, and none experienced re-infection during 163 to 630 days of observation. Since the time interval between diagnosis of prosthetic valve endocarditis and valve re-replacement ranged from 0 to 5 days, early surgical removal of the infected prosthesis and an appropriate course of antibiotics were attributed to good clinical outcomes in our cases.
PMCID: PMC3199242  PMID: 21978659
Prosthetic valve endocarditis; Staphylococcus Capitis; Early surgery; Antibiotics
9.  Replacement of the Aortic and Mitral Valves Using the Starr-Edwards Ball-Valve Prosthesis 
The aortic and mitral valves were replaced in 50 patients at the University of Alberta Hospital using the Starr-Edwards ball-valve prosthesis. The basis of the selection of 20 patients for isolated aortic valve replacement and 27 for mitral valve replacement using this type of prosthesis is presented, and the techniques of insertion of the aortic and mitral valve are described in detail. Of the 27 patients in whom the mitral valve was replaced by the Starr-Edwards prosthesis six died within 30 days of surgery and two after discharge from hospital at two and a half and four months, respectively. Left atrial thrombosis was the cause of death in four of these patients. In 20 patients in whom the aortic valve was replaced, four died in hospital and two died more than 30 days after returning home. Three of these six patients died from bleeding—the result of the use of anticoagulants. The difficulty in assessing whether or not anticoagulants are needed following replacement by a Starr-Edwards prosthesis is considered. It is felt, in our present state of knowledge, that anticoagulants should be used following mitral valve replacement but are probably not essential following replacement of the aortic valve. Two patients survived replacement of both aortic and mitral valves and have been followed up 18 months and seven months, respectively.
PMCID: PMC1927501  PMID: 14179062
10.  Mitral valve replacement in infants and children 5 years of age or younger: Evolution in practice and outcome over three decades with a focus on supra-annular prosthesis implantation 
Successful mitral valve replacement in young children is limited by the lack of small prosthetic valves. Supra-annular prosthesis implantation can facilitate mitral valve replacement with a larger prosthesis in children with a small annulus, but little is known about its effect on the outcomes of mitral valve replacement in young children.
One hundred eighteen children underwent mitral valve replacement at 5 years of age or younger from 1976–2006. Mitral valve replacement was supra-annular in 37 (32%) patients.
Survival was 74% ± 4% at 1 year and 56% ± 5% at 10 years but improved over time (10-year survival of 83% ± 7% from 1994–2006). Factors associated with worse survival included earlier mitral valve replacement date, age less than 1 year, complete atrioventricular canal, and additional procedures at mitral valve replacement, but not supra-annular mitral valve replacement. As survival improved during our more recent experience, the risks of supra-annular mitral valve replacement became apparent; survival was worse among patients with a supra-annular prosthesis after 1991. A pacemaker was placed in 18 (15%) patients within 1 month of mitral valve replacement and was less likely in patients who had undergone supra-annular mitral valve replacement. Among early survivors, freedom from redo mitral valve replacement was 72% ± 5% at 5 years and 45% ± 7% at 10 years. Twenty-one patients with a supra-annular prosthesis underwent redo mitral valve replacement. The second prosthesis was annular in 15 of these patients and upsized in all but 1, but 5 required pacemaker placement for heart block.
Supra-annular mitral valve replacement was associated with worse survival than annular mitral valve replacement in our recent experience. Patients with supra-annular mitral valve replacement were less likely to have operative complete heart block but remained at risk when the prosthesis was subsequently replaced.
PMCID: PMC4230576  PMID: 18954636
11.  Rare early prosthesis obstruction after mitral valve replacement: a case report and literature review 
As a dreadful complication after the mechanical heart valve replacement, prosthetic valve obstruction caused by pannus formation occurs increasingly with time. The authors here present a case of 42-year-old woman who was urgently admitted to hospital with acute heart failure symptoms due to the mechanical mitral valve failure only 3 months after surgery. Transthoracic and transesophageal echocardiography demonstrated that the bileaflet of the mitral prosthesis were completely immobilized with only a small transvalvular jet remained. During the reoperation, the reason of the prosthetic valve obstruction was attributed to the noncircular pannus ingrowth extending from the atrioventricular side. For a better understanding of the prosthetic valve dysfunction caused by pannus formation, the authors then compile a literature review to briefly discuss the status quo of the clinical characteristics of this uncommon complication.
PMCID: PMC3485153  PMID: 22747990
12.  Long term follow up of patients with endomyocardial fibrosis: effects of surgery 
Heart  1998;79(4):362-367.
Aims—To determine the long term outcome of patients with endomyocardial fibrosis and to compare echocardiographic and haemodynamic data before and after ventricular endocardial resection.
Patients—Seventeen patients (11 women and six men; mean age 35.5 years) diagnosed with endomyocardial fibrosis at the University Hospital in Zurich, Switzerland from 1971 to 1995. Twelve patients (70%) had partial obliteration of both ventricles and in five patients (30%) the fibrotic lesions were limited to the left ventricle. 
Methods—Fourteen of the 17 patients had surgical resection: fibrosis was resected from both ventricles in five patients and from the left ventricle only in nine patients. Ten patients had mitral valve replacement and two had tricuspid valve replacement. Left ventricle endocardial resection was done without reconstruction or replacement of the atrioventricular valve in three patients. Preoperative and postoperatve echocardiographic data were available for 11 patients and haemodynamic data for six patients. Patients were followed up for 0.4-19 years (mean 8.6).
Results—Preoperatively four patients were NYHA functional class IV and 10 were class III; postoperatively one patient was class III, seven class II, and six class I. Preoperatively, echocardiography showed obliteration of the left ventricular apex and inflow tract in all patients, which decreased or disappeared after surgery. Left ventricular end diastolic pressure decreased from 25 mm Hg before surgery to 14 mm Hg after successful resection of the fibrosis. Left ventricular end diastolic volume (normal 93 (17) ml/m2) increased from 65 ml/m2 to 97 ml/m2 (p < 0.05) after surgery. Ejection fraction was normal preoperatively (57%) and decreased slightly (52%) after surgery. One patient died five months after surgery from heart failure. Four surgically treated patients died during the follow up period: one each from systolic dysfunction, recurrence of endomyocardial fibrosis, pneumonia, and food poisoning. Overall survival was 65% at five years and 59% at 10 years; the survival rates of the operated patients was 72% and 68%, respectively. Only one of the medically treated patients survived longer than three years from diagnosis.
Conclusions— Endomyocardial fibrosis is a rare disease in European countries and is found mainly in women. The clinical picture is characterised by severe congestive heart failure but heart size is only moderately increased. Systolic performance is normal or only slightly depressed despite severe restriction to filling, atrioventricular valve regurgitation or both. Partial obliteration of the right and/or left ventricle may be detected by echocardiography. Endocardial resection with atrioventricular valve replacement is the treatment of choice with appreciable postoperative improvement and 10 year survival of approximately 70%.

 Keywords: endomyocardial fibrosis;  atrioventricular valve regurgitation;  endocardial resection;  hypereosinophilic syndrome
PMCID: PMC1728653  PMID: 9616343
13.  Use of a Melody Pulmonary Valve in Transcatheter Valve-in-Valve Replacement for Tricuspid Valve Bioprosthesis Degeneration 
Texas Heart Institute Journal  2014;41(5):511-513.
Bioprosthetic heart valves can degenerate and fail over time. Repeat surgery as a means of replacement increases morbidity and mortality rates, and some patients are not candidates for reoperation. A newer treatment, percutaneous transcatheter valve-in-valve implantation, might delay or substitute for invasive procedures. We present the case of a 51-year-old woman, a poor candidate for surgery who had prosthetic tricuspid valve degeneration and stenosis. We successfully performed valve-in-valve placement of a Melody® valve, using a procedure originally intended to treat pulmonary valve conduit obstruction or regurgitation. To our knowledge, this is among the first case reports to describe the use of the Melody pulmonary valve in transcatheter valve-in-valve replacement for prosthetic tricuspid stenosis that was otherwise not correctable. Additional data and longer follow-up periods are necessary to gain an understanding of ideal indications and selection of patients for the percutaneous transcatheter treatment of tricuspid valve stenosis.
PMCID: PMC4189353  PMID: 25425984
Heart valve diseases/pathology; heart valve prosthesis implantation/instrumentation/methods/trends; surgical procedures, minimally invasive/methods; treatment outcome; tricuspid valve insufficiency; tricuspid valve stenosis/therapy
14.  Paraprosthetic leak closure 28 years after mitral caged-ball Starr-Edwards implantation 
In this case report, we present a patient 28 years after mitral valve replacement with the Starr-Edwards prosthesis complicated by periprosthetic leak with severe aortic stenosis and moderate tricuspid regurgitation. We successfully repaired the periprosthetic regurgitation in a patient with extensive mitral annular calcification, without replacement of the valve. No apparent structural deterioration on the caged-ball valve was found. Moreover, aortic valve replacement and tricuspid annuloplasty were performed. One month after reoperation, the patient remained stable with improved clinical status and without any evidence for further paravalvular leak.
PMCID: PMC3715180  PMID: 23599186
Valve disease
15.  Successful management of multiple permanent pacemaker complications – infection, 13 year old silent lead perforation and exteriorisation following failed percutaneous extraction, superior vena cava obstruction, tricuspid valve endocarditis, pulmonary embolism and prosthetic tricuspid valve thrombosis 
A 59 year old man underwent mechanical tricuspid valve replacement and removal of pacemaker generator along with 4 pacemaker leads for pacemaker endocarditis and superior vena cava obstruction after an earlier percutaneous extraction had to be abandoned, 13 years ago, due to cardiac arrest, accompanied by silent, unsuspected right atrial perforation and exteriorisation of lead. Postoperative course was complicated by tricuspid valve thrombosis and secondary pulmonary embolism requiring TPA thrombolysis which was instantly successful. A review of literature of pacemaker endocarditis and tricuspid thrombosis along with the relevant management strategies is presented. We believe this case report is unusual on account of non operative management of right atrial lead perforation following an unsuccessful attempt at percutaneous removal of right sided infected pacemaker leads and the incidental discovery of the perforated lead 13 years later at sternotomy, presentation of pacemaker endocarditis with a massive load of vegetations along the entire pacemaker lead tract in superior vena cava, right atrial endocardium, tricuspid valve and right ventricular endocardium, leading to a functional and structural SVC obstruction, requirement of an unusually large dose of warfarin postoperatively occasioned, in all probability, by antibiotic drug interactions, presentation of tricuspid prosthetic valve thrombosis uniquely as vasovagal syncope and isolated hypoxia and near instantaneous resolution of tricuspid prosthetic valve thrombosis with Alteplase thrombolysis.
PMCID: PMC2649923  PMID: 19239701
16.  Haemolysis with Björk-Shiley and Starr-Edwards prosthetic heart valves: a comparative study 
Thorax  1974;29(6):624-632.
Slater, S. D., Sallam, I. A., Bain, W. H., Turner, M. A., and Lawrie, T. D. V. (1974).Thorax, 29, 624-632. Haemolysis with Björk-Shiley and Starr-Edwards prosthetic heart valves: a comparative study. A comparison was made of the haemolytic complications in 85 patients with two different types of Starr-Edwards cloth-covered ball and cage prosthesis with those in 44 patients with the Björk-Shiley tilting disc valve. Intravascular haemolysis, as detected by the presence of haemosiderinuria, occurred significantly less often with the Björk-Shiley than with the Starr-Edwards valve, the overall incidence with aortic, mitral or multiple replacements being 31%, 15%, and 20% for Björk-Shiley and 94%, 92%, and 88% for Starr-Edwards valves respectively. There was no significant difference in the frequency of haemolysis between each of the two types of Starr-Edwards prosthesis studied at either the aortic (2300 versus 2310 model) or mitral (6300 versus 6310) site.
Haemolytic anaemia developed in only one patient with a Björk-Shiley valve but was common though usually mild with Starr-Edwards prostheses, particularly aortic valve replacements with the 2300 model and in aortic plus mitral (± tricuspid) replacements. The greater severity of haemolysis produced by Starr-Edwards valves, again especially of the latter types, was further demonstrated by higher serum lactate dehydrogenase and 24-hour urinary iron levels.
It is concluded that the Björk-Shiley tilting disc valve represents a significant advance in the amelioration of the haemolytic complications of prosthetic valves.
PMCID: PMC470215  PMID: 4450173
17.  Balloon dilation of tricuspid and pulmonary valves in carcinoid heart disease. 
Texas Heart Institute Journal  1993;20(2):115-119.
Heart involvement is usually the cause of death in patients with carcinoid syndrome, who may survive a long time even after the disease has entered an advanced stage. For this reason, carcinoid heart disease patients have undergone surgical replacement of affected valves. Two of our patients were not good candidates for surgery, due to the extent of hepatic metastasis. Alternatively, we performed percutaneous balloon valvuloplasty on both the tricuspid and pulmonary valves in both patients. To our knowledge, there has been only 1 previous report of successful tricuspid valvuloplasty in a case of carcinoid heart disease, and this did not involve concomitant pulmonary valvuloplasty. Before the procedure, both of our patients had low cardiac output with restriction in the right ventricle, pulmonary and tricuspid stenosis, and moderate tricuspid regurgitation. In the 1st patient, valvuloplasty reduced tricuspid and pulmonary gradients without change in cardiac output. This patient experienced initial clinical improvement but died 8 months after the procedure, of portal hypertension and extensive hepatic metastasis. The 2nd patient showed notably diminished gradients and a very significant increase in cardiac output. She advanced from New York Heart Association functional class IV to class I, and is now maintained with diuretic therapy. In our judgment, balloon valvuloplasty is a sound alternative to surgery for patients with carcinoid heart disease, especially when stenosis is the dominant symptom. Valvuloplasty is contraindicated in cases of severe tricuspid regurgitation.
PMCID: PMC325073  PMID: 8334362
18.  Robotic Mitral Valve Repair 
Texas Heart Institute Journal  2005;32(2):143-146.
Robotically assisted cardiac surgery has been presented as less invasive than conventional surgery, with shortened hospital stays and faster return to daily activities. We evaluated our experience with the da Vinci robot to determine whether we could in fact demonstrate those findings.
All mitral and tricuspid valve repairs were performed by the same surgeon. Cardiopulmonary bypass was performed with femoral cannulation, antegrade cardioplegia, and transthoracic aortic cross-clamping. Multiple valve repair techniques were used, including quadrant resection, cord replacement, Alfieri leaflet coaptation, and ring annuloplasty. Access was by 2 ports and a 5-cm right anterolateral thoracotomy. All annuloplasty rings were secured using surgical clips.
From October 2003 through September 2004, 32 patients underwent robotically assisted mitral valve repair. The mean age of our population was 67.6 years (range, 43–82 years). Four patients also underwent the 1st tricuspid valve repair using the da Vinci robot in the United States. There were 3 conversions for irreparable valves, 1 stroke, and 2 deaths. The average procedure time, cardiopulmonary bypass time, and aortic cross-clamp time were all reduced, when the first 20 patients were compared with the last 12. Length-of-stay also improved. One patient required early mitral valve replacement for recurrent regurgitation. Two patients required late (>3 month) mitral valve replacement for recurrent regurgitation.
We have shown that a dedicated nonacademic institute can develop a robotic cardiac surgery program and perform mitral and tricuspid valve repairs successfully. There is a several-case learning curve, and patient selection is paramount.
PMCID: PMC1163458  PMID: 16107102
Annuloplasty; mitral valve/surgery; robotics; surgery, computer-assisted; surgical procedures, minimally invasive/methods; tricuspid valve/surgery; thoracic surgery, video-assisted
19.  A clinical study of thoracoscopy-assisted mitral valve replacement concomitant with tricuspid valvuloplasty, with domestically manufactured pipeline products for cardiopulmonary bypass 
To discuss the feasibility and experience of treating valvular heart diseases with thoracoscopy-assisted mitral valve replacement concomitant with tricuspid valvuloplasty, with domestically manufactured pipeline products for cardiopulmonary bypass.
A total of 135 patients with valvular heart disease were admitted to our hospital between January 2011 and January 2013. They received thoracoscopy-assisted mitral valve replacement concomitant with tricuspid valvuloplasty, with domestically manufactured pipeline products. A cardiopulmonary bypass with domestically-manufactured pipeline products was established during the surgery. The procedure was accomplished with the assistance of thoracoscopy through a small incision in the right chest wall.
All 135 patients underwent a successful surgery, and were followed up for the duration of half a year to two years. None of them displayed any evidence of complications. Our procedure had the advantage of fewer complications and a significantly shortened time period for the patient care and hospitalization. As opposed to imported pipeline products for cardiopulmonary bypass, our procedure had the advantage of similar clinical results at a lower cost.
Thoracoscopy-assisted mitral valve replacement concomitant with tricuspid valvuloplasty was proved to be a safe and effective method for cardiopulmonary bypass, with the use of domestically manufactured pipeline products.
PMCID: PMC4192743  PMID: 25274144
Thoracoscopy assistance; Minimally invasive; Mitral valve surgery
20.  Anaesthesia for caesarean section in the presence of multivalvular heart disease and severe pulmonary hypertension: a case report 
Cases Journal  2009;2:9383.
Pulmonary hypertension is a rare condition and in combination with pregnancy, it can result in high maternal mortality. Mitral stenosis is one of the complicated cardiac diseases that may occur during pregnancy. In this report, we describe our management of such a case, which was even more difficult in combination with pulmonary hypertension, mitral stenosis, and aortic and tricuspid valve insufficiency requiring emergency caesarean section under general anaesthesia.
Case presentation
A 29-year-old primiparae was presented to the anaesthetic department for an urgent caesarean section with a diagnosis of severe pulmonary hypertension in combination with mitral stenosis. The patient was hospitalized prepartum and received oxygen therapy and anticoagulation with heparin. The patient was monitored during labour and delivery with oximetry and arterial and central venous pressure line. Pulmonary arterial lines were not used due to an increased risk and questionable usefulness. Echocardiography revealed a systolic pulmonary arterial pressure of 75 mmHg, and mitral stenosis, aortic and tricuspid valve insufficiency.
We decided to proceed under general anaesthesia. Anaesthesia was induced with etomidate, and succinylcholine. Dopamine and nitroglycerin infusion was preoperatively started and infusion was also preoperatively continued. Hemodynamic parameters were stable during delivery. Neonatal weight and apgar score were satisfactory. After the delivery of a healthy baby, oxytocin was administered. Surgery was completed uneventfully. During the postoperative period, the patient received furosemide and morphine. As the arterial blood gas analyses were stable and the chest-ray was normal, the patient was extubated postoperatively in the second hour in ICU.
Patients with significant multivalvular heart disease require careful preoperative, multidisciplinary assessment and anesthetic planning before delivery in order to optimize cardiac function during the peripartum period and make informed decisions regarding the mode of delivery and anaesthetic technique.
PMCID: PMC2806397  PMID: 20072681
21.  Tricuspid Anterior Leaflet Replacement with Autologous Pericardium and Polytetrafluoroethylene Chordae, Followed by Edge-to-Edge Repair 
Texas Heart Institute Journal  2007;34(3):310-312.
Treatment of endocarditis of the tricuspid valve is very complex. Valvectomy without replacement can result in significant postoperative morbidity, and replacement is hazardous due to the possibility of prosthetic infection. Repair of the tricuspid valve is the best alternative. Many ingenious methods have been devised to repair the tricuspid valve in patients with infective endocarditis. However, repair of the endocarditic anterior leaflet presents a difficult surgical problem.
We have developed a technique to replace the central portion of the anterior leaflet, in which most of the leaflet is excised and replaced with autologous pericardium. By preserving a small rim of the leaflet, we preserve the lateral and medial chordal attachments. Supplemental neochordae are created with polytetrafluoroethylene sutures. An edge-to-edge repair is used to correct residual insufficiency of the valve.
We have used this technique in 4 patients. One patient died 1 month after surgery, but with a competent tricuspid valve. Three patients are now alive, 48, 34, and 1.5 months after surgery. Their tricuspid valves are functional, moving well, and competent.
We conclude that the centrally infected anterior leaflet of the tricuspid valve can be replaced with autologous pericardium. The implantation of polytetrafluoroethylene neochordae and edge-to-edge repair can be used to achieve valve competence. Short- and medium-term follow-up in patients who have been treated with these techniques demonstrates that the valve remains fully mobile and competent.
PMCID: PMC1995044  PMID: 17948081
Chordae tendineae; endocarditis, bacterial/surgery; heart valve diseases/surgery; polytetrafluoroethylene; substance-related disorders/complications; tricuspid valve/surgery; tricuspid valve insufficiency/surgery
22.  Tricuspid Valve Replacement, Mechnical vs. Biological Valve, Which Is Better? 
The initial trial in tricuspid surgery is repair; however, replacement is done whenever the valve is badly diseased. Tricuspid valve replacement comprises 1.7% of all tricuspid valve surgeries.
Materials and Methods
The present retrospective study was performed using the medical records of 21 cases who underwent tricuspid valve replacement from January 2002 until the end of December 2010. The mean age of the participants was 52.3±8.8 years and 66.7% were females. In addition, tricuspid valve replacement was associated with mitral valve surgery, aortic valve surgery, and both in 14.3%, 4.8%, and 33.3% of the cases, respectively. Yet, isolated tricuspid valve replacement and redo surgery were performed in 10 cases (47.6%) and 8 cases (38.1%), respectively. Besides, trial of repair was done in 14 cases (66.7%). Moreover, biological and mechanical valves were used in 76.2% and 23.8% of the patients, respectively.
According to the results, early mortality was 23.8% and one year survival was 66.7%. Moreover, early mortality was caused by right ventricular failure, multiorgan failure, medistinitis, and intracerbral bleeding in 42%, 28.6%, 14.3%, and 14.3% of the cases, respectively. In addition, 57.1% of the deaths had occurred in the cases where the biological valve was used, while 42.9% of the deaths had taken place where the mechanical one was utilized.
The patients who require tricuspid valve replacement are usually high risk surgical candidates with early and long term mortality. The findings of the current study showed no significant hemodynamic difference between mechanical and biological valves.
PMCID: PMC3987430  PMID: 24757625
Tricuspid Regurgitation; Tricuspid Valve; Valve Repair
23.  Conservative surgery for mitral valve disease: clinical and echocardiographic analysis of results. 
Thorax  1983;38(8):565-571.
Eighty-five patients underwent mitral valve reconstruction by the Carpentier method from January 1976 to December 1981. Concomitant procedures were performed in 30 patients (aortic valve replacement in 23, coronary revascularisation in six, and tricuspid valve repair in seven). Before operation 76 patients (89%) were in clinical class II or III (New York Heart Association) and atrial fibrillation was present in 50. Thirty-six patients had valvular incompetence, while 26 had pure stenosis. The aetiology was rheumatic in 57 cases and dysplastic in 21. The patients were assessed for clinical improvement, durability of valve repair, thromboembolism, and survival. There was one death, an operative mortality rate of 1.2%, and 63 of 74 patients followed for one to six years were in clinical class I after operation. The actuarial survival was 92% with a 93% incidence of freedom from thromboemboli at five years. Six patients had embolic episodes, four of whom had aortic valve replacement. Three patients had a repeat operation 16-20 months later, a valve failure rate of 6.7%. Nineteen patients with ruptured chordae had postoperative echocardiographic assessment of myocardial and mitral valve functions; the peak rates of dimension changes of the left ventricular cavity (indicative of flow across the mitral valve) fell to normal in most patients, and the left ventricular end-diastolic dimensions decreased significantly from 6.4 (1.53) to 5.09 (1.31) cm (mean and SD)--p less than 0.05. Our results confirm that reconstructive mitral surgery is able to restore and maintain normal valve function in addition to providing satisfactory relief of symptoms.
PMCID: PMC459612  PMID: 6612646
24.  Early Thrombosis of a Tricuspid Valve Prosthesis 
Texas Heart Institute Journal  1988;15(1):65-67.
We report on the case of a 35-year-old woman who had undergone tricuspid valve replacement with a Lillehei-Kaster prosthesis 7 weeks prior to admission to our institution. Real-time two-dimensional echocardiography indicated a large mass on the inferolateral surface of the right atrium, as well as a dense band of echoes on the atrial and ventricular surfaces of the prosthesis. The diagnosis, confirmed by angiography, was early, acute thrombosis of the tilting disc prosthesis. After an unsuccessful infusion of urokinase, the patient was taken to emergency surgery; at operation, a large thrombus was discovered on the inferolateral wall, and the valve replaced. The patient recovered uneventfully, with no recurrence of thrombosis. Our experience confirms that two-dimensional echocardiography is the preferred technique for identifying intracardiac thrombi, and that surgery with replacement of the prosthesis is the treatment of choice in cases such as this where the size and age of the clot contraindicate fibrinolytic treatment. (Texas Heart Institute Journal 1988;15:65-67)
PMCID: PMC324789  PMID: 15227284
Echocardiography, two-dimensional; thrombosis, prosthetic valve; tricuspid valve insufficiency; prosthesis; prosthesis failure
25.  The significance of mitral and tricuspid valve systolic lateral annular velocities in the diagnosis of acute pulmonary embolism in patients with chronic heart failure 
The diagnosis of acute pulmonary embolism (APE) in patients with chronic heart failure (CHF) remains a difficult task, despite the refinement of imaging techniques. The goal of this study was to assess the value of measuring tricuspid and mitral valve systolic annular velocities in CHF patients with suspected PE by tissue Doppler imaging (TDI).
Material and methods
The study included 75 patients with previously diagnosed CHF, admitted due to resting dyspnea, with a maximum tricuspid regurgitation pressure gradient (TRPG) of ≥ 35 mm Hg and positive D-dimer assay. Spiral computed tomography (sCT) was performed on all subjects to confirm APE. Acute pulmonary embolism was diagnosed in 35 patients (PE+), and excluded in 40 others (PE–). Tissue Doppler imaging was performed to measure maximum systolic lateral annular velocities in the mitral (SmLV) and tricuspid (SmRV) valves, as well as the SmRV/SmLV ratio.
PE+ subjects were found to have higher SmLV than PE– subjects (6.0 cm/s (2.0–13.8 cm/s) vs. 4.2 cm/s (1.3–9.1 cm/s), p = 0.003). SmRV/SmLV ratios were 1.05 (0.50–2.50) and 1.56 (0.62–4.30), respectively (p < 0.0001). Areas under ROC curves for diagnosis of APE were 0.700 for SmLV and 0.789 for SmRV/SmLV. In multivariate logistic regression analysis, only SmRV/SmLV was statistically significant, with an odds ratio for APE of 6.26 (95% CI: 1.53–25.59; p = 0.009).
Tissue Doppler imaging of the lateral tricuspid and mitral annuli is a useful clinical tool that can help identify PE in CHF patients. Those patients who fulfill these criteria should be considered for further diagnostic studies to confirm PE.
PMCID: PMC3953976  PMID: 24701212
tissue Doppler imaging; pulmonary embolism; chronic heart failure

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