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.
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.
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.
A disc valve of new design was used successfully for the replacement of the mitral valve in patients with rheumatic mitral valve disease. This valve would appear to have the following advantages over the mitral ball valve prosthesis:
• Lower left atrial pressure after replacement.
• Elimination of the hazard of left ventricular outflow tract obstruction with mitral valve replacement.
• Decreased incidence of thromboembolization.
• Abolition of possibility of ventricular septal irritation.
Despite the better outlook for this valve compared with the ball valve for mitral valve substitution, the mitral valve should always be repaired whenever feasible. Repair is possible in the majority of patients.
Eight months after triple valve replacement with Björk-Shiley tilting disc valves a patient developed symptoms and signs suggesting malfunction of the prosthesis in the tricuspid position. This was confirmed by echocardiography and angiocardiography, and at operation thedisc of the prosthesis was found to be stuck half-open by fibrin and clot. A further 11 patients with the same tupe of prosthesis in the triscupid position were then studied by phonocardiography and echocardiography. In one of these the prosthesis was found to be stuck and this was confirmed by angiocardiography and surgery. These 2 cases are reported in detail and the findings in the other 10 are discussed. The implications of this high incidence of malfunction of the Björk-Shiley prosthesis in the tricuspid position are considered. Echocardiography appears to be essential in the follow-up of such patients.
Thrombotic obstruction is the most feared complication of the Björk-Shiley tilting disc prosthesis. From 1971 to 1982 1186 Björk-Shiley valves were implanted in 900 patients. There were 93 deaths in hospital. Eight hundred and seven patients have been followed for a total of 4146 patient years; 14 patients were lost to follow up. Nineteen cases of thrombotic obstruction were identified at necropsy or at a repeat operation in the study group. The mitral prosthesis was thrombosed in 16 patients, the aortic in two, and the tricuspid in one. The incidence for this complication has been calculated to be 0.46 per 100 patient years for all valve positions, 0.79 for single mitral valve replacements, 0.18 for aortic replacements, and 0.63/100 for the tricuspid position. The maximum possible incidence of this complication in this population has been calculated to be 1.4 per 100 patient years. The mortality rate was 41.7% for reoperation and 63% for the development of the complication. Risk factors that have been identified are inadequate anticoagulant control, poor preoperative exercise capacity, and possibly also the implantation of small prostheses.
Cardiac surgery to treat severe heart failure was of benefit to two patients with endomyocardial disease and hypereosinophilia-eosinophilic endomyocardial disease. Both patients had severe biventricular fibrosis with mitral and tricuspid regurgitation. One had predominant right ventricular disease and was treated by right ventricular endocardectomy with tricuspid and mitral xenograft valve replacement. The second patient's main haemodynamic problem was considered to be mitral regurgitation. His mitral valve was replaced by a Starr-Edwards prosthesis; endocardectomy was not performed. Though both patients had toxic confusional states for several weeks postoperatively there was distinct symptomatic and objective evidence of improvement which has been maintained for over 16 months. Previous reports of surgical treatment of 22 patients without eosinophilia (all of whom had endomyocardial resection) and three other patients with eosinophilia have shown equally encouraging results. There has been no evidence of recurrence or progression of heart damage in follow-up periods of up to seven years. It is concluded that cardiac surgery is an important advance in the treatment of endomyocardial disease in patients with or without an eosinophilia.
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)
Echocardiography, two-dimensional; thrombosis, prosthetic valve; tricuspid valve insufficiency; prosthesis; prosthesis failure
A 67-year-old female was evaluated in the out-patient clinic because of shortness of breath on exertion and regular spells of fever. She had been taking ergotamine tartrate to treat migraine for more than 30 years. The patient had undergone aortic-valve replacement for aortic insufficiency three years before. On echocardiographic evaluation, severe retraction and insufficiency of the remaining native heart valves was demonstrated. Endocarditis and carcinoid syndrome were excluded. The mitral, tricuspid and pulmonary valves were all replaced by a mechanical valvular prosthesis. Pathological-anatomical evaluation of the three replaced valves and the aortic valve replaced three years earlier disclosed identical findings, compatible with long-term ergotamine use. Nine months after surgery, a sick sinus syndrome developed necessitating implantation of a DDDR pacemaker with a right atrial and a coronary sinus lead. Functional class according to the New York Heart Association improved from class III to I. After stopping the ergotamine, the fever disappeared. However, the migraine spells reoccurred which are now being treated with paracetamol.
valves; aortic; mitral; pulmonary; tricuspid; ergotamine tartrate
The tricuspid valve has been taken as a non-critical valve in terms of acute or late mortality in a number of conditions. Tricuspid functional regurgitation is a cause of late operations with an increased morbidity. A number of techniques have been described and used in clinical practice in the past forty years and include simple suture techniques and the use of support for annuloplasty with the use of different types of prosthetic rings. The experience accumulated over the years indicates that tricuspid annuloplasty is mandatory to improve late results, which are superior, in general, to replacement of the valve.
The role of echocardiography in defining surgical planning, intraoperative results and follow-up is reviewed as echocardiography is a fundamental tool in cardiac surgery. Surgery for isolated lesions of the tricuspid valve has not received much attention and herein we report the results of the follow-up of a limited series of patients undergoing isolated tricuspid surgery.
The correlation between echocardiographic measurements and surgical measurements was confirmed and was helpful at the time of the confirmation of repair (r=0.53). Forty-seven patients (18 repair, 29 replacement) underwent isolated surgery. Results of isolated tricuspid repair seemed to be superior when compared to those of tricuspid replacement. Survival was 20.7% for tricuspid valve replacement (N=18) and 50% for tricuspid valve repair (N=29) (p=0.04). Freedom from reoperation was 94.4±5.4% for repair and 67.3±12.1% for replacement (p= 0.0011).
The tricuspid valve continues to be a surgical challenge.
tricuspid valve; tricuspid regurgitation; valve repair; echocardiography
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
Tricuspid valve surgery has been associated with a high operative mortality. This study reviewed 51 patients who underwent 53 tricuspid valve procedures between 1975 and 1989. Most patients (82%) had evidence of rheumatic heart disease. Twenty-six patients (51%) had 42 previous cardiac operations, most involving the mitral valve. Eighty-two percent of patients were New York Heart Association (NYHA) class III or IV preoperatively, and almost all patients had associated disease of other valves. The indication for operation was tricuspid regurgitation in 45 patients, infectious endocarditis in 4, and tricuspid stenosis in 2. The tricuspid abnormality was functional in 67% and organic in 33%. There were 32 tricuspid valve replacements, 20 annuloplasties, and 1 tricuspid valve excision. The hospital mortality rate was 11.8% (six patients). On statistical analysis, none of the perioperative variables were a significant risk factor for hospital mortality. Twenty-nine patients (51%) had postoperative complications. Postoperative functional status improved markedly with 80% in NYHA class I and 13% in class II. Long-term follow-up was attempted but was unsatisfactory in this transient, indigent population.
A woman aged 46 was found to have severe tricuspid valve disease 14 years after the diagnosis of a malignant carcinoid tumour of the ileum and 33 years after the onset of symptoms attributable to the disease. Increasing ascites requiring repeated paracentesis had not responded to chemotherapy including infusion of 5-fluorouracil and vincristine into the coeliac artery. The tricuspid valve was replaced by a Björk-Shiley prosthesis. After operation there was no recurrence of ascites or oedema. She remains well one year and 11 months later. It is suggested that valve replacement surgery should be considered more often in patients with carcinoid heart disease. Hepatomegaly and ascites sould not be attributed too readily to advancing malignant disease without careful consideration of the role of right-sided valvar lesions in the production of these signs.
In spite of the efficacy of tricuspid annuloplasty, there remain occasional cases in which tricuspid valve replacement (TVR) is indicated. There is to date no late follow-up data on the Carpentier-Edwards porcine bioprosthesis (CEPB) in the tricuspid position. We present a series of twelve consecutive cases of TVR with the CEPB. Ten patients had multiple valve replacements. The duration of follow-up was 5 to 50 months (mean 27.7 months) on all patients. The operative mortality was 18% (2/12), with 82% (10/12) actuarial 5-year survival. The mean valve follow-up was 2.3 years per prosthesis. Ten patients were in the New York Heart Association (NYHA) Class IV preoperatively. Postoperatively, eight patients moved to Class II, one to Class III and one remained unchanged. There was no valve replacement necessary. Subclinical pulmonary emboli were detected by lung scan in one patient for 4.3% events per year. Echocardiography revealed no evidence of orifice thrombus or leaflet calcification. In our opinion, the Carpentier-Edwards bioprosthesis can be used safely in the tricuspid position with satisfactory functional results.
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.
The following case report describes an early complication of a Carpentier-Edwards porcine heterograft in the mitral position that required emergency replacement of the malfunctioning biological prosthesis with a mechanical one.
The leaflets of the valve were in a fixed-open position and would not unfold with left ventricular contractions, resulting in severe mitral regurgitation. After failure to mobilize the valve leaflets, the porcine heterograft valve was excised intact and replaced with a 27 mm Björk-Shiley monostrut prosthesis.
The patient was discharged 18 days after operation on Digoxin 0.25 mg daily, Lasix 40 mg twice a week, and Sintrom 2 mg daily. He remains in excellent condition 20 months postoperatively. (Texas Heart Institute Journal 1986; 13:337-339)
Porcine heterograft; valve prostheses
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.
Chordae tendineae; endocarditis, bacterial/surgery; heart valve diseases/surgery; polytetrafluoroethylene; substance-related disorders/complications; tricuspid valve/surgery; tricuspid valve insufficiency/surgery
Background. Mitral valve replacement can be very difficult to obtain in infants because the valve annulus diameter can be smaller than the available prosthesis. Case Report. We describe the case of a 2-month-old female weighing 3.5 kg affected by mitral valve dysplasia leading to severe valve stenosis. Despite full medication, the clinical conditions were critical and surgery was undertaken. The mitral valve was unsuitable for repair and the orifice of mitral anulus was 12 mm, too small for a mechanical prosthesis. Therefore, a Ross-Kabbani operation was undertaken, replacing the mitral valve with the pulmonary autograft and reconstructing the right ventricular outflow tract with an etherograft. Results. The postoperative course was uneventful and the clinical conditions are good at 4-month follow-up.
Conclusion. The Ross-Kabbani operation can be an interesting alternative to mitral valve replacement in infants when valve repair is not achievable and there is little space for an intra-annular mechanical prosthesis implant.
A mechanical prosthetic heart valve can become acutely obstructed despite anticoagulation therapy. This can be a life-threatening complication. We report the case of a 38-year-old woman who survived obstruction of her Sorin prosthetic mitral valve. She was admitted to the hospital because of severe pulmonary edema. On auscultation, mechanical valve sounds were absent. Transthoracic echocardiography showed an immobile mechanical valve. The patient suffered a cardiac arrest while being prepared for surgery, but she underwent successful mitral valve replacement after cardiopulmonary resuscitation. When patients with prosthetic mitral valves present with acute dyspnea, the possibility of an obstructed prosthetic valve must be considered in the differential diagnosis.
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.
The new Duromedics Bileaflet Cardiac Valve prosthesis has a special moviṅg hinge mechanism for its two leaflets to wash the critical articulation area and thus reduce thrombus formation.
Between October 1983 and June 1985, we implanted 278 of these prostheses in 254 patients. We did 114 aortic valve replacements, 109 mitral valve replacements, 34 double valve replacements, and two tricuspid valve replacements. Nearly 20% of the patients had had previous cardiac procedures. The hospital mortality was 5.9%. Follow-up was started with 214 surviving Austrian patients, and up to the present time, we have a follow-up period of 1704 patient months. Five patients died late after the operation (3.5 per 100 patient years). We observed 10 valve-related complications in nine patients (7 per 100 patient years). There were three cases of prosthetic endocarditis (2.1 per 100 patient years), two paravalvular leaks, and four bleeding episodes (2.8 per 100 patient years). The mechanical hemolysis was minimal, and the postoperative hemoglobin value averaged 15 g%. The LDH increased from 230 IU to 307 in the aortic valve replacements, 406 in the mitral valve replacements, and 435 in the double valve replacements. Intraoperative pressure gradients and postoperative Doppler echocardiography showed good hemodynamic performance.
We conclude that good clinical results and a low complication rate can be achieved with the Duromedics Valve.
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.
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.
Tricuspid regurgitation; Annuloplasty; Tricuspid valve replacement; Mitral valve surgery; Rheumatic heart disease
In non-addicted patients, several states, such as permanent pacemakers, can provide the predisposing factors for tricuspid-valve endocarditis. In this report, we present a case of a 66-year-old man with pacemaker lead infection and tricuspid-native-valve endocarditis, related to Staphylococcus hominis, very rare cause of infective endocarditis that carries a high-mortality risk. Surgery was indicated for the patient due to persistent enlarging vegetation on the tricuspid valve, severe tricuspid regurgitation, septic pulmonary emboli and finally uncompensated respiratory and heart failure. Many ingenious methods have been devised to repair the tricuspid valve in patients with infective endocarditis. Valve replacement, however, is hazardous due to the possibility of prosthetic infection, and we choose to repair the native valve. The patient has now been weel for 3 years.
Aortic valve replacement with a pulmonary autograft was performed in 24 patients between October 1993 and October 1994, at the All India Institute of Medical Sciences, New Delhi. There were 20 (83.3%) males and 4 (16.7%) females. Their ages ranged from 10 to 56 years (mean, 21.46 +/- 11.45 years). Associated procedures included 10 mitral valve procedures (4 open commissurotomies, 5 mitral valve repairs, and 1 homograft mitral valve replacement) and 1 tricuspid valve repair. There were 4 (16.7%) early deaths, 3 of which were due to bleeding or its sequelae and 1 due to septicemia. There were no late deaths. Follow-up ranged from 1 to 13 months (mean, 198.3 +/- 111.1 days). Nineteen (95%) patients are in New York Heart Association functional class I, and 1 patient (5%) is in class II, due to poor left ventricular function. Only 1 patient showed grade 2/4 aortic regurgitation on follow-up examinations, and none has shown progression of aortic regurgitation. Our early results with the pulmonary autograft are encouraging; however, long-term evaluation is needed.