Prevalence and risk factors for tricuspid valve regurgitation after pediatric heart transplantation.
ABSTRACT Risk factors for tricuspid regurgitation (TR) after adult orthotopic heart transplantation (OHT) have been reported, although there are no pediatric data.
This study was a single-center retrospective analysis of patients <or= 18 years of age who underwent OHT from January 1990 to December 2004. The impact of TR was evaluated with respect to outcomes (graft failure, etc.).
Echocardiograms were available for 99 patients (105 grafts with 6 re-transplants) at a median age of 4.5 years (range 18 days to 17.1 years): 51 (49%) were male; 46 (44%) were transplanted for congenital heart disease; and 76 (72%) had a biatrial anastomosis. Significant TR developed in 30 grafts (29.5%) within a median duration after OHT of 1.2 years (range 0 day to 8.2 years); persistent significant TR until last follow-up was present in 21 grafts (20%). Graft failure (death or need for retransplantation) occurred in 41 grafts (39%), including 14 of 21 grafts (67%) with significant TR. By Kaplan-Meier analysis, freedom from significant TR (95% confidence interval [CI]) at 1, 5 and 10 years was 91.0% (83.4% to 95.2%), 70.2% (55.4% to 80.9%) and 61.5% (39.2% to 77.6%), respectively. No risk factors were identified. Development of significant TR was highly associated with graft failure (p = 0.005).
Significant TR occurs with comparable frequency in pediatric and adult OHT populations; risk factors identified in adults were not present in our pediatric population. Development of significant TR in pediatric heart transplant recipients is highly associated with graft failure.
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ABSTRACT: Tricuspid valve regurgitation occurs with other congenital heart defects, especially the right-sided obstructive lesions. We applied the selective annuloplasty technique for the treatment of tricuspid regurgitation in children. Between 2001 and 2003, 15 patients whose ages averaged 7.6 +/- 3.1 years (range 4 to 17 years old) underwent selective annuloplasty during correction of other heart defects. The patients had repair of pulmonary stenosis (5 patients), pulmonary stenosis and ventricular septal defect (7 patients), and tetralogy of Fallot (3 patients). Eight patients preoperatively had moderate tricuspid regurgitation, and 7 patients had severe tricuspid regurgitation. No deaths nor heart block occurred after the operation. The length of the tricuspid regutgitation flow was significantly decreased from 2.9 +/- 0.7 cm before the operation to 0.9 +/- 0.6 cm after the operation (p < 0.01), and the tricuspid annular diameter decreased from 3.9 +/- 0.3 cm to 3.3 +/- 0.3 cm (p < 0.01). Annular circumference was reduced by 1.9 +/- 0.2 cm. No tricuspid regurgitation was detected in 3 patients (20%), mild tricuspid regurgitation was seen in 10 (67%), moderate tricuspid regurgitation in 2 (13%). The right atrial mean pressure was significantly decreased from 7.5 +/- 0.5 mm Hg before the operation to 3.1 +/- 0.2 mm Hg after the operation (p < 0.01), right ventricular systolic pressure from 55.5 +/- 2.3 mm Hg to 29.8 +/- 1.9 mm Hg (p < 0.01), and right ventricular end-diastolic pressure from 8.4 +/- 0.7 mm Hg to 4.9 +/- 0.9 mm Hg (p < 0.01). Preoperatively, the degree of tricuspid regurgitation flow correlated significantly with the right ventricular systolic pressure (r = 0.89; p < 0.001). There was no correlation between tricuspid regurgitation flow and right ventricular systolic pressure postoperatively (p = 0.88). No child has symptomatic or significant tricuspid stenosis. Selective annuloplasty presents a useful procedure for young patients with moderate or severe tricuspid regurgitation and right-sided obstructive lesions resulting from functional reconstruction of the tricuspid valve.The Annals of thoracic surgery 04/2005; 79(3):937-41. · 3.74 Impact Factor
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ABSTRACT: Severe tricuspid regurgitation (TR) with signs of right-sided heart failure is rare after orthotopic heart transplantation (OHT). In some instances, this condition will require surgical correction using reconstructive surgery or prosthetic valve replacement. Repair techniques of atrioventricular valves are now well described. However, the results of the different surgical procedures in this setting have not been widely reported and may depend on the type of valvular dysfunction and lesions present. Herein we report our experience in a group of patients requiring surgical correction of symptomatic severe TR after OHT. We reviewed our transplant experience during the period from July 1992 to July 1999 (n = 138 cardiac transplants). Eight patients (5.8%) developed symptomatic severe TR requiring surgical correction after a mean duration of 21 months after OHT. Patients were divided into 2 groups based on the mechanism of regurgitation using Carpentier's functional classification. In Group 1 (n = 4), the mechanism of tricuspid regurgitation was Carpentier's Type I, secondary to annular dilation. In Group 2 (n = 4) the mechanism of TR was leaflet prolapse (Type II), due to chordal rupture after biopsy injury. Initially, tricuspid valve integrity was surgically restored in all 8 patients with either valve repair (n = 6) or replacement (n = 2). In Group 1, 2 patients underwent valve repair using a ring annuloplasty and 2 patients underwent valve replacement with a bioprosthetic valve (n = 1) or pulmonary allograft (n = 1). In Group 2, all patients underwent valve repair using a variety of techniques in combination with tricuspid annuloplasty. During the follow-up period, 3 of the 6 (50%) primary repairs (1 patient in Group 1 and 2 in Group 2) failed and required replacement with a bioprosthesis at 8 days, 14 days and 4 years, respectively. The pulmonary allograft failed secondary to valvular stenosis and was replaced with a bioprosthesis after 10 months. Overall, no failures occurred in any of the 5 bioprosthetic valves placed at the primary operation (n = 1) or after failed tricuspid repair/pulmonary allograft (n = 4), after a mean follow-up of 55 months. TR requiring surgical correction after OHT is a rare condition and requires a tailored surgical strategy. This strategy should take into account the mechanism of valve dysfunction and specific valvular lesions. In patients with Type I dysfunction secondary to annular dilation, valve repair with a remodeling annuloplasty should be performed; however, in the presence of any residual TR on transesophageal echocardiography (TEE) at the completion of cardiopulmonary bypass (CPB), a valve replacement with a bioprosthesis is warranted during the same procedure. In patients with Type II dysfunction with leaflet prolapse and biopsy-induced chordal injury, a bioprosthetic valve replacement seems a reliable surgical option.The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 04/2006; 25(3):289-93. · 3.54 Impact Factor
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ABSTRACT: Tricuspid valve insufficiency (TI) is common after orthotopic heart transplantation. However, tricuspid valve replacement or repair (TVR) is rare. The aim of this study is to evaluate our experience with TVR in cardiac transplant recipients. The Utah Transplantation Affiliated Hospitals (UTAH) Cardiac Transplant Program database was queried for TVR in all adult and pediatric heart transplant recipients. Pre-operative parameters and cardiac hemodynamics were compared with post-operative findings. Since 1985, we identified in our database 17 patients who had 16 TVR, and 2 tricuspid valve repair procedures. Thirty-four heart transplant recipients from the same period were used as controls. The indication for TVR was symptomatic right heart failure (RHF) in 89% of cases, and there was no significant difference between the control group and the surgery group in the average number of biopsies. A flail leaflet was found in 16 cases (89%). One patient died post-operatively due to cardiogenic shock, and 1 patient died 8 months after TVR due to progressive RHF. Improvement in heart failure symptoms was seen in 12 cases. The central venous pressure (CVP) decreased from 17.8 +/- 4.1 mm Hg to 11.0 +/- 7.3 mm Hg (p = 0.013). There was no significant change in cardiac output or renal function. However, the furosemide dose decreased significantly from 47.69 +/- 56.44 mg/day to 26.54 +/- 46.43 mg/day (p = 0.009). After orthotopic heart transplantation, TVR is a safe and effective procedure to alleviate RHF symptoms. Flail leaflets are the most common operative finding, suggesting that biopsy-induced trauma is the likely cause of severe TI in these patients.The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 02/2006; 25(1):48-52. · 3.54 Impact Factor