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Mathur M, Malinowski M, Jazwiec T, Timek TA, Rausch MK. Leaflet remodeling reduces tricuspid valve function in a computational model. J Mech Behav Biomed Mater 2024; 152:106453. [PMID: 38335648 PMCID: PMC11048730 DOI: 10.1016/j.jmbbm.2024.106453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 01/23/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024]
Abstract
Tricuspid valve leaflets have historically been considered "passive flaps". However, we have recently shown that tricuspid leaflets actively remodel in sheep with functional tricuspid regurgitation. We hypothesize that these remodeling-induced changes reduce leaflet coaptation and, therefore, contribute to valvular dysfunction. To test this, we simulated the impact of remodeling-induced changes on valve mechanics in a reverse-engineered computer model of the human tricuspid valve. To this end, we combined right-heart pressures and tricuspid annular dynamics recorded in an ex vivo beating heart, with subject-matched in vitro measurements of valve geometry and material properties, to build a subject-specific finite element model. Next, we modified the annular geometry and boundary conditions to mimic changes seen in patients with pulmonary hypertension. In this model, we then increased leaflet thickness and stiffness and reduced the stretch at which leaflets stiffen, which we call "transition-λ." Subsequently, we quantified mean leaflet stresses, leaflet systolic angles, and coaptation area as measures of valve function. We found that leaflet stresses, leaflet systolic angle, and coaptation area are sensitive to independent changes in stiffness, thickness, and transition-λ. When combining thickening, stiffening, and changes in transition-λ, we found that anterior and posterior leaflet stresses decreased by 26% and 28%, respectively. Furthermore, systolic angles increased by 43%, and coaptation area decreased by 66%; thereby impeding valve function. While only a computational study, we provide the first evidence that remodeling-induced leaflet thickening and stiffening may contribute to valvular dysfunction. Targeted suppression of such changes in diseased valves could restore normal valve mechanics and promote leaflet coaptation.
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Affiliation(s)
- Mrudang Mathur
- Department of Mechanical Engineering, University of Texas at Austin, 204 E Dean Keeton Street, Austin, 78712, TX, United States of America
| | - Marcin Malinowski
- Division of Cardiothoracic Surgery, Spectrum Health, 221 Michigan Street NE Suite 300, Grand Rapids, 49503, MI, United States of America; Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
| | - Tomasz Jazwiec
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Tomasz A Timek
- Division of Cardiothoracic Surgery, Spectrum Health, 221 Michigan Street NE Suite 300, Grand Rapids, 49503, MI, United States of America
| | - Manuel K Rausch
- Department of Mechanical Engineering, University of Texas at Austin, 204 E Dean Keeton Street, Austin, 78712, TX, United States of America; Department of Aerospace Engineering and Engineering Mechanics, University of Texas at Austin, 2617 Wichita Street, Austin, 78712, TX, United States of America; Department of Biomedical Engineering, University of Texas at Austin, 107 W Dean Keeton Street, Austin, 78712, TX, United States of America; Oden Institute for Computational Engineering and Sciences, University of Texas at Austin, 201 E 24th Street, Austin, 78712, TX, United States of America.
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Gaweda B, Gaddam M, Jaźwiec T, Bush JD, MacDougall B, Widenka K, Timek TA. Papillary muscle approximation in chronic ovine functional tricuspid regurgitation. J Thorac Cardiovasc Surg 2023; 166:e502-e509. [PMID: 37330209 DOI: 10.1016/j.jtcvs.2023.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/18/2023] [Accepted: 05/31/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Isolated tricuspid ring annuloplasty remains the surgical standard for functional tricuspid regurgitation repair but offers suboptimal results when right ventricular dilation and remodeling along with papillary muscle displacement is present. Addressing subvalvular remodeling with papillary muscle approximation may improve clinical outcomes. METHODS Functional tricuspid regurgitation and biventricular dysfunction were induced in 8 healthy sheep by rapid ventricular pacing (200-240 bpm) for 27 ± 6 days. Subsequently, animals underwent cardiopulmonary bypass for implantation of sonomicrometry crystals on the tricuspid annulus, right ventricle, and papillary muscle tips. Papillary approximation sutures were anchored between anterior-posterior and anterior-septal papillary muscles and externalized through right ventricular free wall to epicardial tourniquets. After weaning from cardiopulmonary bypass, sequential papillary muscle approximations were performed. Simultaneous hemodynamic, sonomicrometry, and echocardiographic data were collected at baseline and after each papillary muscle approximation. RESULTS With rapid pacing, right ventricular fractional area change decreased from 59 ± 6% to 38 ± 8% (P < .001), whereas tricuspid annulus diameter increased from 2.4 ± 0.3 cm to 3.3 ± 0.6 cm (P = .003). Tricuspid regurgitation (0-4+) increased from +0 ± 0 to +3.3 ± 0.7 (P < .001). Both anterior-posterior and anterior-septal papillary muscle approximation significantly reduced functional tricuspid regurgitation from +3.3 ± 0.7 to +2 ± 0.5 and +1.9 ± 0.6, respectively (P < .001). Reduction of tricuspid insufficiency with both subvalvular interventions was associated with decreased distance of the anterior papillary muscle to the annular centroid. CONCLUSIONS Papillary muscle approximations were effective in reducing severe ovine functional tricuspid regurgitation associated with right ventricular dilation and papillary muscle displacement. Further studies are needed to evaluate efficacy of this adjunct to ring annuloplasty in repair of severe functional tricuspid regurgitation.
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Affiliation(s)
- Boguslaw Gaweda
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich; Department of Cardiac Surgery, Faculty of Medicine, Clinical District Hospital No. 2, University of Rzeszow, Rzeszow, Poland
| | - Manikantam Gaddam
- Department of Urology, Stanford University School of Medicine, Stanford, Calif
| | - Tomasz Jaźwiec
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Disease, Medical University of Silesia in Katowice, Zabrze, Poland
| | - Jared D Bush
- Research Department, Corewell Health, Grand Rapids, Mich
| | | | - Kazimierz Widenka
- Department of Cardiac Surgery, Faculty of Medicine, Clinical District Hospital No. 2, University of Rzeszow, Rzeszow, Poland
| | - Tomasz A Timek
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich; College of Human Medicine, Michigan State University, Grand Rapids, Mich.
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Iwasieczko A, Jazwiec T, Gaddam M, Gaweda B, Piekarska M, Solarewicz M, Rausch MK, Timek TA. Septal annular dilation in chronic ovine functional tricuspid regurgitation. J Thorac Cardiovasc Surg 2023; 166:e393-e403. [PMID: 37061178 PMCID: PMC11088945 DOI: 10.1016/j.jtcvs.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/19/2023] [Accepted: 04/05/2023] [Indexed: 04/17/2023]
Abstract
INTRODUCTION Annular reduction with prosthetic rings represents the current surgical treatment of functional tricuspid regurgitation (FTR). However, alterations of annular geometry and dynamics associated with FTR are not well characterized. METHODS FTR was induced in 29 adult sheep with either 8 weeks of pulmonary artery banding (PAB, n = 15) or 3 weeks of tachycardia-induced cardiomyopathy (TIC, n = 14). Eight healthy sheep served as controls (CTL). At the terminal procedure, all animals underwent sternotomy, epicardial echocardiography, and implantation of sonomicrometry crystals on the tricuspid annulus (TA) and right ventricular free wall while on cardiopulmonary bypass. Simultaneous hemodynamic, sonomicrometry, and echocardiographic data were acquired after weaning from cardiopulmonary bypass and stabilization. Annular geometry and dynamics were calculated from 3-dimensional crystal coordinates. RESULTS Mean FTR grade (0-4) was 3.2 ± 1.2 and 3.2 ± 0.5 for PAB and TIC, respectively, with both models of FTR associated with similar degree of right ventricular dysfunction (right ventricular fractional area contraction 38 ± 7% and 37 ± 9% for PAB and TIC, respectively). Left ventricular ejection fraction was significantly reduced in TIC versus baseline (33 ± 9%, vs 58 ± 4%, P = .0001). TA area was 651 ± 109 mm2, 881 ± 242 mm2, and 995 ± 232 mm2 for CTL, FTR, and TIC, respectively (P = .006) with TA area contraction of 16.6 ± 4.2%, 11.5 ± 8.0%, and 6.0 ± 4.0%, respectively (P = .003). Septal annulus increased from 33.8 ± 3.1 mm to 39.7 ± 6.4 mm and 43.1 ± 3.2 mm for CTL, PAB, and TIC, respectively (P < .0001). CONCLUSIONS Ovine FTR was associated with annular dilation and reduced annular area contraction. Significant dilation of septal annulus was observed in both models of FTR. As tricuspid rings do not completely stabilize the septal annulus, continued remodeling may contribute to recurrent FTR after repair.
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Affiliation(s)
- Artur Iwasieczko
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich; Clinical Department of Cardiac Surgery, St Jadwiga Provincial Clinical Hospital, Rzeszow, Poland
| | - Tomasz Jazwiec
- Department of Cardiac Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Manikantam Gaddam
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich
| | - Boguslaw Gaweda
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich; Clinical Department of Cardiac Surgery, St Jadwiga Provincial Clinical Hospital, Rzeszow, Poland
| | | | - M Solarewicz
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich
| | - Manuel K Rausch
- Departments of Aerospace Engineering & Engineering Mechanics, Biomedical Engineering, University of Texas at Austin, Austin, Tex
| | - Tomasz A Timek
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich.
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Pettinari M, De Kerchove L, Van Dyck M, Pasquet A, Gerber B, El-Khoury G, Vanoverschelde JL. Tricuspid annular dynamics, not diameter, predicts tricuspid regurgitation after mitral valve surgery: Results from a prospective randomized trial. JTCVS OPEN 2023; 14:92-101. [PMID: 37425472 PMCID: PMC10328816 DOI: 10.1016/j.xjon.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Objective Current guidelines advise using prophylactic tricuspid valve annuloplasty during mitral valve surgery, especially in the presence of annular diameter enlargement. However, several retrospective studies and a prospective randomized study from our department could not confirm that diameter enlargement is predictive of late regurgitation. We examined whether 2- and 3-dimensional echocardiographic and clinical characteristics could identify patients who will develop moderate or severe recurrent tricuspid regurgitation. Methods Patients with less than severe functional tricuspid regurgitation (FTR) were randomized not to receive tricuspid annuloplasty, and 11 of 53 of them were excluded from the study because 3-dimensional echocardiographic analysis was not possible. Cox regression was used to estimate the model-based probability of moderate or severe FTR (vena contracta ≥3 mm) or progression of TR and FTR regression using valve dimensions (annulus area, diameter perimeter, nonplanar angle, and sphericity index), dynamics (annulus contraction, annulus displacement, and displacement velocity), and clinical parameters as possible predictors. Results At a median follow-up of 3.8 years (range, 3-5.6 years), 17 patients had moderate or severe FTR or progression, and 13 had FTR regression. Our models identified annular displacement velocity as a significant predictor for FTR recurrence and nonplanar angle as a significant predictor for FTR regression. Conclusions Annular dynamics, not the dimension, predict recurrence and regression of FTR. Annular contraction should be systematically investigated as a possible surrogate of right ventricle function to prophylactically treat the tricuspid valve.
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Affiliation(s)
- Matteo Pettinari
- Cardiac Surgery Department, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Laurent De Kerchove
- Division of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Universitè Catholique de Louvain, Brussels, Belgium
| | - Michel Van Dyck
- Division of Anesthesiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Agnes Pasquet
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Universitè Catholique de Louvain, Brussels, Belgium
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Bernhard Gerber
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Universitè Catholique de Louvain, Brussels, Belgium
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gebrine El-Khoury
- Division of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Universitè Catholique de Louvain, Brussels, Belgium
| | - Jean-Louis Vanoverschelde
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Universitè Catholique de Louvain, Brussels, Belgium
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Alghamdi R, Alaloola AA, Aldaghar AS, Alfonso J, Ismail H, Adam AI, Pragliola C, Albabtain MA, Arafat AA. Five-year outcomes of tricuspid valve repair versus replacement; a propensity score-matched analysis. Asian Cardiovasc Thorac Ann 2023:2184923231176508. [PMID: 37192641 DOI: 10.1177/02184923231176508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND Tricuspid valve repair (TVr) is the recommended approach for managing tricuspid regurgitation; however, there is a concern about the long-term durability of the repair. Therefore, this study aimed to compare the long-term outcomes of TVr versus tricuspid valve replacement (TVR) in a matched cohort of patients. METHODS This study included 1161 patients who underwent tricuspid valve (TV) surgery from 2009 to 2020. Patients were grouped according to the procedure into two groups: patients who underwent TVr (n = 1020) and patients who underwent TVR (n = 159). The propensity score identified 135 matched pairs. RESULTS Renal replacement therapy and bleeding were significantly higher in the TVR group compared to the TVr group both before and after matching. Thirty-day mortality occurred in 38 (3.79%) patients in TVr group versus 3 (1.89%) in the TVR group (P ≤ 0.001) but was not significant after matching. After matching, TV reintervention (hazard ratio (HR): 21.44 (95% CI: 2.17-211.95); P = 0.009) and heart failure rehospitalization (HR: 1.89 (95% CI: 1.13-3.16); P = 0.015) were significantly higher in the TVR group. There was no difference in mortality in the matched cohort (HR: 1.63 (95% CI: 0.72-3.70); P = 0.25). CONCLUSIONS TVr was associated with lower renal impairment, reintervention, and heart failure rehospitalization than replacement. TVr remains the preferred approach whenever feasible.
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Affiliation(s)
- Rawan Alghamdi
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Alhnouf A Alaloola
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
- Cardiac Surgery Department, King Fahd Medical City, Riyadh, Saudi Arabia
| | - Abdulelah S Aldaghar
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
- Cardiac Science Department, King Fahd Cardiac Center, Riyadh, Saudi Arabia
| | - Juan Alfonso
- Cardiac Research Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Huda Ismail
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Adam I Adam
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Claudio Pragliola
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Monirah A Albabtain
- Cardiac Research Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Amr A Arafat
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
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Iwasieczko A, Gaddam M, Gaweda B, Goodyke A, Mathur M, Lin CY, Zagorski J, Solarewicz M, Cohle S, Rausch M, Timek TA. Valvular complex and tissue remodelling in ovine functional tricuspid regurgitation. Eur J Cardiothorac Surg 2023; 63:ezad115. [PMID: 36951551 DOI: 10.1093/ejcts/ezad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 03/06/2023] [Accepted: 03/22/2023] [Indexed: 03/24/2023] Open
Abstract
OBJECTIVES Pathophysiology of function tricuspid regurgitation (FTR) is incompletely understood. We set out to comprehensively evaluate geometric and tissue remodelling of the tricuspid valve complex in ovine FTR. METHODS Twenty adult sheep underwent left thoracotomy and pulmonary artery banding (PAB) to induce right heart pressure overload and FTR. After 8 weeks, 17 surviving animals and 10 healthy controls (CTL) underwent sternotomy, echocardiography and implantation of sonomicrometry crystals on right ventricle and tricuspid valvular apparatus. Haemodynamic and sonomicrometry data were acquired in all animals after weaning from cardiopulmonary bypass. Leaflet tissue was harvested for pentachrome histologic analysis and biomechanical testing. RESULTS Animal weight was 62 ± 5 and 63 ± 3 kg for CTL and PAB, respectively (P = 0.6). At terminal procedure, systolic pulmonary artery pressure was 22 ± 3 and 40 ± 7 mmHg for CTL and PAB, respectively (P = 0.0001). The mean TR grade (+0-4) was 0.8 ± 0.4 and 3.2 ± 1.2 (P = 0.0001) for control and banded animals, respectively. Right ventricle volume (126 ± 13 vs 172 ± 34 ml, P = 0.0019), tricuspid annular area (651 ± 109 vs 865 ± 247 mm2, P = 0.037) and area between papillary muscle tips (162 ± 51 vs 302 ± 75 mm2, P = 0.001) increased substantially while systolic excursion of anterior leaflet decreased significantly (23.8 ± 6.1° vs 7.4 ± 4.5°, P = 0.001) with banding. Total leaflet surface area increased from 806 ± 94 to 953 ± 148 mm2 (P = 0.009), and leaflets became thicker and stiffer. CONCLUSIONS Detailed analysis of the tricuspid valve complex revealed significant ventricular, annular, subvalvular and leaflet remodelling to be associated with ovine functional tricuspid regurgitation. Durable surgical repair of severe FTR may require a multi-level approach to the valvular apparatus.
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Affiliation(s)
- Artur Iwasieczko
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
- Department of Cardiac Surgery, State Clinical Hospital Number 2, University of Rzeszow, Rzeszow, Poland
| | | | - Boguslaw Gaweda
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
- Department of Cardiac Surgery, State Clinical Hospital Number 2, University of Rzeszow, Rzeszow, Poland
| | - Austin Goodyke
- Research Department, Spectrum Health, Grand Rapids, MI, USA
| | - Mrudang Mathur
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA
| | - Chien-Yu Lin
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA
| | | | - Monica Solarewicz
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
| | - Stephen Cohle
- Department of Pathology, Spectrum Health, Grand Rapids, MI, USA
| | - Manuel Rausch
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA
| | - Tomasz A Timek
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
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Iwasieczko A, Malinowski M, Solarewicz M, Bush J, MacDougall B, Rausch M, Timek TA. Impact of reductive tricuspid ring annuloplasty on right ventricular size, geometry and strain in an ovine model of functional tricuspid regurgitation. Interact Cardiovasc Thorac Surg 2022; 35:6628589. [PMID: 35781336 PMCID: PMC9270866 DOI: 10.1093/icvts/ivac187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/18/2022] [Accepted: 06/01/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
Reductive ring annuloplasty of the tricuspid annulus represents the contemporary surgical approach to functional tricuspid regurgitation (FTR). We set out to investigate the influence of moderate reductive tricuspid ring annuloplasty on tricuspid regurgitation and right ventricular (RV) size, geometry and strain in an ovine model of chronic FTR.
METHODS
Eight healthy Dorsett male sheep (62.8 + 2kg) underwent a left thoracotomy for placement and tightening of pulmonary artery band to at least double proximal pulmonary artery blood pressure. After 8 weeks of recovery, animals underwent sternotomy, epicardial echocardiography and sonomicrometry crystal implantation. Six crystals were placed around tricuspid annulus and 13 on RV free wall epicardium along 3 parallels defining 3 wall regions (basal, mid and lower) and 1 on the RV apex. All animals underwent beating heart implantation of 26 mm MC3 annuloplasty ring during a second cardiopulmonary bypass run after baseline data acquisition. Simultaneous haemodynamic, sonomicrometry and echocardiography data were acquired at Baseline and after reductive tricuspid ring annuloplasty.
RESULTS
Implantation of reductive ring annuloplasty resulted in 47 ± 7% annular area reduction (996 ± 152 mm vs 516 ± 52 mm2, P = 0.0002) and significantly decreased RV end-diastolic volume (185 ± 27 vs 165 ± 30 ml, P = 0.02). Tricuspid ring annuloplasty effectively reduced FTR grade (3.75 ± 0.6 vs 0.3 ± 0.5, P = 0.00004) and had little influence on RV function, cross-sectional area, radius of curvature or free wall regional strains.
CONCLUSIONS
In adult sheep with 8 weeks of pulmonary artery banding and FTR, tricuspid annulus reduction of 47% with prosthetic ring annuloplasty effectively abolished FTR while maintaining regional RV function and strain patterns.
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Affiliation(s)
- Artur Iwasieczko
- Division of Cardiothoracic Surgery, Spectrum Health , Michigan State College of Human Medicine, Grand Rapids, MI, USA
- Clinical Department of Cardiac Surgery, District Hospital No. 2, University of Rzeszow , Rzeszow, Poland
| | - Marcin Malinowski
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice , Katowice, Poland
| | - Monica Solarewicz
- Division of Cardiothoracic Surgery, Spectrum Health , Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | - Jared Bush
- Division of Cardiothoracic Surgery, Spectrum Health , Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | - Brian MacDougall
- Division of Cardiothoracic Surgery, Spectrum Health , Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | - Manuel Rausch
- Department of Aerospace Engineering & Engineering Mechanics, Department of Biomedical Engineering, Institute of Computational Engineering and Science, University of Texas at Austin , Austin, TX, USA
| | - Tomasz A Timek
- Division of Cardiothoracic Surgery, Spectrum Health , Michigan State College of Human Medicine, Grand Rapids, MI, USA
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Singulane CC, Singh A, Addetia K, Yamat M, Lang RM. Developing Insights Regarding Tricuspid Valve Regurgitation: Morphology, Assessment of Severity, and the Need for a Novel Grading Scheme. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100026. [PMID: 37273466 PMCID: PMC10236825 DOI: 10.1016/j.shj.2022.100026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/17/2022] [Indexed: 06/06/2023]
Abstract
Current understanding that progressive tricuspid regurgitation (TR) is associated with worse outcomes has highlighted the clinical need for a more accurate assessment of TR morphology and severity. This need has been further emphasized owing to the development of a myriad of percutaneous right-sided interventions, which may offer successful treatment of TR in selected patients. Understanding the etiology and quantification of the severity of TR has important implications in the selection of novel therapeutic strategies, i.e., medical vs. percutaneous vs. surgical approaches. Newer grading schemas that better reflect the TR lesion severity have been recently proposed and may facilitate monitoring of the evolution of TR following percutaneous and/or surgical treatment. In this review, we summarize contemporary concepts regarding tricuspid valve morphology, TR etiology, and associated mechanisms and echocardiographic approaches to grade TR severity.
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Affiliation(s)
| | | | | | | | - Roberto Miguel Lang
- Address correspondence to: Roberto Miguel Lang, MD, FASE, FACC, The University of Chicago Medicine, 5758 S. Maryland Avenue, MR 9067, DCAM 5509, Chicago, IL 6063
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Arafat AA, Alfonso J, Hassan E, Pragliola C, Adam AI, Algarni KD. The influence of mitral valve pathology on the concomitant tricuspid valve repair. J Card Surg 2022; 37:739-746. [DOI: 10.1111/jocs.16250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/14/2021] [Accepted: 10/23/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Amr A. Arafat
- Department of Adult Cardiac Surgery Prince Sultan Cardiac Center Riyadh Saudi Arabia
- Cardiothoracic Surgery Department Tanta University Tanta Egypt
| | - Juan Alfonso
- Clinical Research Department Prince Sultan Cardiac Center Riyadh Saudi Arabia
| | - Essam Hassan
- Department of Adult Cardiac Surgery Prince Sultan Cardiac Center Riyadh Saudi Arabia
- Cardiothoracic Surgery Department Tanta University Tanta Egypt
| | - Claudio Pragliola
- Department of Adult Cardiac Surgery Prince Sultan Cardiac Center Riyadh Saudi Arabia
| | - Adam I. Adam
- Department of Adult Cardiac Surgery Prince Sultan Cardiac Center Riyadh Saudi Arabia
| | - Khaled D. Algarni
- Department of Adult Cardiac Surgery Prince Sultan Cardiac Center Riyadh Saudi Arabia
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Algarni KD, Alfonso J, Pragliola C, Kheirallah H, Adam AI, Arafat AA. Long-term Outcomes of Tricuspid Valve Repair: The Influence of the Annuloplasty Prosthesis. Ann Thorac Surg 2021; 112:1493-1500. [DOI: 10.1016/j.athoracsur.2020.09.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 09/18/2020] [Accepted: 09/18/2020] [Indexed: 11/29/2022]
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Jazwiec T, Malinowski MJ, Ferguson H, Parker J, Mathur M, Rausch MK, Timek TA. Tricuspid Valve Anterior Leaflet Strains in Ovine Functional Tricuspid Regurgitation. Semin Thorac Cardiovasc Surg 2020; 33:356-364. [PMID: 32977016 DOI: 10.1053/j.semtcvs.2020.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 09/08/2020] [Indexed: 01/31/2023]
Abstract
Functional tricuspid regurgitation (FTR) is thought to arise due to annular dilation and alteration of right ventricular (RV) geometry in the presence of normal leaflets, yet mitral leaflets have been shown to remodel significantly in functional mitral regurgitation. We set out to evaluate tricuspid valve anterior leaflet deformations in ovine FTR. Eleven animals (FTR group) underwent implantation of a pacemaker with high rate pacing to induce biventricular dysfunction and at least moderate TR. Subsequently, both FTR (n = 11) and Control (n = 12) animals underwent implantation of 6 sonomicrometry crystals around the tricuspid annulus, 4 on the anterior leaflet, and 14 on RV epicardium. Tricuspid valve geometry and anterior leaflet strains were calculated from crystal coordinates. Left ventricular ejection fraction and RV fractional area change were significantly lower in FTR animals versus Control. Tricuspid annular area, septo-lateral diameter, RV pressures were all significantly greater in the FTR group. Mean TR grade (+0-3) was 0.7 ± 0.5 in Control and 2.4 ± 0.5 in FTR (P = < 0.001). The anterior leaflet area and length increased significantly. Global radial leaflet strain was significantly lower in FTR mostly driven by decreased free edge leaflet strain. Global circumferential anterior leaflet strain was also significantly lower in FTR with more remarkable reduction in the belly region. Rapid ventricular pacing in sheep resulted in a clinically pertinent model of RV and annular dilation with FTR and leaflet enlargement. Both circumferential and radial anterior leaflet strains were significantly reduced with FTR. Functional TR may be associated with alteration of leaflet mechanical properties.
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Affiliation(s)
- Tomasz Jazwiec
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Michigan; Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Marcin J Malinowski
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Michigan; Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | - Haley Ferguson
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Michigan
| | - Jessica Parker
- Research Department, Spectrum Health, Grand Rapids, Michigan
| | - Mrudang Mathur
- Department of Mechanical Engineering, University of Texas at Austin, Austin, Texas
| | - Manuel K Rausch
- Department of Aerospace Engineering & Engineering Mechanics, Department of Biomedical Engineering, Oden Institute for Computational Engineering and Science, University of Texas at Austin, Austin, Texas
| | - Tomasz A Timek
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Michigan.
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Calafiore AM, Lorusso R, Kheirallah H, Alsaied MM, Alfonso JJ, Di Baldassare A, Gallina S, Gaudino M, Di Mauro M. Late tricuspid regurgitation and right ventricular remodeling after tricuspid annuloplasty. J Card Surg 2020; 35:1891-1900. [PMID: 32652675 DOI: 10.1111/jocs.14840] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/30/2020] [Accepted: 06/04/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of the present retrospective study was to evaluate the influence of preoperative right ventricular (RV) and tricuspid valve (TV) remodeling on the fate of tricuspid annuloplasty (TA) and right ventricle. METHODS From May 2009 to December 2015, 423 patients who had undergone TA for functional tricuspid regurgitation (TR) were included in the study. Residual and recurrent TR were defined as moderate or more TR at discharge and follow-up, respectively. RV remodeling was defined as RV dysfunction and/or dilation. RESULTS Residual TR after TA was recorded in 54 patients (13%). Five-year freedom from TR recurrence was 81% ± 3% in patients without residual TR and 41 ± 8 in patients with residual TR (P < .001). In patients without residual TR, the following risk factors for recurrent TR and late RV remodeling were identified: preoperative systolic pulmonary artery pressure, preoperative RV remodeling, severe preoperative TR or less than severe TR but with TV apparatus remodeling, and etiology of mitral regurgitation. Cox analysis with time-dependent variables confirmed TR recurrence (hazard ratio [HR]: 3.1) and late RV remodeling (HR: 6.5) as risk factors for lower survival. No protective effect of either flexible band or rigid ring TA compared with DeVega procedure was found. Similarly, preoperative atrial fibrillation and pacemaker dependency, late failure of mitral valve surgery did not affect the fate of TR. CONCLUSIONS Prophylactic TA should be encouraged among surgeons. TA at the time of left-sided valve surgery should take into consideration not only annular size, but also tethering severity and RV remodeling.
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Affiliation(s)
- Antonio M Calafiore
- Department of Cardiac Surgery and Cardiology, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Department of Cardiac Surgery, Gemelli Molise, Campobasso, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Unit, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Hatim Kheirallah
- Department of Cardiac Surgery and Cardiology, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Mojtaba Mohammed Alsaied
- Department of Cardiac Surgery and Cardiology, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Juan J Alfonso
- Department of Clinical Research, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Angela Di Baldassare
- Department of Medicine and Aging Sciences, University "G. d'Annunzio", Chieti-Pescara, Italy
| | - Sabina Gallina
- Department of Medicine and Aging Sciences, University "G. d'Annunzio", Chieti-Pescara, Italy
| | - Mario Gaudino
- Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York City, New York
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Unit, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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