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Ninety-five apparently healthy, non-athletic women aged 24–65 (mean 44) years were screened by Doppler echocardiography for the presence of tricuspid and pulmonary regurgitation ( TR and PR). An Irex Meridian system was used. TR was diagnosed in the presence of a pansystolic regurgitant jet into the right atrium with a maximal velocity of > 1.5 m s⊃1. Regurgitant flow throughout diastole was diagnostic for PR. Right-sided regurgitation was found in 43 women (Group I), 22 with TR, 12 with PR, and nine with combined TR and PR. The remaining 52 women were studied as a control group (Group 2). Group 1 had a significantly larger heart size on X-ray (P

Contrast echocardiography of the right side of the heart allows tricuspid and pulmonary regurgitation to be diagnosed reliably and is useful in detecting left-to-right shunts in patients with a normal M-mode echocardiogram. It is also of value in detecting pulmonary hypertension and in following patients with pericardial effusion or after a surgical correction of an atrial septal defect. The timing of the appearance of the contrast echoes is of great importance for the accuracy of the technique.

The late hemodynamic and radiologic findings were good or excellent in 96 percent of 23 infants in whom tetralogy of Fallot was repaired with the use of profound hypothermia. These results encourage continuation of the policy of early repair rather than palliation in tetralogy of Fallot. The preoperative cineangiocardiographic assessment of the type and severity of the pulmonary stenosis accurately predicted the findings at operation and the type of repair required. In infants between 1 and 21 months of age and 3 and 10 kilograms in weight, a main pulmonary artery (MPA) diameter of less than 7 mm. was the cineangiocardiographic measurement most accurately predicting the necessity for an outflow patch across the pulmonary ring. Postoperative studies showed significant increases in the MPA and pulmonary ring diameters. A method of cineangiocardiographic assessment of pulmonary incompetence is presented. Severe mechanical pulmonary incompetence in some patients produced mild hemodynamic effects by radiologic criteria.

A method is described for quantifying pulmonary regurgitation. This method is based on a comparison of the right and left ventricular stroke volumes which are determined from biplane angiocardiograms. These techniques were applied to study 18 postoperative patients with tetralogy of Fallot. In patients with an outflow patch, regurgitant fraction was well correlated with regurgitant area. The RVEDV/LVEDV ratio was also correlated well with regurgitant fraction. Although majority of patients maintained normal RV ejection fraction, there were small number of pa-tients with large regurgitant fraction and decreased RV ejection fraction.

A case of Fabry's with pulmonary regurgitation is reported, and the cause of valvular involvement, the electrophysiological mechanism of the short PR interval, and the usefulness of the endomyocardial biopsy method in an attempt to establish the diagnosis in Fabry's disease have been discussed.

Adequate growth of the hypoplastic right ventricle in a patient with severe pulmonary stenosis with an intact ventricular septum was documented after pulmonary valvotomy in infancy. It is postulated that the growth of the ventricular chamber is largely the result of pulmonary regurgitation resulting from successful pulmonary valvotomy. Based on this and the observations of others on the growth of the hypoplastic right ventricle in pulmonary atresia (with intact septum) cases, an organized approach to eventual total surgical correction is recommended.

SummaryBackgroundPulmonary regurgitation (PR) is a common complication of right ventricular outflow tract (RVOT) reconstruction and leads to right ventricular (RV) dilatation and dysfunction. Although cardiac magnetic resonance (CMR) is the gold standard for evaluating PR and RV dysfunction, cost and limited availability are problems in many centres.AimsTo determine clinical, electrocardiographic and echocardiographic predictors of these complications and optimize patient selection for their short-term follow-up by CMR.MethodsNinety-four patients with a history of RVOT repair were prospectively included. All patients had a clinical examination, electrocardiography, echocardiography and CMR.ResultsQRS duration, indexed end-diastolic RV (EDRV) diameter and area on echocardiography were significantly associated with RV dilatation on CMR (P

ObjectivesThe objectives of this study were to evaluate outcomes of pulmonary valve replacement (PVR) in patients with chronic pulmonary regurgitation (PR) and to better define the optimal timing of PVR.BackgroundAlthough PVR is effective in reducing right ventricular (RV) volume overload in patients with chronic PR, the optimal timing of PVR is not well defined.MethodsA total of 170 patients who underwent PVR between January 1998 and March 2011 for chronic PR were retrospectively analyzed. To define the optimal timing of PVR, pre-operative and post-operative cardiac magnetic resonance imaging (MRI) data (n = 67) were analyzed.ResultsThe median age at the time of PVR was 16.7 years. Follow-up completeness was 95%, and the median follow-up duration was 5.9 years. Overall and event-free survival at 10 years was 98% and 70%, respectively. Post-operative MRI showed significant reduction in RV volumes and significant improvement in biventricular function. Receiver-operating characteristic curve analysis revealed a cutoff value of 168 ml/m2 for non-normalization of RV end-diastolic volume index (EDVI) and 80 ml/m2 for RV end-systolic volume index (ESVI). Cutoff values for optimal outcome (normalized RV volumes and function) were 163 ml/m2 for RV EDVI and 80 ml/m2 for RV ESVI. Higher pre-operative RV ESVI was identified as a sole independent risk factor for suboptimal outcome.ConclusionsMidterm outcomes of PVR in patients with chronic PR were acceptable. PVR should be considered before RV EDVI exceeds 163 ml/m2 or RV ESVI exceeds 80 ml/m2, with more attention to RV ESVI.

Objective The long-term outcome of Tetralogy of Fallot (TOF) surgical repair in developing countries is still unknown. Therefore the aim of the study was the quantification of pulmonary regurgitation (PR) and right ventricular functions using cardiac magnetic resonance (CMR) in order to follow up midterm post transannular patch repair of asymptomatic TOF patients. Methods We prospectively studied 37 asymptomatic corrected TOF patients (aged 18 years or less), aged at surgery was of median, min/max of (19, 8/48 months). Cardiac functions were assessed using routine steady state free precession techniques. PR quantification was performed using the routine velocity encoding phase contrast in the main pulmonary artery. Results Four patients had mild PR, 26 had moderate PR and seven had severe PR, with a median value of PR% in CMR amounting to 29% (max: 75% and min: 13%). Indexed right ventricle end-diastolic volume amounted to (mean ± SD) 130 ± 38 ml, and indexed right ventricle end-systolic volume amounted to 63 ± 26 ml. Conclusion Accurate quantitative assessment of PR in the mid and long-term course of TOF patients is paramount. CMR has to be introduced as a new modality in Egypt in the follow up course of asymptomatic TOF patients.

Introduction The Venus p‑valve (MedTech, Shanghai, China) is a self-expanding percutaneous heart valve designed to be implanted in a native patched right ventricle outflow tract. The worldwide clinical experience with this valve is just beginning and the results have so far been encouraging. We present our initial early experience implanting the Venus p‑valve in the native right ventricle outflow tract of patients with Tetralogy of Fallot repaired with a transannular patch. Methods In 10 selected patients a procedure for percutaneous pulmonary valve implantation was performed using the Venus p‑valve. The patients mean age was 32 years (13–57), mean weight 59.6 kg (40–80). All patients had Tetralogy of Fallot with moderate to severe pulmonary regurgitation and an indication for pulmonary valve replacement. Results The implantation procedure was successful in all the patients resulting in an immediately functional valve. No procedure-related complications were observed. Follow-up after 12 months (4–21) resulted in an improvement in NYHA class. There was a reduction of the mean right ventricle diastolic volume from 139 ml/m2 (105–179) to 78 ml/m2 (65–100) and improvement in the regurgitation fraction from 42% (29–58) to 1% (0–5), as seen on routine cardiac magnetic resonance 6 months after the implantation. No stent fractures have been observed so far. Conclusion Percutaneous pulmonary valve implantation with the Venus p‑valve resulted in a safe and effective procedure. The valve has predictable and sustained functional competence, resulting in clinical improvement in the patients.

Due to recurrent right ventricular outflow tract (RVOT) dysfunction, patients with complex congenital heart disease of the RVOT traditionally require multiple surgical interventions during their lifetimes. Percutaneous pulmonary valve implantation (PPVI) has been developed as a nonsurgical alternative for the treatment of right ventricular to pulmonary artery stenosis or pulmonary regurgitation. PPVI has been shown to be a safe and effective procedure in patients with dysfunctional surgical RVOT conduits. In this population, PPVI has the potential to improve symptoms, functional capacity, and biventricular hemodynamics. However, limitations to the anatomical substrate and size of the RVOT currently restrict PPVI eligibility to less than one-quarter of patients with RVOT dysfunction. The current review discusses contemporary practices in PPVI, evidence supporting the procedure, and future technologies and developments in the field.

ResumenLa endocarditis sobre válvula pulmonar aislada es extremadamente infrecuente. Presentamos el caso un adolescente de 15 años, portador de una comunicación interventricular y endocarditis infecciosa sobre válvula pulmonar, en que luego de 8 semanas de tratamiento médico fue necesario intervenir quirúrgicamente por presentar grandes vegetaciones en los velos pulmonares, algunas pediculadas, e insuficiencia pulmonar severa. En nuestro país, en ese momento no teníamos válvulas biológicas, por lo que decidimos reconstruir la válvula pulmonar con pericardio autólogo fresco. Ocho meses después, el paciente mantiene una evolución clínica, hemodinámica y ecocardiográfica satisfactoria.AbstractIsolated pulmonary valve endocarditis is very rare. The case is presented of a 15 year-old child, who after eight weeks medical treatment required surgical intervention. This patient had large vegetations in all pulmonary cusps. At that time, there were no biological valves in our country, so it was decided to reconstruct the pulmonary valve with fresh autologous pericardium. The clinical and hemodynamic outcomes were good eight months later.

Contains fulltext : 71166.pdf (Publisher’s version ) (Closed access) OBJECTIVE: The aim of the study was to assess the long-term results of a selective policy toward pulmonary valve replacement in adult patients with repaired tetralogy of Fallot and severe pulmonary regurgitation. METHODS: Sixty-seven patients with tetralogy of Fallot were followed up from 15 +/- 3 years until 27 +/- 3 years after surgery. RESULTS: Twenty-two patients had mild-to-moderate pulmonary regurgitation. No significant changes occurred in the follow-up period. Of 45 patients with severe pulmonary regurgitation and severe right ventricular dilatation, 28 (62%) remained free of symptoms and did not undergo pulmonary valve replacement. No changes in right ventricular size or exercise capacity were found. In 3 (11%) of 28 patients, QRS duration increased to more than 180 ms. Seventeen patients had symptoms and underwent pulmonary valve replacement: 9 (54%) of 17 patients improved clinically and echocardiographically, and QRS duration shortened postoperatively. Right ventricular dimensions did not regress despite pulmonary valve replacement in 8 patients. CONCLUSION: Refraining from pulmonary valve replacement in asymptomatic patients led to no measurable deterioration in 25 (89%) of 28 patients. Referring symptomatic patients for pulmonary valve replacement led to an improvement in 9 (53%) of 17 patients. In 11 (24%) of 45, a selective approach led to questionable or unsatisfactory results.

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The postoperative course of 9 patients who have had autologous fascia-lata reconstruction of the right ventricular outflow tract is described. After six months there was clinical and investigatory evidence of progressive shrinkage and pulmonary regurgitation in 6 patients. After a year, right-heart enlargement and failure were common; 1 has had replacement of the fascial valve and 2 are awaiting it. The results are so disappointing that we no longer advise or use the operation.

Although the tricuspid valve can be identified in almost all patients, it is in general difficult to obtain a complete registration of the TV leaflets. Most often, only the anterior tricuspid valve leaflet (ATVL) is seen in systole and early diastole.

The introduction of echocardiography as a noninvasive tool has proved to be of great interest in the study of septal motion, as this has been shown to be abnormal in various cardiac disorders.

Fourteen infants, all under 6 months of age, underwent surgery for the relief of severe valvar pulmonary stenosis. A modified Brock (transinfundibular valvotomy) procedure was performed in all cases. Dilatation of the pulmonary valve with a mosquito clamp and biliary dilator is the basis of the modified operation. All infants survived the operation. In two patients there is residual, significant pulmonary stenosis, and in two additional cases pulmonary regurgitation is present.

We report the successful treatment of absent pulmonary valve syndrome in an infant. The treatment consisted of intracardiac repair of pulmonary regurgitation with a homograft valve, which allowed for early extubation and survival.

A procedure termed two-cusp plasty, which prevents pulmonary regurgitation in complete repair of tetralogy of Fallot, is described.

The analysis of systolic time intervals (STI) has provided an indirect method of assessing left ventricular performance in man (1–4). These intervals are conveniently derived from the simultaneous recording of the electrocardiogram, the indirect carotid pulse tracing, and the phonocardiogram. Noninvasive measurement of right ventricular STI, however, has not been possible because of the inability to define the onset of right ventricular ejection. Recently echocardiography has been used to determine right as well as left ventricular STI (5–7).

Pulmonary regurgitation (PR) is one of the serious sequelae after correction of tetralogy of Fallot (TF), because it may lead to right ventricular failure in severe cases [1, 2]. However, quantitative evaluation of PR by noninvasive methods is yet to be established.

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A group of cases of tetralogy of Fallot with congenital absence of the pulmonary valve are presented, and it is indicated that this abnormality presents a characteristic clinical, physiologic, and pathologic syndrome. It is postulated that the aneurysmal dilatation of the pulmonary artery may result either from a congenital weakness at the base of the pulmonary artery or from the hemodynamic effects of a ventricular septal defect and infundibular stenosis in the presence of pulmonary regurgitation. The absence of the pulmonary valve has not been a deterrent to successful corrective surgery aimed at the basic pathology of tetralogy of Fallot in three cases.

There is a growing appreciation for the adverse long-term impact of right-sided valvular dysfunction in patients with congenital heart disease. Although right-sided valvular stenosis and/or regurgitation is often better tolerated than left-sided valvular dysfunction in the short and intermediate term, the long-term consequences are numerous and include, but are not limited to, arrhythmias, heart failure, and multi-organ dysfunction. Surgical right-sided valve interventions have been performed for many decades, but the comorbidities associated with multiple surgeries are a concern. Transcatheter right-sided valve replacement is safe and effective and is being performed at an increasing number of centers around the world. It offers an alternative to traditional surgical techniques and may potentially alter the decision making process whereby valvular replacement is performed prior to the development of long-term sequelae of right-sided valvular dysfunction.

Disruption of pulmonary valve integrity after Tetralogy of Fallot repair often results in a cascade of hemodynamic and electrophysiological abnormalities. Here we report an uncommon case of severe pulmonary regurgitation with concomitant rheumatic mitral stenosis diagnosed 25 years after primary Tetralogy of Fallot repair. A 33-year-old man presented with symptomatic palpitation and exercise intolerance and was treated successfully with pulmonary and mitral valve replacement, after which his symptoms improved dramatically.

Background Patients may suffer from right ventricular (RV) failure and malignant cardiac arrhythmias after late pulmonary valve replacement correcting pulmonary regurgitation (PR). But the underlying mechanisms of the refractory arrhythmias are not well understood. Methods The aim of present study was to characterize the RV myocardium after percutaneous pulmonary valve implantation (PPVI) in a porcine model after severe PR for 3months. RV histology was evaluated with morphometric methods and RV function was assessed with electrophysiology, echocardiography, and biochemical measures: The results were compared with age-matched sham-operated animals. Results At euthanasia, RV weight was increased compared to sham-animals, median 127g (115–137) vs. 71g (69.5–76.5), p=0.0007. RV myocyte diameters corrected for individual variation with the RV/LV ratio were enlarged, 1.06 (1.02–1.13) vs. 0.84 (0.80–0.91), p=0.0006. There were no excess collagen tissue (RV/LV ratio), p=0.77. Electrophysiological stimulation resulted in RV arrhythmia in 67% of the animals compared to 25% in the sham-operated animals, but this difference was not statistically significant, p=0.28. Echocardiography revealed geometrical dilation in end-systolic RV area, mean±SD, 11.8±4.9cm 2 vs. 6.0±3.5cm 2 , p=0.05, and end-diastolic area, 23.3±10.4cm 2 vs. 12.7±2.5cm 2 , p=0.08. RV anterior free wall thickness was not increased, 0.7±0.2cm vs. 0.7±0.1cm, p=0.66. Echocardiographic functional parameters and plasma natriuretic peptides were unchanged. Conclusions The RV does not completely recover after three months of PR with persistent myocardial hypertrophy one month after PPVI. Future studies should address whether RV chamber and cellular hypertrophy, without fibrosis or interventional scar tissue, may be substrate for arrhythmia.

A protodiastolic murmur was noted in a 24-year-old man with phaeochromocytoma, the murmur disappearing three months after tumour resection. It was probably the result of pulmonary regurgitation, caused by reversible changes in the pulmonary vascular bed or pulmonary valve from the increased catecholamine production.

Excerpt Dynamically significant pulmonary regurgitation of organic origin has been infrequently observed. Renewed interest in the antemortem diagnosis has been shown by several recent reports in th...

Pulmonary regurgitation (PR) that develops after right ventricular (RV) outflow reconstruction including the Rastelli and Norwood procedure may often result in serious cardiac events early after surgery. We hypothesized that PR may be associated with pulmonary vascular resistance (PVR) and RV contraction. Accordingly, we assessed the impact of PVR on PR and RV function using a swine model.

Tetralogy of Fallot is the most common form of cyanotic congenital heart disease. Following surgical correction, most patients present with pulmonary insufficiency (PI) which plays a pivotal role in right ventricular (RV) dysfunction. Multiple prior studies have demonstrated the accuracy of CMR for assessment of RV volumes, ejection fraction and pulmonary regurgitant fraction, especially in the setting of an enlarged right ventricle. The deleterious effect of chronic pulmonary regurgitation on RV function is well known and pulmonary valve replacement has been shown to improve ventricular function in these patients. However, the effects of residual pulmonary stenosis on RV function are not well understood. Using CMR and conductance catheter techniques, a study performed in a growing pig model demonstrated that chronic pulmonary stenosis and insufficiency (PSPI) results in improved RV myocardial contractility when compared to a group with isolated PI, indicating a possible protective effect. The combined effect of PSPI on RV function has never been reported in a human model.

Background Severe right ventricular (RV) dilation and dysfunction due to chronic pulmonary regurgitation (PR) requires pulmonary valve replacement (PVR) late after repair of Tetralogy of Fallot (rTOF). Cardiac magnetic resonance (CMR) is the gold standard method to evaluate the pathophysiology after rTOF and the main tool to support the decision for PVR in asymptomatic patients. Given the various options available for PVR, we sought to evaluate the usefulness of CMR to address patients towards either a surgical or an interventional procedure.

Background CMR can provide details on ventricular pumping by subdividing the contribution to stroke volume (SV) into longitudinal shortening and radial inward motion of the ventricular borders. Previous studies have shown that patients with volume loaded dilated right ventricles (RV) due to pulmonary regurgitation (PR) have decreased longitudinal contribution to RVSV. Patients with atrial septal defects (ASD) also have volume loaded dilated RVs but it is not known if this affects longitudinal shortening.

Pulmonary regurgitation (PR) is a significant determinant of right ventricular and global functional performance late after repair of tetralogy of Fallot (rTOF). We have previously shown that PR can be quantified using pressure volume loops by measuring RV volume increase during isovolumic relaxation period. This (digitisation of RV angiograms) and other methods of RV volume measurement (eg. MRI) do not allow real time analysis. However, measurement of RV blood volume by a conductance catheter may allow beat to beat analysis of RV volume and PR fraction. A conductance catheter method was validated which would enable continuous on line recording of pressure volume loops from which pulmonary incompetence could be directly assessed. Five silicone human right ventricular casts were constructed and an assessment of the accuracy and linearity of the conductance catheter was undertaken to compare conductance against known volume. The mean correlation coefficient (r2) and Y intercept for all the right ventricular cast studies was 0.94 (SE 0.02) and –0.225 (SE 1.72) respectively. Five patients late after rTOF with clinically significant PR had right heart catheterisation during which simultaneous microtip pressure and conductance volume were measured. All five patients had pressure volume loops typical of PR (Figure). The PR volume was indexed to stroke volume and varied significantly with respiration (p l 0.05), decreased with Valsalva manoeuvre (p l 0.05) and increased with transient right pulmonary artery occlusion (p l 0.05). Conductance measurement allows real time dynamic assessment of PR and demonstrates the impact of different loading conditions. Download : Download high-res image (258KB) Download : Download full-size image

Patients with repaired Tetralogy of Fallot (TOF) develop progressive right ventricular(RV) enlargement and dysfunction due to pulmonary regurgitation (PR) leading to exercise intolerance and they often have associated aortic abnormalities. Using multimodality imaging, we sought to assess predictors