Tricuspid Valve Tethering Is Associated with Residual Regurgitation after Valve Repair in Hypoplastic Left Heart Syndrome: A Three-Dimensional Echocardiographic Study

Sachie Shigemitsu; Kandice Mah; Richard B Thompson; Justin Grenier; Lily Q Lin; Amal Silmi; Mirza Vamiq Rasool Beigh; Nee Scze Khoo; Timothy Colen

doi:10.1016/j.echo.2021.06.007

Tricuspid Valve Tethering Is Associated with Residual Regurgitation after Valve Repair in Hypoplastic Left Heart Syndrome: A Three-Dimensional Echocardiographic Study

J Am Soc Echocardiogr. 2021 Nov;34(11):1199-1210. doi: 10.1016/j.echo.2021.06.007. Epub 2021 Jun 18.

Authors

Sachie Shigemitsu¹, Kandice Mah¹, Richard B Thompson², Justin Grenier², Lily Q Lin¹, Amal Silmi¹, Mirza Vamiq Rasool Beigh¹, Nee Scze Khoo¹, Timothy Colen³

Affiliations

¹ Division of Pediatric Cardiology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.
² Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada.
³ Division of Pediatric Cardiology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada. Electronic address: colen@ualberta.ca.

PMID: 34147648
DOI: 10.1016/j.echo.2021.06.007

Abstract

Background: Tricuspid valve regurgitation (TR) is a risk factor for morbidity and mortality in children with hypoplastic left heart syndrome (HLHS). Surgical tricuspid valve (TV) repair is common, but durable repair remains challenging. The aim of this study was to examine mechanisms of TR requiring surgery, features associated with unsuccessful repair, and TV changes after surgical repair.

Methods: Thirty-six patients with HLHS requiring TV repair (TVR) and 36 matched control subjects with HLHS were assessed using two-dimensional and three-dimensional echocardiography. Using three-dimensional echocardiography, TV coordinates from the annulus, leaflet, and ventricle were used to measure annular, leaflet, prolapse, and tethering values and anterior papillary muscle angle. TR grade and ventricular size, function, and shape were assessed using two-dimensional echocardiography.

Results: Patients requiring TVR had greater total leaflet prolapse, larger TV annular and leaflet areas, and flatter annuli, with no difference in tethering, coaptation index, or anterior papillary muscle angle. In patients with HLHS, successful TVR at follow-up (58%) was associated with preoperative total leaflet prolapse (especially posterior). Unsuccessful repair was associated with preoperative tethering of the septal leaflet. TVR in patients with HLHS caused a reduction of total annular and leaflet size and reduced prolapse and tethering of the posterior leaflet but did not affect anterior leaflet prolapse or septal leaflet tethering.

Conclusions: Features associated with TVR include a flattened and dilated TV annulus with leaflet prolapse. The additional presence of a tethered septal leaflet before TVR is associated with significant postoperative TR. Current surgical techniques, predominantly posterior annuloplasty and commissuroplasty, adequately address annular size and posterior leaflet pathology, but not septal leaflet tethering. Individualized and innovative surgical techniques are vital to improve surgical repair success.

Keywords: Hypoplastic left heart syndrome; Pediatrics; Prolapse; Tethering; Three-dimensional echocardiography; Tricuspid valve.

Publication types

Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

Child
Echocardiography
Echocardiography, Three-Dimensional*
Humans
Hypoplastic Left Heart Syndrome* / diagnostic imaging
Hypoplastic Left Heart Syndrome* / surgery
Tricuspid Valve / diagnostic imaging
Tricuspid Valve / surgery
Tricuspid Valve Insufficiency* / surgery