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

• Published in: Journal of the American Society of Echocardiography Vol. 34; no. 11; pp. 1199 - 1210
• Main Authors: Shigemitsu, Sachie, Mah, Kandice, Thompson, Richard B., Grenier, Justin, Lin, Lily Q., Silmi, Amal, Beigh, Mirza Vamiq Rasool, Khoo, Nee Scze, Colen, Timothy
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.11.2021
• Subjects: Cardiovascular; Child; Echocardiography; Echocardiography, Three-Dimensional; Humans; Hypoplastic left heart syndrome; Hypoplastic Left Heart Syndrome - diagnostic imaging; Hypoplastic Left Heart Syndrome - surgery; Pediatrics; Prolapse; Tethering; Three-dimensional echocardiography; Tricuspid valve; Tricuspid Valve - diagnostic imaging; Tricuspid Valve - surgery; Tricuspid Valve Insufficiency - surgery; Pediatrics; TV; Hypoplastic left heart syndrome; RV; Three-dimensional echocardiography; Tethering; LV; Prolapse; HLHS; BSA; TVR; 2DE; 3DE; Tricuspid valve; APM; TR; Tricuspid valve repair; Two-dimensional echocardiography; Left ventricular; Tricuspid valve regurgitation; Anterior papillary muscle; Right ventricular; Body surface area
• DOI: 10.1016/j.echo.2021.06.007
• ISSN: 0894-7317; 1097-6795

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. 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. 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. 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. •TR mechanisms and factors related to surgical success in HLHS were assessed on 3DE.•Preoperative TV tethering is associated with residual TR after valve repair.•Preoperative tricuspid leaflet prolapse is associated with successful repair.•Valve repair improves TR by reducing annular size but does not change tether volume.