J Thorac Cardiovasc Surg 2004;128:329
© 2004 The American Association for Thoracic Surgery
Tricuspid valve in hypoplastic left heart syndrome
Siew Yen Ho, PhDa,
Christof Stamm, MDa
a Department of Cardiac Surgery, University of Rostock, Rostock, Germany
To the Editor:
With great interest, we read the article by Ohye and colleagues,1 describing their institutional experience with surgery for tricuspid valve regurgitation (TR) in patients with hypoplastic left heart syndrome (HLHS). The detailed analysis and clear presentation are praiseworthy. The authors focus on right ventricular (RV) volume overload and annular dilation of the tricuspid valve as the most common mechanism leading to significant TR, whereas structural abnormalities of the tricuspid valve in HLHS are mentioned only briefly as leaflet prolapse and leaflet tethering. We believe, however, that some morphologic features unique to the tricuspid valve in HLHS deserve closer attention.
Some years ago, we specifically studied the tricuspid valve morphology in a series of 82 anatomic specimens of HLHS.2 One finding was that structural abnormalities of the tricuspid valve were markedly more frequent in hearts with a patent mitral valve. Overall, we found some dysplasia of tricuspid valve leaflets in 35% of the HLHS specimens and in up to 50% of those with mitral stenosis. It would be interesting to know whether the authors' clinical experience also reflects this notion; that is, whether the majority of the patients with HLHS requiring tricuspid valve repair had mitral stenosis rather than atresia. If this were the case, one might infer that patients with HLHS and mitral stenosis are indeed predisposed to clinically relevant TR and might necessitate closer follow-up examinations and perhaps earlier intervention.
Regarding repair of a regurgitant tricuspid valve, the authors favor a partial annuloplasty that effectively eliminates the posterior leaflet and results in a functionally bifoliate valve. Because the coronary artery in the atrioventricular groove can be put at risk with annuloplasty procedures, it is worth noting that a previous study3 described a significant prevalence of left coronary dominance (56%) in hearts with aortic and mitral atresia compared with regular right coronary dominance in hearts with aortic atresia and mitral stenosis.
The final point we would like to raise is the use of a partial ring for reinforcement of an annuloplasty. In HLHS the septal leaflet of the tricuspid valve differs markedly from that in a normal heart. We found that in hearts with mitral atresia, when the RV aspect of the interventricular septum is concave (ie, bulging toward the left ventricle), the usual direct chordal attachments of the septal leaflet are replaced by additional papillary muscles.2 The interventricular septum in HLHS becomes essentially part of the RV free wall, and the architecture of the septal leaflet resembles that of the anterosuperior leaflet. Therefore it would be interesting to know how the authors orientate the partial ring, with the opening facing the anterosuperior leaflet or the septal leaflet. With the right atrioventricular valve in HLHS being supported to a greater extent by RV free wall musculature, one wonders whether a closed ring might not be more effective in preventing redilation.
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References
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- Ohye RG, Gomez CA, Goldberg CS, Graves HL, Devaney EJ, Bove EL. Tricuspid valve repair in hypoplastic left heart syndrome. J Thorac Cardiovasc Surg. 2004;127:465–472[Abstract/Free Full Text]
- Stamm C, Anderson RH, Ho SY. The morphologically tricuspid valve in hypoplastic left heart syndrome. Eur J Cardiothorac Surg. 1997;12:587–592[Abstract]
- Sauer U, Gittenberger-de Groot AC, Geishauser M, Babic R, Bühlmeyer K. Coronary arteries in the hypoplastic left heart syndrome. Histopathologic and histometrical studies and implications for surgery. Circulation. 1989;80(suppl I):I168–176
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