Clinical heart transplantation
Tricuspid Valve Chordal Tissue in Endomyocardial Biopsy Specimens of Patients With Significant Tricuspid Regurgitation

https://doi.org/10.1016/j.healun.2004.11.007Get rights and content

Objectives

Tricuspid regurgitation is the most common valvular abnormality after orthotopic heart transplantation, with multiple etiologic factors implicated. The purpose of this study was to determine if the endomyocardial biopsy specimens of patients who developed significant tricuspid valve regurgitation (TVR) after cardiac transplantation had evidence of chordal tissue.

Methods

The echocardiograms of 98 patients who had cardiac transplantation between 1986 and 2002 were reviewed for evidence of significant TVR greater than mild. The biopsy specimens of all patients with significant TVR were then reviewed for histologic evidence of tricuspid chordal tissue and frequency and severity of rejection episodes. Clinical information collected included the presence of any systolic murmurs, significant dyspnea, and invasive hemodynamic measurements.

Results

The incidence of significant TVR was 19% (n = 19 patients). Histologic evidence of chordal tissue was present in 9 patients (47%) with significant TVR. Patients whose biopsy specimens evidenced chordal tissue tended to have a greater degree of TVR, but this was not statistically significant (odds ratio, 2.07; 95% confidence interval, 0.537–8.01, p = 0.32). There was no statistically significant difference in the number of biopsy specimens (p = 0.798), the number of rejection episodes (p = 0.73), or overall left or right ventricular systolic function between the patients with and without biopsy specimen evidence of chordal tissue disruption. Most of the patients with evidence of significant TVR after chordal tissue biopsy were clinically asymptomatic, with no significant change in their hemodynamics.

Conclusion

Histologic evidence of chordal tissue in endomyocardial biopsy specimens was present in 47% of patients with significant TVR and did not relate to the number of biopsy procedures performed or the frequency of rejection episodes. This study provides histologic evidence that chordal tissue damage can occur after cardiac biopsy, resulting in significant TVR; however, it is clinically well tolerated by affected patients.

Section snippets

Methods and patients

Between 1986 and 2003, 213 orthotopic heart transplantations with biatrial anastomosis were performed at the University of Ottawa Heart Institute. Ninety-eight (46%) of these patients had echocardiographic assessments available at either 1 and/or 2 years after transplantation and were included in the study. Twenty-two patients (22%) were women and 76 (77%) were men. The average patient age at transplantation was 48.5 ± 6.3 years.

Prevalence of Significant TVR

The study comprised 98 patients. Thirty patients (31%) had only echocardiographic assessments at 1 year post-transplant, 2 (2%) had echocardiograms only at 2 years post-transplant, and 66 (67%) had echocardiograms available at both 1 and 2 years post-transplant. Significant TVR between 1 and 2 years after cardiac transplant in this study occurred in 19 patients (19%), 2 (10%) of which had severe regurgitation (Table 2).

Prevalence and Significance of Chordal Tissue

Nineteen of 98 patients in this study had significant TVR by echocardiogram.

Prevalence of TVR After Cardiac Transplantation

TVR has a reported prevalence of 65% to 85% in echocardiographic studies of patients after cardiac transplantation.1 It is the most common valvular abnormality after orthotopic heart transplantation, with a prevalence and severity greater than in healthy subjects. Color Doppler studies show that the prevalence of any degree of TVR in the general population can be as high as 15% to 70%. Almost all of this regurgitation is trivial and of no physiologic significance. In our study, the prevalence

Cited by (32)

  • Native Cardiac Valve Pathology

    2012, Surgical Pathology Clinics
    Citation Excerpt :

    Closed chest trauma can lead to papillary muscle rupture and flail of the tricuspid leaflet.52–55 Another cause is right ventricular myocardial biopsy which inadvertently damages the papillary muscle or chord resulting in flail of the tricuspid leaflet.56,57 Other causes of tricuspid regurgitation are infective endocarditis and Ebstein’s anomaly.58–60

  • Complications of endomyocardial biopsy in heart transplant patients: A retrospective study of 2117 consecutive procedures

    2011, Transplantation Proceedings
    Citation Excerpt :

    We have encountered valve tissue in nearly 11% of our patients. Mielniczuk and colleagues reported a similar rate of valvular fragment collection (9.2%) among 205 EMB.20 Fiorelli et al reported a much lower rate (3.2%),21 probably due to the use of transthoracic echocardiography guidance during the EMB procedures.

View all citing articles on Scopus
View full text