Tricuspid Regurgitation and Rt. Heart Failure

[DottyCece]

In Jan., I developed sudden onset of uncontrolled Atr. Fib. secondary to severe MV regurg. I had a mitral valve replacement and modified maze in May.  At the time I had mod. to severe tricuspid regurg.  My cardiologist felt the TV needed to be repaired, the surgeon disagreed and didn't do it. No I have right heart failure, JVP, edema and mild pulm HTN (per echo last week).  I have difficulty taking diuretics secondary to no parathyroids etc. so my electrolytes drop significantly.  Supplements don't seem to keep the values up.  I also continue to be plagued with Atrial flutter..cardioverted four times, failed ablation attempt.  I do have a PPM, was implanted posp op.  My question is since I had no evidence of pulm HTN on previous four echos, is this a sign of worsening right heart failure.  There was mod regurg in the TV, mild biatrial enlargement (was mod to severe initially).  Should I consider TV repair and intraoperative mapping and ablation for the flutter?   My ablation failed because the TV was so diseased that the EP MD could not get the catheter in place to do the ablation. I did well with first surgery and do not believe there would be any problems with a second one.  Of course, I believe this should be a last option for all the obvious reasons.

[CCF-M.D.-RCJ]

DottyCece,

Happy Thanksgiving.

Q1:"... is this a sign of worsening right heart failure"

No,  Pulmonary Hypertension can be caused by left heart failure, but not right.  However, pulmonary hypertension can lead to right heart failure, but it would be unusual for mild pulmonary hypertension to lead to right heart failure.  One possibility for the right heart failure and severe TR is the pacemaker.  The pacemaker leads can perforate the tricuspid valve, and thus lead to TR.  Another possibility is that the long-standing MR lead to pulmonary hypertension (that is being underestimated) and that then lead to the right heart failure.

Q2:"Should I consider TV repair and intraoperative mapping and ablation for the flutter?"

This is a difficult decision, and really needs to be answered by someone actually seeing you.  A minority of patients with severe TR and right heart failure get better after TV repair, but some certainly do.  In regards to the aflutter, most surgeons are not skilled at intra-operative mapping and surgical correction.  This procedure is not commonly performed by many surgeons anymore.  In fact, here at the CCF where we have incredible surgeons, only 1 of 11 actually performs intra-operative mapping, and he has not done this in quite sometime.  I think that seeing an EP physician at a large center might allow for ablation without surgery.

Good luck.

[DottyCece]

I had mod to severe TV regurgitation before the pacemaker was implanted.  That occurred after the mitral valve replacement.  Regarding the intra operative mapping and ablation...this would be done by a very skilled electrophysiology, not by the surgeon.  The surgeon would work with him.  The catheter ablation failed and the intra operative mapping and ablation was offered as an alternative to AV nodal ablation.  Could you tell me what the log term effects might be related to AV nodal ablation?  If atrial flutter persists after a AV nodal ablation, is it true that there would be a decrease in Cardiac Output?

[angelapple]

Hank, HELP, please.  Thank you for your time and knowledge.  My question.  I have a son who is 21.  He has had skips, extras or what I call bloops off and on for a long time. No big deal just one or two every once in a while.  The past 2 months he has them verrrrrrry frequently.  Some days all day long.  He has stopped drinking coffee.  It stopped. Then it started again even without the caffeine.  He doesn't drink on a regular basis, but does like to party once in a while on the weekend.  He owns a little parking lot stiping business and is leaving for Colorado on Tuesday for the winter so he's had to finish up with his striping here in the Northeast.  He's been working many hours especially nighttime, even all night. So I can see he's very tired. I can't convince him to just get it checked out.  He thinks I'm just nagging him but I know he's concerned.  I do have PAC's and take toprol for them.  I've had episodes for hours of what feels like what I feel on his pulse.  He finally went to the ER last night (by himself and didn't tell anyone).  He had it all day yesterday, but was up all night working Thanksgiving eve and also went out and partied with his friends.  When he got to the hopspital it stopped.  They did an EKG of course normal.  But it started skipping again so they hooked him up for about 90 minutes.  The dr said it was normal and his blood work was normal.  Now, it was jumping around and Bryan could see it on the monitor. Couldn't the dr? I don't understand. If the blooping was PAC's or PVC's should the dr have seen that? I'm very frightened because he is going so far away for 4 months and he will be walking and working in snow- a little stressful on your heart to walk thru.  Maybe I'm just being a neurotic mother, but I wish I would have known he was going last night so I could have asked the dr these questions. He's leaving in 4 days and try and get an appointment with a cardio now, yeah right!  Please tell me what you think.  Thanks so much.  Angela

[jan]

Hi Dotty,

Mild elev. pulmonary pressure is based on TR, but the significance?

What I am saying is in my echos it has always stated mild TR (along with mild MVP and MR).  My last one stated mild elev. pulmonary pressure.  I questioned the cardio and did some researching of my own.  It wasn't anything new, it could've been stated on any of the echos showing the TR.

My valvular disease in no way compares to yours, I just wanted to share that the mildly elev. pulmonary pressure could very well mean nothing.  My cardio said unless other symptoms arise we can wait 5yrs. to do another echo. (The only reason I see a cardio is for treatment of IST and NCS, although they do seem to be keeping an eye on the valvular disease).

He did ask me these questions in regards to the PP: 1)Do I smoke? 2)Do I have asthma? 3) Have I ever had pneumonia or a serious bout of bronchitis?  (My answer was "No", to all).

I hope this has helped some.

[CCF-M.D.-RCJ]

Q:"Could you tell me what the log term effects might be related to AV nodal ablation?"

The long-term effects of AV nodal ablation are that you become "pacer-dependent", meaning that you cannot live without it.

Q:"If atrial flutter persists after a AV nodal ablation, is it true that there would be a decrease in Cardiac Output"

It is quite possible, and perhaps probable, but not definite, that the cardiac output will diminish.  Most persons are not symptomatic from this drop, however.

Good luck.

[angelapple]

Hi Hank, Just wanted to thank you for answering me.  I really appreciate it and when Bryan gets to Colorado he reassured me he would contact a cardiologist and get the proper testing.
Thanks again and have a great day. Angela

[DottyCece]

What is the relationship of the BNP (Beta Naturetic Peptide) value to the severity of CHF?  

If there there is moderate to severe tricuspid regurgitation with normal RV function, enlarged atria, EF of 50%, would a tricuspid repair improve the symptoms of ight heart failure (peripheral edema, JVD, mild pulmonary hypertension.?

[DottyCece]

What is the relationship of the BNP (beta naturetic peptide) to the degree of congestive heart failure?

[DottyCece]

I have moderate to severe tricuspid regurgitation with normal RV function, enlarged atria, EF of 50-55%. Would a tricuspid repair improve the symptoms of right heart failure (peripheral edema, JVD, mild pulmonary hypertension, elevated BNP)?