title: Tricuspid valve injury after heart transplantation due to endomyocardial biopsy: an analysis of 3550 biopsies.
abstract: BACKGROUND
  Tricuspid regurgitation (TR) is the most commonly valvular dysfunction found after heart transplantation (HTx). It may be related to endomyocardial biopsy (EMB) performed for allograft rejection surveillance.
  
  
  OBJECTIVE
  This investigation evaluated the presence of tricuspid valve tissue fragments obtained during routine EMB performed after HTx and its possible effect on short-term and long-term hemodynamic status.
  
  
  METHODS
  This single-center review included prospectively collected and retrospectively analyzed data. From 1985 to 2010, 417 patients underwent 3550 EMB after HTx. All myocardial specimens were reviewed to identify the presence of tricuspid valve tissue by 2 observers initially and in doubtful cases by a third observer. The echocardiographic and hemodynamic parameters were only considered for valvular functional damage analysis in cases of tricuspid tissue inadvertently removed during EMB.
  
  
  RESULTS
  The 417 HTx patients to 3550 EMB, including 17,550 myocardial specimens. Tricuspid valve tissue was observed in 12 (2.9%) patients corresponding to 0.07% of the removed fragments. The echocardiographic and hemodynamic parameters of these patients before versus after the biopsy showed increased TR in 2 cases (2/12; 16.7%) quantified as moderate without progression in the long term. Only the right atrial pressure showed a significant increase (P = .0420) after tricuspid injury; however, the worsening of the functional class was not significant enough in any of the subjects. Thus, surgical intervention was not required.
  
  
  CONCLUSIONS
  Histological evidence of chordal tissue in EMB specimens is a real-world problem of relatively low frequency. Traumatic tricuspid valve injury due to EMB rarely leads to severe valvular regurgitation; only a minority of patients develop significant clinical symptoms. Hemodynamic and echocardiographic alterations are also less often observed in most patients.
authors.affiliation: Heart Institute of Sao Paulo University Medical School, Sao Paulo, Brazil. fiorelliai@uol.com.br
authors.forename: A I
authors.initials: AI
authors.lastname: Fiorelli
authors.forename: G H B
authors.initials: GH
authors.lastname: Coelho
authors.forename: V D
authors.initials: VD
authors.lastname: Aiello
authors.forename: L A
authors.initials: LA
authors.lastname: Benvenuti
authors.forename: J F
authors.initials: JF
authors.lastname: Palazzo
authors.forename: V P
authors.initials: VP
authors.lastname: Santos Júnior
authors.forename: B
authors.initials: B
authors.lastname: Canizares
authors.forename: R R
authors.initials: RR
authors.lastname: Dias
authors.forename: N A G
authors.initials: NA
authors.lastname: Stolf
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001706:Biopsy / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D004699:Endocardium / Q000473:pathology*; D006084:Graft Rejection / Q000209:etiology / Q000473:pathology*; D006335:Heart Injuries / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology; D016027:Heart Transplantation / Q000009:adverse effects*; D006439:Hemodynamics; D006801:Humans; D008875:Middle Aged; D009206:Myocardium / Q000473:pathology*; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014261:Tricuspid Valve / Q000293:injuries; D014262:Tricuspid Valve Insufficiency / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology; D014463:Ultrasonography; D055815:Young Adult