Tricuspid valvectomy following tricuspid valve endocarditis on an intravenous drug addict

Abstract

Objective-To evaluate urinary glucocorticoid excretion profiles in a cohort of recently diagnosed young hypertensive patients. Methods-After excluding patients with secondary causes, 60 individuals with premature hypertension were recruited (diagnosed by ambulatory blood pressure monitoring before the age of 36 years). In addition, 30 older hypertensive controls (age of onset > 36 years, "middle aged hypertensive controls"), and 30 normal controls (age matched to the young hypertensive group) were studied. All provided 24 hour urine collections for mass spectrometry for total cortisol metabolites and total androgen metabolites by gas chromatography. Results-Among male patients, those with premature hypertension had higher total urinary excretion of cortisol metabolites (mean (SD), 13 332 (6472) µg/day) than age matched normal controls (7270 (1788) µg/day; p = 0.00001) or middle aged hypertensive controls (8315 (3565) µg/day; p = 0.002). A similar increase was seen among the female patients, although the absolute concentrations were lower. There was no significant diVerence between middle aged hypertensive patients and normal controls. Urinary total androgen excretion profiles in female patients also showed an unusual increase in the premature hypertension group (2958 (1672) µg/ day) compared with the other groups (middle aged hypertensive controls, 1373 (748) µg/day, p = 0.0003; normal controls, 1687 (636) µg/day, p = 0.002). In all subjects, serum sodium and creatinine concentrations were within the normal range; serum potassium concentrations were found to be low before the start of treatment. Conclusions-Individuals presenting with premature hypertension have an abnormally high excretion of glucocorticoid metabolites in the urine. While the mechanism remains uncertain, these findings are compatible with partial resistance of the glucocorticoid receptors, with a compensatory increase in cortisol and androgen metabolites. The mineralocorticoid eVects of the latter (sodium and water retention) may contribute to an abnormally high blood pressure and may have implications for targeted selection of first line treatment in young hypertensive patients.

Pathophysiology of Tricuspid Regurgitation

“…[15][16][17] An alternative hypothesis of TR murmur changes based on respiratory TR severity changes is doubted because patients with tricuspid valvulectomy, who obviously have very severe TR, are not reported to have respiratory TR murmur variation. 18 Hence, TR physiological characteristics and the presence and magnitude of respiratory TR changes remain uncertain. These gaps in knowledge affect not only TR physiological comprehension but also clinical evaluation and assessment of its impact on outcome and management.…”

Long-Term Prognosis of Isolated Significant Tricuspid Regurgitation

“…[2][3][4] Significant TR is also present without significant left-sided valvular heart disease or myocardial disease, but the prognostic value of this isolated significant TR has not been established. As reported previously, even TV valvectomy can be performed without early post-operative mortality in patients with TV endocarditis, 5,6 which raises questions about the clinical significance of significant isolated TR. Although TV surgery may be recommended to symptomatic patients with severe TR, 2 the surgical benefit for asymptomatic significant isolated TR has not been demonstrated.…”

Incremental prognostic value of early postoperative right ventricular systolic function in patients undergoing surgery for isolated severe tricuspid regurgitation

“…Based on the mistaken belief that TR is not a significant disease and does not alter exercise capacity or long-term prognosis, corrective surgery remains low on the list of treatment priorities 13. Most patients suffering from severe TR probably receive only diuretics for alleviating RV preload, without consideration of corrective surgery.…”