Asian Cardiovasc Thorac Ann 2008;16:25-28
© 2008 Asia Publishing EXchange Ltd
Long-Term Results of Isolated Tricuspid Valve Replacement
Shigehiko Tokunaga, MD,
Munetaka Masuda, MD,
Akira Shiose, MD,
Yukihiro Tomita, MD,
Shigeki Morita, MD,
Ryuji Tominaga, MD
Department of Cardiovascular Surgery, Kyushu University Hospital, Fukuoka, Japan
For reprint information contact: Shigehiko Tokunaga, MD, Tel: 81 92 642 5557, Fax: 81 92 642 5566, Email: shiget{at}heart.med.kyushu-u.ac.jp, Department of Cardiovascular Surgery, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
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ABSTRACT
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The long-term outcome of isolated tricuspid valve replacement is unclear because this procedure is rare and usually performed in combination with replacement of other valves. The results of all 31 isolated tricuspid valve replacements carried out in 23 patients in Kyushu University Hospital between 1975 and 2004 were retrospectively reviewed. A bioprosthesis was used in 27 cases and a mechanical valve in 4. There were 2 operative deaths and 4 late deaths. One patient with a mechanical prosthesis needed redo tricuspid valve replacement due to valve thrombosis 6 months after surgery. The mean cardiothoracic ratio and functional class improved significantly postoperatively. At 15 years after tricuspid valve replacement, actuarial survival was 75.6% and freedom from valve-related events was 84.9%. For bioprostheses, freedom from structural valve deterioration at 5, 10 and 15 years was 95.2%, 95.2% and 85.7%, respectively. The long-term results of tricuspid valve replacement are considered satisfactory, and a bioprosthesis can be recommended due to its good outcome and no need for anticoagulation. We should not wait until the development of endstage cardiac impairment before carrying out tricuspid valve surgery.
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INTRODUCTION
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The long-term outcome of isolated tricuspid valve replacement (TVR) is unclear because valve repair is usually tried first. When TVR is performed, it is usually as a combined procedure with replacement of other valves. Tricuspid valve repair does not always succeed, and it is sometimes difficult to decide on TVR for an isolated tricuspid valve lesion because the long-term results are not well defined.
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PATIENTS AND METHODS
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The 31 isolated TVR operations performed in Kyushu University Hospital between 1975 and 2004 were retrospectively reviewed. During this period, there were 390 cases of tricuspid valve repair combined with other valve procedures; valve repair was preferred if possible. All 31 cases in this series were considered impossible to repair or had a failed repair. Tricuspid valve replacement was performed for isolated severe regurgitation in the cases of primary TVR. There were 23 patients (10 males) aged 9–69 years (mean age, 38.5 ± 18.0 years); 6 of them needed one redo TVR, and 1 needed 2 redo TVR operations. The indications for TVR are listed in Table 1
. Most patients had no other valve lesion. Procedures combined with TVR were closure of ventricular septal defect in 4 cases, closure of atrial septal defect (patent foramen ovale) in 5, closure of residual ventricular septal defect in 2, mitral annuloplasty in one, mitral valve repair in one, bidirectional Glenn shunt in one, pericardiectomy for constrictive pericarditis in one, and closure of a left ventricle-to-right atrial communication in one. Aortic cross clamping was used in all except one case. Warfarin was used in 12 patients with atrial fibrillation.
Data are presented as mean and standard deviation. The differences pre and post-TVR were analyzed using Student’s t test. Analyses of freedom from adverse events, survival and freedom from structural valve deterioration were performed by the Kaplan-Meier method and log-rank test. Statistical significance was established when p < 0.05. Rates are presented with 95% confidence limits.
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RESULTS
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The types of prosthesis are described in Table 2. The mean size of prosthesis was 30.9 ± 1.7 mm (range, 27–33 mm). The preoperative grade of tricuspid regurgitation in the 23 patients undergoing primary TVR was 3.57 ± 0.51. Two patients had rheumatic pathology and 5 had pulmonary hypertension; all of these patients were discharged from hospital. There were 2 hospital deaths due to multiorgan failure on the 36th and 40th postoperative day. Both patients had severe right heart failure preoperatively; one had hypertrophic cardiomyopathy and the other had Ebstein’s anomaly. There were 4 late deaths: one of the hypertensive patients died from heart failure 1.4 years postoperatively, and the other deaths were from an unknown cause at 2.2 years, heart failure at 3.3 years, and pneumonia at 12.8 years. The mean follow-up duration was 7.8 years in this series.
Seven patients needed redo TVR. One of these needed 2 redo TVR operations, both due to primary tissue failure of a Hancock valve; the patient requested a mechanical valve at the 2nd redo TVR. This patient is still alive. The interval from 1st to 2nd TVR was 3.4 years, and from the 2nd to 3rd TVR was 14.6 years. The follow-up period after the 3rd operation was 11.9 years, so this patient has been followed up for 29.9 years. A mechanical valve was also used because of difficultly inserting a bioprosthesis due to right ventricular hypertrophy in one case, at the patient’s request in two cases, and for an unknown reason in a 4th case. There was no operative death among the redo TVR patients. The cardiothoracic ratio improved significantly from 62.8% ± 10.2% preoperatively to 56.8% ± 7.2% postoperatively (reduction-plasty of the right atrium was performed in 5 cases). New York Heart Association functional class also improved significantly postoperatively (Figure 1). Postoperative complications were cardiac tamponade in one case, primary tissue failure in 5 (3.3–19.0 years after surgery), thrombosis in one St. Jude Medical valve (0.5 years), prosthetic valve endocarditis in one (7 years), pulmonary embolism in one (18 years) and permanent pacemaker implantation in 5 (bradycardia with atrial fibrillation within one month in 4, complete atrioventricular block at 18.3 years in one). No complete atrioventricular block occurred perioperatively. The actuarial survival rate at 5, 10 and 15 years was 86.4%, 75.6 % and 75.6%, respectively (Figure 2).
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Figure 1. New York Heart Association functional class before and after isolated tricuspid valve replacement. *p < 0.05.
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Freedom from valve-related events at 5, 10 and 15 years was 92.0%, 84.9 % and 84.9%, respectively (Figure 3). One patient had a thrombosed valve at 6 months postoperatively and underwent redo TVR with a bioprosthesis; this patient is alive. The indications for redo TVR in the other cases were primary tissue failure in 6 (one Carpentier-Edwards Pericardial valve, 4 Hancock and one Ionescu-Shiley, at 3.4–19.0 years postoperatively), prosthetic valve endocarditis in one (Hancock at 7.1 years) and an incidental procedure with mitral valvuloplasty for severe mitral regurgitation in one (Carpentier-Edwards at 4 years). Freedom from structural valve deterioration in bioprostheses in 5, 10 and 15 years was 95.2%, 95.2% and 85.7%, respectively (Figure 4).
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Figure 4. Freedom from structural deterioration in bioprostheses after isolated tricuspid valve replacement.
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DISCUSSION
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When faced with tricuspid regurgitation, we usually try valve repair first. Some patients retain an acceptable grade of tricuspid regurgitation after repair, but others need reoperation.1,2 The choice of prosthesis for valve replacement in the tricuspid position is still controversial.3–7 Tricuspid valve replacement with a mechanical valve may increase the risks of a thromboembolic complication and valve dysfunction by pannus formation or thrombosis, as seen in previous studies.8–10 In our 4 cases of TVR with a mechanical valve, there was one thrombosed valve after 6 months. On the other hand, TVR with a bioprosthesis has no need for anticoagulation and good long-term durability.11,12 As our group previously demonstrated the superiority of bioprostheses as right-sided cardiac valves, a bioprosthesis is the first choice for TVR in our institute.13,14 The 4 Hancock bioprostheses that failed due to structural deterioration (tricuspid stenosis due to calcification) were used in the early stage of the series (1975–1981). There were no hospital deaths in redo TVR. Even if a patient needs redo TVR due to primary tissue failure, it can be safely carried out.
The hospital mortality in this series was 6.5%, which is better than in previous studies of isolated TVR. Mangoni and colleagues15 reported the outcome of isolated TVR in 15 consecutive patients of whom 20% died within 30 days after surgery and 40% died within 3 months. The higher preoperative New York Heart Association class of their patients (3.33) compared to ours (2.53) probably accounts for this difference. The importance of timely referral before the development of end-stage cardiac impairment has been emphasized.16 Tricuspid valve replacement with a bioprosthesis showed satisfactory durability, and our results are compatible with other reports of bioprostheses in the tricuspid position.17–19 There is an opinion that freedom from reoperation is important when comparing bioprostheses with mechanical valves. However, we think that freedom from reoperation is not so important because most patients who accept a bioprosthesis regard it as the prosthesis that needs redo surgery. Valve selection should be based on discussion with the patient, including the possibility of redo surgery and its risks, life-long warfarin therapy and its quality of life, and the patient’s lifestyle and view of life.
It was concluded from this study that the long-term outcome of isolated TVR is satisfactory, with good durability and survival. Based on our experience and previous reports, a bioprosthesis should be the first choice for TVR.13,14 We should not wait until the development of endstage cardiac impairment for tricuspid valve surgery to have good operative results.
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REFERENCES
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ABSTRACT
INTRODUCTION
