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7/28/2019 What to Expect After Tricuspid Valve Replacement Long-Term Results
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By Sihar Deddy Siahaan
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Surgeons encountering an organic tricuspid lesionin daily practice often try to avoid a valvereplacement as much as possible, and generallyprefer some sort of repair with or without using
annuloplasty rings Interestingly, although the technique for
tricuspid valve replacement is prettystraightforward when compared to various repairoptions which necessitates considerable skill and
experience, there is continuing debate on someaspects of the valve replacement, such as thechoice of the prosthesis type according to ageand risk groups.
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a. Demographics
Forty-two patients, 16 male (38%) and 26 female
(62%);with a mean age of 33 15 (range: 770 years)
underwent 42 tricuspid valve replacements between March
1987 and December 2004. The etiology of tricuspid valve disease was rheumatic in 27
(64%), Ebsteins anomaly in 13 (31%), and endocarditis in 2
(5%).
b. Clinical presentation
10 pts were in New York Heart Association Class-IIfunctional capacity (24%), 19 were in Class III (45%), and 13
were in class IV (31%)
Dyspnea was present in 26 patients (62%), tachyarrhythmia
in 25 (60%), congestive symptoms and signs in 25 (60%),
cyanosis in 8 (19%) and fever in 2 (5%).
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c. Procedure
isolated tricuspid valve replacement 20 pts (48%)
mitral and tricuspid replacement 17 pts (40%)
Aortic ,mitral and tricuspid replacement 5 pts (12%)
Tricuspid replacement device was mechanical (St.Jude or Carbomedics)in 15 patients (36%) andbioimplant (Carpentier-Edwards or St. Jude) in 27(64%)
A bioimplant was preferred in patients undergoing
isolated tricuspid valve replacement with nopreviously implanted mitral or aortic mechanicalvalves, especially in the old age group, and for thosein whom the anticoagulant therapy would beproblematic
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d. Follow-up
The mean follow-up time was 5.6 years (up
to 18.3 years, a total of 175 patient years)
Three patients underwent reoperation forrepeat tricuspid replacement during the
follow-up,two for prosthetic valve
thrombosis and one for bioprosthesis
degeneration 2 years after the primaryoperation.
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e. Statistical analysis
Means are presented standard deviation.
Determinantsof mortality or complications
were analyzed by Chi-square orFishers exacttests when applicable.
Survival and complication-free survival
estimates were expressed as KaplanMeier
curve
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a. Early outcome
Hospital mortality was 26% (11 patients, 8
females and 3 males, p = 0.48; mean age: 39.5
14.9; range 2170 years).
The major cause for early mortality was right
heart failure and low cardiac output syndrome
The risk factors associated with perioperative
mortality were, (1) Rheumatic etiology, (10 of
27; 37% vs only 1 of 13 patients ofEbsteins
anomaly group; p = 0.05), (2) Reoperation ( 11%;
p = 0.01) and (3) Elevated pulmonary artery
pressure (exceeding 30 mmHg; 5.9%; p = 0.004).
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Early complications :
low cardiac output requiring inotropic
support in (50%)
transient bradyarrhythmia in (19%), cardiac tamponade in 4 (9.5%).
respiratory complications necessitating
prolonge mechanical ventilatory support
(4.8%),
transient renal function impairment (2.4%)
sepsis (2.4%)
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Perioperative low cardiac output
development was strongly associated with
poor preoperative functional class,as it
developed in 9 of the 19 patients in NYHAClass-III and 10 of the 13 patients in Class-IV,
in contrast to only 2 of the 10patients in
Class-II ( p = 0.007).
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b. Long-term outcome
Survivors were followed up for an average
postoperative period of 5.6 5.5 years (up to 18.3
years, a total of 175 patient years). Nine
patients died during postoperativefollow-up.
Three patients underwent repeat tricuspid valve
replacements
The KaplanMeier survival estimates were 37
11% at 10 years (Fig. 1) and 30 11% at 15 yearswith an average survival was 8.5 1.41 years (all
including operative mortality), and longest
postoperative follow-up was 18 year
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c. Risk factors influencing long-term outcome
For the patients with elevated pulmonary arterypressure(exceeding 30 mmHg) the long-termsurvival was less favorable with a 10-yearKaplanMeier survival rate of21%, in contrast to54% in those with normal pulmonary arterypressures ( p = 0.01) (Fig. 2).
survival rates did not differed between thedifferent preoperative functional class groups interms of statistical significance
Another factor influencing the long-time survivalwas the underlying disease, as 10-year KaplanMeier survival was 53% in patients of congenitalorigin (Ebstein) versus 41% in those of rheumaticorigin (Fig.3)
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d. Reoperations and event-free survival
Two patients underwent repeated tricuspid valvereplacements due to prosthetic valve thrombosisin the mechanicalvalve group while anotherpatient from bioprosthesis group underwentreoperation due to bioprosthesis degeneration 2years after the primary operation
In all these reoperations,tricuspid prosthesis wasreplaced by a bioprosthetic valve
No statistically significant difference wasdetected between mechanical or bioprostheticvalves in regard to perioperative mortality, lowcardiac output, long-term survival or event-freesurvival.
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e. Functional capacity improvement
A comparison between preoperative and
postoperativefunctional capacity based on
NYHA Classification is representedin Fig. 4.
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A tricuspid disease sustained long enoughmay cause extensive compromise both locally(valve apparatus and/or right ventricle) andsystemically (hemodynamic effects on the
end-organs, especially the liver).Our results are in accordance with this
observation, with a relatively high operativemortality, and a 10-year survival of only 37%
(including operative mortality). Ten-yearevent-free survival was 31% for the wholegroup, with no statistically significantdifference between mechanical orbioprosthetic valves
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The risk factors for early mortality were
rheumatic etiology, reoperation and elevated
pulmonary artery pressure.Low cardiac
output developed more frequently in those
with decreased functional capacity (NYHA
Class III an IV),congestive symptoms and
those of rheumatic origin.
rheumatic etiology more frequentlynecessitates valve replacement instead of
repair
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Some authors advocate using bioprostheses
in tricuspid position due to high
thromboembolic complications following
mechanical valve implants .Our results did
not support this argument,probably because
of the relatively low incidence of valve
related events in our series.
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Some authors advocate the use of biologic
prostheses even in young patients because of
limited life expectancy unrelated to the type
of tricuspid prostheses at long-term follow-
up.Others suggest that even greater care is
needed to prevent valve thrombosis in
mechanical valves, there is still a greater
chance for reoperation in bioprosthetic
valves
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All these arguments above need to be more
elucidated to go beyond being simple
speculations. Nevertheless, the fact is that
the short and long-term results after
tricuspid valve replacement are poorer than
those of left-sided replacements
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Long-Term Survival
- Our study indicated that about 50% of patientswere alive 10 years after surgery
- In our experience,late deaths have not been
due to valve-related complications but haveresulted mainly from continuing heart failureand its attendant morbidity
- Surgical technique, including type ofprosthesis, did not have any bearing on long-term survival in our experience.
- It is possible that improved medicalmanagement may be a strategy to increase thelong-term survival.
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Mechanical or Bioprosthetic Valve
-The choice of prosthesis for TVR remainscontroversial with some groups favoring
mechanical,others biological,and some areindifferent .In our series the long-term
survival was similar regardless of prosthesis
type. Although we found a high incidence of
anticoagulation-related bleeding in themechanical group
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-Because there is no clear superiority of oneprosthesis over another, the decision should
be individualized to the patient.
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Immediate- and Long-Term Survival
- There were 14 deaths (17%) in patients who
underwent tricuspid valve replacement with
bioprostheses and 3 deaths (20%) in patientswith mechanical tricuspid valve replacement
within 30 days of operation (p 0.7). Seven
patients died of multiorgan failure, 5 of
mediastinal bleeding at the time ofoperation, 4 of cardiogenic shock, and 1
after a stroke.
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Long-Term Complications
-One patient died of thrombosis of atricuspid mechanical valve (CarboMedic) 2years after the operation, and another
patient underwent reoperation because oftricuspidvalve dysfunction 1 year afterimplantation of a Duromedic heart valve inthe tricuspid position
- Reoperative tricuspid valve replacementand the use of a bioprosthesis or amechanical valve had no significant effect onmortality after operation.
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Comment
- Our experience with patients averaging 50
years of age and having had multiple
previous left-sided valve replacementsindicates that tricuspid valve replacement
with the Carpentier-Edwards pericardial
bioprosthesis is a good option
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Repair of Ebsteins anomaly. Atrialized portion of the right ventricle
is obliterated by tying of the sutures. Closure of the atrial septal
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y y g p
defect. Placement of the suture for shortening of the tricuspid annulus
in the area of the dysplastic and downward displaced posterior leafl et.
After tying of the suture, a functionally monocuspid valve will be
created.
(According to Danielson et al. [28, 29])
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Tricuspid valve repair is associated withbetter perioperative and long-term outcome
than valve replacement
The incidence of re-operation is low with no
significant difference whether the tricuspidvalve has been repaired or replaced
When valve replacement is necessary we
recommend the use of a biological prosthesis
considering the poor long-term survival
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Mild increased PAP = 2.6 - 2.9 m/s (27-33 mmhg)
Moderate increased PAP = 3.0 - 3.9 m/s (36-60 mmhg)
Severe increased PAP = 4.0 (64 mmhg )
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1/The normal tricuspid inflow velocity is less than 0.5 to1 m/s, with a mean gradient less than 2 mm Hg.
2/The evaluation of tricuspid valve stenosis with Doppler
echocardiography is similar to the
method described for mitral stenosis , although theconstant of 190 has been proposed of the PHT
method .
3/Tricuspid stenosis is considered severe when the mean
gradient is 7 mm Hg or more and PHT is 190
milliseconds or longer.
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