What to Expect After Tricuspid Valve Replacement Long-Term Results

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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Documents

What to Expect After Tricuspid Valve Replacement Long-Term Results