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Ann Thorac Surg 2000;69:1295
© 2000 The Society of Thoracic Surgeons

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CORRESPONDENCE

Tricuspid valve replacement: results comparing mechanical and biological prostheses

^a Departments of Cardiovascular Surgery and Cardiology, St. Jude Medical Center, 301 Bastanchury Rd, Ste 195, Fullerton, CA 92835, USA

To the Editor

We read with great interest the article by Ratnatunga and colleagues [1]. They studied retrospectively 425 patients from the UK Heart Valve Registry who underwent tricuspid valve replacement (TVR). Approximately half of the patients received biological valves and half received mechanical valves. Thirty-eight percent had isolated TVR. Their 5-year survival rate was 60%. They reported no significant statistical difference in performance between both types of valves and concluded that "the exercise of personal preference by the implanting surgeon in the choice of biological or mechanical prosthesis for the tricuspid position seems reasonable." Their study did not collect etiologic data.

Patients with tricuspid valve endocarditis secondary to long-term intravenous drug addiction pose a significant problem because they often lack peripheral venous access. Monitoring of anticoagulation may become virtually impossible. We recently had a patient in whom it was necessary to insert a central venous line to perform a preoperative transesophageal echocardiogram because her superficial peripheral veins were inaccessible. Even if these patients still have adequate peripheral veins, their compliance with oral anticoagulants and monitoring with laboratory testing is poor. We have previously reported a small series of patients with TVR with the Carpentier-Edwards bioprosthesis with improved results [2]. Our series cannot be compared directly with this report for a number of reasons. All our patients remained anticoagulated postoperatively. Although these data cannot be extrapolated to drug addicts with bioprostheses without anticoagulation, a bioprosthesis should theoretically have a lower thromboembolic risk in this situation. As the UK Registry does not collect data for thrombosis or hemorrhage, differences between mechanical valves and bioprostheses would not be detected. Age is an independent predictor of survival [3]. Our series had an improved 5-year actuarial survival rate of 82%. However, our population was 8 years younger than Ratnatunga and colleagues’ series (mean, 57.1 versus 49.1 years). Eighty-two percent of our patients were in New York Heart Association class IV preoperatively, which is a negative prognostic factor. All our patients had had rheumatic fever.

The strongest argument against the use of biological valves in the tricuspid position is that the rate of reoperation escalates after 10 to 15 years. However, bioprostheses may outlast patients with drug addiction and previous endocarditis, thus negating the benefit of a mechanical valve. Based on the above arguments we believe that drug addicts requiring TVR will perform favorably with biological prostheses.

References

1. Ratnatunga C.P., Edwards M.B., Dore C.J., Taylor K.M. Tricuspid valve replacement. Ann Thorac Surg 1998;66:1940-1947.[Abstract/Free Full Text]
2. Del Campo C., Akalin H., McKenzie F.N. Evaluation of the Carpentier-Edwards porcine bioprosthesis in the tricuspid position. Tex Heart Inst J 1982;9:299-302.[Medline]
3. Glower D.D., White W.D., Smith R., et al. In-hospital and long-term outcome after porcine tricuspid valve replacement. J Thorac Cardiovasc Surg 1995;109:877-884.[Abstract]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Carlos Del Campo Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Del Campo, C. Articles by Sherman, J. R. Search for Related Content PubMed Articles by Del Campo, C. Articles by Sherman, J. R.