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Ann Thorac Surg 2000;70:796-799
© 2000 The Society of Thoracic Surgeons

Original articles: cardiovascular

Long-term follow-up after carpentier-Edwards ring annuloplasty for tricuspid regurgitation

Koji Onoda, MD, PhDa, Fuyuhiko Yasuda, MD, PhDa, Motoshi Takao, MD, PhDa, Takatsugu Shimono, MD, PhDa, Kuniyoshi Tanaka, MD, PhDa, Hideto Shimpo, MD, PhDa, Isao Yada, MD, PhDa

a Department of Thoracic and Cardiovascular Surgery, Mie University School of Medicine, Mie, Japan

Address reprint requests to Dr Onoda, Department of Thoracic and Cardiovascular Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
e-mail: k-onoda{at}clin.medic.mie-u.ac.jp


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. Use of flexible rings for tricuspid ring annuloplasty is becoming popular. This study was undertaken to evaluate Carpentier-Edwards (C-E) rigid ring annuloplasty for tricuspid regurgitation (TR), secondary to mitral valve disease and clinical outcome on a long-term basis.

Methods. From December 1985 to March 1996, 45 patients with secondary TR underwent C-E ring annuloplasty. Thirty-nine patients (95.1%) were in New York Heart Association (NYHA) functional class III or IV. The mean follow-up was 96.7 ± 48.5 months or 362.6 patient-years.

Results. There were three in-hospital and nine late deaths that were not related to tricuspid annuloplasty. Actuarial survival at 10 years was 68.3%. Echocardiographic studies showed that TR was well controlled within grade 2+ in all survivors. Residual pulmonary hypertension (PH) was recognized in 9 of 21 patients (42.9%) with preoperative PH, however, no TR was seen in 6 patients. A TR grade of 2+ was observed in 3 patients. Thirty of the total survivors (96.8%) were in NYHA class I and II, but 1 patient was in NYHA class III. The actuarial rate of freedom from tricuspid valve reoperation after 10 years was 97.5%.

Conclusions. C-E ring annuloplasty is acceptable for repair of secondary TR and improvement in clinical status on a long-term basis.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
The surgical treatment of significant secondary tricuspid regurgitation (TR) associated with disease of the mitral or aortic valve, or both, is now widely accepted, although secondary TR often disappears after repair of the valves of the left heart [1]. As this phenomenon is unpredictable, residual TR results in a persistent degree of right ventricular failure and makes postoperative management difficult [2].

Suture annuloplasty, such as the Kay method [3] or the De Vega method [4], and ring annuloplasty have been used as surgical techniques of tricuspid annuloplasty. Carpentier-Edwards (C-E) rigid ring has been widely accepted for tricuspid annuloplasty [5]. However, the flexible ring (Duran ring) was developed to change the size and shape of the annulus during the cardiac cycle [6]. Furthermore, recent progress in annular rings has allowed us to preserve physiologic annulus function [7]. Yet there are no reports indicating which type of ring is better for right ventricular function and regulation of TR. However, use of flexible rings is becoming popular. For the past 15 years, we have used C-E ring for repair of secondary TR. In the present study, we evaluated the regulation of TR and the clinical outcome in patients with secondary TR who underwent annuloplasty using the C-E ring on a long-term basis.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
From December 1985 to March 1996, 103 patients with secondary TR underwent tricuspid annuloplasty at our institution. Among them, 45 patients (43.7%) had C-E ring annuloplasty (Baxter Healthcare Corp., Santa Ana CA). There were 13 male patients and 32 female patients whose ages ranged from 32 to 69 years (mean 54.6 years). Thirty-nine patients (95.1%) were in New York Heart Association (NYHA) functional class III or IV. Fifteen patients (33.3%) had cardiac cachexia. Thirty-seven patients had associated mitral lesions, and 8 patients had mitral and aortic lesions. Thirty-three patients received mitral valve replacement (MVR), 4 patients underwent open mitral commissurotomy, and in 8 patients, both aortic and mitral valves were replaced. Twenty-eight patients (62.2%) had had previous mitral and/or aortic valve operations (Table 1). One patient had concomitant aortocoronary bypass grafting and 1 patient had closure of an atrial septal defect. Follow-up was complete (95.6%) in all but 2 patients, who moved with unknown addresses. The mean follow-up was 96.7 ± 48.5 months (maximum 160 months), or 362.6 patient-years.


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  		Table 1. Previous Cardiac Operations in 28 Patients (62.2%)

 
All patients were investigated preoperatively by means of Doppler echocardiography. The classification of significant TR was made by Doppler echocardiography as previously reported [8]. Briefly, the severity of TR was assessed in four grades based on the distance in the four-chamber view from the cardiac apex: 1+, less than 15 mm; 2+, 15 to 30 mm; 3+, 30 to 45 mm; 4+, over 45 mm. The mode of TR was determined by the direction of regurgitation signals: type A, toward the atrial septum; type B, toward the center; type C, externally. C-E ring annuloplasty was performed for TR graded 3+ or 4+ with regurgitation in multiple directions.

The surgical technique of C-E ring annuloplasty was performed as described by Carpentier [9].

Forty-four patients (97.8%) received cardiac catheterization preoperatively. The diagnosis of pulmonary hypertension (PH) was made by right-sided heart catheterization, and over 30 mm Hg of mean pulmonary artery pressure (mPAP) was defined as PH.

All hospital survivors were followed up by cardiac surgeons or physicians in a dedicated valve clinic every month after leaving our hospital. Postoperative cardiac catheterization was performed around 6 months after the operation and echocardiography was done at hospital dischage and almost every year after leaving our hospital.

Deaths and complications were stringently defined according to published guidelines of The Society of Thoracic Surgeons and The American Association for Thoracic Surgery [10].

Statistical analysis
Values are expressed as the mean ± standard deviation. The Kaplan-Meier metnod was used for determining rates for actuarial survival and freedom from tricuspid valve reoperation.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
Mortality and causes of death
Two patients (4.4%) died within 30 days of operation. The causes of death were multiple organ failure and low cardiac output syndrome, respectively. They were in no way related to the tricuspid procedure. One patient (2.2%) died in hospital 3 months after operation. The cause of death was pneumonia due to methicillin-resistant Staphylococcus aureus. Nine late deaths (20.0%) were recongized. The causes of death were cardiac failure in 5 patients, brain emboli in 1, brain bleeding in 1, and cancer in 2. None of the late deaths was related to tricuspid annuloplasty with the C-E ring.

Including operative deaths, actuarial overall survival at 5 and 10 years was 86.7% and 68.3%, respectively (Fig 1).



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  		Fig 1. Actuarial overall survival including operative deaths.

 
Clinical condition
In all survivors, an improvement of NYHA class was recognized at the most recent evaluation (Fig 2). Thirty of 31 patients (96.8%) were in NYHA class I and II, but a patient with MVR was in NYHA class III because of low cardiac output and paroxysmal atrial tachycardia.



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  		Fig 2. Clinical condition assessed by NYHA classes before Carpentier-Edwards ring tricuspid annuloplasty (preoperative, left column) and at the latest observation (postoperative, right column).

 
Evaluation of TR
According to the most recent echocardiography, TR was well controlled within grade 2+ in all survivors (Fig 3). In 9 of the late death patients, the regulation of TR with the C-E ring was excellent during the follow-up period as well.



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  		Fig 3. Grades of TR by echocardiography before C-E ring tricuspid annuloplasty (preoperative, left column) and at the latest observation (postoperative, right column).

 
Furthermore, the regulation of TR was evaluated in the patients with residual PH. Of the 44 patients undergoing cardiac catheterization preoperatively, 27 patients (61.4%) had PH. Twenty-one of the 27 patients received cardiac catheterization postoperatively, and PH was still recognized in 9 patients (42.9%). However, no TR was recognized in 6 patients, and TR of grade 2+ was recognized in 3 patients on the recent echocardiography. Two of the 9 patients had moderate paravalvular leak (PVL) of the mitral prosthesis and their mean pulmonary pressure and systolic pulmonary pressure were 40 and 30 mmHg, and 50 and 80 mm Hg, respectively, whereas TR was not recognized in both patients. The two patients received reoperaton for only mitral prosthetic valve 4 or 6 years after the previous operation.

Reoperation of the tricuspid valve
One patient needed reattachment of the C-E ring due to rupture of the suture thread of the septal leaflet 2 years after the preivous operation. In this patient, pleural effusion had been found on a chest roentgenogram examination and TR of grade 3+ had been recognized 1 year after the previous operation. No structural dysfunction of the C-E ring was found during the follow-up period in any patients. The actuarial rate of freedom from tricuspid valve reoperation after 10 years was 97.5% for all patients (Fig 4).



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  		Fig 4. Freedom from tricuspid valve reoperation after C-E ring tricuspid annuloplasty.

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
We use Kay’s method [3] as our primary method for suture annuloplasty and the C-E ring as our first choice in cases of ring annuloplasty for secondary TR. The selection between the two methods was decided by the direction of regurgitation signals on a Doppler echocardiography as described in "Patients and Methods": Kay’s method for the single directon; C-E ring method for the multiple directions [8]. Although Kay’s method is easy and convenient, recurrence of TR has been recognized in patients with residual PH and deterioration of left-sided lesion during the follow-up period (unpublished data). De Vega’s method [4] also has been widely used for suture annuloplasty, however, Holper and coworkers have reported that recurrence of TR was rated as moderate in 15% and severe in 18.8% among 80 perioperative survivors [11]. Furthermore, De Paulis and coauthors have reported that residual TR was judged as moderate in 11.9% and severe in 4.3% among 136 hospital survivors, and that in 7 patients who required reoperation for recurrence of TR, 6 also had a mitral prosthesis malfunction or a periprosthetic leak [1].

There were few reports on the long-term results of tricuspid annuloplasty using the C-E ring [12, 13]. Although these studies were evaluated in a very small number of patients, it was described that C-E ring tricuspid annuloplasty was effective for repair of secondary TR on a long-term basis. In our study, C-E ring tricuspid annuloplasty also demonstrated excellent results in regulation of secondary TR, and control of TR even in cases with residual PH and/or the deterioration of the residual disease of the mitral valve on a long-term basis. Only 1 patient required reoperation for C-E ring tricuspid annuloplasty, but it was due to rupture of the suture thread. Two patients received reoperation due to severe perivalvular leak of the mitral prosthesis. Although marked PH was also recognized in these patients, TR was well controlled. In 9 patients, including the 2 patients, residual PH was recognized, but there were no patients with significant TR over a long-term follow-up period. Therefore, our findings suggest that C-E ring tricuspid annuloplasty is an acceptable method for secondary TR, especially if there is PH preoperatively.

A problem for C-E ring annuloplasty is the loss of tricuspid annular contraction involved in right ventrichlar function. de Groote and coworkers demonstrated that right ventricular ejection fraction in addition to the NYHA functional classification and the percent of maximal predicted peak oxygen consumption was an independent predictor of survival and of major cardiac events [14]. To resolve the problem, a flexible ring was developed to preserve physiologic annulus function. However, there have been no reports indicating a relationship between right ventricular function and rigid or flexible rings in the tricuspid position. The effect of prosthetic rings even in the mitral position on left ventricular function is still controversial, as indicated in several reports [15–18]. It is more difficult to evaluate the effect of prosthetic rings in the tricuspid position on right ventricule function because left-sided surgery and left heart condition have a significant effect on right ventricular function. For this reason, we could not evaluate the effect of the C-E ring on right ventricular function in the small number of patients with diverse backgrounds.

In conclusion, C-E ring annuloplasty is acceptable for regulation of functional TR even in patients with residual PH and improvement in clinical status on a long-term basis. However, as long as disadvantages of flexible ring implants are not identified, rigid rings may give way to flexible rings in the future.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. De Paulis R., Bobbio M., Ottino G., et al. The De Vaga tricuspid annuloplasty. Perioperative mortality and long term follow-up. J Cardiovasc Surg 1990;31:512-517.[Medline]
  2. Pluth J.R., Ellis F.H., Jr Tricuspid insufficiency in patients undergoing mitral valve replacement. J Thorac Cardiovasc Surg 1969;58:485-489.
  3. Kay J.H., Maselli-Campagna G., Tsuji H.K. Surgical treatment of tricuspid insufficiency. Ann Surg 1965;162:53-58.[Medline]
  4. De Vega N.G. La anuloplastia selectiva, regulable y permanente. Una technica original para el tratamiento de la insuficiencia tricuspide. Rev Esp Cardiol 1972;25:555-556.[Medline]
  5. Carpentier A., Deloche A., Dauptain J., et al. A new reconstructive operation for correction of mitral and tricuspid insufficiency. J Thorac Cardiovasc Surg 1971;61:1-13.[Medline]
  6. Duran C.G., Ubago J.L. Clinical and hemodynamic performance of a totally flexible prosthetic ring for atrioventricular valve reconstruction. Ann Thorac Surg 1976;22:458-463.[Abstract]
  7. McCarthy J.F., Cosgrove D.M., III Tricuspid valve repair with the Cosgrove-Edwards annuloplasty system. Ann Thorac Surg 1997;64:267-268.[Abstract/Free Full Text]
  8. Yada I., Tani K., Shimono T., Shikano K., Okabe M., Kusagawa M. Preoperative evaluation and surgical treatment for tricuspid regurgitation associated with acquired valvular heart disease. J Cardiovasc Surg 1990;31:771-777.[Medline]
  9. Carpentier A. Cardiac valve surgery-the "French correction.". J Thorac Cardiovasc Surg 1983;86:323-337.[Medline]
  10. Edmunds L.H., Jr, Clark R.E., Cohn L.H., Grunkemeier G.L., Miller D.C., Weisel R.D. Guidelines for reporting morbidity and mortality after cardiac valvular operations. Ann Thorac Surg 1996;62:932-935.[Abstract/Free Full Text]
  11. Holper K., Haehnel J.C., Augustin N., Sebening F. Surgical for tricuspid insufficiency. Thorac Cardiovasc Surgeon 1993;41:1-8.[Medline]
  12. Konishi Y., Tatsuta N., Minami K., et al. Comparative study of Kay-Boyd’s, DeVega’s and Carpentier’s annuloplasty in the management of functional tricuspid regurgitation. Jpn Circ J 1983;47:1167-1172.[Medline]
  13. Kratz J.M., Crawford F.A., Stroud M.R., Appleby D.C., Hanger K.H. Trends and results in tricuspid valve surgery. Chest 1985;88:837-840.[Abstract/Free Full Text]
  14. De Groote P., Millaire A., Foucher-Hossein C., et al. Right ventricular ejection fraction is an independent predictor of survival in patients with moderate heart failure. J Am Coll Cardiol 1998;32:948-954.[Abstract/Free Full Text]
  15. David T.E., Komeda M., Pollick C., Burns R.J. Mirtal valve annuloplasty. Ann Thorac Surg 1989;47:524-528.[Abstract]
  16. Okada Y., Shomura T., Yamaura Y., Yoshikawa J. Comparison of the Carpentier and Duran Prosthetic rings used in mitral reconstruction. Ann Thorac Surg 1995;59:658-663.[Abstract/Free Full Text]
  17. Castro L.J., Moon M.R., Rayhill S.C., et al. Annuloplasty with flexible or rigid ring does not alter left ventricular systolic performance, energetics or ventricular-arterial coupling in conscious, closed-chest dogs. J Thorac Cardiovasc Surg 1993;105:643-659.[Abstract]
  18. Carpentier A.F., Lessana A., Relland J.Y.M., Belli E., Mihaileanu S., Berrebi A.J., Palsky E., Loulmet D.F. The "Physio-Ring". Ann Thorac Surg 1995;60:1177-1186.[Abstract/Free Full Text]
Accepted for publication April 12, 2000.




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