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Ann Thorac Surg 2001;71:S240-S243
© 2001 The Society of Thoracic Surgeons

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Valvular bioprostheses over 15 years

Comparison of durability of bioprostheses in tricuspid and mitral positions

^a Division of Cardiovascular Surgery, Mitsui Memorial Hospital, Tokyo, Japan
^b Clinical Laboratory, Mitsui Memorial Hospital, Tokyo, Japan

Address reprint requests to Dr Ohata, Division of Cardiovascular Surgery, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka 543-0035, Japan
e-mail: tohata{at}aol.com

Presented at the VIII International Symposium on Cardiac Bioprostheses, Cancun, Mexico, Nov 3–5, 2000.

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Few reports have assessed differences in the durability of mitral and tricuspid bioprostheses after simultaneous implantation of the same bioprosthesis in both positions. We investigated the long-term outcome after simultaneous mitral valve replacement (MVR) and tricuspid valve supraannular implantation (TVSI) with the Carpentier-Edwards bioprostheses in patients with severe tricuspid regurgitation and advanced mitral valve disease.

Methods. Between 1982 and 1998, 37 patients in our hospital underwent MVR and TVSI with Carpentier-Edwards bioprostheses. The mean age of the patients was 55 ± 11 years. The average postoperative follow-up was 7.9 ± 4.5 years after surgery (range 0 to 14.6 years, 315.1 patient-years). The follow-up rate was 100%. We evaluated the actuarial survival rate, the actuarial freedom from structural valve deterioration (SVD) and reoperation, and postoperative complications.

Results. The overall actuarial survival rate at 13 years after the operation was 69% ± 31%. The actuarial freedom from SVD and reoperation in the mitral and tricuspid positions were 78 ± 22 and 100% and 70 ± 30 and 90% ± 10% (p = 0.03), respectively. No patient had systemic or pulmonary thromboembolism, or complications associated with fatal arrhythmia.

Conclusions. These results suggest that the bioprostheses in the tricuspid position yield significantly better long-term results than those in the mitral position after simultaneous MVR and TVSI.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Tricuspid valve regurgitation (TR) is usually accompanied by advanced mitral valve disease and is present in 10% to 50% of patients with severe mitral stenosis or regurgitation [1]. Because severe functional TR rarely regresses spontaneously after repair of the mitral lesion, surgery for TR is almost always required [1, 2].

In general, mechanical valves in the mitral position have been reported to be more durable than bioprostheses [3]. Despite gradual improvement in their durability and long-term results, mitral bioprostheses have also been less satisfactory than aortic or tricuspid bioprostheses [4, 5]. Bioprostheses such as the Hancock valve and the Carpentier-Edwards pericardial valve have provided good long-term results in the tricuspid position, including a low incidence of structural valve deterioration and need for reoperation [6]. However, few reports have compared the durability of mitral and tricuspid bioprostheses after simultaneous mitral valve replacement (MVR) and tricuspid valve replacement (TVR) with the same bioprosthesis [7].

Tricuspid valve supraannular implantation (TVSI) differs from TVR in that it preserves the native tricuspid valve. Moreover, since the bioprosthesis is implanted in the supraannular position, TVSI prevents residual TR without increasing the risk of fatal arrhythmia or thromboembolism [8].

In this study, we investigated the long-term outcome after simultaneous MVR and TVSI with the same bioprosthesis in patients with severe tricuspid valve regurgitation and advanced mitral valve disease.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patients
We studied 37 patients with severe TR complicated by advanced mitral valve disease who underwent simultaneous MVR and TVSI with Carpentier-Edwards bioprostheses at Mitsui Memorial Hospital between 1982 and 1998. The mean patient age at operation was 54 ± 11 years [34–73]. There were 11 men and 26 women. The mean duration of postoperative follow-up was 7.9 ± 4.5 years (range 0 to 14.6 years; 315.1 patient-years) and the follow-up rate was 100%. The surgical indication for TVSI was grade 4/4 TR as determined by right ventriculography or Doppler echocardiography. Postoperatively all patients received anticoagulation therapy with warfarin and were followed-up with Doppler echocardiography after discharge.

Measurements
We evaluated late mortality and its causes, actuarial survival rate, actuarial freedom from structural valve deterioration (SVD) and reoperation, and postoperative complications. Echocardiography was used to examine the implanted bioprosthesis in mitral and tricuspid position, and to identify thrombus formation between the native valve and implanted bioprosthesis and peak velocity through the implanted bioprosthesis.

Statistical analysis
All values were expressed as mean ± standard deviation. Overall actuarial survival and actuarial freedom from structural valve deterioration and reoperation were determined by the Kaplan-Meier method. All analyses were performed using the Statview version 4.5 statistical package (Abacus Concepts Inc, Berkeley, CA).

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Patient survival and overall actuarial survival rate
Six patients (16.2%) died during hospitalization, 3 of cardiac failure and 3 of multiple organ failure. Seven patients (21.9%) died in the late postoperative period, 1 of a cardiogenic cause, 2 of stroke, 1 of multiple organ failure, 1 of neoplasm, and 2 of unknown causes. The overall actuarial survival rate at 13 years after the operation was 69 ± 31 (Fig 1).

View larger version (11K): [in this window] [in a new window]   Fig 1. Actuarial survival curves showing overall mortality. Overall actuarial survival rate 13 years after the operation was 69% ± 31%.

View larger version (12K): [in this window] [in a new window]   Fig 2. Actuarial rate of freedom from structural valve deterioration 13 years after operation was 78% ± 22% in the mitral (M) and 100% in the tricuspid (T) position.

View larger version (15K): [in this window] [in a new window]   Fig 3. Actuarial rate of freedom from reoperation 13 years after operation was 70% ± 30% in the mitral (M) and 90% ± 10% in the tricuspid (T) position (p = 0.034). Bioprostheses in the tricuspid position had significantly better long-term results than those in the mitral position.

The peak velocity through the implanted bioprosthesis in the mitral position was 1.8 ± 0.5 m/s, and no mitral stenosis was found. There was no thrombus formation around the implanted bioprosthesis in any patient.

Thromboembolism and postoperative arrhythmia
No patient had any obvious systemic or pulmonary thromboembolism. In addition, no thrombus formation on the cusp was found in any of the 12 explanted bioprostheses. Minor cerebral infarction induced by anticoagulant therapy was also not found in these cases. Three patients had spontaneous ventricular tachycardia, 2 had transient atrioventricular block, and 1 had atrial fibrillation bradycardia. However, no patient had complete atrioventricular block or fatal arrhythmia occurred during postoperative periods. No late pacemaker implantation was necessary.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
This study shows that Carpentier-Edwards bioprosthesis provides significant better long-term results in the tricuspid position than in the mitral position after simultaneous MVR and TVSI in patients with severe tricuspid regurgitation and mitral valve disease. Our findings are consistent with previous reports showing that bioprostheses in the mitral position are less satisfactory than that in tricuspid position [9]. They also confirm the favorable long-term outcomes, including a low incidence of structural valve deterioration and reoperation, with bioprostheses such as Hancock valve and Carpentier-Edwards pericardial valve in the tricuspid position [6, 10].

Mitral valve reoperation was performed because of leaflet tear, perforation, calcification, and strut detachment, whereas tricuspid valve reoperation was performed for paravalvular leakage and pannus formation. The differences in long-term outcomes of bioprostheses in the mitral versus tricuspid position and the indications for reoperation likely reflect factors relating solely to the position of the implanted valves; because, in all cases, the same bioprosthesis was implanted in both positions and because interindividual differences in factors such as local inflammation and metabolism were minimized. Differences in pressure or velocity at the two valve locations are a more likely explanation. In previous studies, mechanical stress on the cusps was reported to be the main cause of leaflet tear and perforation [11]. Leaflet tear, perforation, and strut detachment are thought to depend on the fragility of the bioprosthesis and its structure; high pressure or velocity against the cusps may cause progressive destruction of the bioprosthesis. Although second-generation bioprostheses are less fragile than first-generation bioprostheses [12], the problems of cusp calcification, fragility, and pannus formation have not been solved completely [5, 12, 13]. If cusp calcification, in particular, can be prevented, the long-term results of bioprostheses in the mitral position might approach those in the tricuspid position.

Freedom from structural deterioration of Carpentier-Edwards bioprostheses has been reported. In the study of Sarris and colleagues [9] it was 60% ± 10%. Jamieson and colleagues [14] reported no structural deterioration at 15 years in 89% ± 8% of patients older than 70 years, 23% ± 8% in those 61 to 70 years, 26% ± 6% in those 51 to 60 years. In our study, there was freedom from structural deterioration 13 years postoperatively in 78% ± 22% of patients in the mitral position and 100% in the tricuspid position. The difference in operative procedure and in anticoagulation therapy by warfarin might contribute to these results, although there were a number of younger individuals in our series.

In summary, our findings suggest that bioprostheses in the tricuspid position provide significantly better long-term results than those in the mitral position after simultaneous mitral valve replacement and tricuspid valve supraannular implantation.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ohata, T. Articles by Wanibuchi, Y. Search for Related Content PubMed PubMed Citation Articles by Ohata, T. Articles by Wanibuchi, Y. Related Collections Valve disease