Ann Thorac Surg 2001;72:615-617
© 2001 The Society of Thoracic Surgeons
Case report
Tricuspid dura mater bioprostheses: more than 20-year follow-up of 3 patients
Luiz Boro Puig, MDa,
Carlos Manuel de Almeida Brandão, MDa,
Pablo Maria Alberto Pomerantzeff, MDa,
Fábio Antônio Gaiotto, MDa,
Sérgio Almeida de Oliveira, MDa
a Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
Accepted for publication July 16, 2000.
Address reprint requests to Dr Puig, Heart Institute (InCor), University of São Paulo Medical School, Av Dr Enéas de Carvalho Aguiar, 44, 05403-000 São Paulo, Brazil
e-mail: lpuig{at}incor.usp.br
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Abstract
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Replacement of the tricuspid valve is sometimes necessary. We report 3 consecutive patients with tricuspid insufficiency who underwent valve replacement with glycerol-preserved, homologous dura mater cardiac bioprostheses between 1971 and 1973. The first 2 patients are well 28 and 27 years later; the last patient was lost to follow-up after 20 years. We conclude that preservation of homologous dura mater bioprostheses in glycerol may reduce rates of thromboembolism, thrombosis, and structural dysfunction during the late postoperative period.
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Introduction
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Compared with mechanical prostheses, bioprostheses in the tricuspid position are associated with fewer complications such as thrombosis or pannus ingrowth. In 1971 Puig and coworkers [1] introduced the homologous dura mater cardiac bioprosthesis for cardiac valve replacement (Fig 1). The present article reports long-term outcomes for 3 consecutive patients with tricuspid insufficiency who underwent tricuspid valve replacement with homologous dura mater cardiac bioprostheses between 1971 and 1973 at the Heart Institute of the University of São Paulo Medical School. These bioprostheses had been preserved in glycerol (at 98%) at room temperature and sterilized in antibiotic solution before implantation.
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Case reports
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Patient 1
The patient, a woman, had a history of rheumatic fever, mitral valve stenosis, and tricuspid valve insufficiency. In March 1971, at 25 years of age, she underwent mitral valve commissurotomy and tricuspid valve replacement with a dura mater bioprosthesis (size 33); the immediate and late results of the tricuspid valve replacement were good. In 1980 the patient was reoperated for mitral restenosis and received a bovine pericardial bioprosthesis. In 1993 she received another bovine pericardial bioprosthesis for mitral bioprosthesis dysfunction (calcification). During both repeat operations the right atrium was opened to observe the dura mater tricuspid bioprosthesis. The thickness and the pliability of the valve’s tissue were preserved, except for pannus at the cusps’ base. No calcification or rupture was noted.
The patient has been evaluated twice yearly since her first operation. At her most recent clinical follow-up, 28 years after tricuspid valve replacement, she remained in New York Heart Association (NYHA) functional class I with the use of digitalis and was working as a secretary. A Doppler echocardiographic study demonstrated discrete tricuspid prosthetic stenosis, with a mean transvalvular gradient of 11 mm Hg and a peak gradient of 16 mm Hg.
Patient 2
This male patient with Ebstein’s disease was 18 years of age at the time of operation. In August 1972 he underwent tricuspid valve replacement, in the annular position, with a homologous dura mater cardiac bioprosthesis (size 33) and good results. Late during the postoperative period he received a pacemaker for atrioventricular heart block. During clinical follow-up until December 1999, 27 years after valve replacement, the patient has remained in NYHA functional class I without the use of medication. He currently works as a musician. A recent Doppler echocardiographic study showed discrete tricuspid prosthetic stenosis, with a mean transvalvular gradient of 5 mm Hg and a peak gradient of 9 mm Hg.
Patient 3
This male patient with Ebstein’s disease was 23 years of age at the time of operation. In August 1973 he underwent tricuspid valve replacement, in the annular position, with a homologous dura mater cardiac bioprosthesis (size 33) and good immediate and late results. During clinical follow-up through 1993, he remained in NYHA functional class I without the use of medication. We subsequently lost contact with him.
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Comment
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Tricuspid valve replacement is uncommon, independent of the cause of the valvopathy. Valve repair is frequently possible for tricuspid valve dysfunction or anomaly. However, there are some cases in which it is necessary to replace the tricuspid valve (eg, endocarditis, Ebstein’s disease) because valve repair is impossible.
In these cases, the choice between bioprosthesis or mechanical prosthesis remains controversial. Ratnatunga and coworkers [2] found no superior outcomes for biological or mechanical prostheses in the tricuspid positions of 425 patients in the United Kingdom Heart Valve Registry. Whereas Van Nooten and associates [3] found mechanical prostheses to be superior in 146 consecutive patients followed for 7 years, Munro and coworkers [4] reported that bioprostheses are superior in the tricuspid position because of infrequent structural valve deterioration and the avoidance of thrombosis with anticoagulant therapy. We have not used anticoagulant therapy during the early or late postoperative period with bioprostheses.
Kiziltan and colleagues [5] described 158 tricuspid valve replacements with porcine bioprostheses in patients with Ebstein’s anomaly. Survival was 92.5% at 10 years, and 80.6% had not undergone reoperation. We agree with these authors that their favorable experience with bioprostheses may be due to the large size of the implanted bioprostheses and usually low right ventricular systolic pressure. Our 3 patients received size 33 bioprostheses, which could explain the excellent late results. We think, and noted in patient 1, that pannus ingrowth always occurs and begins at the cusps’ suture line. However, this growth of tissue may stop, and it does not progress in all directions if the homologous dura mater tissue has been preserved in glycerol. This means that the thickness and the pliability of most of the cusp are maintained without the growth of pannus, which could preserve satisfactory valve function. The absence of calcification and tissue degeneration could reflect avoidance of structural modification with use of glycerol as a preservative.
Clinical use of the homologous dura mater valve was discontinued in 1979, when satisfactory results [6] made pericardial bioprostheses preferred at our institution. However, the dura mater bioprosthesis represents a reasonable valve substitute, especially for tricuspid valve replacement. We also have identified a significant number of patients who, after mitral valve replacement with a homologous dura mater valve, had durable bioprostheses 15 to 28 years later. However, only a few patients who underwent aortic valve replacement reached 20 years without having the dura mater bioprosthesis replaced. Our first 2 patients are currently engaged in normal social and professional activities. The preserved thickness and pliability of the homologous dura mater valve could suggest that tissue preservation with glycerol facilitates good long-term results.
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References
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Puig L.B., Verginelli G., Kawabe L., et al. Homologous dura mater cardiac valves. Study of 553 surgical cases. J Thorac Cardiovasc Surg 1975;69:722-728.[Abstract]
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Ratnatunga C.P., Edwards M.B., Dore C.J., Taylor K.M. Tricuspid valve replacement: UK Heart Valve Registry mid-term results comparing mechanical and biological prostheses. Ann Thorac Surg 1998;66:1940-1947.[Abstract/Free Full Text]
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Van Nooten G.J., Caes F., Tayemans Y., et al. Tricuspid valve replacement: postoperative and long-term results. J Thorac Cardiovasc Surg 1995;110:672-679.[Abstract/Free Full Text]
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Munro A.I., Jamieson W.R.E., Tyers G.F.O., Germann E. Tricuspid valve replacement: porcine bioprostheses and mechanical prostheses. Ann Thorac Surg 1995;59:S470-S474.
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Kiziltan H.T., Theodoro D.A., Warnes C.A., O’Leary P.W., Anderson B.J., Danielson G.K. Late results of bioprosthetic tricuspid valve replacement in Ebstein’s anomaly. Ann Thorac Surg 1998;66:1539-1545.[Abstract/Free Full Text]
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Puig L.B., Verginelli G., Pomerantzeff P.M.A., et al. Aortic valve replacement with bovine pericardium bioprostheses. Rev Hosp Clin Fac Med Sao Paulo 1983;38:73-79.[Medline]
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Abstract
Introduction
