Ann Thorac Surg 2005;79:937-941
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Selective Annuloplasty for Tricuspid Regurgitation in Children
Jian Wang, MDa,*,
Yi-wu Liang, MDb,
Jun-ichi Hayashi, MDa
a Department of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
b Department of Cardiac Surgery, The 2nd Hospital of Hebei Medical University, Shijiazhuang, P.R. China
Accepted for publication August 23, 2004.
Abbreviations and Acronyms TRtricuspid regurgitation; PSpulmonary stenosis; TOFtetralogy of Fallot; VSDventricular septal defect; NYHANew York Heart Association; RAright atrium; TADtricuspid annular diameter; RAMPright atrial mean pressure; RVSPright ventricular systolic pressure; RVEDPright ventricular end-diastolic pressure
* Address reprint requests to Dr Wang, Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto 606–8507, Japan (E-mail: wangjian91{at}hotmail.com).
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Abstract
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BACKGROUND: Tricuspid valve regurgitation occurs with other congenital heart defects, especially the right-sided obstructive lesions. We applied the selective annuloplasty technique for the treatment of tricuspid regurgitation in children.
METHODS: Between 2001 and 2003, 15 patients whose ages averaged 7.6 ± 3.1 years (range 4 to 17 years old) underwent selective annuloplasty during correction of other heart defects. The patients had repair of pulmonary stenosis (5 patients), pulmonary stenosis and ventricular septal defect (7 patients), and tetralogy of Fallot (3 patients). Eight patients preoperatively had moderate tricuspid regurgitation, and 7 patients had severe tricuspid regurgitation.
RESULTS: No deaths nor heart block occurred after the operation. The length of the tricuspid regutgitation flow was significantly decreased from 2.9 ± 0.7 cm before the operation to 0.9 ± 0.6 cm after the operation (p < 0.01), and the tricuspid annular diameter decreased from 3.9 ± 0.3 cm to 3.3 ± 0.3 cm (p < 0.01). Annular circumference was reduced by 1.9 ± 0.2 cm. No tricuspid regurgitation was detected in 3 patients (20%), mild tricuspid regurgitation was seen in 10 (67%), moderate tricuspid regurgitation in 2 (13%). The right atrial mean pressure was significantly decreased from 7.5 ± 0.5 mm Hg before the operation to 3.1 ± 0.2 mm Hg after the operation (p < 0.01), right ventricular systolic pressure from 55.5 ± 2.3 mm Hg to 29.8 ± 1.9 mm Hg (p < 0.01), and right ventricular end-diastolic pressure from 8.4 ± 0.7 mm Hg to 4.9 ± 0.9 mm Hg (p < 0.01). Preoperatively, the degree of tricuspid regurgitation flow correlated significantly with the right ventricular systolic pressure (r = 0.89; p < 0.001). There was no correlation between tricuspid regurgitation flow and right ventricular systolic pressure postoperatively (p = 0.88). No child has symptomatic or significant tricuspid stenosis.
CONCLUSIONS: Selective annuloplasty presents a useful procedure for young patients with moderate or severe tricuspid regurgitation and right-sided obstructive lesions resulting from functional reconstruction of the tricuspid valve.
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Introduction
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Although tricuspid valve regurgitation (TR) is uncommon as a primary isolated lesion in children, functional TR occurs in association with other congenital heart defects, especially those with right-sided obstructive lesions [1]. These children have functional TR caused by right ventricular dilation and the resultant stretching of the tricuspid valve annulus. The situation is analogous to rheumatic mitral disease with secondary TR in the face of a structurally normal tricuspid valve. Many of these regurgitation tricuspid valves can be made competent by reducing the annulus size with the selective annuloplasty [2]. We reasoned that this experience in adults could be applied to children undergoing repair of other congenital defects with secondary TR. We applied the selective annuloplasty technique to 15 children with moderate or severe TR during correction of other heart defects.
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Patients and Methods
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Patient Data
Between 2001 and 2003, a method of tricuspid valve annuloplasty was attempted in 15 patients (6 males and 9 females) with congenital heart disease (pulmonary stenosis in 5; pulmonary stenosis and ventricular septal defect in 7; tetralogy of Fallot in 3). The average age of the patients was 7.6 ± 3.1 years (range 4 to 17 years old). Preoperatively, 4 patients were in functional class III according to the New York Heart Association (NYHA) classification and 2 patients were in functional class IV. All patients had sinus rhythm.
Echocardiography and Hemodynamic Measurements
Tricuspid regurgitation degree was assessed using two-dimensional Doppler flow echocardiography before the operation and 7 days, 3 months, and 6 months after the operation. Each patient lay in a supine position and breathed quietly. The TR jet was observed in the following views: parasternal long-axis view of the right ventricular inflow tract, apical four-chamber view, and parasternal short-axis at the level of the aortic valve. The TR flow signal was obtained from the tricuspid valve to the posterior wall of the right atrium (RA). Image of the TR flow was frozen on the color display and recorded in the end-expiratory phase. The tricuspid annular diameter (TAD) was measured at end-diastole with two-dimensional echocardiography. This value was defined as the maximum length of the tricuspid annulus determined by the longest distance between the bases of the opposing two leaflets.
Tricuspid regurgitation was categorized as mild, moderate, and severe (Fig 1) [3]. Mild TR was defined when TR flow did not extend beyond the line from the third of the tricuspid annulus to the posterior wall of the RA; moderate TR was defined as a band jet greater than 2 cm in diameter extending to the middle third of the RA; severe TR flow extended broadly into the distal aspect of the RA and the width of the flow was greater than 3 cm. TR flow within 0.5 cm of the tricuspid valve was thought to be trivial and not pathologic. Using this grading system, 8 patients preoperatively had moderate TR and 7 patients had severe TR.
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Fig 1. Grading of TR. Mild TR was defined that TR flow did not extend beyond the line from the third of the tricuspid annulus to the posterior wall of the RA; moderate TR was defined as a band jet was greater than 2 cm in diameter extending to the middle third of the RA; severe TR flow extended broadly into the distal aspect of the RA and the width of the flow was greater than 3 cm. (LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle; TR = tricuspid regurgitation.)
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All patients underwent preoperative and postoperative right heart catheterization studies. Right atrial mean pressure (RAMP), right ventricular systolic pressure (RVSP) and right ventricular end-diastolic pressure (RVEDP) before and after the operation were recorded.
Treatment of TR
Cardioplegic arrest with standard cardiopulmonary bypass techniques and moderate general hypothermia were used for all operations. No patient in this study underwent operation solely for TR. After the primary operation, the tricuspid valve was exposed through a right atriotomy and tested for incompetence by injecting saline into the right ventricle. Details of the tricuspid valve annuloplasty are illustrated in the legend for Figure 2. The anterior and posterior leaflets were separated from the annulus along the lateral commissure, allowing the three leaflets to show a good coaptation. An average of 1.9 ± 0.2 cm of the free part of the annulus was excluded by interrupted suture. Starting from the middle, the cut edge of the tricuspid leaflets was anchored to the remaining of the annulus by continuous suture. Only the stretched portion of the annulus was excluded. This was important to avoid a malcorrection of the valve insufficiency, which might lead to stenosis. The disappearance of regurgitation was confirmed by the injection of saline solution into the right ventricle after TR repair. In 4 patients, ventricular septal defect (VSD) was closed through the RA. In 6 patients, VSD was closed through the pulmonary artery.
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Fig 2. (a) Schematic of the tricuspid regurgitation and the dotted line is incision. (b) Anterior and posterior leaflets of the valve were separated from the annulus along the lateral commissure. The three leaflets show a good coaptation in the middle. (c) One third of the free part of the annulus has been excluded by interrupted suture. Starting from the middle, the cut edge of the tricuspid leaflets has been anchored to the remaining of the annulus by a continuous suture. (d) Status of the tricuspid orifice after the operation. (A = anterior leaflet; P = posterior leaflet; S = septal leaflet.)
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Statistical Analysis
Statistical analysis was performed with SPSS statistical software (SPSS Inc., Chicago, IL). The data were presented as the mean ± standard deviation. Statistical differences were evaluated with the paired Student's t test. For correlation analysis, Pearson test was used. p < 0.05 was considered as statistically significant.
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Results
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No patient developed significant tricuspid stenosis or heart block after operation. All survivors had an uneventful recovery and could be discharged from the hospital at 11.5 ± 2.9 days postoperatively. The average time required for the tricuspid annuloplasty was 15.3 ± 2.0 minutes. No patient required reoperation for recurrent TR. Patient characteristics are listed in Table 1.
Doppler examination demonstrated an improvement in the degree of TR in all survivors 7 days after operation. The length of the TR flow was significantly decreased from 2.9 ± 0.7 cm before the operation to 0.9 ± 0.6 cm after the operation (p < 0.01). No detectable TR was evidenced in 3 patients (20%), mild TR was seen in 10 (67%), and moderate TR in 2 (13%). The TAD decreased from 3.9 ± 0.3 cm before the operation to 3.3 ± 0.3 cm after the operation (p < 0.01).
The RAMP was significantly decreased from 7.5 ± 0.5 mm Hg before the operation to 3.1 ± 0.2 mm Hg after the operation (p < 0.01), RVSP from 55.5 ± 2.3 mm Hg to 29.8 ± 1.9 mm Hg (p < 0.01), and RVEDP from 8.4 ± 0.7 mm Hg to 4.9 ± 0.9 mm Hg (p < 0.01). Preoperatively, the degree of TR flow correlated significantly with the RVSP (r = 0.89; p < 0.001; Fig 3). There was no correlation between TR flow and RVSP postoperatively (p = 0.88).
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Fig 3. Relationship between the TR flow and RVSP. (a) There was significant correlation between TR flow and RVSP preoperatively (r = 0.89; p < 0.001). (b) There was no relation between TR flow and RVSP postoperatively (p = 0.88). (a) Preoperation; (b) postoperation. (RVSP = right ventricular systolic pressure; TR = tricuspid regurgitation.)
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There were no operative or late deaths at follow-up of 6 months. All survivors were in NYHA functional class I-II. No patient had valve-related complications. Doppler study showed that no detectable TR was evidenced in 3 patients, mild TR was seen in 10, and moderate TR in 2. No tricuspid valve stenosis occurred.
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Comment
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Functional TR in children, uncommon as a primary isolated lesion, occurs in association with other congenital heart defects, especially along with the right-sided obstructive lesion. Rocchini and colleagues [4] reported that moderate or severe TR was present in 11 of 102 patients undergoing cardiac catheterization after tetralogy of Fallot repair. All 11 patients had chronic congestive heart failure [4]. Coles and coworkers [5] found a 19% incidence of TR at follow-up of children who had relief of critical pulmonary stenosis in infancy. Functional TR is first originated by right ventricle pressure or volume overload. Furthermore, development of TR causes volume overload in the right ventricle by TR itself along with dilation of the tricuspid annulus [6, 7].
Our patients originally had obstructive lesions of the right ventricular outflow tract. All patients had moderate or severe tricuspid regurgitation. Preoperatively, the degree of TR flow correlated significantly with the RVSP (r = 0.89; p < 0.001). Kobayashi and associates [3] showed that significant TR was associated with high RVSP, high RVEDP, and significant pulmonary regurgitation and residual ventricular septal defect, which increased the right ventricular end-diastolic volume. TR may produce an irreversible deterioration of right ventricle function [8]. TR in children after repair of right-sided obstructive lesions can be caused by chronic right ventricular volume or pressure overload with or without right ventricular dysfunction. This leads to dilation of the tricuspid annulus with resultant regurgitation despite a structurally normal valve [1].
Hachida and colleagues [9] reported that distension of the tricuspid annulus was usually seen in the anterior and posterior portion of the annulus to the same degree, and segmental ratio (anterior leaflet annulus:septal leaflet annulus:posterior leaflet annulus) was changed 1:1:0.75 in normal to 1.22:1:0.75 in TR with distension of tricuspid annulus. In 1990, Minale and colleagues [10] reported selective annuloplasty of the tricuspid valve. Applying the technique, our patients had excellent postoperative results. None of the children had symptomatic TR, although 2 patients (performed the total correction of tetralogy of Fallot) had moderate TR. Pulmonary regurgitation is common after correction of tetralogy of Fallot and is well tolerated [11]. Pulmonary regurgitation may cause right ventricle dilation and TR. During the period of follow-up, no patient needed reoperation for exacerbation or recurrence of TR. All patients exhibited an improvement in functional status. RAMP, RVSP, and RVEDP decreased significantly.
Annuloplasties involving bicuspidization of the tricuspid valve, such as the Kay technique, have been abandoned because they may lead to shortening of the annular circumference, persistent TR, or continuous annular dilation with recurrence of TR. The Carpentier ring and De Vega annuloplasty have improved the surgical results considerably and are now widely used. The former can't be used in a growing child for fear of creating long-term tricuspid stenosis. De Vega's technique may result in a semicircular deformation of the orifice and infolding of the leaflet tissue. Moreover, centripetal forces of the suture may cause tearing of the anterior annulus, which may lead to some degree of right ventricular inflow obstruction. In our technique, the dilated annulus is reduced selectively on the anterior and posterior portions without excluding the active surface of the valve leaflet and it also maintains the natural relationship of the tricuspid valve orifice.
Functional TR may spontaneously regress after correction of primary problem (eg, pulmonary insufficiency or right ventricular outflow tract obstruction). The resultant decrease in right ventricular volume or pressure work would allow for improved tricuspid valve function as the tricuspid annulus decreases in size. However, increasing experience demonstrates that tricuspid annuloplasty decreases postoperative morbidity and mortality in the presence of significant insufficiency [12]. Our results have not revealed any disadvantage of this procedure.
There is the concern of fixing the size of the tricuspid valve annulus in a growing child for fear of long-time tricuspid valve stenosis. For that reason, we avoided the use of an annuloplasty ring in children. Obviously, one could argue that as the children continue to grow, the suture material might show some distortion of the tricuspid valve. In our patients, no children have seen tricuspid stenosis during follow-up time.
The durability of the selective annuloplasty in children is unknown. At follow-up, no patients had reoperation on the tricuspid valve. None of the children had symptomatic TR, although 12 patients had TR on the echocardiography study. No tricuspid valve stenosis occurred. The long-term studies on the durability of the procedure remain to be seen.
In summary, our study presents the selective tricuspid annuloplasty that excludes the dilated annulus involving the anterior and posterior leaflets. The procedure shows that it is efficient in reducing TR. However, further studies in larger series are needed to confirm our results.
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References
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Abstract
Introduction
