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Ann Thorac Surg 2006;81:2172-2178
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Short- and Long-Term Results of Triple Valve Surgery in the Modern Era

Bahaaldin Alsoufi, MD, Vivek Rao, MD, PhD * , Michael A. Borger, MD, PhD, Manjula Maganti, MS, Susan Armstrong, MS, Christopher M. Feindel, MD, Hugh E. Scully, MD, Tirone E. David, MD

Peter Munk Cardiac Center, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada

Accepted for publication January 17, 2006.

* Address correspondence to Dr Rao, Alfredo and Teresa DeGasperis Chair in Heart Failure Surgery, Toronto General Hospital, 200 Elizabeth St, Toronto, Ontario, Canada, M5G 2C4. (Email: vivek.rao{at}uhn.on.ca).

Presented at the Fifty-second Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 10–12, 2005.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 
BACKGROUND: Triple valve surgery is usually complex and carries a reported operative mortality of 25% and 10-year survival of 40%. We examined surgical results in the modern era.

METHODS: A total of 174 consecutive patients, mean age 58 ±12 years underwent triple valve surgery from 1990 to 2004. The most common aortic and mitral valve disease was rheumatic disease (61%), followed by prosthetic valve dysfunction (22%). Tricuspid valve disease was functional regurgitation in 72% of patients. Ninety-four percent of patients were in New York Heart Association class III and IV, and 60% had had previous cardiac operations. The aortic valve procedures consisted of 160 replacements and 14 repairs, the mitral valve procedures, 153 replacements and 21 repairs, and the tricuspid valve procedures, 12 replacements and 162 repairs. Univariate and multivariable analyses were performed to identify predictors of early and late survival.

RESULTS: Operative mortality was 13% (n = 22). Univariate factors associated with mortality included urgent surgery, shock, tricuspid valve replacement, preoperative renal failure, and peripheral vascular disease. Survival at 5 and 10 years was 75% and 61%, respectively. Seventy-three percent of patients were in New York Heart Association class I and II at their most recent follow-up. Ten-year freedom from thromboembolism was 88%, from anticoagulation-related hemorrhage, 83%, from endocarditis, 96%, and from cardiac reoperation, 92%.

CONCLUSIONS: Patients with advanced rheumatic valve disease and prosthetic valve dysfunction are at risk for requiring triple valve surgery. Compared with historic reports, the results of triple valve surgery, primary and reoperative, have improved. Although early mortality is high, long-term and event-free survival are comparable with that of patients undergoing single valve replacement.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Discussion
 References
 
Several cardiac diseases such as rheumatic and degenerative valve disease, as well as endocarditis, may affect multiple valves and require double or triple valve surgery [1–6]. In addition, patients with prosthetic valve dysfunction frequently require multiple valve surgery owing to extensive fibrosis and calcification at the base of the heart, progress of the cardiac disease in the remaining heart valves, and functional tricuspid valve regurgitation secondary to severe left-side valvular dysfunction [7–11].

Despite improvements in operative and myocardial protection techniques, triple valve surgery (TVS) remains challenging. Patients are subjected to long cardiopulmonary bypass and myocardial ischemic times; in addition, such patients often require additional major reconstruction of the valve annuli or the base of the heart secondary to infection, calcification, fibrosis, or insufficient space to secure the placement of prosthetic heart valves of adequate size.

Reported operative mortality after TVS is high and ranges between 20% and 25% [1–5]. Moreover, multiple valve replacement exposes the patients to added long-term prosthetic valve-related morbidities such as endocarditis, thromboembolism, anticoagulation-related hemorrhage, and paravalvular leak compared with single valve replacement [1, 2, 6]. Finally, TVS has been associated with diminished long-term survival, with reported survival at 5 and 10 years of 55% and 35% respectively [2, 4].

In the present study, we reviewed our experience with TVS in the modern era with a focus on factors associated with perioperative mortality, long-term survival, and valve-related morbidity.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Discussion
 References
 
Inclusion Criteria
From January 1990 to January 2004, 174 consecutive patients with multiple valve disease underwent TVS at Toronto General Hospital. Clinical, operative, and outcome variables were reviewed. Data were collected prospectively in a computerized database. Institutional review board approval was obtained before data collection.

Patient Characteristics
The mean age of the patients was 58.2 ± 11.8 years (range, 20 to 79 years). There were 53 men and 121 women. The vast majority of patients were in New York Heart Association functional class III or IV. One hundred four patients (60%) had undergone previous cardiac surgery. One hundred fifty-four patients (66%) were operated on electively, 41 (24%) during the same hospital admission, and 19 patients (11%) were operated on urgently. The choice of the valve prosthesis was determined on the basis of the patient's age and comorbid factors. In the aortic position 126 mechanical and 34 bioprosthetic valves were implanted. The majority of mechanical valves included St. Jude (St. Jude Medical Inc, Minneapolis, MN) (n = 90), Carbomedics (Sulzer Carbomedics Inc, Austin, TX) (n = 19), and Monostrut (Shiley Inc, Irvine, CA) (n = 15) valves. Similarly, 127 mechanical and 26 bioprosthetic valves were implanted in the mitral position, including St. Jude (n = 92), Monostrut (n = 18), and Carbomedics (n = 17) valves. Only 12 valves were implanted in the tricuspid valve position, and they included 8 mechanical and 4 bioprosthetic valves: St. Jude (n = 4), Monostrut (n = 4), and Hancock II (n = 4). The complete clinical profile of the patients is summarized in Table 1.


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  		Table 1. Clinical Profile of All Patients
 
The most common aortic valve and mitral valve disorder was rheumatic valve disease, followed by prosthetic valve dysfunction. In contrast, the most common tricuspid valve disease was functional regurgitation secondary to left heart disease, followed by rheumatic valve disease. The complete listing of valve disease presentation and pathologic diagnosis is presented in Table 2.


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  		Table 2. Distribution of Preoperative Valve Disease and Pathologic Diagnosis in the Whole Group
 
Surgical Technique
Intraoperative transesophageal echocardiography was performed in all patients to assess the extent and mechanism of valve disease and the quality of the replacement or repair postoperatively. All procedures were done through a midline sternotomy. Valve operations were performed under the usual methods of cardiopulmonary bypass with a single aortic cross-clamp technique. Myocardial protection strategies varied according to surgeon preference but usually included antegrade cardioplegia introduced directly into the coronary ostia and retrograde cardioplegia through a coronary sinus cannula. Mild hypothermia was used, and the core temperature allowed to drift to 32° to 34°C. Distal coronary anastomoses were performed first, followed by the valve procedures. After excision of the aortic valve, the mitral valve was approached, usually through the interatrial groove, and was assessed for possible repair versus replacement. Standard mitral valve repair and replacement techniques were used. If mitral valve annular reconstruction was needed as in cases of extensive calcification or annular abscess owing to endocarditis, this was done with the use of autologous pericardium, glutaraldehyde-fixed bovine pericardium, or polyethylene terephthalate (Dacron) polyester fabric before implantation of the mitral valve prosthesis. This surgical technique has been described previously [7, 8].

After the mitral valve procedure, the aortic valve was replaced (or infrequently repaired) in the standard fashion. Tricuspid valve repair was subsequently performed with either a modified pledgeted De Vega technique or with an annuloplasty ring or band. Less frequently, the tricuspid valve was replaced. Finally the proximal coronary anastomoses were performed.

The intervalvular fibrous body was reconstructed when required, such as in patients with significant calcification of the base of the heart, active endocarditis with abscess, or inadequate intervalvular fibrous tissue to secure a prosthetic valve because of multiple previous operations. The intervalvular body was reconstructed with glutaraldehyde-fixed bovine pericardium or Dacron polyester fabric as previously described [8]. The operative variables for all patients are listed in Table 3.


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  		Table 3. Complete Operative Data for the Whole Group of Patients (n = 174)
 
Follow-Up
Late outcomes were determined from clinic records when available or from written correspondence with patients' physicians and direct patient contact with mailed questionnaire or telephone interviews when necessary. All follow-up data were collected by our research personnel and were 100% complete. Mean follow-up was 4.5 ± 3.7 years and ranged from 1 month to 14 years. Echocardiographic data at latest follow-up were collected by contacting referring cardiologists.

Statistical Analysis
All data analyses were performed with SAS version 8.1 software (SAS Institute, Cary, NC). Descriptive statistics are reported as mean ± standard deviation for continuous variables and as frequencies and percentages for categorical variables. Unrelated two-group comparisons were done with unpaired, two-tailed Student's t tests for continuous variables and {chi}2 or Fisher's exact test for categorical data. Predictors of perioperative mortality were identified using multivariable logistic regression analysis. Long-term survival and freedom from morbid events were estimated using the Kaplan–Meier method. Cox regression was used to determine the independent predictors of late outcomes. The appropriateness of variable transformations was determined by means of univariate analysis. Variables with a univariate p value of less than 0.05 or those with known biologic significance but failing to meet this critical {chi}2 level were submitted to multivariable models.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Discussion
 References
 
Operative Mortality and Morbidity
There were 22 in-hospital deaths (12.6%): 8 because of multiorgan failure and sepsis, 4 in the operating room because of either failing to wean from cardiopulmonary bypass or uncontrolled hemorrhage, 4 because of myocardial failure and continuous low cardiac output syndrome, 2 because of sudden cardiac arrest, 2 because of cardiac tamponade, and 2 patients who died in the operating room after requiring early reoperation for technical complications.

Ten patients (6%) required reexploration of the mediastinum for bleeding, and 30 (17%) required placement of a permanent pacemaker for heart block. Other morbidities included pulmonary complications in 26 patients (15%), sepsis in 10 patients (6%), renal failure in 7 patients (4%), tamponade in 7 patients (4%), sternal infection in 4 patients (2%), stroke in 2 patients (1%), and sternal dehiscence in 1 patient.

Univariate analysis revealed the following variables to be associated with increased operative mortality: hypertension (p = 0.03), peripheral vascular disease (p = 0.001), preoperative shock (p = 0.01), preoperative renal failure (p < 0.0001), the need for aortic annular enlargement (p = 0.008), tricuspid valve replacement (p < 0.0001), urgent surgery (p = 0.0001), postoperative stroke (p = 0.0009), sepsis (p = 0.0003), renal failure (p = 0.0003), and sternal infection (p = 0.02). None of these variables remained significant on multivariable analysis.

Late Mortality and Morbidity
There were 26 late deaths, with 14 of them for cardiac causes: congestive heart failure (n = 7), sudden death (n = 2), myocardial infarction (n = 1), arrhythmias after coronary revascularization (n = 1), anticoagulation-related hemorrhage (n = 1), internal bleeding (n = 1), endocarditis (n = 1). The other 12 deaths were because of noncardiac reasons.

Five-year and 10-year survival was 75% ± 4% and 61% ± 5%, respectively, as illustrated in Figure 1. The freedom from valve-related mortality and cardiac-related death at 10 years was 96% ± 2% and 87% ± 4%, respectively. Five patients had prosthetic valve endocarditis, 3 early and 2 late. Two of them required reoperation and are alive, whereas the other 3 were treated conservatively and 1 of them died. The 10-year freedom from prosthetic valve endocarditis was 96% ± 2% (Fig 2).


Figure 1
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  		Fig 1. Long-term survival.

 

Figure 2
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  		Fig 2. Long-term freedom from prosthetic valve endocarditis.

 
Ten-year freedom from thromboembolism was 88% ± 4% (Fig 3), whereas 10-year freedom from anticoagulation-related hemorrhage was 83% ± 5% (Fig 4). Ten-year freedom from other valve-related morbidities, such as structural valve deterioration, valve thrombosis, and paravalvular leak, was 99% ± 1%, 98% ± 1%, and 97% ± 2%, respectively.


Figure 3
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  		Fig 3. Long-term freedom from thromboembolic complications.

 

Figure 4
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  		Fig 4. Long-term freedom from anticoagulation-related hemorrhage.

 
Reoperations
Ten patients required late reoperation (Fig 5). Ten-year freedom from reoperation was 92% ± 3%. All patients survived repeat surgery and are alive on latest follow-up. A summary of patients who underwent reoperation, including indication for reoperation, intervals between surgeries, and the reoperative procedures, is displayed in Table 4.


Figure 5
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  		Fig 5. Long-term freedom from cardiac reoperation.

 

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  		Table 4. Complete List of Patients Requiring Reoperation During the Follow-Up Period
 
Late Functional Class
On latest follow-up, 126 patients were alive. Among them 44% were in New York Heart Association functional class I, 29% were in class II, 25% were in class III, and 2% were in class IV. All patients had normally functioning prosthetic valves at the latest echocardiographic study.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Discussion
 References
 
Primary and reoperative TVS are complicated and challenging operations. Patients often have underlying myocardial dysfunction as a result of their multiple valve disease, and they are exposed to prolonged cardiopulmonary and myocardial ischemic times. In addition, several anatomic factors necessitate other procedures such as replacement of the aortic root and reconstruction of the mitral annulus or intervalvular fibrous body, which increase operative morbidity and mortality. The added technical challenge of redo sternotomy in an often-dilated heart was present in 60% of the patients in this series.

In a previous review from our institution, 1.5% of all patients undergoing mitral valve surgery required mitral valve reconstruction for extensive calcification [7]. In our current series, annular reconstruction of the mitral valve was required in 35 patients (20%) after extensive debridement for excessive calcification or invasive infection. This increased need to reconstruct the mitral annulus reflects the advanced and extensive disease in this population of patients and increases the complexity of surgery and may affect surgical outcomes. Similarly, there was a high incidence of 25 patients (14%) requiring reconstruction of the intervalvular fibrous body. Indications included extensive calcification of the base of the heart, active infective endocarditis with abscess, and inadequate intervalvular fibrous tissue to secure a prosthetic valve because of multiple previous operations. Continuous surveillance of these patients is needed as we have demonstrated in a previous study that those patients have a high 10-year reoperation rate of 50% that is related to prosthetic valve endocarditis or patch and valve dehiscence [8]. We have already had two failures in our current series attributable to valve dehiscence. We currently prefer to use Dacron polyester fabric graft material for this purpose rather than glutaraldehyde-preserved bovine pericardium as the latter calcifies more often and may rupture, causing paravalvular leak and patch dehiscence [8].

The relatively high proportion of complex TVS in the current series is more a reflection of the tertiary referral of our practice than the true incidence of these diseases.

Reported operative mortality after TVS ranges between 20% and 25% [1–5]. Our operative mortality remains high (12.6%) and was similar for first-time (12%) and reoperative (13%) surgery. We identified several risk factors for perioperative mortality with univariate analysis, but were unable to identify any independent risk factors on multivariable analysis. This is likely to be related to the heterogeneity of patients, the variety of problems associated with TVS, and the relatively small sample size.

Previous reports indicate that TVS is associated with poor long-term survival, with reported survival at 5 and 10 years of 55% and 35%, respectively [2, 4]. The majority of studies reporting high rates of long-term mortality, however, were published many years ago. In the current series we found a 5-year and 10-year survival of 75% and 61%, respectively. We believe that improved perioperative care, including increased experience with complex surgical procedures and improved myocardial protection, and improved postoperative care, including treatment of congestive heart failure and decreased valve-related complications, contributed to the very good long-term survival rates observed in our series. We also believe that extensive decalcification and debridement of infected tissue leads to improved long-term results after any valvular operation [7–9].

Prosthetic valve-related complications have been reported to be more common in patients undergoing TVS compared with single valve replacement [1, 2, 6]. In our current series, 80% of prosthetic valves were mechanical. Although we did not compare valve morbidities among patients undergoing single valve surgery versus TVS in our institution, our valve-related complications in this current series were comparable to the reported rate after single valve replacement in other recently published series [12, 13]. The only exception is the freedom from cardiac reoperation: 92% at 10 years in our current series compared with greater than 98% after single valve replacement [12]. Ten patients underwent reoperation for various causes including valve thrombosis, pannus formation, and patch or valve dehiscence. The distinctive anatomy associated with multiple valve replacement, the frequent need for annular and fibrous body reconstruction, and the frequent incidence of prosthesis–patient mismatch will explain the higher incidence of these complications, and follow-up is necessary to detect valve dysfunction.

The high rates of thromboembolic and bleeding complications reported in early series of TVS were associated with older-generation mechanical valves such as the Starr-Edwards and Björk-Shiley mechanical prostheses [1, 2, 4]. These valves were reported to have a higher incidence of thromboembolic complications and required higher anticoagulation level than newer-generation mechanical prostheses. Current international normalized ratio target levels of 2.5 to 3.5 are advocated after mitral valve replacement using a mechanical prosthesis and are the same target levels we recommend after multiple valve replacement. In our current series, valve choice (mechanical versus bioprosthesis) did not significantly affect short-term or long-term outcomes on univariate analysis.

More current series of TVS have similarly showed lower embolic and bleeding complication rates in agreement with our findings [14, 15]. Improvement of valve design in new-generation valves and lower anticoagulation target levels may explain the improved results.

Triple valve surgery may be required in patients with rheumatic valve disease, prosthetic valve dysfunction, and endocarditis. Triple valve surgery procedures are complex, and major cardiac reconstruction is often needed, increasing the complexity of these procedures. Clearly, patients undergoing such extensive surgery comprise a highly selected cohort. Nonetheless, short-term and long-term outcomes have improved compared with older reports. We found acceptable rates of perioperative mortality for TVS in the modern era, with good long-term results. The majority of TVS patients are in New York Heart Association class I or II during follow-up, and long-term valve-related complications rates are similar to patients undergoing single valve replacement. The good results after triple valve operation in patients with advanced valvular heart disease justifies aggressive surgical therapy in these patients.


   Discussion
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
References
 
DR ROBERT A. GUYTON (Atlanta, GA): Excellent presentation and excellent results. I think that one might question your conclusion that triple valve outcomes are equivalent to single valve outcomes in that you are comparing current triple valve outcomes with historical single valve outcomes. So I am not sure we have a contemporaneous single valve series.

The questions that I want to ask are focused primarily on what we can take home from this experience, and in particular, what process changes you think may have occurred that can account for these improved outcomes. In particular, how do you manage preoperative Coumadin (warfarin), how do you manage preoperative ACE (angiotensin-converting enzyme) inhibitors or angiotensin receptor blockers? Do you give preoperative ß-blockers to all of these patients, as it has been shown to be effective in patients with coronary disease?

Second question. Your numbers are not sufficient to do a surgeon-by-surgeon analysis of results, but did you do at least an eyeball analysis of outcomes in your busiest valve surgeon versus the others together? Is this, in part, exceptional surgical technique in this series? Thank you very much.

DR ALSOUFI: Thank you, Dr Guyton. We did not compare the outcomes between patients undergoing single valve versus triple valve surgery at our institution. However, our comparison was made with recently published long-term valve outcome studies such as the one by Dr Emery describing 25-year experience with the St. Jude mechanical valve. Our long-term triple valve-related morbidity was almost similar to that of single valve replacement reported in those studies except for a higher reoperation rate in our group of patients.

There are several factors that may have contributed to the improved short- and long-term results noted in our current series. We have gained increased experience with aggressive debridement and valve reconstruction for endocarditis; we believe that complete eradication of infection is essential. In addition, aggressive debridement in redo surgery with reconstruction of intervalvular fibrous body allows us to remove calcifications and place adequately sized valves. Moreover, improved intraoperative and perioperative management of the patients and the treatment of congestive heart failure contributed to superior surgical results. As for the long-term outcome, both enhanced valve design and improved management of Coumadin have led to a decrease in valve-related complications compared to that reported in older literature, including patients receiving Starr-Edwards and Björk-Shiley valves mainly.

A lot of our patients are on Coumadin preoperatively, and that is continued until a few days before surgery. We have been using Lovenox (enoxaparin) in our patients. High-risk patients including those with atrial fibrillation, severe left ventricular dysfunction, or a history of embolization are usually admitted and started on intravenous heparin. We do not administer vitamin K to any of those patients.

A lot of those patients take ACE inhibitors preoperatively, and that is restarted after surgery. I am aware of several studies showing that ß-blockers perioperatively will decrease the risk of atrial fibrillation. We have been relying more on amiodarone in our institution.

As for your final question, I have not compared the outcomes among different surgeons. The most complex and higher risk cases, especially those with invasive endocarditis, or requiring intervalvular fibrous body reconstruction, are usually done by the two senior surgeons in our institution, so I believe that comparison may be inconclusive.

DR THORALF SUNDT (Rochester, MN): We are paying more attention to the tricuspid valve now than we used to. Could you touch on the indications for going ahead and intervening on the valve? When do you make a double valve operation a triple valve?

DR ALSOUFI: We have been taking an aggressive approach toward the tricuspid valve, and any patient with moderate or severe tricuspid valve regurgitation will receive tricuspid valve repair. As for the type of repair, there has been a shift in our preference, and we have been using rings and bands more and more rather than the De Vega technique as there have been several reports, including a recent one from our institution, showing improved results with the band or ring compared to the De Vega technique. Patients with significant dilatation of the right ventricle and tricuspid valve annulus and those expected to have persistent pulmonary hypertension are more likely to receive a band or a ring. Obviously, tricuspid valves with organic valve abnormalities will be replaced.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 

  1. Gersh BJ, Schaff HV, Vatterott PJ, et al. Results of triple valve replacement in 91 patientsperioperative mortality and long-term follow-up. Circulation 1985;72:130-137.[Abstract/Free Full Text]
  2. Mullany CJ, Gersh BJ, Orszulak TA, et al. Repair of tricuspid valve insufficiency in patients undergoing double (aortic and mitral) valve replacement. Perioperative mortality and long-term (1 to 20 years) follow-up in 109 patients J Thorac Cardiovasc Surg 1987;94:740-748.[Abstract]
  3. Galloway AC, Grossi EA, Baumann FG, et al. Multiple valve operation for advanced valvular heart diseaseresults and risk factors in 513 patients. J Am Coll Cardiol 1992;19:725-732.[Abstract]
  4. Kara M, Langlet MF, Blin D, et al. Triple valve proceduresan analysis of early and late results. Thorac Cardiovasc Surg 1986;34:17-21.[Medline]
  5. Macmanus Q, Grunkemeier G, Starr A. Late results of triple valve replacementa 14-year review. Ann Thorac Surg 1978;25:402-406.[Abstract]
  6. Brown Jr PS, Roberts CS, McIntosh CL, Swain JA, Clark RE. Late results after triple-valve replacement with various substitute valves Ann Thorac Surg 1993;55:502-508.[Abstract]
  7. Feindel CM, Tufail Z, David TE, Ivanov J, Armstrong S. Mitral valve surgery in patients with extensive calcification of the mitral annulus J Thorac Cardiovasc Surg 2003;126:777-782.[Abstract/Free Full Text]
  8. De Oliveira NC, David TE, Armstrong S, Ivanov J. Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous bodyan analysis of clinical outcomes. J Thorac Cardiovasc Surg 2005;129:286-290.[Abstract/Free Full Text]
  9. d'Udekem Y, David TE, Feindel CM, Armstrong S, Sun Z. Long-term results of operation for paravalvular abscess Ann Thorac Surg 1996;62:48-53.[Abstract/Free Full Text]
  10. Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatationwhich should be the criteria for surgical repair?. Ann Thorac Surg 2005;79:127-132.[Abstract/Free Full Text]
  11. King RM, Schaff HV, Danielson GK, et al. Surgery for tricuspid regurgitation late after mitral valve replacement Circulation 1984;70(3 Pt 2):I-193-I-197.[Medline]
  12. Emery RW, Krogh CC, Arom KV, et al. The St. Jude Medical cardiac valve prosthesisa 25-year experience with single valve replacement. Ann Thorac Surg 2005;79:776-782.[Abstract/Free Full Text]
  13. Vesey JM, Otto CM. Complications of prosthetic heart valves Curr Cardiol Rep 2004;6:106-111.[Medline]
  14. Carrier M, Pellerin M, Bouchard D, et al. Long-term results with triple valve surgery Ann Thorac Surg 2002;73:44-47.[Abstract/Free Full Text]
  15. Michel PL, Houdart E, Ghanem G, Badaoui G, Hage A, Acar J. Combined aortic, mitral and tricuspid surgeryresults in 78 patients. Eur Heart J 1987;8:457-463.[Abstract/Free Full Text]



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