Ann Thorac Surg 2006;81:2179-2182
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Edge-to-Edge Tricuspid Valve Repair: An Adjuvant Technique for Residual Tricuspid Regurgitation
Yong-Qiang Lai, MD
*
,
Xu Meng, MD,
Tao Bai, MD,
Chun Zhang, MD,
Yi Luo, MD,
Zhao-Guang Zhang, MD
Division of Cardiac Surgery, Beijing Anzhen Hospital, Capital University of Medical Sciences, Beijing, China
Accepted for publication January 10, 2006.
* Address correspondence to Dr Lai, Division of Cardiac Surgery, Beijing Anzhen Hospital, Capital University of Medical Sciences, 36 Wuluju Chaoyang District, Beijing 100029, China. (Email: yongqianglai{at}yahoo.com).
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Abstract
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BACKGROUND: Tricuspid regurgitation is a very common valve disease. Significant morbidity and mortality is associated with tricuspid valve replacement and tricuspid valve plasty is still a preferred choice. Because of the abnormality of valve and subvalvular apparatus, tricuspid valve plasty is sometimes complicated and associated with suboptimal results. This report deals with our surgical experience in using edge-to-edge valve plasty technique in cases with severe residual tricuspid regurgitation.
METHODS: From April 2001 to November 2004, 15 patients with severe residual tricuspid regurgitation underwent edge-to-edge tricuspid valve plasty. The etiology of tricuspid regurgitation was secondary to rheumatic heart disease in 5 cases, secondary to congenital heart disease in 5 cases, to congenital tricuspid valve dysplasia in 1 case, and to posttraumatic and degenerative disease in 2 cases, respectively. After tricuspid valve repair was performed with traditional methods, severe tricuspid regurgitation was still present. Edge-to-edge tricuspid valve plasty was used in these patients.
RESULTS: There was 1 hospital death. No or trivial tricuspid regurgitation was found in 6 cases, and mild tricuspid regurgitation was present in 9 cases after operation. The follow-up ranged from 8 to 51 months (median, 25.3). Trivial to mild tricuspid regurgitation was present in 12 cases and mild to moderate tricuspid regurgitation in 2 cases.
CONCLUSIONS: Edge-to-edge tricuspid valve plasty is an effective adjuvant procedure for patients who have severe residual tricuspid regurgitation.
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Introduction
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Tricuspid regurgitation (TR) secondary to pulmonary hypertension due to left-sided heart valve lesions or left-to-right shunt congenital heart disease is very common. Significant morbidity and mortality is associated with tricuspid valve replacement (TVR) in this setting. Most series reported the operative mortality for TVR to be 14.3% to 24.5% [1–6]. Tricuspid valve plasty (TVP) is still a preferred choice for patient with TR. Tricuspid valve plasty is complicated in some patients because of the abnormality of the valve and subvalvular apparatus. Annuloplasty sometimes does not completely resolve this problem, and severe residual TR may still present. It remains a great challenge for cardiac surgeons to repair complicated tricuspid lesions and to correct severe residual TR in this setting.
The edge-to-edge valve plasty technique, as described by Alifieri and colleagues [8], has been used in a standardized approach to treat mitral leaflet prolapse and regurgitation with low mortality and a high percentage of freedom from reoperation [7–9]. Recent studies suggest that it is also effective for TR with good surgical results [10–13]. Herein, we report our surgical experience in using edge-to-edge tricuspid valve plasty (ETVP) to correct severe residual TR in patients with tricuspid valve pathology.
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Material and Methods
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The study was approved by our Institutional Review Board, and individual consent was obtained before each operation. From April 2001 to November 2004, 452 patients received TVP in our institute, and 15 of them (3.3%) with severe residual TR underwent ETVP. There were 7 females and 8 males. The age ranged from 14 years to 67 years (mean, 37.5). The etiology of TR was secondary to rheumatic heart disease in 5 cases, secondary to congenital heart disease in 5 cases, to congenital tricuspid valve dysplasia in 1 case, and to posttraumatic and degenerative in 2 cases, respectively. Four patients were in New York Heart Association (NYHA) functional class II, 6 in class III, and 5 in class IV. Seven patients had atrial fibrillation. Prior mitral valve replacement had been performed in 2 cases (Table 1).
The operation was performed under cardiopulmonary bypass and mild hypothermia. Cold antegrade blood cardioplegia was used in all patients. The tricuspid valve was exposed through a conventional oblique right atriotomy. Tricuspid valve plasty was performed after surgical correction of other concomitant anomalies. Concomitant intracardiac procedures included mitral valve replacement and aortic valve replacement in 2 cases, mitral valve replacement or repair in 6 cases, atrial septal defect repair in 3 cases, and atrioventricular canal correction in 2 cases.
All TVP procedures were performed with the heart arrested. Annuloplasty included ring annuloplasty (Medtronic, Minneapolis, Minnesota) in 12 cases and posterior annulus Key repair in 3 cases. Other TVP procedures included chordal replacement, leaflet transfer, and leaflet enlargement with autologous pericardium. Three patients underwent chordal replacement. Chordal replacement was performed by attaching a single 4-0 Gore-Tex suture (W. L.Gore & Associates, Flagstaff, Arizona) to the free edge of the prolapsed tricuspid leaflet. The suture then passed through the corresponding papillary muscle, adjusted to proper length, and tied. Part of the septal leaflet of tricuspid valve was absent in 2 cases. Posterior leaflets and part of the anterior leaflet were incised along the annulus and advanced to amend the absent septal leaflet. The anterior and posterior leaflets were sutured together to bicuspidalized the tricuspid valve in 1 case. Because the chordae tendineae was short and thick in 1 patient with congenital tricuspid valve dysplasia, the tricuspid valve was rendered parachutelike, and absence of central coaptation of the leaflets due to severe tethering was detected. The leaflets were enlarged with autologous pericardium to increase leaflet apposition. After the correction, tricuspid valvular competence was tested by loading the right ventricle with saline solution. Tricuspid leaflet apposition was found obviously inadequate in 13 patients, and ETVP was applied in these patients simultaneously. Severe residual TR was found during rewarming with epicardial echocardiography in 2 cases. The aorta was reclamped, and ETVP was used to correct TR.
The residual TR was usually central in these patients. Stay stitches were placed to approximate the free edges of leaflets at the site of regurgitation. A U-shaped 5-0 polypropylene (Prolene; Ethicon, Somerville, New Jersey) stitch reinforced with small pericardial pledgets was applied. The suture was passed through the middle point of the free edges of the tricuspid leaflets, just at the edge turned down to attach to the primary chordae (Fig 1). After ETVP was created, a cold saline injection was repeated. Tricuspid leaflet apposition was assessed to avoid postoperative distortion and residual leakage. If marginal residual regurgitation was still present, direct edge-to-edge suture was used to eliminate the regurgitation. The orifices were measured with sizers. After weaning from cardiopulmonary bypass, epicardial or transesophageal echocardiography were performed to reevaluate valve function.
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Fig 1. A U-shaped 5-0 polypropylene stitch reinforced with small pericardial pledgets passes through the middle point of the free edges of the tricuspid leaflets. The anterior leaflet is anchored to the facing edges of posterior and septal leaflets to create a triple orifice tricuspid valve.
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All of the patients were reexamined with transthoracic echocardiography before discharge. Follow-up periods ranged from 8 to 51 months (25.3 ± 14.4). Follow-up information regarding clinical status and echocardiographic findings were obtained (Table 2).
The results are expressed as means ± SD. Statistical significance was obtained by two-tailed paired t test for continuous variables.
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Results
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There was 1 hospital death (hospital mortality 6.7%). This patient received MVR, ETVP, and ablation for atrial fibrillation. She died of multiorgan failure on the 10th postoperative day. One patient required reexploration and recovered well. The intensive care unit courses were uneventful, with no postoperative morbidity in other patients. They were extubated within 24 hours after operation.
The valve orifice area ranged from 2.5 cm2 to 4.0 cm2 (3.1 ± 0.4 cm2). No or trivial TR was found in 6 cases, and mild TR presented in 9 cases after operation. Mean diastolic transtricuspid valve gradient ranged from 1.6 mm Hg to 4.8 mm Hg (3.0 ± 1.0 mm Hg) before discharge.
During a mean 25.4 months of follow-up, no late mortality occurred. Transthoracic echocardiography demonstrated trivial-to-mild TR in 12 cases and mild-to-moderate TR in 2 cases. There was a statistically significant reduction of the right ventricle size (36.6 ± 14.7 mm versus 27.6 ± 9.6 mm; p < 0.05). Mean diastolic transtricuspid valve gradient ranged from 2.2 mm Hg to 4.6 mm Hg (3.3± 0.9 mm Hg) during follow-up. No tricuspid stenosis was revealed in any patient. Seven patients were in NYHA functional class I and 7 in class II.
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Comment
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Tricuspid regurgitation secondary to pulmonary hypertension due to left-sided heart valve lesions or left-to-right shunt congenital heart disease is a common valve problem in China. Despite improvement in myocardial protection, cardiopulmonary bypass technique, and postoperative care, tricuspid valve operations are still challenging for cardiac surgeons. Tricuspid valve replacement has been associated with high morbidity and mortality. Most series reported the operative mortality for TVR was 14.3% to 24.5% [1–6]. The late survival rate is also suboptimal, with the 5-year and 10-year survival at 56% to 70% and 45% to 52%, respectively [1, 14–16]. Tricuspid valve plasty is still the preferred choice for TR. Residual TR and recurrent TR are two important risk factors for tricuspid valve reoperation. Residual TR occurred in 14% of patients early after operation for all types of annuloplasty [17]. Residual TR of more than grade 2 early after tricuspid annuloplasty was a significant risk factor for late tricuspid valve reoperation [18]. It is a great challenge to repair complicated tricuspid lesions and correct the residual TR in these patients.
Although traditional repair may solve most regurgitation problems, it is inadequate to effectively correct TR in some complicated lesions. Because of the abnormality of the valve and subvalvular apparatus, tricuspid leaflet apposition was usually inadequate after traditional TVP, and severe residual TR may still present in some patients. Several surgical techniques have been applied to resolve TR before ETVP was applied in our patients, but the results are disappointing. In this circumstance, ETVP was applied as an adjuvant technique for residual TR, with a relatively satisfactory result in our patients. No or trivial TR was found in 6 cases, and mild TR was present in 9 cases after operation.
Edge-to-edge valve plasty was first described and applied by Alifieri and colleagues [8], and it has been used in a standardized approach to treat mitral leaflet prolapse and regurgitation with a low mortality and a high percentage of freedom from reoperation [7–9]. Repair of a regurgitant valve is superior to valve replacement, and is associated with lower hospital mortality, longer survival, better preservation of ventricular function, fewer thromboembolic complications, and reduced risk of endocarditis. This is more beneficial for TR, because of the poor early and late results of TVR. Recently, several reports suggested that edge-to-edge valve plasty was also effective for TR with good surgical results [10–13]. Tricuspid regurgitation may be organic or functional secondary to left-side heart valve lesions. It is difficult to distinguish organic versus functional TR in some circumstance. Regardless of the etiology, the hemodynamics of TR are similar and can cause the dilation of right ventricle and right heart failure. The etiology of TR is complicated in our patients. It includes TR secondary to rheumatic heart disease and congenital heart disease, congenital tricuspid valve dysplasia, and posttraumatic and degenerative TR. That indicates that in association with other TVP procedures, ETVP can be effectively applied in many kinds of TR to avoid TVR with relatively good results.
The operative techniques for TVP have been dictated by the specific anatomical lesions and the surgeon's clinical judgment at the time of surgery. Generally, traditional TVP techniques can provide good relief of TR and result in a low rate of failure and good patient survival at a long-term follow-up [19, 20]. For some complicated lesions, traditional TVP techniques cannot satisfactorily correct TR, and residual TR still presents. That may add to the risks for tricuspid valve reoperation in the future. In this situation, traditional TVP techniques in association with ETVP can effectively solve some complicated problems. Indeed, ETVP procedure is more effective to correct central regurgitation than routine procedures. The procedure is simple as described by Alifieri and associates [11]. We usually use one 5-0 polypropylene stitch reinforced with small pericardial pledgets. The small pericardial pledgets can reduce the stitch tension to prevent the suture from dehiscence. Greater stitch tension on the mitral valve had been demonstrated in diastole after Alfieri procedure, and it might, at least in theory, affect the durability of the procedure [21]. If marginal residual regurgitation is present, direct edge-to-edge suture can be applied to eliminate the regurgitation easily.
The long-term result of edge-to-edge valve plasty is still controversial. The etiology of valve regurgitation is an important factor that affects the surgical results [8, 22]. During follow-up, mild-to-moderate TR was present in 2 patients. Edge-to-edge tricuspid valve plasty and posterior annulus Key repair was applied in one of them. The progress of TR may be caused by the dilation of tricuspid annulus. Clinical observation had found that stabilization of the tricuspid annulus with a ring had a better long-term results [17]. A similar phenomenon was also observed in mitral valve plasty. Residual mitral regurgitation with a trend to progress was noticed without a ring annuloplasty [23, 24]. To get an improved long-term result, it is better to use ETVP in association with a ring annuloplasty for these complicated tricuspid valve lesions. It may reduce the occurrence of regurgitation deterioration after operation.
In conclusion, edge-to-edge tricuspid valve plasty is an easy and effective adjuvent procedure for patients who have complex lesions and severe residual tricuspid regurgitation.
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Acknowledgments
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The authors acknowledge Dr Gus J. Vlahakes, Chief, Division of Cardiac Surgery, Massachusetts General Hospital, for reviewing this manuscript.
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Abstract
Introduction
