Ann Thorac Surg 2006;82:1729-1734
© 2006 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Triple-Valve Procedures: Impact of Risk Factors on Midterm in a Rheumatic Population
Tankut Hakki Akay, MD*,
Bahadir Gultekin, MD,
Süleyman Ozkan, MD,
Erdal Aslim, MD,
Bülent Saritas, MD,
Atilla Sezgin, MD,
Sait Aslamaci, MD
Department of Cardiovascular Surgery, Baskent University Hospital, Ankara, Turkey
Accepted for publication May 16, 2006.
* Address correspondence to Dr Akay, Çankaya PTT, PK-56 Çankaya Ankara, 06552/Turkey (Email: tankutakay{at}gmail.com).
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Abstract
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BACKGROUND: We aimed to determine the influence of preoperative, intraoperative, and postoperative variables on short and midterm results in patients undergoing triple-valve surgery.
METHODS: Between September 1989 and December 2003, 157 patients underwent triple-valve surgery with mechanical prosthetic valves. Preoperative, operative, and postoperative data were retrospectively analyzed and risk factors affecting hospital mortality and short and midterm survival were evaluated.
RESULTS: The hospital mortality was 2.5%. Multivariate analysis revealed that New York Heart Association functional class IV, low left ventricular ejection fraction (< 0.35) and increased left ventricular end diastolic diameter (> 50 mm Hg) were associated with increased short and midterm mortality. The freedom rate from reoperation and thromboembolic complications at 5 years were 93% ± 4% and 81% ± 7%, respectively. In echocardiographic assessments, significant decrease in left ventricular end-diastolic and end-systolic diameters (53.1 ± 8.3 vs 50.1 ± 7.1, p = 0.002 and 35.3 ± 7.4 vs 32.6 ± 7.2, p = 0.002) was observed.
CONCLUSIONS: Triple-valve surgery offers satisfactory short and midterm results and prevents ventricular dilatation. Mortality significantly decreases if surgery is performed before left ventricle functions deteriorate.
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Introduction
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Although there is a decline in the incidence of operations for rheumatic valve diseases in the Western world, the surgical treatment of valvular diseases still constitutes an important number of cardiac operations, especially in nonindustrialized countries. Triple-valve surgery (either replacement of aortic, mitral, and tricupid valves or combined replacement of aorta and mitral valves with tricuspid valve repair) is still a challange for most of the surgeons due to prolonged periods of cardiopulmonary bypass and aortic cross-clamp times [1–8]. Therefore; understanding the risk factors that influence the short and midterm survival after triple-valve surgery has great importance. We sought to determine the impact of preoperative, intraoperative, and postoperative variables on short and midterm (5 and 10 years) outcome of triple-valve surgery.
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Patients and Methods
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Between September 1989 and December 2003, 157 patients have undergone triple-valve surgery. In this study, triple-valve surgery defines the patients who underwent aortic and mitral valve replacement combined with either tricuspid repair or replacement during the same surgical procedure. Patients who underwent concomittant procedures (such as coronary artery bypass surgery associated with surgery) were excluded from the study. This study was approved by the Internal Review Board of our institute and detailed written informed consents were obtained from all patients after giving them information about all the procedures and the study.
There were 105 women (66.9%) and 52 men (33.1%) with a mean age of 41.8 ± 11.6 years. All patients had rheumatic valve disease with stenosis, regurgitation, or combination of stenosis and regurgitation. The number of patients who have undergone surgery formed 12.1% of total valvular surgery (n = 1,299). The mean follow-up time was 76.1 ± 42.8 months. The follow-up was complete in 146 patients (92.9%). All patients were followed at Baskent University Hospital at least once in every six month interval for a detailed physical examination combined with echocardiographic assessment, and at least once a month for arrangement of anticoagulant therapy.
Preoperative, operative, and early postoperative data (first 30 days) were retrospectively analyzed by using a computer-based databank, surgery notes, and patient files. Follow-up data were analyzed by using cardiology and cardiovascular surgery outpatient follow-up notes, computer-based databank, and telephone interviews. Information was gathered either directly from the patient or from family members.
The following preoperative and intraoperative variables were analyzed in this study: age, gender, New York Heart Association (NYHA) functional class, indication for operation, type of prosthesis, number of previous operation(s), cardiac rhythm, urgent operation, cerebrovascular accident, creatinine level, pulmonary edema, left ventricular ejection fraction (LVEF), left ventricular end-systolic and end-diastolic diameters (LVESD, LVEDD), atrial diameters, cardiopulmonary bypass, and aortic cross-clamp times. All data were obtained from a computer-based databank system to evaluate risk factors affecting hospital mortality and short and midterm survival. The echocardiographic assessments and measurements were evaluated (especially by focusing on LVESD and LVEDD) and the results were compared with the preoperative data.
Operative Technique
Median sternotomy was the standard surgical approach. Cardiopulmonary bypass was established by cannulating the ascending aorta and venae cavae through the right atrium in all patients. Myocardial protection was performed by mild hypothermia at 28°C and cardioplegic arrest was achieved by administering cold crystalloid cardioplegia into the aortic root in antegrade fashion. Coronary ostia were selectively cannulated and perfused with cardioplegia in patients with aortic regurgitation. Various types of mechanical prosthetic valves were preferred for all patients. A continuous suturing technique was preferred in mitral valve replacement. We have used four sutures in four portions of the mitral annulus (virtually dividing the mitral annulus into four hour plates). Multiple interrupted single sutures were preferred in aortic valve replacement. Tricuspid valve repair was achieved with either commissurotomy or De Vega techniques when possible. When tricuspid valve repair was not possible tricuspid valve replacement was performed.
Anticoagulant Therapy and Antibiotic Prophylaxis
In the postoperative period, permanent anticoagulation with warfarin was initiated for all patients if there was no evidence of active bleeding. Prothrombin time (PTZ) was aimed to be maintained between 23 and 30 seconds, and to keep the international normalized ratio (INR) levels between 2.5 and 3.0 in all patients. The fluctuant levels of PTZ and INR required more frequent follow-up (2 weeks or 1 month) and were arranged by either telephone interviews or in-hospital. Valve-related complications were reported according to the guidelines of the Ad Hoc Liaison Committee of The Society of Thoracic Surgeons and The American Association of Thoracic Surgery [9]. We continued antibiotic prophylaxis (prophylactic penicillin administration) after the operation.
Statistical Analysis
Statistical analysis was performed with SPSS software version 10.0 (SPSS Inc, Chicago, IL). Clinical data were expressed as mean values ± standard deviation, percents. Survival data were analyzed with standard Kaplan-Meier actuarial techniques for estimation of survival probabilities. To evaluate independent risk factors for hospital mortality, preoperative and intraoperative variables were examined by multivariate analysis by forward stepwise logistic regression. Linear regression analysis and the Student t test were used when appropriate. Continous variables were coded (ejection fraction [EF] was categorized less than or greater than 0.35, LVEDD was categorized less than or greater than 50 mm Hg, and creatinine levels greater than or less than 1.2 mg/dL, etc) and analyzed. Variables of survivors and dead patients were also analyzed with one-way analysis of variance. Differences were considered significant when p was less than 0.05.
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Results
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Preoperative and Operative Data
One hundred and thirteen patients underwent aortic and mitral valve replacement combined with tricuspid repair; in 44 patients aortic, mitral, and tricuspid valves were replaced with mechanical prosthetic valves. Prosthetic valves that were substituted and tricuspid plasty techniques are listed in Tables 1 and 2.
Operation indications were determined due to the guidelines of the American Heart Association. Congestive heart failure was the main indication for surgery. There were 14 patients (8.9%) who had undergone previous valvular surgery: closed mitral commissurotomy in 6, open mitral in 3, mitral valve replacement in 3, and aortic valve replacement in 2 patients. Atrial fibrillation was present in 64 patients (40.8%). Aortic clamp and cardiopulmonary bypass time were 95.6 ± 14.2 and 116.1 ± 19.6 minutes, respectively. Hospital stay time and intensive care unit stay times were 11.1 ± 4.2 and 3.1 ± 1.6 days, respectively.
Mortality and Morbidity
The hospital mortality was 2.5% (4 patients). Three patients died due to multiorgan failure (in one of them sepsis was also present), and one due to a stroke. In the postoperative period, the incidence of complications was 33.1% (n = 52 patients), the number of complications was 68 (43.3%) (in some patients there were more than one complication). The complications are summarized in Table 3. The majority of the complications were bleeding, renal dysfunction, congestive heart failure, supraventricular arrhythmia with rapid ventricle response, and pulmonary complications. One patient was treated with hemodialysis due to acute renal failure. There was only one patient with mediastinitis and that patient was treated with surgical debridement and antibiotic treatment. Patients with supraventricular arrhythmia with rapid ventricle response were treated with either cardioversion or various antiarrhythmic drugs. There were 64 patients (40.8%) with preoperative atrial fibrillation (AF). In the postoperative period there were 55 patients with persistant AF despite medical therapy (preoperative AF persisted in the 85.9% of the patients with preoperative AF). In 11 patients, rapid ventricle response accompanied AF. Normal sinus rhythm was maintained in these patients by the administration of antiarrhythmic agents and cardioversion. Pulmonary complications included pneumonia, atelectasis, and pleural effusions. Two patients needed pacemaker implantation due to permanent conduction block.
Risk Factors for Short-Term Survival
The 1, 5, and 10 year actuarial survival rates were 94% ± 4%, 83% ± 6%, and 73 ± 11% (Fig 1). New York Heart Association (NYHA) functional class IV, low left ventricular ejection fraction (LVEF < 0.35), increased LVEDD (> 50 mm Hg), creatinine level higher than 2 mg/dL, and pulmonary edema were found to be risk factors in short-term survival (5 years) by using univariate analysis (Table 4). Multivariate analysis revealed that only NYHA functional class IV, low LVEF (< 0.35), and increased LVEDD (> 50 mm Hg) were associated with increased short-term mortality (Table 5).
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Fig 1. The curve of Kaplan-Meier survival analysis. (The x axis represents the time in years, the y axis represents the percentage; - - - = survival function; + = censored.)
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Risk Factors for Midterm Survival
Univariate analysis revealed that female gender, NYHA functional class IV, low LVEF (< 0.35), increased LVEDD (> 50 mm Hg), and preoperative or postoperative renal dysfunction (creatinine level higher than 2 mg/dL) were risk factors in midterm survival (Table 4). But in multivariate analysis it is found that only NYHA functional class IV, increased LVEDD (> 50 mm Hg), and low LVEF (< 0.35) were associated with midterm mortality (Table 5).
The mean and median follow-up periods were 75.1 ± 42.8 and 75 months, respectively. The causes of death in patients who died after discharge were as follows: congestive heart failure in 10 patients, stroke in 2, sudden death in 5, intracranial hemorrhagia in 2, arrhythmia in 1, and other system-related causes in 2 (abdominal operation in 1 and renal failure in 1).
The freedom rate from reoperation at 5 years was 93% ± 4%. Reoperations were the following: tricuspid valve replacement in 3 patients, retricuspid valve replacement in 1 patient, reaortic valve replacement in 2 patients, and aortic paravalvular leak repair in 3 patients.
The 1, 5, and 10 year actuarial freedom rates from thromboembolic complications were 91% ± 8% , 81% ± 7%, 77% ± 9%, and freedom from major bleeding (intracranial, intraarticular, or urinary hemorraghia) due to anticoagulant therapy at 1, 5, and 10 years were 93± 5%, 88± 5%, and 83 ± 8% (Figs 2; 3).
The midterm survivors were in NYHA functional class I and II at the last follow-up. In the echocardiographic assessments, a significant decrease in LVEDD and LVESD was observed (53.1 ± 8.3 vs 50.1 ± 7.1, p = 0.002 and 35.3 ± 7.4 vs 32.6 ± 7.2, p = 0.002). A slight increase in the EF was observed when compared with preoperative calculations but it was not statistically significant (p = 0.57). Tricuspid repair or replacement had no significant effect on mortality after surgery in both the short term and long term.
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Fig 2. Kaplan-Meier curve for thromboembolic complications. (The x axis represents the time in years, the y axis represents the percentage; - - - = survival function; + = censored.)
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Fig 3. Kaplan-Meier curve for bleeding complications. (The x axis represents the time in years, the y axis represents the percentage; - - - = survival function; + = censored.)
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Comment
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Combined surgery for aortic, mitral, and tricuspid valves remains a challenge for cardiac surgeons. There are reports describing short and long-term survivals for surgery [3, 4, 5, 7–11]. Mullany and colleagues [10] reported survival rates of 58% and 35%, 5 and 10 years after aortic and mitral valve replacement associated with tricuspid repair. Galloway and colleagues [11] showed that patients undergoing triple-valve surgery had a 5-year actuarial survival of 62%. Yilmaz and colleagues [7] reported that the actuarial survival rates were 85%, 72%, and 48% at 5, 10, and 15 years after triple-valve surgery. Although Brown and colleagues [2] reported similar patient survival, they favored mechanical prostheses because of a lower rate of reoperation during follow-up. Gersh and colleagues [1] stressed that patients in NYHA class IV prior to triple-valve surgery had significantly higher hospital mortality and lower long-term survival. In our study our survival rates in 1, 5, and 10 years are 92%, 78%, and 62%, respectively, which are comparable with the other series described above. Our hospital mortality was 2.5%. In our series, the patient population was suffering from rheumatic valve disease with stenosis, regurgitation, or a combination of stenosis and regurgitation. These patients were also at a younger age. In more industrialized countries the patient population may differ. The population may consist of patients with advanced age and ischemic background (at least in the classical population of western countries). Advanced age is associated with decreased physiologic reserve and increased comorbid factors. Therefore, we believe that operation at younger age may be advantageous for better surgical outcomes. This may be the main reason for our better survival rates in this complex category of patients. The increased survival rates in our series also may be attributed to the new technology valves, improvements in myocardial protection, and close follow-up as well.
In this study we tried to investigate the risk factors affecting the short and long-term survival. We found that NYHA functional class IV, low LVEF (< 0.35), and increased LVEDD (> 50 mm Hg) are the factors that have impact on survival. Similar results have been shown by Michel and colleagues [3] and Kara and colleagues [3]. In the study by Stephenson and colleagues [12] it was reported that patients in functional class IV, those with pulmonary hypertension, and those who are operated under emergent circumstances had apparently poor prognosis. In our series there was no emergent operation.
Another important problem in the evaluation of a patient with triple valvular surgery is the surgical approach to the tricuspid valve. The type of tricuspid valve repair is not standard. Some authors believe that tricuspid rings are beneficial to achieve maximal stability of the repair of the tricuspid valve [8]. We choose to perform a De Vega annuloplasty in our institute.
The experience of prosthetic valve replacement in the tricuspid position is limited and the optimal choice for tricuspid valve is still controversial. Some authors point out that tricuspid repair or replacement had no significant effect on mortality after surgery [13]. On the other hand some authors report that replacement is associated with a high risk and a late mortality [14, 15]. We did not find tricuspid valve replacement as an independent risk factor.
Some authors have reported excellent results regarding the antithrombogenic characteristics of bioprostheses with relatively greater durability and some authors recommend this choice for tricuspid valve replacement [16, 17]. On the other hand, satisfactory results with the newly developed bileaflet mechanical valve have been demonstrated [18, 19]. We did not prefer a specific type of valve in our series. We used different types of prosthetic mechanical valves in all our patients. In our opinion, when a patient has already planned to have mechanical prostheses in the aortic and mitral position, a mechanical valve may be a better choice than a bioprosthesis, because such patients will require anticoagulation regardless of the kind of prosthesis used in the tricuspid position. Additionally, an important part of the patient population has a history of previous valve surgeries even in young ages (in our series 8.9%), so any future potential surgery should be avoided because of the possibility of bioprosthesis degeneration and increased surgical risk.
Thromboembolic events are the major problems due to anticoagulation [7–9]. Gersh and colleagues [1] reported a probability of freedom from thromboembolic events of 70% at 5 years of follow-up. In our series this rate was 81% for the same period. This may be defined as a high incidence of thromboembolic events at 5 years despite an anticoagulation regime. In developing countries, the patient cooperation seems to be the major factor concerning the problems in anticoagulant therapy and close follow-up is of vital importance in preventing possible thromboembolic events.
This study is a retrospective (although the follow-up period was performed prospectively) single center study and a larger number of patients will give more definite results. Our follow-up data cover only the midterm results. The results in 15 years will give the exact long-term results. Another limitation of our study is the lack of information about the preoperative pulmonary artery pressure in our patients as this preoperative factor may influence the surgical outcome. However, we conclude that surgery with mechanical prosthesis, either in aortic, mitral, or tricuspid positions (or aortic, mitral valve replacement associated with tricuspid annuloplasty) offers encouraging short-term, midterm, and long-term patient survival and prevents ventricular chamber dilatation. New York Heart Association functional class IV, LVEF, and increased left ventricular diameter were associated with increased midterm and long-term mortality. Earlier surgical management before the development of severe heart failure and myocardial dysfunction would improve the results of surgery. Thromboembolic events and bleeding may be decreased by very close follow-up of the anticoagulant therapy regimens.
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The Society of Thoracic Surgeons Policy Action Center
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The Society of Thoracic Surgeons (STS) is pleased to announce a new member benefit—the STS Policy Action Center, a website that allows STS members to participate in change in Washington, DC. This easy, interactive, hassle-free site allows members to:
- • Personally contact legislators with one's input on key issues relevant to cardiothoracic surgery
- • Write and send an editorial opinion to one's local media
- • E-mail senators and representatives about upcoming medical liability reform legislation
- • Track congressional campaigns in one's district—and become involved
- • Research the proposed policies that help—or hurt— one's practice
- • Take action on behalf of cardiothoracic surgery
This website is now available at www.sts.org/takeaction.
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Acknowledgments
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This study was performed only in the Department of Cardiovascular Surgery, Baskent University Faculty of Medicine, Ankara, Turkey, and there was no external financial support.
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References
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- Michel PL, Houdart E, Ghanem G, Badaoui G, Hage A, Acar J. Combined aortic, mitral and tricuspid surgery: results in 78 patients Eur Heart J 1987;8:457-463.[Abstract/Free Full Text]
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Abstract
Introduction
