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Ann Thorac Surg 2008;86:1485-1493. doi:10.1016/j.athoracsur.2008.07.007
© 2008 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Eight-Year Outcomes of Tricuspid Annuloplasty Using Autologous Pericardial Strip for Functional Tricuspid Regurgitation

Byung-Chul Chang, MD, PhDa,*,*, Suk-Won Song, MD, PhDb,*, Sak Lee, MDa, Kyung-Jong Yoo, MD, PhDa, Meyun-Shick Kang, MD, PhDa, Namsik Chung, MD, PhDc

a Division of Cardiovascular Surgery, Yonsei Cardiovascular Center and Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
c Division of Cardiology, Yonsei Cardiovascular Center and Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
b Division of Thoracic and Cardiovascular Surgery, Yongdong Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

Accepted for publication July 1, 2008.

* Address correspondence to Dr Chang, Division of Cardiovascular Surgery, Yonsei Cardiovascular Center, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul, 120-752, Republic of Korea (Email: bcchang{at}yuhs.ac).

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 Footnotes
 Acknowledgments
 References
 
Background: Although several techniques of tricuspid annuloplasty have been used to treat tricuspid regurgitation (TR), TR can persist or recur with redilatation of the annulus or disease progression. We compared the long-term results of newly developed tricuspid annuloplasty procedure using autologous pericardial strip with that of conventional suture annuloplasty.

Methods: From January 1997 to April 2006, 334 patients (mean age, 52.7 years) underwent tricuspid annuloplasty for functional TR. Concomitant procedures included mitral valve replacement in 261 patients and mitral-aortic valve replacement in 73. We performed conventional suture annuloplasty (De Vega or Kay) in 117 patients and autologous pericardial strip annuloplasty in 217 patients.

Results: There were 8 in-hospital deaths (mortality, 2.4%). Mean follow-up was 42.1 months, and total follow-up duration was 1,145 patient-years. Significant TR before discharge was noted in 34 patients (11.1%). The severity of TR improved with time in the autologous pericardial strip annuloplasty group; however, it became worse in conventional suture annuloplasty group (p = 0.05). Multivariate analysis demonstrated that preoperative severity of TR and conventional suture annuloplasty were significant predictors of recurrent TR. Overall survival was comparable between two groups (p = 0.742); however, recurrence-free survival was better for the autologous pericardial strip annuloplasty group than for the conventional suture annuloplasty group (86.8% versus 71.9%; p = 0.039).

Conclusions: The long-term recurrence-free survival after autologous pericardial strip annuloplasty appeared to be better than that of conventional suture annuloplasty. Autologous pericardial strip annuloplasty appears to be a simple, easily reproducible, and valid option for surgical treatment of functional TR.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Discussion
 Footnotes
 Acknowledgments
 References
 
Tricuspid regurgitation (TR), which often accompanies mitral or mitral and aortic valve disease, is mostly functional rather than organic and is associated with pulmonary hypertension or right ventricular dilatation [1]. Although surgical management for functional TR can be easily performed, postoperative morbidity and mortality are high when severe TR is combined with other left heart valve disease.

Because many asymptomatic patients are in early stages of TR, there are questions regarding the indications and appropriate technique for TR [2]. Tricuspid annuloplasty (TAP) techniques for the treatment of TR include the De Vega [3] and Kay [4] methods and ring annuloplasty [5, 6], each of which gives acceptable results. However, there are still problems in recurrence after TAP, which has been used for a long time.

Beginning in 1998, we developed a new method of TAP using autologous pericardial strip and nonabsorbable mattress suture technique. This method was considered to maintain annular structures, to maintain flexibility of right ventricular pumping action, and to prevent redilatation. In this study, we compared the long-term results of TAP using autologous pericardial strip with those using conventional suture annuloplasty. In addition, we also analyzed the risk factors for recurrence of TR after TAP.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Discussion
 Footnotes
 Acknowledgments
 References
 
From January 1997 to April 2006, 334 patients (mean age, 52.7 years) underwent annuloplasty for tricuspid valve regurgitation at the Yonsei Cardiovascular Center, Severance Hospital, Yonsei University College of Medicine. This study was approved by our institutional review board (Yonsei IRB No. 4-2008-0017), and informed consent was obtained from the patients and next of kin for use of surgery-related clinical and serologic data.

Patients with concomitant procedures, such as coronary artery bypass grafting or aortic surgery, or patients who underwent TAP using prosthetic annuloplasty ring were excluded from this analysis. Patients with endocarditis or significant organic disease of the tricuspid valve leaflets or patients with congenital anomalies were also excluded. However, patients with TR with mild fibrosis of the tip of the tricuspid valve were included in this study. Patients who underwent mitral valve repair were also excluded, because confounding phenomenon of residual mitral regurgitation after surgery could impact on the TR. Therefore, we only included patients who underwent TAP with mitral valve replacement and mitral-aortic valve replacement. Patients' preoperative, operative, and postoperative variables were retrieved from the prospectively collected computerized Yonsei Cardiovascular Surgery Database System.

Concomitant procedures included mitral valve replacement in 261 patients and mitral-aortic valve replacement in 73 patients. The three types of annuloplasty used were the De Vega and Kay methods, performed in 117 patients (C-TAP group), and autologous pericardial strip annuloplasty (AP-TAP), performed in 217 patients; use of the latter was started in February 1998 (Fig 1). Types and size of the annulus of the TAP were selected with the preference of the surgeons. We followed anticoagulation protocol after TAP according to that of left-sided heart valve replacement.


Figure 1
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  		Fig 1. Tricuspid annuloplasty techniques during the study period (white bar, autologous pericardial strip tricuspid annuloplasty; shaded bar, conventional suture tricuspid annuloplasty).

 
Patients' records included age, sex, presence of previous heart surgery, findings of physical examination (cyanosis, jaundice, neck vein engorgement, ascites, hepatomegaly, and pitting edema), diagnosis, New York Heart Association functional class, liver function test (aspartate aminotransferase, alanine aminotransferase, total bilirubin), and presence of atrial fibrillation on electrocardiogram.

Three surgeons performed operations during the study periods (M.S.K., K.J.Y., B.C.C.). The choice of TAP methods was selected by the surgeons' preference. Patients with TR grade II or less underwent TAP based on the surgeon's decision with preoperative clinical data or echocardiographic report. However, all patients with significant TR equal to or higher than grade III underwent TAP.

Beginning in February 1998, all AP-TAPs were performed exclusively by a single surgeon (B.C.C.). After preparing an autologous pericardial strip (6 to 7 cm in length, 3 to 5 mm in width), the pericardial strip was folded over for smooth outer surface and was sutured to the tricuspid annulus with interrupted mattress sutures of 10 to 12 nonabsorbable 2-0 Ethibond suture (Ethicon, Inc, Somerville, NJ), starting from the posteroinferior aspect of the septal leaflet to the anterior septal commissure. Two- to three-millimeter-interval sutures in the autologous pericardial strip and 5- to 6-mm-interval sutures in the tricuspid annulus can shorten the tricuspid annulus by 50% to 67% (Fig 2). When two thirds of the circumference of the tricuspid valve was shortened to 7 cm, a tricuspid annular diameter would be reduced to about 2.7 to 3.2 cm. After the procedure, we measured the annulus diameter using a valve sizer that we made. The entire procedure may be accomplished in less than 15 minutes.


Figure 2
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  		Fig 2. Tricuspid annuloplasty using autologous pericardial strip. (A) Operative photograph of the autologous pericardial strip - tricuspid annuloplasty. (B) Schematic drawing of annuloplasty. To make a tricuspid diameter (2R) about 27 to 32 mm after tricuspid annuloplasty, estimated length of autologous pericardial strip (L) is approximately 2/3 to 3/4 x 2{pi}R {fallingdotseq} approximately 60 to 70 mm. (AL = anterior leaflet; CS = coronary sinus; PL = posterior leaflet; SL = septal leaflet.)

 
To evaluate the TR immediately after TAP in the operating room, saline was injected into the right ventricle of the arrested heart. After the operation, a transesophageal echocardiogram was performed in all patients and recorded after termination of cardiopulmonary bypass. A favorable result was defined when TR was less than grade II.

Patient Follow-Up
The status of all patients was assessed cross-sectionally in 2007. Data were obtained by telephone interview with patients, their families, or physicians using an institutional review board–approved questionnaire. Echocardiographic reports as well as functional status, vital status, and occurrence of tricuspid valve reoperations were solicited from the Yonsei Cardiovascular Hospital Database System. Patients lost to follow-up in January 2007 were considered traced from time of surgery to time of last contact. Ten patients were lost to follow-up, and 96.9% (316 of 326) of patients were followed up completely. Mean follow-up duration was 42.1 ± 34.5 months (median, 35 months; range, 12 to 121 months), and the total follow-up duration available for analysis was 1,145.2 patient-years.

Assessment of Tricuspid Annuloplasty
Preoperative and postoperative transthoracic echocardiographic results were used to assess grade of TR and right ventricular systolic pressure. Postoperatively, echocardiography was performed routinely in all patients before discharge. None of the echocardiographic data in this report was based on intraoperative determinations. Follow-up echocardiograms were available in 289 of the 316 patients (91.5%) during the follow-up periods. A total of 919 postoperative echocardiographic reports were analyzed. Median duration from surgery to follow-up echocardiographic assessment was 2.5 years (25th percentile, 1 year; mean, 3.4 ± 2.5 years; range, 0.5 to 8.8 years).

Hemodynamic indices of pre-TAP and post-TAP changes included grade of TR, central venous pressure (right atrial pressure), right ventricular systolic pressure, left ventricular ejection fraction, and mean pulmonary artery pressure. Tricuspid regurgitation was graded conventionally as grades I through IV, determined by the regurgitant area on echocardiograms before and after TAP. Central venous pressure and pulmonary artery pressure were recorded using a Swan-Ganz catheter after induction of general anesthesia, immediately after surgery, and on the first postoperative day in the intensive care unit.

Right ventricular systolic pressure was measured indirectly by measuring the velocity of TR flow, and left ventricular ejection fraction was measured by two-dimensional echocardiography. All echocardiographic examinations were performed by a skilled echocardiography technician and confirmed by cardiologists.

Endpoints
We compared the long-term results of AP-TAP with those of C-TAP in patients with functional TR. We also assessed the risk factors for recurrence of TR after surgery, as well as the overall survival and recurrence-free survival in both groups, and the degree of functional improvement after tricuspid valve repair.

Statistics
All data are presented as mean ± standard deviation of the mean. All statistical analyses were performed using the Statistical Package for Social Sciences Software version 12.0 (SPSS Inc, Chicago, IL). Preoperative and operative categorical variables were compared between groups using Fisher's exact test, whereas continuous variables were compared using Student's t test. Tricuspid regurgitation as a function of time, including mean TR and prevalence of TR grade, was evaluated for each annuloplasty technique using repeated-measures mixed models (SAS Proc Mixed; SAS Institute, Inc, Cary, NC) and longitudinal ordinal logistic regression (SAS Proc Glimmix). These longitudinal methods ensured that patients with more repeat echocardiograms or more follow-up visits were not given excessive weight and did not have a disproportionate influence on estimated means and proportions as a function of time. Survival curves were calculated by the Kaplan–Meier method and compared using the log-rank test. Probability values less than 0.05 were considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Discussion
 Footnotes
 Acknowledgments
 References
 
Preoperative patient characteristics are provided in Table 1. There were 117 patients who underwent C-TAP and 217 patients who underwent AP-TAP. There was a statistically significant difference in mean age between the two groups (C-TAP, 49.8 ± 12.4 years versus AP-TAP, 54.2 ± 12.2 years; p = 0.002). There were 31 women among 117 patients in the C-TAP group and 56 women among 217 patients in the AP-TAP group (p = 0.897). Preoperatively, 31 patients (11.1%) were in New York Heart Association functional class IV in the C-TAP group. Meanwhile, 56 patients were class IV in the AP-TAP group (16.6%; p = 0.073). In contrast, there was a large percentage (64.1%) of significant TR equal to or greater than grade III in the C-TAP group compared with 54.4% in the AP-TAP group. However, this was not statistically significant different. Also, there were higher incidences of neck vein distention (28.2% versus 13.8%; p = 0.002), hepatomegaly (10.3% versus 5.0%; p = 0.107), and pretibial pitting edema (14.5% versus 8.3%; p = 0.092) in the C-TAP group.


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  		Table 1 Patient Characteristics and Preoperative Variables
 
Preoperative hemodynamic data are listed in Table 2. There was no statistical difference between the two groups in terms of preoperative left ventricular ejection fraction, central venous pressure, right ventricular systolic pressure, and mean pulmonary artery pressure.


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  		Table 2 Preoperative Echocardiographic and Hemodynamic Data
 
Operative Mortality
There were 4 (1.8%) early deaths (within 30 days of surgery or during the same hospitalization) in the AP-TAP group and 4 (3.4%) in the C-TAP group. The causes of death included right heart failure in 2 patients, sepsis in 4 patients, left ventricular rupture in 1 patient, and cardiac tamponade in 1 patient. During long-term follow-up, there were 10 deaths (3.1%); the causes of death included acute myocardial infarction in 1, right heart failure in 3, cerebral hemorrhage in 1, progression of liver cirrhosis in 1, and unknown in 4 patients.

Hemodynamic Improvement of Tricuspid Valve According to Tricuspid Annuloplasty Methods: Changes in Tricuspid Regurgitation as a Function of Time
To assess the overall efficacy and durability of annuloplasty, we evaluated TR grades by three different methods. We determined TR grade in echocardiography at last follow-up, freedom from development of TR equal to or greater than grade III as a function time using Kaplan–Meier analysis, and serial echocardiographic assessment for mean TR and TR prevalence as a function of time using longitudinal regression analysis. The degree of TR grade improved significantly immediately after TAP without significant difference between two groups. From baseline to last follow-up, mean TR grade decreased approximately 60% in both groups (Fig 3A). At the last echocardiographic follow-up, TR in the AP-TAP group was grade 0 to I in 73.9%, grade II in 16.4%, grade III in 4.0%, and grade IV in 5.7%. However, in the C-TAP group, TR grade was 0 to I in 64.7%, grade II in 19.1%, grade III in 5.9%, and grade IV in 10.3%. Figures 3B and 3C show predicted TR prevalence as a function of time in both groups. Evolution of TR was similar in both groups. Mean TR grade dropped significantly after surgery, was maintained for up to 3 years, and increased gradually from 3 to 5 years postoperatively. Mean TR improved as a function of time in the AP-TAP group; however, it got worse in the C-TAP group (p = 0.05; Fig 3A). The percentage of patients with TR equal to or greater than grade III was higher in the C-TAP group than in the AP-TAP group, but the distribution of TR grade was similar in the two groups.


Figure 3
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  		Fig 3. Predicted mean tricuspid regurgitation (TR) and tricuspid regurgitation prevalence using longitudinal regression analysis. (A) Mean change in tricuspid regurgitation as a function of time for each annuloplasty technique (p = 0.050). (B) Predicted prevalence of tricuspid regurgitation grades after autologous pericardial strip tricuspid annuloplasty (AP-TAP). (C) Predicted prevalence of tricuspid regurgitation grades after conventional suture tricuspid annuloplasty (C-TAP). (TAP = tricuspid annuloplasty.)

 
Central Venous Pressure (Right Atrial Pressure), Right Ventricular Pressure as a Function of Time: Left Ventricular Ejection Fraction and Functional Status
Central venous pressure (right atrial pressure) decreased significantly in both groups after TAP without significant difference between the two groups (p = 0.75). Right ventricular pressure also decreased significantly as a function of time after TAP, but there was no difference between the two groups (p = 0.97). Left ventricular ejection fraction did not change significantly after surgery (p = 0.40), and there was no difference between the two groups (p = 0.68). Although New York Heart Association functional class improved significantly after TAP in both groups, there was no difference between the two groups (p = 0.79).

Risk Factors for Residual Tricuspid Regurgitation After Tricuspid Annuloplasty
We evaluated the effect of preoperative and intraoperative variables on the occurrence of significant residual TR after TAP, defined as grade III or higher. Of the 334 study patients, 296 (88.6%) had echocardiograms 7 days after surgery. Of those, 33 (11.1%) had grade III or IV TR, and 17 (5.7%) had grade IV TR after TAP. Univariate analysis showed that preoperative hepatomegaly and neck vein engorgement, and preoperative TR grade were risk factors for residual TR after TAP (p < 0.05). By multivariate binary logistic regression analysis, higher preoperative TR grade (odds ratio, 2.954; 95% confidence interval, 2.132 to 4.093; p < 0.001) was identified as an independent predictor for development of significant postoperative residual TR after TAP. In this study, there was significant postoperative residual TR early after De Vega or Kay annuloplasty in 11.8% (11 of 93 patients) and in 10.8% (22 of 203 patients) after AP-TAP (p = 0.843). The method of TAP was not identified as a risk factor for postoperative residual TR.

Risk Factors for Recurrent Tricuspid Regurgitation During Follow-Up
We also evaluated the effect of preoperative, intraoperative, and follow-up variables on recurrent TR during follow-up, defined as grade III or higher. Univariate analysis showed that preoperative hepatomegaly, neck vein engorgement, preoperative TR grade, left atrial diameter, suture annuloplasty, and atrial fibrillation during follow-up were risk factors for recurrent TR during follow-up (p < 0.05). Multivariate binary logistic regression analysis showed that preoperative TR grade (odds ratio, 8.743; 95% confidence interval, 3.232 to 23.652; p < 0.0001) and suture annuloplasty (odds ratio, 6.307; 95% confidence interval, 1.843 to 21.580; p = 0.003) were independent predictors for recurrence of TR during follow-up (Table 3). According to the Cox proportional hazards model, higher preoperative TR (odds ratio, 6.823; 95% confidence interval, 2.783 to 16.724; p < 0.0001) and the use of suture annuloplasty (odds ratio, 2.718; 95% confidence interval, 1.054 to 7.009; p = 0.039) were risk factors for development of recurrent TR (Fig 4B).


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  		Table 3 Univariate and Multivariate Logistic Regression Analysis for Recurrent Tricuspid Regurgitation After Operation
 

Figure 4
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  		Fig 4. Kaplan–Meier curves of overall survival (A) and echocardiographic recurrence-free survival (B) at 8 years in the autologous pericardial strip tricuspid annuloplasty (AP-TAP) and conventional suture tricuspid annuloplasty (C-TAP) groups. Overall survival was 92.1% in the autologous pericardial strip tricuspid annuloplasty group and 95.6% in the conventional suture tricuspid annuloplasty group (p = 0.742). Echocardiographic recurrence-free survival was 86.8% in the autologous pericardial strip tricuspid annuloplasty group and 71.9% in the conventional suture tricuspid annuloplasty group (p = 0.039).

 
Postoperative Early and Late Major Complications
Thirty patients (12.0%) had early postoperative complications, including reexploration for postoperative bleeding in 6, right heart failure in 10, bleeding associated with warfarin in 7 (gastric bleeding in 5 and cerebral hemorrhage in 2), cerebral infarction in 1, transient ischemic attack in 2, paravalvular leakage in 1, Torsade de point in 1, pericardial effusion in 10, and pleural effusion in 2. Thirty-three patients (10.1%) had late major complications during follow-up, including cerebral hemorrhage in 1, other bleeding complications with warfarin in 6, pericardial effusion in 5, arrhythmia in 4, cerebral infarction in 7, right heart failure in 6, mechanical valve dysfunction in 1, and infective endocarditis in 3 patients.

Reoperation
A total of 6 patients underwent reoperation during the follow-up period (reoperation rate, 1.9%). Two of the reoperations were necessary because of left-sided valvular disease (prosthetic valve endocarditis and prosthetic valve failure). One patient who had previous TAP with the Kay method underwent redo-TAP with De Vega method. Three patients who had previous TAP with De Vega, Kay, and autologous pericardial strip underwent tricuspid valve replacement because of recurrent severe TR. Two patients (33%) died after reoperation.

Survival
Overall survival for up to 8 years after surgery was comparable in the C-TAP and AP-TAP groups (95.6% versus 92.1%; p = 0.742; Fig 4A). Echocardiographic recurrence-free survival at 8 years was higher in the AP-TAP group than that of the C-TAP group (86.8% versus 71.9%; p = 0.039; Fig 4B).


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Discussion
 Footnotes
 Acknowledgments
 References
 
Treatment of patients with functional TR with left-sided valvular heart disease remains important in cardiac surgery owing to uncertainties regarding accurate diagnosis, surgical indication, the appropriate surgical procedure, and the late results of surgical treatment. Tricuspid regurgitation left uncorrected at the time of surgery for left-sided valvular disease has been reported as a predictor of unfavorable outcomes [7, 8]. Surgical treatment of moderate to severe TR has been recommended to enhance prognosis [7–10], but a mild degree of functional TR is expected to diminish after surgical relief of left-sided valve disease [11]. After suture TAP using the De Vega or Kay method, the tricuspid annulus can contract flexibly with the right ventricular pumping action, but elevation of right ventricular pressure can enhance complications, including suture material detachment and escape. In contrast, ring annuloplasty with the Carpentier-Edwards ring may be associated with loss of tricuspid annular contraction involved in right ventricular function; however, it can prevent redilatation and recurrence of TR. Therefore, questions have arisen regarding the most physiologic and biocompatible method for TAP.

Beginning in February 1998, we have performed TAP using autologous pericardial strips, which are flexible and can prevent redilatation against highly elevated right ventricular pressure. We have compared the early and long-term results of this newly developed TAP method using autologous pericardial strips with conventional suture annuloplasty. We also evaluated the risk factors for postoperative residual TR and recurrent TR during follow-up period.

Long-term outcomes of De Vega TAP were reported as a good surgical technique; however, it was associated with a postoperative residual TR of grade II in 29.9%, grade III in 11.1%, and grade IV in 4.3% of patients, a reoperation rate of 1.2% owing to failure of TAP, and an operative mortality rate of 11.1% [12]. In a second study, postoperative residual TR after De Vega TAP was grade II in 10.2% and grade III in 4.1% of patients, and the operative mortality rate was 7.6% [13]. In a study reporting the operative results of De Vega TAP, postoperative residual TR higher than grade II was 12%, and the operative mortality rate was 12% [14]. Echocardiograms in 194 patients who underwent TAP by De Vega or ring annuloplasty demonstrated that 49 patients (25%) had residual TR higher than grade II, and the operative mortality rate was 8.9% [15].

Risk factors for recurrent TR after TAP include recurrence of left-sided valvular heart disease, progression of right heart dysfunction, postoperative pulmonary artery pressure, postoperative pulmonary vascular resistance, and preoperative TR grade [8, 9, 16–18].

The operative mortality rate in our series was 2.4%, which is lower than that of other series [12–15] of TAP (7.6% to 28%), probably owing to the recent patient cohort with good myocardial protection strategy and with relatively early operation before development of severe heart failure.

Thirty-three (11.1%) patients had significant residual TR 7 days after TAP, and those numbers were comparable to the rates of 12.0% to 45.3% in other series [12–15]. And preoperative TR grade was the only independent predictor for development of postoperative residual TR after TAP. However, in this study the TAP method used did not have a significant impact on immediate postoperative residual TR.

Recently, TAP using prosthetic rings was performed in several reports for functional TR [19, 20]. They reported that suture bicuspidization annuloplasty was comparable to ring annuloplasty during 3 years postoperatively. At 3 years postoperatively, TR in patients treated by bicuspidization annuloplasty was zero to mild in 75%, moderate in 11%, moderate to severe in 6%, and severe in 8% of patients. In those undergoing ring annuloplasty, TR was zero to mild in 69%, moderate in 14%, moderate to severe in 7%, and severe in 10%. There was no significant difference between the two groups (p = 0.18). Our data with autologous pericardial strip is comparable with their ring annuloplasty. However, the long-term effect of ring annuloplasty more than 3 years after the procedure was not clear.

In our study, we have evaluated TR as a function of time after conventional and autologous pericardial strip TAP. In our experience, mean TR, which was decreased significantly after the operation, was unchanged for up to 3 years, but it was increased gradually from 3 to 5 years postoperatively in most patients in the suture annuloplasty group. Meanwhile, mean TR improved as a function of time in the AP-TAP group (p = 0.05). This result suggests that autologous pericardial strip annuloplasty prevents redilatation of the tricuspid annulus, whereas suture annuloplasty does not.

During long-term follow-up, higher preoperative TR and use of the suture annuloplasty technique were significantly associated with development of recurrent TR. In terms of atrial fibrillation during follow-up, it was associated with recurrence of TR (p = 0.034) in the univariate analysis, whereas it was not statistically significant in multivariate analysis (Table 3). Association between atrial fibrillation and recurrent TR should be further explored in the future.

Patients with no or mild TR have been reported to have a significantly lower mortality than patients with moderate-to-severe TR [21]. In our analysis, 73.9% of patients after 5 years of AP-TAP had no or grade I TR. Thus, we believe that TAP should be performed not only in patients with severe TR, but in all patients with even less than moderate TR, especially when an effective annuloplasty technique can be performed rapidly and reproducibly. Dreyfus and colleagues [22] even advocate that any patient with substantial annular dilation should undergo repair regardless of TR grade or even no TR, because annular dilation eventually would produce TR in the long-term follow-up. We believe that autologous pericardial strip annuloplasty is a relatively simple, inexpensive technique that can be performed rapidly. Therefore, we suggest that AP-TAP can be used in all patients with TR, even mild TR with annular dilatation, at the time of left-sided valve surgery. McCarthy and associates [20] reported that rigid ring annuloplasty showed superiority compared with suture-based TAP because of persistent postoperative pulmonary hypertension. We agree with McCarthy's group if we perform TAP in the patient with severe right ventricular failure and annular dilatation. However, we believe that most of the right ventricular failure and pulmonary hypertension are reversible and autologous pericardial strip annuloplasty can maintain normal physiologic tricuspid annulus with normal annular motion during systole and diastole.

There were several limitations in this study. First, the echocardiographic data were subject to significant selection and ascertainment bias. Symptomatic patients were more likely to receive follow-up echocardiography than asymptomatic patients. Although the statistical methods we used were adjusted for these differences, the true TR prevalence may have been lower if all patients were routinely screened with echocardiography. Second, this is a retrospective analysis. The patients were not randomized, creating an inherent selection bias with regard to the annuloplasty performed. In our institute, however, the choice of TAP method was selected by an individual surgeon. Although preoperative variables of the two groups were very similar, the AP-TAP group was slightly older than the other group. Finally, there were no definite criteria regarding reduction in tricuspid annular size. Further comparisons of TAP methods should be carried out in a prospective randomized manner.

In conclusion, we have demonstrated that suture annuloplasty (ie, the De Vega or Kay method) and autologous pericardial strip annuloplasty for functional TR were equally effective for TAP in functional TR for up to about 3 years postoperatively. Subsequently, however, TR grade appeared to be getting worse in the conventional suture annuloplasty group. However, overall survival and New York Heart Association functional class during follow-up were not significantly different between the two groups. These results indicate that although echocardiographic TR improved significantly in the AP-TAP group compared with the C-TAP group, all differences between the two groups were subclinical. Preoperative TR grade and use of suture annuloplasty were independent risk factors for development of recurrent TR during long-term follow-up. Follow-up TR grade and echocardiographic recurrence-free survival were superior in the AP-TAP group.

In conclusion, AP-TAP can be considered for a routine technique for patients with functional TR with dilatation annulus undergoing aortic or mitral valve surgery because it is very simple and inexpensive and a reliable method for TAP.


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
Footnotes
 Acknowledgments
 References
 
DR GUS J. VLAHAKES (Boston, MA): In looking at the drawing of the finished annuloplasty procedure, does the pericardial strip cross the commissure between the posterior and septal leaflets?

Second question: Is recurrent tricuspid regurgitation related to late pulmonary artery pressure?

DR CHANG: I'd like to show you the last slide regarding the changes of right ventricular pressure, comparing the preoperative and the postoperative changes of right ventricular pressure. As you can see in this slide, most of the patients have a decrease in their pulmonary artery pressure after the operation, and there was no differences between the two groups.

And for the surgical technique, we started the annuloplasty sutures at the inferior margin of the septal leaflet, crossed the septal posterior commissure, and finished at the anterior septal commissure. We focused on reducing the septal-posterior and the posterior-anterior commissures.

DR ROBERT S.D. HIGGINS (Chicago, IL): Can you postulate why there is a survival benefit with the autologous technique as opposed to conventional annuloplasty intermediate?

DR CHANG: There was no statistically significant difference between the AP-TAP (autologous pericardial strip tricuspid annuloplasty) group compared to the suture annuloplasty group. However, the long-term survival is better than any other previous reports. The reason we assume is that our patient group is younger than those of other reports from western countries, and the United States. Our patient group is about 55 years old and Dr McCarthy's reported mean age is about 65.

And also, we excluded the patients who underwent mitral valve repair, because the residual mitral regurgitation may influence the postoperative pulmonary artery pressure and it would affect the grade of tricuspid regurgitation.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 Footnotes
 Acknowledgments
References
 
The authors are grateful to Soon-Young Sul, RN, for her valuable contributions in collecting the data and for providing the schematic illustration used in this article.


   Footnotes
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 Footnotes
Acknowledgments
 References
 
* The first two authors contributed equally to this work. Back


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 Footnotes
 Acknowledgments
 References
 

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