Ann Thorac Surg 2009;87:726-730. doi:10.1016/j.athoracsur.2008.12.005
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Valve Repair With Autologous Pericardium for Organic Lesions in Rheumatic Tricuspid Valve Disease
Hao Tang, MD,
Zhiyun Xu, MD*,
Liangjian Zou, MD,
Lin Han, MD,
Fanglin Lu, MD,
Xilong Lang, MD,
Zhigang Song, MD
Department of Cardiothoracic Surgery, Changhai Hospital, Shanghai, China
Accepted for publication December 1, 2008.
* Address correspondence to Dr Xu, Department of Cardiothoracic Surgery, Changhai Hospital, 168 Changhai Rd, Shanghai, 200433, China (Email: zhiyunx{at}hotmail.com).
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Abstract
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Background: Surgical repair of pathologic tricuspid valve disease often fails because of severe anatomic distortion of the valve apparatus, particularly in patients with rheumatic heart disease. This usually leads to tricuspid valve replacement despite the associated prosthesis-related complications. This study examines our experience of tricuspid valve repair with autologous pericardium for organic rheumatic tricuspid valve disease.
Methods: From 1996 to 2007, 31 patients underwent repairs for rheumatic tricuspid valve disease characterized by retracted leaflets and inadequate leaflet area. The patients, aged 14 to 56 years, had a mean New York Heart Association (NYHA) class of 2.9 ± 0.6. All patients presented with severe tricuspid regurgitation and coexisting left-sided heart valve disease. Glutaraldehyde-treated autologous pericardial patch was used to augment tricuspid valve leaflets. Other techniques were applied as needed, including commissurotomy, leaflet mobilization, annuloplasty, and prosthetic ring implantation. Concomitant operations included left-sided valve replacement in all, and left atrial thrombus removal in 3 patients. Follow-up duration was 4 to 126 months.
Results: No deaths or late reoperations occurred. All patients demonstrated clinical improvements on follow-up. Echocardiographic studies before hospital discharge showed less than mild tricuspid regurgitation in all patients. The most recent echocardiographic follow-up showed no tricuspid regurgitation in 10 patients (32.3%), trivial regurgitation in 12 (38.7%), mild regurgitation in 8 (25.8%), and moderate regurgitation in 1 (3.2%).
Conclusions: In selected patients, organic rheumatic tricuspid valve disease can be treated with pericardial patch to augment the retracted leaflets in combination with other techniques. Follow-up reveals excellent tricuspid valve function.
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Introduction
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Tricuspid valve insufficiency is most often functional regurgitation secondary to left-sided valvular or myocardial diseases; however, some patients will present with organic tricuspid valve pathology caused primarily by rheumatic heart disease, infective endocarditis, myxomatous disease, or carcinoid syndrome. These patients, although relatively small in population, have composed a special subgroup for which surgical treatment is more technically challenging. Conventional tricuspid valve repair techniques, such as De Vega annuloplasty, Kay-Wooler annuloplasty, and Carpentier ring annuloplasty, have proved highly effective for functional tricuspid insufficiency but are often inadequate for correction of the more pronounced valvular anatomical distortions in organic tricuspid lesions. A considerable proportion of these patients have consequently undergone tricuspid valve replacement, although it has been well established that the rate of early and late mortality rate is higher after tricuspid valve prosthetic replacement compared with valve repair [1–3].
In contrast to publications on techniques of mitral valve repair, there has been a relative paucity of reports on the surgical management of organic tricuspid valve disease. This might be attributed to the eradication of rheumatic fever in developed countries, but in China and other developing countries, where organic tricuspid disease is more common due to a relatively higher prevalence of rheumatic heart disease [4], efforts are constantly being made to seek innovative and comprehensive techniques for tricuspid valve repair. In this report we describe a novel technique of tricuspid valve repair using autologous pericardium, which according to our 12-year experience, may produce satisfactory results.
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Material and Methods
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This study was conducted under a protocol approved by the Institutional Research Board of the Changhai Hospital with a waiver of individual patient consent (March 14, 2008).
Patients
From January 1996 to December 2007, 3635 patients underwent surgical treatment for rheumatic valvular heart disease at our institution. More than mild degree of tricuspid regurgitation (2+ or more on a 4+ scale) was detected in 2730 patients by preoperative echocardiography, and organic tricuspid valve lesions were found in 226 on surgical exploration. Tricuspid valve replacement was performed in 24 patients and tricuspid valve repair in 202.
Techniques routinely involved in the repair procedures included commissurotomy, mobilization of the subvalvular structures, segmental annuloplasty, prosthetic ring annuloplasty, and double-orifice valvuloplasty. In most patients, a combination of multiple techniques was used to yield tricuspid valve competency. But in 31 patients who had inadequate leaflet tissues due to severe leaflet fibrosis and for whom these techniques had failed and valve replacement had seemed inevitable, we used a self-developed repair technique in which a patch of autologous pericardium is used to augment the leaflets and successfully restore tricuspid valve competence while preserving the native tricuspid valve.
For this study we reviewed the records of the 31 consecutive patients, which included clinical histories, perioperative echocardiograms, operative notes, and follow-up data. Specifically, preoperative and postoperative transthoracic echocardiographic (TTE) studies used in this report were obtained exclusively from our institution.
The preoperative demographics of these patients are listed in Table 1. Standard TTE was performed in each of the patients before operation, and the data are summarized in Table 2. The diagnosis of organic tricuspid valve disease was made primarily from the echocardiographic findings of fibrotic thickening of the leaflets and severe regurgitation. In particular, organic tricuspid stenosis was diagnosed according to the criteria described by Nanna and colleagues [5]. Of note, 7 patients (22.6%) in this cohort who were diagnosed with functional tricuspid regurgitation by preoperative TTE were found to have organic tricuspid valve disease intraoperatively. Coexisting left-sided valvular diseases were present in all patients. This was combined with mitral valve disease in 16 patients and with both mitral and aortic valve disease in 15. In 3 patients, thrombus formation was also found in the left atrium.
Operative Techniques
Moderate hypothermic cardiopulmonary bypass through a standard median sternotomy was used in all operations. The heart was arrested with antegrade perfusion of cold crystalloid cardioplegic solutions through the aortic root, followed by intermittent perfusion of cold blood cardioplegia every 20 minutes. In those who underwent concurrent aortic procedures, continuous retrograde perfusion of cold blood cardioplegia through the coronary sinus was used after the initial dose had been given through the aortic root.
The tricuspid valve was exposed through an oblique right atriotomy parallel to the atrioventricular groove. After inspection of the tricuspid valvular pathology, a piece of autologous pericardial patch was harvested. It was dissected free of the loose connective tissues, bathed in 0.2% glutaraldehyde solution for 10 minutes, and then taken out and rinsed 5 times with normal saline, ready for use. Mitral or aortic valve replacement or other intracardiac procedures were accomplished first before the tricuspid valve was addressed.
The tricuspid valve was exposed by 2 retractors placed near the anterior annulus through the atriotomy and retracting generously upward and rightward. The dominant mechanism of tricuspid insufficiency was studied and in this group identified to be the malcoaptation between the shrunk anterior leaflet and the septal leaflet. A curvilinear incision was made along the base of the anterior leaflet (2 mm from the annulus) between the anteroseptal and the anteroposterior commissures (Fig 1), thereby creating a deficit in the anterior leaflet. The width of the deficit (W) was measured while the free edge of the anterior leaflet was being retracted to reach the septal annulus, and the length of the deficit (L) was also measured.
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Fig 1. A curvilinear incision is made at the base of the anterior leaflet parallel to the annulus and between the anteroseptal and posteroseptal commissures. A 2-mm leaflet margin is left for pericardial patch sutures.
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The glutaraldehyde-treated pericardial patch was then fashioned into an oval-shaped strip, the width of which was determined by W + 0.5 cm, and the length by L + 0.5cm. The patch was sewn into the anterior leaflet between the cut edges by continuous stitching with 5-0 polypropylene suture (Fig 2), thereby widening the anterior leaflet and eliminating the anteroseptal malcoaptation. With the pulmonary artery occluded, tricuspid competency was examined by saline injected into the right ventricle through the valve with a bulb syringe. Remaining regurgitation was further eliminated by a variety of other common techniques, which are summarized in Table 3.
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Fig 2. The autologous pericardial patch is sewn into the created leaflet deficit, thereby widening the anterior leaflet.
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The effective valvular orifice area was improved by commissurotomies performed at the anteroseptal or posteroseptal commissural fusions, or both. In the few cases of subvalvular chordae fusions, the leaflets were mobilized by resection of some secondary chordae tendineae, as necessary. For tricuspid regurgitation with significant annular dilation, classical or segmental De Vega annuloplasty was routinely performed. In all patients with evidence of chronic right ventricular dysfunction or pulmonary hypertension, a rigid or flexible prosthetic ring was applied for prevention of further annular dilation. An average of more than three techniques (109 in 31) were used in combination for each of the patients.
Concomitant operations in this group included 16 patients with mitral valve replacement and 15 with mitral valve and aortic valve replacement. All patients received mechanical prosthetic valves because of their relatively young age. Left atrial thrombus removal was also performed in the 3 patients with thrombus formation in the left atrium.
Assessment and Follow-Up
Tricuspid valve competence was examined intraoperatively by direct inspection and by transesophageal echocardiography (TEE) after the device became available in our operating room. Postoperatively, all patients had routine TTE examination before hospital discharge. This was repeated at our institution 6 months postoperatively and then once yearly thereafter. The patients were also contacted by telephone every 6 months and were asked to answer questions designed to evaluate their life quality and heart function.
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Results
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No operative deaths occurred in this group of patients. Intraoperatively, aortic cross-clamp time was 80.5 ± 24.4 (range, 50 to 45 minutes) and cardiopulmonary bypass time was 110.2 ± 30.7 (range, 72 to 186 minutes). Postoperatively, 1 patient required mediastinal reexploration for excessive bleeding, 5 were maintained on mechanical ventilation for more than 72 hours, and 1 patient sustained acute dialysis-dependant renal insufficiency that eventually recovered before discharge. One patient presented transient third degree atrioventricular block that resolved 10 days after operation. All patients were placed on inotropic support for a mean 2.9 ± 1.0 days (range, 1 to 5 days). Warfarin anticoagulation was used in all patients postoperatively because they were all in atrial fibrillation rhythm and received mechanical prosthesis for left-sided heart valve replacement.
Intraoperative TEE in 12 patients revealed no more than mild tricuspid regurgitation, which correlated very well with the saline injection test. Predischarge TTE showed no regurgitation in 19 patients (61.3%), trivial regurgitation in 7 (22.6%), and mild regurgitation in 5 (16.1%).
Follow-up was complete in this group, and the median follow-up duration was 42 months (range, 6 to 126 months). No late death or cardiac reoperation occurred. Symptomatic improvements were noted in all patients and, as determined by their response to the telephone inquiry, all patients stayed in New York Heart Association (NYHA) class I to II with a fairly good life quality. The most recent follow-up echocardiograms showed no signs of dehiscence of the patch or patch calcification or rigidification that leads to more than moderate tricuspid valve incompetence. TTE showed no regurgitation in 10 patients (32.3%), trivial regurgitation in 12 (38.7%), mild regurgitation in 8 (25.8%), and moderate regurgitation in 1 (3.2%).
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Comment
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Tricuspid valve involvement has been reported in about one-third of the patients with chronic rheumatic heart disease, and 15% to 30% of these patients have pathologic evidence of tricuspid valve lesions [6–8]. Proper management of tricuspid valve disease has an important effect in the long-term outcome of patients with rheumatic heart disease after mitral and aortic valve replacement.
Patients with functional tricuspid regurgitation—and also some with organic tricuspid lesions—can usually be successfully treated by tricuspid valve repair [9, 10]. In other patients, however, conventional valvuloplasty techniques often fail because of the pathologic anatomy of the tricuspid valve. By our observation, these patients typically present with mildly thickened leaflets and rolling free edges, resulting in marked reduction of leaflet surface area. The annulus is frequently dilated, which worsens the malcoaptation of the leaflets and produces moderate to severe regurgitation. Although a common finding in these patients, commissural fusions rarely lead to severe stenosis of the tricuspid orifice. Lesions of the subvalvular structures are generally far less severe than those seen with the mitral valve; hence, the tethering effect is of lesser importance in the mechanism of the tricuspid regurgitation.
Prosthetic valve replacement is usually the answer for this condition, although it has long been recognized that the long-term outcome is poor after tricuspid valve replacement [11], particularly with a mechanical prosthesis because of the requirement for often-unsatisfying anticoagulation. Besides, the hemodynamic performance of the mechanical prosthetic valve in the tricuspid position is often suboptimal compared with that in the mitral position, presumably because of less vis a tergo of blood reaching the right atrium. In China and other developing countries where medical insurance coverage is still inadequate, the extra expense imposed by the prosthetic valve is also a consideration for economically stressed patients.
To address this clinical conundrum, we developed the technique described in this article after a careful analysis of the pathology of organic rheumatic tricuspid lesions. By augmenting the dimensions of the anterior leaflet (and also posterior leaflet in some cases) with autologous pericardium, the leaflet surface area is resumed, which allows for the restore of coaptation and elimination of regurgitation. This technique can also be used with other valvuloplasty techniques such as commissurotomy, chordal resection, and annulus remodeling as necessary to accomplish the competence of the tricuspid valve.
The method is technically easy, and the results are reliable and reproducible. Once the appropriate candidates were identified and the decision to repair was made, no patients in our series were ever converted to valve replacement because of technical difficulties or unacceptable TEE results.
We chose to apply this technique in relatively young patients (<65 years old) who had organic tricuspid lesions with marked leaflet-edge rolling or contraction but good leaflet motion, with or without commissural fusion. We performed tricuspid valve replacement in those who had severe tricuspid stenosis, thickened and stiffened leaflets, diseased subvalvar structures that limited anterior and posterior leaflets motion, or in those who were aged older than 65 years and eligible for a bioprosthetic valve replacement.
According to our experience, for a successful repair with this method, the following points are advisable:
- • The augmentation must be adequate, and a certain degree of "oversize" may best accomplish the goal.
- • The leaflet incision should be parallel and adjacent to the annulus, leaving a good portion of the native leaflet tissue to the inner part after reconstruction and creating a more pliable "free edge" for better coaptation and less likelihood of future deterioration.
- • This technique should be combined with other valvuloplasty techniques, where applicable, for mobilization of the leaflets, remodeling of the annulus, and prevention of future incompetence.
An important concern about the technique is the long-term outcome of the pericardial patch. Similar methods have been used in the repair of organic mitral and aortic valves with satisfactory results [12, 13]. Dehiscence of the patch was not documented in published reports or in our series.
Another practical concern is the pathologic changes that may occur to the patch in time. Fresh autologous pericardium undergoes fibrotic retraction, and pericardium that is overly treated with glutaraldehyde calcifies rapidly. Compared with the methods described by other authors [12, 13], our method differs in the concentration of the glutaraldehyde solution. We based our choice of the concentration on our previous experimental study on the "best" concentration for the pericardial patch to be endothelialized. Song and colleagues [14] reported that 0.2% glutaraldehyde-treated pericardium is associated with significantly better endothelialization compared with higher concentrations. We assume that better endothelialized pericardial patches are less likely to undergo rapid deterioration in time.
Another consideration to counter the possible retraction is the properly designed oversize of the patch, which allows for a safety margin for the leaflet area in the long run. Moreover, we believe that the durability of the patch will be better for the tricuspid valve than for the mitral or aortic valve because of the significantly lower pressure that will be exerted on the valve in the right heart system.
In conclusion, our experience with this technique indicates that in selected cases, organic tricuspid valve lesions of chronic rheumatic heart valve pathology can be treated with a comprehensive repair technique that uses autologous pericardial patch to augment the retracted leaflets in combination with other conventional techniques. Although more cases and longer follow-up are needed for better determination of its efficacy, particularly in terms of long-term outcome, present data suggest that this technique may produce excellent early and medium-term results and should be considered in the armamentarium of any surgeon who deals with rheumatic heart valve disease regularly.
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References
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Abstract
Introduction
