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Ann Thorac Surg 2009;88:1216-1223. doi:10.1016/j.athoracsur.2009.04.121
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Early and Midterm Outcomes for Tricuspid Valve Surgery After Left-Sided Valve Surgery

Choung Kyu Park, MD, Pyo Won Park, MD*, Kiick Sung, MD, Young Tak Lee, MD, Wook Sung Kim, MD, Tae-Gook Jun, MD

Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Accepted for publication April 30, 2009.

* Address correspondence to Dr Park, Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwondong, Kangnamgu, Seoul, 135-710, Korea (Email: pwpark{at}skku.edu).

Presented at the Poster Session of the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: The purpose of this study was to compare the early and midterm results of tricuspid valve replacement (TVR) versus tricuspid valve repair (TVr) for late tricuspid regurgitation after left-sided valve surgery.

Methods: Fifty-one consecutive patients who underwent tricuspid valve surgery after left-sided valve surgery between January 1995 and April 2008 were included. Thirty-seven patients underwent TVR, and 14 patients underwent TVr. Tricuspid valve replacement was performed along with concomitant procedures in 27 patients (73.0%). Patients undergoing TVR were more likely to have severe tricuspid regurgitation (64.3% versus 89.2%; p = 0.037), or a previous history of tricuspid regurgitation repair (7.1% versus 51.4%; p = 0.004).

Results: There was no hospital death in both TVr and TVR groups. However, in comparison to TVr patients, TVR patients needed a greater amount of hemofiltration (59 ± 23 versus 80 ± 36; p = 0.026) and had longer periods of hospital stays (13.5 ± 4.4 versus 26.9 ± 25.7 days; p = 0.049). Survival rates at 1, 5, and 10 years were 97%, 93%, and 63% for patients undergoing TVR, and 93%, 93%, and 81% for patients undergoing TVr, respectively. There was no statistical difference in midterm survival rates between the two groups. Cox regression analysis revealed that left ventricular ejection fraction of 0.40 or less (p = 0.034) and age (p = 0.035) were independent predictors of late mortality after TVR or TVr.

Conclusions: Patients undergoing TVR had a more advanced preoperative tricuspid regurgitation grade and significantly prolonged hospital stays. However, there were no statistical differences in early and midterm outcomes between the two groups.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Late tricuspid valve regurgitation (TR) is a major complication after left-sided valve surgery (LSVS), as it is often associated with right ventricular dysfunction [1]. According to the literature [2, 3], TR in patients with mitral valve disease does not invariably disappear or improve after surgical correction of mitral valve disease, despite improved right ventricular hemodynamics; it often persists and can even worsen after surgery. Tricuspid regurgitation has a harmful effect on long-term survival, leading to biventricular heart failure. Moderate or greater TR has been associated with increased mortality regardless of pulmonary artery systolic pressure or left ventricular ejection fraction (LVEF) [4].

The hospital mortality of tricuspid valve (TV) replacement patients is known to be higher than that of TV repair patients. In-hospital mortality rates after TV repair versus TV replacement have been reported as 4% versus 22% (p ≤ 0.0001) [5] and 13.9% versus 33% (p ≤ 0.001) [6]. Therefore, the objectives of the present study were to compare the early and midterm results between the TV replacement and the TV repair groups and to identify the risk factors of late mortality for TV surgery.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Our institutional review board approved this study and waived the need for individual consent from patients or relatives (No. 2008-10-010). We retrospectively reviewed and analyzed the data for 51 consecutive patients who underwent TV surgery for late TR developing after LSVS. Data were extracted from hospital charts and a computerized database.

Patient Characteristics
The study population consisted of 51 consecutive patients who underwent TV surgery for more-than-moderate TR after LSVS between January 1995 and April 2008 at the Samsung Medical Center. The preoperative clinical and hemodynamic data for the study population are summarized in Table 1. The average age at the time of surgery was 53 ± 12 years (range, 24 to 74 years). Seventy-five percent (n = 38) of the patients were female. Atrial fibrillation was present in 82% of the patients (n = 42). The mean interval from previous LSVS was 10.8 ± 5 years (range, 0.2 to 19 years) in the TV replacement group and 11 ± 6 years (range, 1 to 21 years) in the TV repair group. The underlying disease was defined as rheumatic in 44 patients (86.3%), Behçet's disease in 2 (3.9%), degenerative in 3 (5.9%), cardiomyopathy in 1 (2.0%), and atrial septal defect in 1 (2.0%).


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  		Table 1 Preoperative and Operative Characteristics of Patients With Tricuspid Regurgitation Undergoing Tricuspid Valve Surgery (n = 51) a
 
Surgical Technique
Fourteen patients (28%) underwent TV repair, and 37 patients (62%) underwent TV replacement. Three techniques were used for TV reconstruction: De Vega annuloplasty in 7 patients (50%), prosthetic ring annuloplasty with a St. Jude Tailor Flexible Ring (St. Jude Medical, Inc, St. Paul, MN) in 5 patients (36%), and prosthetic ring annuloplasty with a Carpentier-Edwards Semi-rigid Ring (Edwards Lifesciences, Irvine, CA) in 2 patients (14%). Thirty of the 37 patients who underwent TV replacement (81%) received a mechanical prosthesis, and 7 patients (19%) received a bioprosthesis. Fourteen St. Jude Medical (St. Jude Medical, Inc), 11 On-X (Medical Carbon Research Institute, Austin, TX), and 5 ATS (ATS Medical Inc, Minneapolis, MN) mechanical valves were used. Two types of bioprosthetic valve were used. Six St. Jude Epic Biocor valves (St. Jude Medical Inc) and 1 Hancock valve (Medtronic Inc, Minneapolis, MN) were implanted. Biologic prostheses are the treatment of choice in elderly patients (≥65 years of age) requiring TV replacement, because the incidence of structural valve degeneration is markedly diminished in this population. Also, we implanted mechanical valves in the tricuspid position during TV replacement when the previously placed left-sided prosthetic valve is mechanical.

Isolated TV replacement was performed in 10 patients (27.0%). Concomitant procedures performed along with TV surgery are presented in Table 2. We combined TV replacement with other valve surgeries in 27 patients (73.0%). Concomitant redo aortic valve replacement was performed in 24 patients (47.1%), redo mitral valve replacement was performed in 26 patients (51.0%), and there were no concomitant coronary artery bypass graft operations.


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  		Table 2 Operative Procedures Concomitant With Tricuspid Valve Surgery
 
A standard midline sternotomy was performed in all 51 patients. Cardiopulmonary bypass was performed under mild to moderate systemic hypothermia (28° to 34°C) in a conventional manner. Tricuspid valve surgery was performed under arrested heart conditions in 48 patients (94.1%) and beating heart conditions in 3 patients (5.9%). Myocardial protection was achieved through antegrade or combined antegrade and retrograde infusion of cold (4°C) blood cardioplegia. The technique for secure fixation of a TV is with pledgeted mattress sutures using an everting suture technique. The TV leaflets are left in place, preserving the subvalvular structures. To avoid injury to the conduction tissue, in the area near the atrioventricular node, we place two or three valve sutures at the leaflets. Additionally, we applied a triangular-shaped bovine pericardial patch on the conduction area if the TV leaflet is very friable or if there is a bulging of aortic or mitral prosthetic valve. Hemofiltration was performed in 12 of 14 TV repair patients (85.7%) and in 35 of 37 TV replacement patients (94.6%). Conventional ultrafiltration was performed during cardiopulmonary bypass. Modified ultrafiltration was carried out for 3 to 8 minutes immediately after the conclusion of cardiopulmonary bypass using an adult Gambro FH 66 hemofilter (Gambro Dialysatoren GmbH, Hechingen, Germany) or an adult hemofilter (Hemofilter PAN-06; Asahi Kasei Medical Co, Tokyo, Japan).

Follow-Up
Follow-up data were obtained based on hospital chart reviews and telephone interviews with patients or family members. Follow-up was closed on April 30, 2008. We described postoperative events and results according to the guidelines for reporting mortality and morbidity after cardiac valve interventions, approved by The Society of Thoracic Surgeons [7]. Follow-up was 98% complete, with a mean follow-up period of 53.8 ± 38 months (range, 2 to 152 months). The mean time to last follow-up in the TV repair group was 68.7 ± 37 months (range, 10 to 149 months), and that in the TV replacement group was 48.2 ± 38 months (range, 2 to 152 months).

Statistical Analysis
Continuous variables are expressed as mean ± standard deviation. Categorical variables were compared using the {chi}2 test or Fisher's exact test. Continuous variables were compared using Student's t test. In the case of nonnormal distribution, the nonparametric Wilcoxon test was used.

Univariate analysis was performed using the Breslow test and log-rank test to determine whether any of the collected variables were predictors of late mortality. Multivariate analysis was performed using Cox regression as well. Survival was expressed using Kaplan-Meier curves. Midterm survival and freedom from morbid events (event-free survival status) were compared using the Kaplan-Meier method; independent predictors were determined by means of Cox regression analysis. Statistical data were analyzed using SPSS software version 12.0 (SPSS Inc, Chicago, IL). Probability values of 0.05 or less were considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Preoperative and Operative Characteristics
Table 1 shows the preoperative and intraoperative characteristics of the 51 patients who underwent either repair (n = 14) or replacement (n = 37) surgery for late TR after LSVS. The patients who required TV replacement were more likely to have severe TR (64.3% versus 89.2%; p = 0.037), a previous history of TR repair (7.1% versus 51.4%; p = 0.004), or greater amounts of hemofiltration (59 ± 23 mL/kg versus 80 ± 36 mL/kg; p = 0.026). Cardiopulmonary bypass times, aortic cross-clamp times, and EuroSCOREs [8] were not different between the two groups. The mean EuroSCORE of the TV replacement group was 7.0 ± 1.6, and that of the TV repair group was 7.6 ± 1.6 (p = 0.202 by Wilcoxon).

In-Hospital Outcomes
Early results are recorded in Table 3. Postoperative hospital stays (p = 0.049) were significantly prolonged in the TV replacement group. However, ventilator support (p = 0.512) and intensive care unit stays (p = 0.250) were similar. The values for ventilator support, intensive care unit stay, and hospital stay are expressed as median (quartile) because the values are not normally distributed. There was no hospital death in both the TV repair and TV replacement groups. No differences were found for postoperative intraaortic balloon pump insertion, acute renal failure, stroke, mediastinitis, reexploration for bleeding, delayed sternal closure, or pacemaker insertion.


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  		Table 3 In-Hospital Outcomes in Tricuspid Regurgitation Patients Undergoing Tricuspid Valve Surgery (n = 51) a
 
Long-Term Outcomes
Late complications occurred in 3 patients (21.4%), with 4 events (28.6%), in the TV repair group (2 strokes, 1 infective endocarditis, 1 [7.1%] late reoperation), and in 9 patients (24.3%), with 10 events (27.0%), in the TV replacement group (3 strokes, 1 infective endocarditis, 1 TV late thrombosis, 2 permanent pacemaker insertions, 3 (8.1%) late reoperations). There were 2 late deaths (14.3%) in the TV repair group. Causes of late mortality in the TV repair group included heart failure (n = 1), and sepsis after endocarditis (n = 1). There were 4 late deaths (10.8%) attributable to congestive heart failure in the TV replacement group. There were no statistically significant differences between the patient groups with regard to late mortality or morbidity.

Kaplan-Meier survival rates at 1, 5, and 10 years were 97%, 93%, and 63% for the TV replacement patients, and 93%, 93%, and 81% for the TV repair patients, respectively (Fig 1). There was no significant difference in midterm survival (Breslow p = 0.7379). Our results revealed that 5- and 10-year freedom from valve-related mortality were 93% ± 7% and 81% ± 12%, respectively, in the TV repair group, versus 93% ± 5% and 63% ± 20%, respectively, in the TV replacement group (Breslow p = 0.7379). There were no significant differences in valve-related mortality between the TV repair group and the TV replacement group.


Figure 1
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  		Fig 1. Kaplan-Meier curve comparing survival in patients who underwent tricuspid valve surgery (n = 51) after left-sided valve surgery. (TVr = tricuspid valve repair; TVR = tricuspid valve replacement.)

 
Late Reoperation
During an observation period of 13 years, 4 patients (7.8%) required late reoperation 1 month to 12 years (mean, 5.3 ± 5 years) after the initial operation: 1 patient (7.1%) in the TV repair group and 3 patients (8.1%) in the TV replacement group. Tricuspid valve-related reoperation was required in 1 patient (7.1%) after TV repair (64 months after initial operation) and in 1 patient (2.7%) after TV replacement (146 months after initial operation; 3.9%; 2 of 51). Tricuspid valve-related reoperation in the TV repair group was required because of partial dehiscence of the prosthetic TV ring, and in the TV replacement group was required because of TV thrombosis.

Valve-Related Complications Including Thromboembolic Events and Bleeding Complications
There was one case of late TV thrombosis after TV replacement. Five patients (2 after TV repair and 3 after TV replacement) presented with stroke as a late complication. The prevalence of freedom from TV thrombosis or stroke at 10 years after TV repair was 91.96% ± 3.84%, and that after TV replacement was 94.39% ± 3.86% (log-rank p = 0.9458). There were no late cerebral infarctions caused by cerebral embolic events in either the TV repair or TV replacement groups. The rates of event-free survival are shown in Figure 2. The linearized incidence of valve-related events for all patients was 9.22% per patient-year. There was no statistically significant difference between the two groups (Breslow p = 0.3955; log-rank p = 0.1702).


Figure 2
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  		Fig 2. Kaplan-Meier estimated freedom from valve-related events. (TVr = tricuspid valve repair; TVR = tricuspid valve replacement.)

 
Risk factor analysis using logistic regression revealed that LVEF of 0.40 or less (p = 0.018) on univariate analysis and age (p = 0.039) and LVEF of 0.40 or less (p = 0.025) on multivariate analysis were risk factors for prolonged ventilator support of greater than 72 hours (Table 4). Prolonged cardiopulmonary bypass time greater than 240 minutes was not a risk factor for prolonged ventilator support. And univariate analysis showed that significant risk factors for late mortality were preoperative LVEF of 0.40 or less (p = 0.012) and central venous pressure greater than 20 mm Hg (p = 0.014; Table 5). Multivariate analysis by Cox regression identified LVEF of 0.40 or less (p = 0.034) and age (p = 0.035) as independent predictors of late mortality after TV replacement or TV repair.


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  		Table 4 Risk Factors for Perioperative Ventilator Support a
 

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  		Table 5 Independent Predictors of Late Mortality for Tricuspid Valve Surgery After Left-Sided Valve Surgery a
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
According to the literature [1], the development of severe TR is likely to indicate right heart failure with right ventricular decompensation and dilatation. The need for TV surgery reflects an advanced stage of heart disease, often associated with severe right ventricular dysfunction [1, 3]. Tricuspid regurgitation in patients with normal leaflets is usually functional or secondary to left-sided valvular disease. It is the most common cause of TV disease in North America, and TV repair is considered to be the initial treatment of choice [9]. Tricuspid valve replacement is mainly applied to patients with organic valve disease [6].

Recently, TV surgeries, including both TV repair and TV replacement for severe TR, have been performed with acceptable hospital mortality after surgery for left-sided heart valve disease (8.8% [10], 3.6% [11]). Tricuspid valve repair is associated with a lower perioperative and midterm mortality than valve replacement (4% versus 22%; p < 0.0001 [5] and 13.9% versus 33%; p ≤ 0.001 [6]). Tang and coworkers [12] reported a 30-day mortality of 4% and 7% in a series of 702 patients who underwent TV repair with and without rings, respectively. McCarthy and coworkers [13] reported a 30-day mortality of 6% in a series of 790 patients who underwent TV annuloplasty. On the other hand, TV replacement is associated with a higher 30-day mortality than TV repair is [5]. The operative mortality and hospital mortality rates for TV replacement have been reported to be 16.4% to 26% [14–16]. In one of the most recent studies, Guenther and coworkers [6] reported that 30-day mortality after TV replacement was 33%, but during the most recent study period from 2000 to 2003, mortality also decreased to 11.1%.

Moderate or greater TR was found to adversely impact survival [4]. Tang and coworkers [12] reported that placement of an annuloplasty ring during TV repair was associated with decreased recurrence of TR and with improved long-term and event-free survival. Tricuspid valve annuloplasty has no serious associated complications, is easy to perform, requires relatively short operative time, and does not carry an increased operative risk.

In our study, there were no hospital deaths in both the TV repair and TV replacement groups. Possible reasons for favorable early results in the both TV repair and TV replacement groups are attributable to the following speculations. First, our cases were performed more recently. Our patients were younger (54 ± 12 years) than those in the study by Guenther and coworkers [6] (57.9 ± 13 years). Some authors believe that afterload reduction of the right ventricle by a decrease of pulmonary vascular resistance is critical in the patients who underwent TV surgery with right ventricular dysfunction. Overall surgical skill and myocardial protection in redo surgery have improved recently. Furthermore, we applied aggressive hemofiltration in our patients. With respect to hemofiltration, we drained greater amounts of free water compared to the study by Luciani and colleagues [17]. In our study, the mean amount of hemofiltration was 80 ± 36 mL filtrate/kg (range, 30 to 153 mL/kg) in the TV replacement group and 59 ± 23 mL filtrate/kg (range, 27 to 103 mL/kg) in the TV repair group. The mean amount of hemofiltration in the study by Luciani and colleagues [17] was 1300 mL/patient (18 mL filtrate/kg). If the vital signs were not acceptable after modified ultrafiltration, another 1 or 2 L of fluid was removed to improve hemodynamics. Modified ultrafiltration is known to reduce early morbidity and to decrease transfusion requirements in adult cardiac patients after cardiopulmonary bypass [17]. Randomized or multicenter studies are needed to prove the beneficial effects of aggressive ultrafiltration in TV surgery after LSVS.

Many authors have made TV repair the treatment of choice for functional TV disease and have made TV replacement the treatment of choice for organic TV disease, referring to the American College of Cardiology and the American Heart Association 2006 guidelines [18]. We consider performing TV replacement in patients who have failed attempts at TV repair, who have developed organic changes in the TV (especially when a stenotic component is associated), who have a history of previous TR repair, who have a severely dilated right ventricle and severe right ventricular dysfunction, or who have a history of multiple previous open cardiac operations. We think our indications for performing TV replacement after LSVS are more generous than those of other studies.

Other studies [9, 10] have documented a higher incidence of recurrent TR after De Vega annuloplasty, in addition to better long-term survival, event-free survival, and freedom from recurrent TR after annuloplasty ring placement; we now predominantly use ring annuloplasty. Prosthetic ring annuloplasty seems to be performed more frequently in the recent study period compared with the previous study period [6].

The early outcomes analyzed in our study, such as 30-day mortality and morbidity, appeared favorable, but midterm results such as Kaplan-Meier survival at 10 years remained unsatisfactory. Late mortality also remained high, presumably because of heart failure. Heart failure is considered a systemic inflammatory disease, which eventually progresses to end-stage disease. Several authors have reported the influence of surgery type on midterm outcome. Singh and coworkers [5] reported better perioperative, midterm, and event-free survival in patients with organic TV disease who underwent TV repair as opposed to TV replacement. They reported that the 10-year survival after TV repair was 76% ± 5% and that after TV replacement was 55% ± 6% (log-rank p ≤ 0.001) [5]. Guenther and coworkers [6] reported that TV repair resulted in significantly better survival when compared with TV replacement (at 10 years, 47.5% ± 3.5% versus 37.0% ± 4.8%, respectively; p = 0.002).

Currently, right ventricular function is considered to be one of the most important factors in midterm and long-term survival in patients with valvular heart disease [19]. Pinzani and coworkers [20] reported that operative mortality increased from 5% to 11% in the presence of right ventricular failure, and late mortality increased from 8% to 22%. If right heart failure persisted after valve replacement, patients had a higher 5-year mortality rate (39% versus 4% for patients without right heart failure; p < 0.0001). Hence, we could speculate that the functional status of the right ventricle is very important in predicting the prognosis and outcomes of patients undergoing valve surgery. Therefore, we think surgical correction of significant TR should be done in an expedient manner, before irreversible damage is sustained to the right ventricle secondary to advanced left-sided valvular lesions. In addition, the status of the right ventricle needs to be assessed thoroughly in these patients during preoperative clinical evaluation [13]. We currently evaluate right ventricular function with cardiac magnetic resonance imaging.

Study Limitations
Our study is limited by its retrospective nature with all of the inherent limitations. No consistent, accurate echocardiographic data (especially in the early operative period) were available. This study has a relatively small number of cases, and the duration of the late follow-up was short. But all patients in our study had a history of previous LSVS, and therefore this report is a helpful study comparing TV repair with TV replacement for late TR after LSVS. Preoperative evaluation of right ventricular function such as magnetic resonance imaging was not available in the early operative period in these studies.

Conclusions
In the present study, patients undergoing TV replacement had more advanced preoperative TR grade and significantly prolonged hospital stays. However, there were no statistical differences in early and midterm outcomes between the two groups. On multivariate analysis, LVEF of 0.40 or less and age (p = 0.035) were independent risk factors of late mortality for TV surgery.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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  7. Akins CW, Craig Miller D, Truina MI, et al. Guidelines for reporting mortality and morbidity after cardiac valve interventions Ann Thorac Surg 2008;85:1490-1495.[Free Full Text]
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  18. Bonow RO, Carabello BA, Kanu C. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary: a report of American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons Circulation 2006;114:450-527.[Free Full Text]
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