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Ann Thorac Surg 2009;88:1845-1850. doi:10.1016/j.athoracsur.2009.08.052
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Results of 141 Consecutive Minimally Invasive Tricuspid Valve Operations: An 11-Year Experience

Teng C. Lee, MD, Bhargavi Desai, BS, Donald D. Glower, MD*

Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina

Accepted for publication August 20, 2009.

* Address correspondence to Dr Glower, Box 3851, Duke University Medical Center, Durham, NC 27705 (Email: glowe001{at}mc.duke.edu).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: Reports of minimally invasive tricuspid valve operations are rare. We reviewed our experience and results of tricuspid valve operation using mini-thoracotomy during an 11-year period.

Methods: Consecutive patients (n = 141) undergoing tricuspid valve operation using mini-thoracotomy were retrospectively analyzed. Access was through a 6-cm right thoracotomy and cardiopulmonary bypass was instituted by means of the femoral artery (n = 16) or ascending aorta (n = 125) with augmented venous return. In most cases, vacuum assist without caval occlusion and snaring the cavae was used to minimize mediastinal dissection. In all cases, the tricuspid valve operation was done with the heart unclamped, and the heart either beating or fibrillating.

Results: Seventy-three percent (103 of 141 patients) of the patients underwent combined mitral and tricuspid valve operations. The tricuspid valve was repaired instead of being replaced in 61% (86 of 141 patients). Previous sternotomy was present in 49% (69 of 141 patients). The average patient age was 64 years. Conversion rate to median sternotomy was only 3% (4 of 141 patients). The mean cardiopulmonary bypass time was 216 minutes. Thirty-day mortality was 2.1% (3 of 141 patients). Stroke occurred in 2.8% (4 of 141 patients), and reexploration for bleeding occurred in 5.6% (8 of 141 patients). The stroke rate was 3 of 16 patients (18.8%) using mini-thoracotomy through femoral cannulation versus 1 of 125 patients (0.8%) through aortic cannulation (p = 0.005).

Conclusions: In this largest reported series of patients undergoing tricuspid valve operation, mini-thoracotomy provides excellent short-term morbidity and mortality in these high-risk patients while avoiding redo sternotomy with a low conversion rate. Mini-thoracotomy with aortic cannulation is an attractive alternative approach to the tricuspid valve, particularly in patients with previous sternotomy.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Minimally invasive approaches to the mitral valve and aortic valve have been well described either through a mini-thoracotomy or partial sternotomy [1–7]. The term minimally invasive here is defined as an operation using smaller than usual incisions [8]. However, there is a paucity of studies regarding minimally invasive tricuspid valve operations [4]. Since 1997, we have performed tricuspid valve operations through a right mini-thoracotomy as the procedure of choice, and hence have accumulated 11 years of experience in this technique. We describe here the results in a large series of tricuspid valve operations through a right mini-thoracotomy incision.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
All patients who underwent a tricuspid valve operation using mini-thoracotomy between 1997 and June 2008 at Duke University Medical Center were retrospectively reviewed. The Institutional Review Board approved the study and granted a waiver of patient consent. The indication for tricuspid valve operation in all patients was the presence of at least moderate to severe tricuspid regurgitation (usually severe) along with New York Heart Association class III or more symptoms or other signs of right heart failure, including pedal edema, ascites, pleural effusion, or central venous pressure greater than 14 mm Hg.

Surgical Technique
Patients were all positioned supine with the right shoulder elevated. After intubation with a dual-lumen endotracheal tube or a single-lumen tube with a bronchial blocker, a 6-cm right anterolateral thoracotomy incision was made over the fourth intercostal space. The fourth intercostal space was then entered. A reusable chest retractor (Edwards Lifesciences, Irvine, CA) provided upward lift on the third and fourth ribs. The pericardium was opened vertically from the diaphragm to the base of the brachiocephalic artery, exposing the ascending aorta and staying 2 cm anterior to the phrenic nerve. Lateral retraction sutures were placed on the posterior pericardial edge, and the patient was anticoagulated with heparin.

Initial venous access was obtained by passing a percutaneous wire from the right femoral vein into the superior vena cava using transesophageal echocardiography guidance. A 25F venous catheter (QD-25; Edwards Lifesciences) was passed over the wire into the femoral vein after serial dilations. The venous cannula was placed in the right atrium using a combination of transesophageal echocardiography, direct visualization, or palpation using a finger or instrument. Bicaval cannulation was delayed until just before the tricuspid procedure to avoid cluttering the operative field.

The patients underwent either direct aortic or femoral artery cannulation. Before femoral arterial cannulation, the descending thoracoabdominal aorta and iliofemoral arteries were assessed using either arteriography or computed tomography. Because of limited choices in available cannulas, femoral arterial cannulation was the technique of choice early in the series. Once better aortic cannulas became available later in the series, aortic cannulation was preferred unless contraindicated. Candidates for aortic cannulation were screened for appropriate aortic anatomy by a combination of aortography, computed tomography, transesophageal echocardiography, and direct inspection to avoid cannulation near prior grafts or significant aortic disease. For aortic cannulation, a 16-gauge needle was passed through the first intercostal space in the midclavicular line with the needle directed toward the chosen aortic cannulation site 1 to 1.5 cm proximal to the base of the brachiocephalic artery. An 11.5-mm port was then inserted along the path of the 16-gauge needle after withdrawing it. When inserted through the port, the aortic cannula and introducer (DF-K-24 or SS-23; Edwards Lifesciences) should point directly at the chosen cannulation site. Two concentric pursestring sutures of pledgeted 2-0 polyester were placed at the aortic cannulation site. Using a retractable blade incorporated into the aortic cannula introducer, the cannula was passed through the port between the pursestring suture and into the aorta. The aortic cannula was then secured with plastic tourniquets that were brought through the 11.5-mm port. Sixteen of the patients underwent femoral artery cannulation.

After initiation of cardiopulmonary bypass, total drainage of the atrium was accomplished using vacuum assist. Any mitral valve procedure was performed first using either cardioplegic arrest or ventricular fibrillation. Arrest was achieved by using an external Cosgrove clamp applied directly to the ascending aorta below the arterial cannulation site. Antegrade cardioplegia was delivered through a 4-0 polypropylene pursestring suture in the ascending aorta. Retrograde cardioplegia was delivered through a coronary sinus catheter through the thoracotomy directly into the right atrium. The surgical field was flooded with carbon dioxide at a flow of 2 L/min.

The tricuspid procedures were all done after completion of any mitral procedure to decrease cross-clamp time. In patients who required systemic hypothermia as the only option to maintain ventricular fibrillation (owing to a scarred mediastinum or open coronary grafts), we performed the tricuspid procedure during rewarming. A 28F angled venous cannula was placed in the superior vena cava through a pursestring suture. We also retracted the femoral venous cannula into the inferior vena cava. This was followed by placing tourniquets around the superior and inferior vena cavae if feasible and needed to prevent excessive air entrapment into the venous cannulas. Otherwise, reduced vacuum assist at 10 to 15 cm H2O without caval tapes was usually adequate to avoid entrapment of air in the venous circuit. With air entrapment eliminated from the venous circuit, no excess micro air embolism was noted on transcranial Doppler or on transesophageal echocardiography. Coronary sinus blood was returned with a flexible suction device in the coronary sinus orifice, and the relatively anterior location of the tricuspid valve generally provided a dry view of the valve itself, despite the beating heart. The tricuspid procedure was done during normal cardiac rhythm in all patients to avoid left ventricular distension from ventricular fibrillation and to avoid prolonged aortic clamping. Tricuspid repair was preferred over replacement, and tricuspid replacement was used when leaflet fibrosis or distortion was sufficient to preclude successful repair from annuloplasty or local leaflet resection. The right atrium was opened with a linear vertical atriotomy, and the right atrium was held open using a dedicated atrial retractor passed through the chest wall (Edwards Lifesciences). Standard tricuspid valve repair or replacement techniques were used.

With the right atrium closed, the patient was ventilated and rewarmed to 36°C, and cardiopulmonary bypass was discontinued. The aortic cannula was removed, and the aortic pursestring sutures were secured with direct manual tying through the thoracotomy. Both superior and inferior venous cannulas were removed, and the 1-cm groin puncture site was closed with a 2-0 absorbable suture in the subcutaneous tissue followed by a 3-0 absorbable subcuticular suture.

A right pleural chest tube was placed through a separate stab incision. A silicone elastomer sump catheter was placed through the right pleura into the pericardium and brought out through a separate stab incision as well. The pericardium was then loosely closed. The thoracotomy incision was closed in a standard fashion. The chest tube was removed within 12 hours and the silicone elastomer drain was removed in 3 to 4 days.

Statistical Analysis
Data analysis was performed with StatsDirect (Chesire, United Kingdom), and all categorical data were expressed as proportions or 25th percentile/median/75th percentile. Continuous variables were expressed as mean ± standard deviation. Survival was calculated using the Kaplan-Meier method. Statistical significance was defined as a probability value less than 0.05.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
A total of 141 consecutive patients who underwent tricuspid valve operations were included in this analysis. The average patient was 64 years old with severe tricuspid regurgitation and significant congestive heart failure (New York Heart Association functional class III or IV). Other demographic data and comorbidities are listed in Table 1. About a quarter of our patients had renal disease (often as a result of high diuretic dependency from right heart failure), and slightly more than half had atrial fibrillation. The causes of tricuspid disease are listed in Table 2.


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  		Table 1 Demographics
 

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  		Table 2 Tricuspid Etiologies
 
Our follow-up was 100% complete (as of July 1, 2008) with a mean follow-up of 31.2 ± 32.4 months. Follow-up was performed by phone contact with patients, family members, or referring physicians or by accessing the national death index. However, only 45% of the patients had a local echocardiogram available at follow-up owing to a large number of patients being referred from other medical centers.

Only 25% (n = 35) of patients had isolated tricuspid valve operations (both repair and replacement). A combined mitral and tricuspid procedure was performed in 104 of 141 patients (74%; Table 3). Previous sternotomies were present in 49% of patients. Of all the tricuspid valve operations, 55 patients (39%) had their tricuspid valve replaced whereas 86 patients (61%) had their tricuspid valve repaired. A bioprosthesis was used in all cases when the valve had to be replaced. Average valve size was 27 ± 2 mm. Of the 55 tricuspid repairs, 22 of 55 procedures (40%) used a rigid ring, 24 of 55 procedures (44%) used a flexible ring, and 9 of 55 procedures (16%) used a DeVega suture annuloplasty, with the flexible ring annuloplasty being preferred in the later series. Total clamp time in 67 patients was 101 ± 35 minutes. Operations were performed without clamping in 74 patients. Average cardiopulmonary bypass time was 216 ± 78 minutes.


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  		Table 3 Associated Surgical Procedures
 
Overall 30-day mortality was 2.1% (Table 4). Patients who underwent tricuspid valve repair had a 30-day mortality of 2.3% whereas those who underwent tricuspid valve replacement had a 30-day mortality of 1.8% (p = 1.0). Perioperative morbidity was otherwise relatively low (Table 4). Four patients (2.8%) had to be converted to median sternotomy. The reasons for conversion included bleeding and inability to apply the cross-clamp. Nine patients (6.3%) required reoperations for bleeding. Sixteen patients had pericarditis, but none had mediastinitis. Four patients had stroke. Three strokes occurred in patients with femoral cannulation, and only one stroke occurred in the aortic cannulation group (3 of 16 patients [18.8%] versus 1 of 125 patients [0.8%]; p = 0.005). Transient postoperative delirium occurred in 8 of 141 patients (6%) and was not associated with presence or absence of caval tapes.


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  		Table 4 Outcomes
 
Freedom from reoperation for tricuspid valve disease was 100%. Late tricuspid regurgitation grade in patients undergoing tricuspid repair was 0.8 ± 0.9 (n = 63) at 1.1 ± 1.8 years of follow-up. Overall survival was 65% at 5 years and 48% at 10 years (Fig 1). Survival at 5 years was 72% ± 6% for patients having combined mitral and tricuspid surgery versus 48% ± 12% for patients having tricuspid surgery alone (p = 0.2).


Figure 1
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  		Fig 1. Patient survival after tricuspid valve operation through a right mini-thoracotomy.

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
There is a paucity of literature regarding the treatment of tricuspid valve disease when compared with mitral valve disease. However, cardiologists and cardiac surgeons increasingly recognize it as an important entity in structural heart disease. Cardiac operations through a right mini-thoracotomy have been used increasingly by many centers in the world. Excellent midterm results have been published for mitral valve operations using this technique [5–7]. Most of these studies reported having less wound infection, less bleeding, less pain, and earlier return to work. However, there is a lack of data regarding tricuspid valve operations. Almost all the currently available literature regarding minimally invasive tricuspid operations are included in mitral valve studies. We present here our midterm results on a large series of minimally invasive tricuspid valve operations during an 11-year period.

Traditionally, tricuspid valve operations through a standard sternotomy were related with high morbidity and mortality. Data from The Society of Thoracic Surgeons database as reported by Rankin and colleagues [9] showed an unadjusted 30-day mortality rate of 10.7% for isolated tricuspid valve surgeries and 10.8% for combined tricuspid and mitral valve surgeries. This is in line with other reported series with mortalities ranging from 4% to 22% [10–21]. However, overall 30-day mortality was 2.1% in our series when we combine both replacements and repairs.

We believed that we were able to achieve our low morbidity and mortality through a right mini-thoracotomy approach to the tricuspid valve because of several important technical considerations that have evolved and been refined during the last 11 years. Achieving adequate lung isolation either through the use of a double-lumen endotracheal tube or bronchial blockers allows for better visualization in a small space. To provide a bloodless working environment, we used bicaval cannulation techniques with caval tapes. However, in recent years, we have been increasingly using vacuum assist without caval tapes to achieve a bloodless field. This is a useful technique in reoperative situations when it is not easy to dissect out the cavae to put tapes around them. However, caution is still warranted with this technique to avoid air entrapment in the venous return and risk of arterial microembolism. In many patients we have also used the technique of ventricular fibrillation without aortic clamping. This is especially useful in reoperative situations when it is not easy to get a clamp across the aorta, especially when there are multiple grafts from previous coronary artery bypass graft procedures. However, this technique is contraindicated if there is an incompetent aortic valve.

Like the current series, some early reports of valve surgery through a right mini-thoracotomy showed a higher incidence of stroke with femoral versus aortic cannulation [22–24]. This may partly be attributable to peripheral cannulation with associated risk of retrograde embolism from the descending thoracoabdominal aorta. Yet the current series and others may also be biased in that femoral artery cannulation was used in the earlier experience. Femoral artery cannulation has been associated with a lower stroke rate in more recent series [25].

Although the operative mortality was low in this high-risk group, the late survival of about 60% at 5 years was not unlike that of other series of tricuspid valve operations in high-risk patients [16, 17, 26, 27]. Prior cardiac surgery, concurrent mitral valve surgery, and a high incidence of other comorbidities such as renal, coronary, or lung disease all would diminish late survival relative to other series of isolated tricuspid or first-time tricuspid operations in younger patients [21, 28]. As in most series of patients with functional tricuspid disease, our patients generally had extended preoperative histories of valvular heart disease. These long-term outcomes emphasize the growing interest in addressing tricuspid regurgitation earlier in the natural history of the disease [29].

In our series, 39% of patients had tricuspid valve replacement instead of repair. Traditionally, tricuspid valve replacements had been associated with significantly higher early mortality [14, 17, 20, 30]. Recent studies have shown improved mortality with replacement [16], as was seen in out results. To avoid recurrent tricuspid regurgitation, we have been more liberal in replacing tricuspid valves in recent years, especially in patients with markers of long-standing disease, such as previous operations, pacemaker, recurrent tricuspid regurgitation, chronic atrial fibrillation, or pulmonary hypertension.

There are several disadvantages related to this minimally invasive technique. Operative times and cardiopulmonary bypass times were longer than might have been expected for standard sternotomy. These longer times probably resulted from working in a smaller surgical field, along with the fact that one half of procedures were reoperative with attendant scarring and adhesions. Other reports have actually seen a less significant increase in procedure time versus sternotomy when comparable reoperative sternotomy cases are examined [22]. There is also a significant learning curve associated with this procedure, and our report spans the entire curve including our initial experience. The costs of disposable equipment for this technique are also higher because of the cannulas used. A major disadvantage of this technique is the inability to perform an aortic valve or pulmonic valve procedure or coronary artery bypass grafting. Hence, it is essential to have complete echocardiographic and catheterization evaluation of the patient before surgery.

The major limitation of this study is the fact that it is a retrospective study at a single center, and therefore will inevitably be biased in patient selection and in the technique used. Although this is one of the largest reported series of tricuspid valve operations through a right mini-thoracotomy, it is still a small series with only 141 patients. Additionally, we do not have long-term follow-up data beyond 10 years with this technique. Although the incomplete echocardiographic follow-up limits conclusions about the durability of the tricuspid repairs, the lack of subsequent reoperation or significant known valve failures is reassuring. Finally, this series cannot compare results directly with those of standard sternotomy because no control group was examined.

In conclusion, tricuspid valve operations through a mini-thoracotomy incision are safe and are associated with low morbidity and early mortality. It has become the standard of care at our institution. Further studies are required to allow a direct comparison between mini-thoracotomy and median sternotomy. Long-term data are also needed regarding the durability of these procedures.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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