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Ann Thorac Surg 2002;73:44-47
© 2002 The Society of Thoracic Surgeons

Original article: cardiovascular

Long-term results with triple valve surgery

Michel Carrier, MD*b, Michel Pellerin, MDb, Denis Bouchard, MDb, Louis P. Perrault, MD, PhDb, Raymond Cartier, MDb, Yves Hébert, MDb, Arsène Basmadjian, MDa, Pierre Pagé, MDb, Nancy C. Poirier, MDb

a Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
b Department of Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada

Accepted for publication August 31, 2001.

* Address reprint requests to Dr Carrier, Montreal Heart Institute, Research Center, 5000 Bélanger St East, Montreal, Quebec, H1T 1C8 Canada
e-mail: carrier{at}icm.umontreal.ca


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. Whether to use biological or mechanical prostheses and whether to repair or replace the tricuspid valve during primary and reoperative triple valve surgery remains controversial. The objective of the present study was to review our experience with primary and reoperative triple valve surgery using CarboMedics (CM) and Carpentier-Edwards (C-E) heart valves.

Methods. All 73 patients undergoing triple valve surgery since 1982 were prospectively followed at the Montreal Heart Institute valve clinic. Aortic valve replacement was performed with CM prostheses (57 patients) and with C-E prostheses (16 patients). Mitral valve replacement was performed with mechanical prostheses (56 patients) and with biological valves (14 patients). Mitral valve repair was done in 3 patients. Tricuspid valve annuloplasty or commissurotomy or both were performed in 66 patients and the tricuspid valve was replaced in 7 patients. Patient survival, complications, and the type of valve procedures were analyzed.

Results. Thirty patients averaging 62 ± 10 years of age underwent primary triple valve surgery and 43 patients averaging 60 ± 10 years of age underwent reoperative triple valve surgery (p = 0.5). Tricuspid repair consisted of annuloplasty with the Bex linear reducer (n = 47), the C-E ring (n = 13), or the De Vega technique (n = 5). Tricuspid valve replacement was done using the C-E pericardial prostheses. The 30-day mortality was 17% and 12% in patients with primary and reoperative surgery, respectively (p = 0.5) and patient survival averaged 80% ± 7%, 75% ± 8%, and 41% ± 15%, and 70% ± 7%, 57% ± 9%, and 50% ± 10%, respectively 1, 5, and 10 years following surgery (p = 0.5). The freedom rate from thromboembolism and from bleeding complications were 87% ± 6% and 95% ± 3% in primary and reoperative patients, respectively, 5 years following surgery.

Conclusions. Triple valve surgery, either as a primary or a reoperative procedure, results in acceptable long-term survival with both mechanical and biological prostheses.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
The choice between repair or replacement of the tricuspid valve in patients undergoing aortic and mitral valve replacement remains difficult because most of these patients have had numerous valve operations in the past, and all seek a definitive treatment [1]. Moreover, the choice between biological and mechanical prostheses for mitral and aortic valve replacement remains controversial. We have chosen tricuspid valve repair whenever possible in our most recent experience with triple valve surgery using the CarboMedics (CM) mechanical prostheses and the Carpentier-Edwards (C-E) pericardial heart valves.

The objective of the present study was to review our experience with primary and reoperative triple valve surgery. Results with mechanical and biological prostheses for left-sided valve replacements and with repair and replacement of the tricuspid valve were also analyzed.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
Seventy-seven patients who underwent aortic, mitral, and tricuspid surgery between 1982 and 1999 were reviewed. All patients were prospectively followed at the Montreal Heart Institute valve clinic with a follow-up visit at annual intervals. The follow-up was complete in all except 4 patients (5%) for a study focusing on results of 73 patients. Duration of follow-up averaged 40.3 months extending to 17 years.

Valve-related complications are reported according to the guidelines of the Ad Hoc Liaison Committee of The Society of Thoracic Surgeons and The American Association of Thoracic Surgery [2].

In the present study, triple valve surgery defines patients who underwent aortic valve replacement combined with mitral and tricuspid repair or replacement during the same surgical procedure. Reoperative triple valve surgery was defined as aortic valve replacement associated with mitral and tricuspid repair or replacement in patients who had undergone prior valve replacement.

The data are presented as the mean and standard deviation. The difference between groups was analyzed using the Student’s t test or the Fisher’s exact test. Analysis of survival was performed with the Kaplan-Meier method and the log-rank test. Proportional hazards regression (Cox) was used to study the influence of covariates (age, gender, reoperation, prosthesis dysfunction, tricuspid repair and replacement, mechanical and biological valves) and the overall mortality following triple valve surgery. The statistical significance was established with a p less than 0.05 and some rates are presented with the 95% confidence limit (95% CL).


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
Characteristics of patients
Nineteen women (63%) and 11 men (37%) with a mean age of 62 ± 10 years underwent primary triple valve surgery (group 1) and 27 women (63%) and 16 men (37%) with a mean age of 60 ± 10 years underwent reoperative triple valve surgery (group 2). Congestive heart failure was the indication for surgery in all primary triple valve patients and prosthetic valve dysfunction (34 of 43, 79%) was the most common indication for reoperative triple valve surgery (Table 1). All patients had rheumatic valve disease with stenosis, regurgitation, or mixed diseases except 1 who underwent surgery following an episode of acute bacterial endocarditis. Tricuspid valve regurgitation was shown in 68 patients (68 of 73, 93%) and tricuspid valve stenosis in 4 other patients (4 of 73, 5%). One patient had a C-E porcine prosthesis in tricuspid position and 2 patients have had tricuspid annuloplasty 12 years, 2 months, and 11 years, respectively, before reoperative triple valve surgery.


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  		Table 1. Characteristics of the 2 Patient Groups

 
Patient characteristics are shown in Table 1. Mechanical valves were used in both aortic and mitral positions in 21 (21 of 30, 70%) primary triple valve patients and in 35 (35 of 43, 81%) reoperative triple valve patients. Biological prostheses were used in both aortic and mitral positions in 7 patients of both groups. Mitral repair was combined with an aortic biological prosthesis in 2 patients and with an aortic mechanical prosthesis in another patient. All seven tricuspid valve replacements were performed using biological prostheses associated with mechanical valve replacements of left-sided valves. Tricuspid valvular annuloplasty was done using the Bex linear reducer in 47 patients (71%), the C-E ring in 13 patients (20%), and the De Vega annuloplasty technique in 5 patients (8%). An isolated tricuspid commissurotomy was done in 1 patient.

Immediate and long-term survival
There were 5 deaths (5 of 30, 17%) in patients who underwent primary triple valve surgery and 5 deaths (5 of 43, 12%) in patients with reoperative triple valve surgery within 30 days of surgery (p = 0.5). Five patients died from multi-organ failure, 3 from mediastinal bleeding at surgery, 1 from sepsis, and another following a stroke.

The 1, 5, and 10-year actuarial survival rates were 80% ± 7%, 75% ± 8%, and 41% ± 15% in group 1 primary triple valve patients, and 70% ± 7%, 57% ± 9%, and 50% ± 10%, respectively, in group 2 reoperative triple valve patients (p = 0.5) (Fig 1).



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  		Fig 1. Actuarial survival of the 73 patients who underwent primary and reoperative triple valve surgery.

 
The 1- and 5-year survival of patients who underwent triple valve surgery with preoperative diagnosis of prosthetic valve dysfunction were 71% ± 8% (95% CL: 55 to 86) and 53% ± 11% (95% CL: 31 to 75) compared with 77% ± 7% (95% CL: 63 to 90) and 73% ± 7% (95% CL: 58 to 88) in those without dysfunction (p = 0.3) (Fig 2). The 1- and 5-year survival of patients with mechanical valve replacements were 75% ± 6% (95% CL: 64 to 87) and 67% ± 6% (95% CL: 53 to 80) compared with 69% ± 12% (95% CL: 71 to 100) and 59% ± 13% (95% CL: 33 to 85) in patients undergoing biological valve replacements (p = 0.9) (Fig 3). The 1-year survival rate of patients who underwent tricuspid valve repair compared with that of patients with tricuspid valve replacement was 76% ± 5% (95% CL: 65 to 87) and 57% ± 19% (95% CL: 20 to 94), respectively (p = 0.3).



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  		Fig 2. Actuarial survival of patients undergoing triple valve surgery with and without the preoperative diagnosis of prosthesis dysfunction.

 


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  		Fig 3. Actuarial survival of patients undergoing reoperative triple valve surgery with mechanical and biological heart valves.

 
Long-term complications
The actuarial freedom rate from thromboembolic complications was 86% ± 7% (95% CL: 73 to 99) in patients with mechanical prostheses and 92% ± 7% (95% CL: 78 to 100) in patients with biological prostheses (log-rank test, p = 0.01) 5 years following surgery. The freedom rate from bleeding complications was 95% ± 4% (95% CL: 87 to 100) in patients with mechanical valves and 100% in those with biological valves (p = 0.2). The freedom rate from reoperation was 94% ± 3% (95% CL: 88 to 100), 95% ± 4% (95% CL: 88 to 100) in patients with mechanical valves and 90% ± 9% (95% CL: 71 to 100) in those with biological valves (p = 0.9). Eighty-eight percent (45 of 51) of long-term survivors were in New York Heart Association (NYHA) functional class I and II at the last follow-up.

The causes of death of patients surviving the first 30 days following triple valve surgery were thromboembolic complications in 4 patients, congestive heart failure in 4, hemorrhagic complications in 2, reoperation in 3, sudden death in 2, prosthesis dehiscence in 1, and arrhythmia in 1.

In a multivariate analysis, patient age at surgery in years (odds ratio: 1.07 and 95% CI: 1.01 to 1.13, p = 0.03) was the only risk factor significantly correlated with short- and long-term mortality following triple valve surgery. Reoperative triple valve surgery, tricuspid repair or replacement, and the presence of prosthesis dysfunction prior to triple valve surgery had no significant effect on mortality following surgery.


   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
Combined surgery for aortic, mitral, and tricuspid valves remains a formidable challenge. The present study showed that patients with primary and reoperative triple valve surgery had similar long-term survival. Moreover, patients with the preoperative diagnosis of prosthetic valve dysfunction prior to triple valve surgery had a lower 5-year survival rate (53% ± 11%) compared with that of patients without prosthetic dysfunction (73% ± 7%), although the difference was not statistically significant because of the small number of patients included in the study. The use of mechanical and of biological prostheses in aortic and mitral position did not affect the 5-year survival rates of patients, but the rate of thromboembolic complications was significantly lower in patients with biological prostheses. Thus, the current approach consisting of replacement of both aortic and mitral valves with mechanical prostheses in the younger patients, and with biological valves in the elderly, is well supported by the results of our study.

Other authors have reported similar survival following triple valve surgery. Mullany and colleagues [1] reported survival rates of 58% and 35%, 5 and 10 years following aortic and mitral valve replacement associated with tricuspid repair. Galloway and colleagues [3] showed that patients undergoing triple valve surgery had a 5-year actuarial survival of 62%. Although Brown and colleagues [4] reported similar patient survival, they favored mechanical prostheses because of a lower rate of reoperation during follow-up. Gersh and colleagues [5] stressed that patients in NYHA class IV prior to triple valve surgery had a significant higher hospital mortality and a lower long-term survival.

Although our early mortality averaged a sobering 14%, this rate compares favorably with the experience of other centers [3, 4]. Gersh and colleagues [5] reported a thromboembolic rate of 12% patient/year and a probability of freedom from thromboembolic events of 70% at 5 years of follow-up. In the present study, 86% of our patients with mechanical valves and 92% of patients with biological valves remained free from thromboembolic complications 5 years following surgery. The later rate of events is higher than the one reported with the same mechanical valves in aortic position but remain lower than other experiences reported with triple valve surgery [4–6]. Finally, Coll and colleagues [7] suggested that bioprostheses in the tricuspid position should give more favorable results than mechanical valves in patients with triple valve surgery.

Most patients of the present series had tricuspid valve disease, especially regurgitation that was corrected with standard annuloplasty techniques. Although the C-E prosthetic ring and the De Vega annuloplasty technique were once viewed as the end of the tricuspid challenge [8], the Bex linear reducer, a partial ring annuloplasty, was favored in this experience [9]. The latter is a simple flexible band attached to the anterior and the posterior tricuspid annulus reducing the overall tricuspid annulus diameter. It was shown to achieve good tricuspid competency over long term [10]. Because there was no reoperation for tricuspid valve dysfunction following the triple valve surgery, the three techniques of tricuspid repair used in this experience appear to result in good long-term survival and clinical functional status. Gillinov and colleagues [11], in presenting results of double valve surgery, reported that mitral valve repair with aortic valve replacement resulted in improved patient survival compared with double valve replacement. We agree that both tricuspid and mitral valve repair with mechanical aortic valve replacement may improve the overall results of triple valve surgery, although our clinical experience is too limited to sustain that statement.

Limitations of the present study
Although the present study was planned retrospectively, the data was collected prospectively at our valve clinic with consistent follow-up of patients. Furthermore, we presented the results of triple valve surgery with two prostheses widely used in today’s clinical practice.

The absence of a significant improvement in overall survival of the present cohort of patients compared with previous reports is noteworthy. Hospital mortality was high and related to preoperative clinical status of these complex surgical patients. The higher 5-year mortality of patients with preoperative prosthetic valve dysfunction and reoperative triple valve surgery explains in part the lack of survival benefit of the current series of patients. The 5-year survival rate averaging 75% in patients undergoing primary triple valve surgery, without prior valve dysfunction, compares favorably with the modern practice of valvular surgery. Although primary triple valve surgery offers the best long-term survival, 50% of reoperative triple valve patients were long-term survivors, results that remain acceptable but suboptimal.

Conclusions
Triple valve surgery with the CM mechanical prosthesis, and with the biological C-E pericardial prosthesis, in aortic and mitral positions associated with tricuspid annuloplasty repair appears to offer satisfactory short- and long-term patient survival in primary and reoperative triple valve procedures.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Mullany C.J., Gersh B.J., Orszulak T.A., et al. Repair of tricuspid valve insufficiency in patients undergoing double (aortic and mitral) valve replacement. J Thorac Cardiovasc Surg 1987;94:740-748.[Abstract]
  2. Edmunds L.H., Grunkemeier G.L., Miller D.C., Weisel R.D. Guidelines for reporting morbidity and mortality after cardiac valvular operations. Ann Thorac Surg 1996;62:932-935.[Abstract/Free Full Text]
  3. Galloway A.C., Grossi E.A., Baumann F.G., et al. Multiple valve operation for advanced valvular heart disease: results and risk factors in 513 patients. J Am Coll Cardiol 1992;19:725-732.[Abstract]
  4. Brown P.S., Robert C.S., McIntosh C.L., Swain J.A., Clark R.E. Late results after triple-valve replacement with various substitute valves. Ann Thorac Surg 1993;55:502-508.[Abstract]
  5. Gersh B.J., Schaff H.V., Vatterott P.J., et al. Results of triple valve replacement in 91 patients: perioperative mortality and long-term follow-up. Circulation 1985;72:130-137.[Abstract/Free Full Text]
  6. Carrier M., Pellerin M., Perrault L.P., et al. Aortic valve replacement with mechanical and biological prostheses in middle-aged patients. Ann Thorac Surg 2001;71:S253-S256.[Abstract/Free Full Text]
  7. Coll M.J., Jegaden O., Janoby P., Rumolo A., Bonnefoy J.Y., Mikaeloff P. Results of triple valve replacement: perioperative mortality and long-term results. J Cardiovasc Surg 1987;28:369-373.[Medline]
  8. Grondin P., Meere C., Limet R., Lopez-Bescoc L., Delcan J.L., Rivera R. Carpentier’s annulus and De Vega’s annuloplasty. The end of the tricuspid challenge. J Thorac Cardiovasc Surg 1975;70:852-859.[Abstract]
  9. Hecart J., Blaise C., Bex J.P., Bajolet A. Technique for tricuspid annuloplasty with a flexible linear reducer: medium-term results. J Thorac Cardiovasc Surg 1980;79:689-692.[Abstract]
  10. Limayen F., Carrier M., Vanderperren O., Petitclerc R., Pelletier L.C. Comparative, clinical and echocardiographic study of the Bex and De Vega annuloplasties. Arch Mal Coeur 1991;84:937-941.
  11. Gillinov M.A., Blackstone E.H., White J., et al. Durability of combined aortic and mitral valve repair. Ann Thorac Surg 2001;72:20-27.[Abstract/Free Full Text]



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This Article
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Louis P. Perrault
Raymond Cartier
Pierre Pagé
Nancy C. Poirier
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