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Ann Thorac Surg 2003;75:47-50
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Tricuspid valve replacement: an analysis of 25 years of experience at a single center

^a Department of Surgery, The Montreal Heart Institute and the University of Montreal, Montreal, Quebec, Canada
^b Department of Medicine, The Montreal Heart Institute and the University of Montreal, Montreal, Quebec, Canada

Accepted for publication August 1, 2002.

* Address reprint requests to Dr Carrier, Department of Surgery, Montreal Heart Institute, 5000 Belanger St E, Montreal, Quebec H1T 1C8, Canada
e-mail: carrier{at}icm.umontreal.ca

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: Tricuspid valve replacement is seldom used in clinical practice, but the choice between mechanical and biologic prostheses remains controversial.

METHODS: Between 1977 and 2002, 97 patients underwent tricuspid valve replacement and were followed at the Montreal Heart Institute Valve Clinic. Patients underwent replacement with bioprostheses (n = 82) and mechanical valves (n = 15).

RESULTS: Patients with bioprosthetic tricuspid replacements averaged 53 ± 13 years of age compared with 48 ± 11 years in those with tricuspid mechanical valve replacements (p = 0.2). Isolated tricuspid valve replacement was performed in 11 patients (73%) in the mechanical valve group compared with 31 patients (38%. p = 0.01) in the bioprosthetic replacement group. In patients undergoing bioprosthetic tricuspid replacement, 51 (62%) underwent multiple associated valve replacements. The 5-year survival after tricuspid replacement averaged 60% ± 13% in the mechanical valve group and 56% ± 6% in the biologic replacement group (p = 0.8). The 5-year freedom rate from tricuspid valve reoperation averaged 91% ± 9% in patients with mechanical valves and 97% ± 3% in those with biologic valves (p = 0.2).

CONCLUSIONS: Patient survival after tricuspid valve replacement is suboptimal but related to the clinical condition at operation. The use of biologic prostheses for tricuspid valve replacement remains a good option in young patients because of limited life expectancy unrelated to the type of tricuspid prostheses at long-term follow-up.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Tricuspid valve replacement is seldom used in clinical practice, but the choice between mechanical valves and bioprostheses remains controversial. Several authors have reported conflicting results and have supported the use of either mechanical valves or bioprostheses. Rizzoli and colleagues [1] have suggested that mechanical valves could be associated with superior long-term results contrary to the experience of Dalrymple-Hay and colleagues [2], who favored bioprosthesis because of its good initial durability and low reoperation rate at long-term follow-up.

The objectives of the present study were to analyze the results of patients who underwent tricuspid valve replacement with mechanical valves and with bioprostheses during the last 25 years in our center. We focused our analysis in comparing patients who underwent isolated tricuspid valve replacement with those undergoing multiple valve replacements, in comparing mechanical valves with bioprostheses, and in describing the preoperative clinical status of these patients.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Ninety-seven patients who underwent isolated, reoperative, or combined tricuspid valve replacement with an associated mitral or aortic replacement between 1977 and 2002 were reviewed. All patients were prospectively followed at the Montreal Heart Institute Valve Clinic with annual follow-up visits. The follow-up was complete in all except 3 patients (3%). The follow-up duration averaged 4 ± 5 years, ranging from 0 to 21 years. During the same period, 463 patients underwent a conservative approach to tricuspid valvular operation consisting of tricuspid annuloplasty, commissurotomy, or valvuloplasty.

During the 25 years of this experience, our attitude toward tricuspid operation has not changed, that is to repair all tricuspid valves whenever possible and to replace only as a last resort [3]. From 1977 to 2002, most surgeons of our group have favored the use of bioprostheses in tricuspid valve replacement, but a few have implanted bileaflet mechanical heart valves. This attitude allowed the analysis of clinical results with the two prostheses.

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 [4].

In the present study, isolated tricuspid replacement defines patients who underwent only tricuspid valve replacement at the time of operation. Combined tricuspid valve replacement defines patients who underwent tricuspid valve replacement concomitant with replacement or repair of the mitral or the aortic valve during the same surgical procedure. Reoperative tricuspid valve replacement includes patients who had undergone prior tricuspid valve replacement.

The data are presented as the mean and standard deviation. The difference between groups was analyzed using Student’s t test or 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, sex, cardiopulmonary bypass time, reoperation, bioprostheses, and mechanical valves) and the overall mortality after triple valve operation. Statistical significance was established with a p less than 0.05, and rates are presented with the 95% confidence limits.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Characteristics of patients
Sixty-one women (74%) and 21 men (26%) with a mean age of 53 ± 13 years underwent tricuspid valve replacement with a bioprosthesis (group 1, n = 82), and 10 women (66%) and 5 men (33%) with a mean age of 48 ± 11 years underwent tricuspid valve replacement with a mechanical valve (group 2, n = 15). Congestive heart failure and prosthetic valve dysfunction were the two indications for operation in both groups (Table 1). Significant tricuspid regurgitation was the most common indication for replacement in 56 patients (68%) of group 1 and in 9 patients (60%) of group 2, and tricuspid stenosis was present in 14 patients of group 1 (17%) and in 2 patients (13%) of group 2. Tricuspid prosthesis dysfunction was the indication for operation in 12 patients of group 1 (15%) and in 4 patients (27%) of group 2. Ten patients of group 1 (12%) and 2 patients of group 2 (13%) have had a tricuspid annuloplasty in a previous attempt to repair the tricuspid valve. Of the total of 97 patients, 47 showed signs of severe right heart failure (48%), with ascites in 23 (24%) before tricuspid valve replacement.

Thirty-one patients (38%) underwent isolated tricuspid valve replacement with bioprostheses compared with 11 patients (73%) with mechanical valves (p = 0.01). Overall, 69 patients of group 1 (84%) and 8 patients of group 2 (53%) had mitral or aortic prosthesis in addition to the tricuspid valve during the present follow-up (Table 2).

The 1-year and 5-year actuarial survival rates were 67% ± 5% and 56% ± 6%, respectively, in patients with bioprostheses compared with 60% ± 13% and 60% ± 13%, respectively, in patients with mechanical tricuspid valves (p = 0.9; Fig 1). The 1-year and 5-year freedom rates from tricuspid reoperation averaged 100% and 97% ± 3%, respectively, in patients with tricuspid bioprostheses compared with 91% ± 9% and 91% ± 9%, respectively, in patients with mechanical valves (p = 0.2; Fig 2). The 1-year and 5-year rates of survival free from tricuspid reoperation averaged 66% ± 5% and 52% ± 6%, respectively, in patients with bioprostheses compared with 53% ± 13% and 53% ± 13%, respectively, with mechanical tricuspid valves (p = 0.8).

View larger version (18K): [in this window] [in a new window]   Fig 1. Actuarial survival including hospital mortality of patients who underwent tricuspid valve replacement with bioprostheses and with mechanical valves. Age-adjusted p value = 0.9.

View larger version (18K): [in this window] [in a new window]   Fig 2. Freedom rate from tricuspid reoperation of patients who underwent tricuspid valve replacement with biologic and with mechanical prostheses. Age-adjusted p value = 0.2.

Congestive heart failure was the most significant causes of long-term deaths (16 of 35, 46%) at follow-up. Two patients died during reoperation for tricuspid valve dysfunction of a biologic prosthesis.

In a multivariate analysis, age of patient at operation in years (odds ratio, 1.03; 95%confidence limits, 1.002, 1.05; p = 0.03) and the cardiopulmonary bypass time in minutes (odds ratio, 1.006; 95%confidence limits, 1.002, 1.01; p = 0.002) were the only risk factors significantly correlated with mortality after tricuspid valve replacement. Reoperative tricuspid valve replacement and the use of a bioprosthesis or a mechanical valve had no significant effect on mortality after operation.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Tricuspid valve replacement remains the second and the last choice of treatment in patients with tricuspid regurgitation and in the rare occurrence of tricuspid stenosis in which repair is not feasible or has already failed. In the present study, most patients had previous left-sided valve replacements. Mechanical valves were most often used in patients undergoing isolated and reoperative tricuspid valve replacement as opposed to those undergoing combined tricuspid and left-sided valve replacements in which the tricuspid valve was replaced with a bioprosthesis. Although the hospital mortality was high, reflecting the poor preoperative condition of these patients with right-sided heart failure, enlarged liver, and ascites, the 1-year and 5-year survival rates of patients with bioprostheses and mechanical valves in the tricuspid position were similar. Moreover, the freedom rates from tricuspid reoperation was also similar between the two types of prostheses.

Most series, even the most recent one published in the literature, compare a large variety of mechanical and of biologic valves in the tricuspid position because of the low number of tricuspid replacements performed in single centers [4–6]. In the present study, the Carpentier-Edwards pericardial prostheses and the bileaflet mechanical prostheses (CarboMedics and St. Jude valves) were most often used. There was no difference in patient survival and in the rate of tricuspid valve reoperation between the latter prostheses.

Tricuspid valve replacement with biologic prostheses is associated with the need for tricuspid reoperation for prosthetic dysfunction [7]. Six patients of the present cohort were reoperated on for tricuspid bioprosthetic dysfunction 9 years after the initial tricuspid replacement. Only 2 of 44 patients (5%) needed reoperation 3 and 7 years after a tricuspid valve replacement with the Carpentier-Edwards pericardial prostheses. As suggested by Ohata and colleagues [8], the latter bioprosthesis appears to offer good long-term outcome of patients who underwent tricuspid valve replacement with a bioprosthesis. However, Glower and colleagues [9] have shown similar results with porcine bioprostheses, and McGrath and colleagues [10] have also favored tissue valves in 87% of patients undergoing tricuspid valve replacement.

Tricuspid valve replacement with mechanical valves was associated with thrombosis of the prosthesis in one of our patients who underwent tricuspid replacement with a CarboMedic prosthesis (1 of 7, 14%) [11]. Kawano and colleagues [12] reported tricuspid St. Jude Medical valve thrombosis in 6 of 23 patients who underwent tricuspid replacement. Ratnatunga and colleagues [13], studying 435 patients of the UK Heart Valve Registry, showed similar survival and rate of reoperation between patients with biologic and mechanical prostheses. Kaplan and colleagues [14] reported similar results in 122 patients averaging 35 years of age at the time of tricuspid replacement. Although re-replacement of the tricuspid mechanical valve, valve thrombosis, and pulmonary embolism occurred in 10 patients, Kaplan and colleagues [14] recommend the use of low-profile bileaflet mechanical valves.

Despite our sobering 18% 30-day mortality rate, tricuspid valve replacement with bioprostheses offers good 5-year results without the thrombotic complication related to mechanical valves. Our experience with patients averaging 50 years of age and having had multiple previous left-sided valve replacements indicates that tricuspid valve replacement with the Carpentier-Edwards pericardial bioprosthesis is a good option, the freedom rate from tricuspid reoperation averaging 83% ± 8% 10 years after operation. Mechanical valves remain a valuable choice in patients with previous tricuspid valve replacement who want to limit the risk of reoperation at long-term follow-up.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Rizzoli G., De Perini L., Bottio T., Minutolo G., Thienne G., Casarotto D. Prosthetic replacement of the tricuspid valve: biological or mechanical?. Ann Thorac Surg 1998;66(Suppl):S62-67.
2. Dalrymple-Hay M.J., Leung Y., Ohri S.K., et al. Tricuspid valve replacement: bioprostheses are preferable. J Heart Valve Dis 1999;8:644-648.[Medline]
3. 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]
4. Edmunds L.H., Grunkemeir 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]
5. Scully H.E., Armstrong C.S. Tricuspid valve replacement. Fifteen years of experience with mechanical prostheses and bioprostheses. J Thorac Cardiovasc Surg 1995;109:1035-1041.
6. Mangoni A.A., DiSalvo T.G., Vlahakes G.J., Polanczyk C.A., Fifer M.A. Outcome following isolated tricuspid valve replacement. Eur J Cardiothorac Surg 2001;19:68-73.[Abstract/Free Full Text]
7. Nakano K., Ishibashi-Ueda H., Kobayashi J., Sasako Y., Yagihara T. Tricuspid valve replacement with bioprostheses: long-term results and causes of valve dysfunction. Ann Thorac Surg 2001;71:105-109.[Abstract/Free Full Text]
8. Ohata T., Kigawa I., Tohda E., Wanibuchi Y. Comparison of durability of bioprostheses in tricuspid and mitral positions. Ann Thorac Surg 2001;71(Suppl):S240-243.[Abstract/Free Full Text]
9. Glower D.D., White W.D., Smith L.R., et al. In-hospital, and long-term outcome after porcine tricuspid valve replacement. J Thorac Cardiovasc Surg 1995;109:877-884.[Abstract]
10. McGrath L.B., Gonzalez-Lavin L., Bailey B.M., Grunkemeier G.L., Fernandez J., Laub G.W. Tricuspid valve operations in 530 patients. Twenty-five year assessment of early and late phase events. J Thorac Cardiovasc Surg 1990;99:124-133.[Abstract]
11. Shapira Y., Hirsch R., Vaturi M., Vidne B., Sagie A. Mid-term clinical and echocardiographic follow-up of patients with CarboMedics valves in the tricuspid position. J Heart Valve Dis 2000;9:396-402.[Medline]
12. Kawano H., Oda T., Fukunaga S., et al. Tricuspid valve replacement with the St. Jude Medical valve: 19 years of experience. Eur J Cardiothorac Surg 2000;18:565-569.[Abstract/Free Full Text]
13. Ratnatunga C.P., Edwards M.B., Dore C.J., Taylor K.M. Tricuspid valve replacement: UK Heart Valve Registry mid-term results comparing mechanical and biological prostheses. Ann Thorac Surg 1998;66:1940-1947.[Abstract/Free Full Text]
14. Kaplan M., Kut M.S., Demirtas M.M., Cimen S., Ozler A. Prosthetic replacement of tricuspid valve: bioprosthetic or mechanical. Ann Thorac Surg 2001;73:467-473.[Abstract/Free Full Text]

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