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Ann Thorac Surg 2004;78:2069-2074
© 2004 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Tricuspid Valve Repair: An Old Disease, a Modern Experience

^a Department of Cardiovascular Surgery
^b Department of Cardiology, Hospital Universitario Valdecilla, Universidad de Cantabria, Santander, Spain

Accepted for publication June 2, 2004.

^* Address reprint requests to Dr Bernal, Department of Cardiovascular Surgery, Universidad de Cantabria, Hospital Universitario Valdecilla, E-39008 Santander, Spain (E-mail: ccabmj{at}humv.es).

	Abstract

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
BACKGROUND: We review our experience in patients who required surgical correction of tricuspid valve disease with concomitant disease of the mitral or aortic valve, or both, operated on between 1987 and 1999.

METHODS: We studied 232 consecutive patients (mean age, 59.8 years) followed for a mean of 6.8 years (range, 2 to 12 years). All patients were investigated by means of Doppler echocardiography, with hemodynamic studies in 135. Median tricuspid insufficiency was 3+. The cause was rheumatic heart disease in 186 patients and degenerative in 46. All patients underwent suture annuloplasty (De Vega or segmental) at the time of mitral or aortic valve surgery. Tricuspid lesions were functional in 128 patients and organic in 104.

RESULTS: The hospital and late mortality rates were 8.1% and 23.3%, respectively. These figures were independent of the type of annuloplasty performed. Predictors of hospital mortality were biologic prosthesis, renal insufficiency, time of cardiopulmonary bypass, and use of inotropic drugs. Predictors of late mortality were age older than 60 years, left ventricular ejection fraction less than 0.50, and New York Heart Association functional class IV. At 12 years, the actuarial survival rate was 50.5% ± 6.1%, and the actuarial curve free from reoperation 75.7% ± 7.3%. The actuarial curve for freedom from valve-related complication was 39.0% ± 6.3% at 11 years.

CONCLUSIONS: Despite the use of modern technologic advances in the diagnosis and treatment of valvular hear disease, tricuspid insufficiency continues to be a poor prognostic factor in patients with concomitant disease of the mitral or aortic valve, or both.

	Introduction

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Tricuspid valve disease with concomitant disease of the mitral or aortic valve, or both, has been consistently associated with a high mortality rate and an increased risk of early and late-phase events [1, 2]. Results reported by a group from the Mayo Clinic in patients undergoing triple valve surgery showed a perioperative mortality of 21% and a 15-year survival rate of 27% [1]. At the present time and in the light of eradication of rheumatic fever in developed countries, updated information on the management of the tricuspid valve in patients with concomitant valvular disease is lacking. Inasmuch as in our country the eradication of rheumatic fever had occurred lately, a substantial number of patients with left-sided valvular lesions and a dysfunctional tricuspid valve have still been diagnosed and treated using modern technologies. The purpose of this study was to review our experience in patients who required correction of tricuspid valve disease operated on between 1987 and 1999 and to determine those factors that influence operative risk, complications, and late survival.

	Material and Methods

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Patients
From 1987 to 1999, a total of 232 consecutive patients with a diagnosis of mitral or aortic valve lesions, or both, combined with significant tricuspid dysfunction underwent tricuspid suture annuloplasty (without prosthetic ring) at our institution. This cohort accounted for the most recent and homogeneous group from a total of 1,069 patients with tricuspid valve disease operated on from June 1974 to May 1999. There were 67 male patients and 165 female patients whose ages ranged from 28 to 78 years (mean, 59.8 years). Seventeen patients (7.3%) were in New York Heart Association (NYHA) functional class II, 148 (63.8%) in class III, and 67 (28.9%) in class IV. A total of 195 patients (84.1%) had atrial fibrillation. Prior cardiac operations had been performed in 92 patients (39.6%): 58 for the mitral valve, 7 for the aortic valve, 12 for both mitral and aortic valves, and 15 for the mitral and tricuspid valve. Twenty-seven patients had had prior percutaneous mitral valvuloplasty, and 1 patient had prior percutaneous tricuspid valvuloplasty.

All patients were investigated preoperatively by means of Doppler echocardiography. Echocardiographic assessment of tricuspid incompetence was on the basis of gradation of tricuspid regurgitation severity according to color Doppler flow criteria [3] and analysis of the hepatic vein flow by pulsed-wave Doppler [4]; evaluation of the right ventricular function and the size of the tricuspid annulus [5]; and estimation of the pulmonary artery systolic pressure by continuous Doppler [6]. Preoperative cardiac catheterization and angiography was performed in 135 patients to exclude concomitant coronary artery disease, to complete echocardiographic studies, or because of the patient's age or the presence of risk factors. Results of echocardiographic and hemodynamic studies are shown in Table 1. Tricuspid regurgitation graded on a scale of 1+ to 4+ showed a median value of 3+ on both echocardiographic and hemodynamic evaluations.

The decision concerning the surgical approach for the tricuspid regurgitation relied on the integration of echocardiographic and clinical data, so that surgical indication of tricuspid valve surgery was established preoperatively and in none of the cases according to intraoperative findings (digital examination of the right atrium). On the basis of clinical and intraoperative data, tricuspid lesions were considered functional in 128 patients (dilation of the valvular ring without valvular lesion) and organic in 104 (involvement of the leaflets or the subvalvular apparatus) [7].

Surgical Procedure
Operations were performed through median sternotomies with extracorporeal circulation. The details of the operative technique of mitral valve repair have been previously described [8]. Tricuspid valve repair was performed after surgical treatment of the mitral or aortic valve. Myocardial protection was achieved with crystalloid cardioplegia in patients operated on until 1993 and with anterograde or retrograde cardioplegia since 1993. Patients with aortic lesions (n = 90) underwent aortic valve prosthetic replacements (mechanical prosthesis, 67; bioprosthesis, 23). Patients with mitral lesions (n = 227) underwent mitral prosthetic valve replacement (n = 198; mechanical prosthesis, 158; bioprosthesis, 40) and mitral valve repair (n = 29; flexible ring annuloplasty, 29; mitral commissurotomy, 12; repair techniques of the subvalvular apparatus, 9). Repair of the tricuspid valve was performed on an ischemic heart in 201 patients and with the heart beating in the remaining 31 patients. Tricuspid valve operations included De Vega's annuloplasty in 93 patients (40.1%) and segmental annuloplasty [9] in 139 (59.9%). The decision to perform a De Vega annuloplasty or segmental annuloplasty was left to the discretion of the attending surgeon. Tricuspid commissurotomy was also performed in 29 patients. Coronary artery revascularization procedures were performed in 4 patients (1.7%), substitution of the ascending aorta (with or without the aortic arch) in 2 (0.9%), and pericardiectomy in 3 (1.3%). Thromboembolic prophylaxis used in our department [10] included antiplatelet therapy for patients undergoing mitral valve repair or implantation of biologic valves in sinus rhythm and sodium warfarin (Coumadin; Novartis Farmacéutica, Barcelona, Spain) for those patients with atrial fibrillation or undergoing mechanical prosthetic replacement.

Follow-Up
All surviving patients received 3- and 6-month follow-up after surgery and then annually in our outpatient clinic. The follow-up data for this study were procured during a 4-month period (October 2000 through January 2001). The patients were assessed through direct contact at home or with their cardiologists. When follow-up was not possible, information on vital status (alive or death) was obtained through the social security database. All surviving patients with direct follow-up had a Doppler echographic study during the year 2000. The mean follow-up was 6.8 years, with a range from 2 to 12 years. Follow-up was 95.6% complete, with a cumulative follow-up of 1,462.7 patients per year.

Statistical Analysis
The Patient Analysis and Tracking System database, version 06.02.03 (Dendrite Clinical System, Inc, Portland, OR) was used. Values are expressed as mean ± standard deviation. The Student's t test was used for the comparison of quantitative variables. Actuarial curves were obtained by the actuarial method. Proportional hazards regression (Cox) was used to study the influence of covariates on mortality and reoperation. Multivariate analysis was performed with the Stata Intercooled, release 6 (Stata Corp. College Station, TX) computer program. Statistical significance was set at p less than 0.05.

	Results

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Hospital mortality occurred in 19 patients (8.1%). The causes of death were heart failure in 11 patients, respiratory insufficiency in 5, and multiorgan failure in 3. Hospital mortality for patients undergoing a De Vega annuloplasty was 10.8% (10 of 93) and for patients having a segmental annuloplasty, 6.5% (9 of 139; not significant). In the univariate analysis, significant risk factors for hospital mortality were age older than 60 years, preoperative renal insufficiency, NYHA functional class IV, systolic pulmonary hypertension, enlarged left ventricular end-diastolic diameter, implantation of a biologic prosthesis, and time of extracorporeal circulation greater than 120 minutes. In the multivariate analysis, independent factors significantly associated with hospital mortality were preoperative renal insufficiency, need of inotropic medication (dobutamine, dopamine, epinephrine) to discontinue extracorporeal circulation, use of a biologic prosthesis, and duration of extracorporeal circulation (Table 2).

In the univariate analysis, significant risk factors for late mortality were age older than 60 years at the time of operation, diabetes mellitus, NYHA class IV, pulmonary artery systolic pressure more than 40 mm Hg, left ventricular end-diastolic diameter more than 35 mm, and surgical operation performed before December 1991. In the multivariate analysis, independent factors significantly associated with late mortality were age older than 60 years, left ventricular ejection fraction less than 0.50, and NYHA class IV (Table 2). Actuarial survival rate was 50.5% ± 6.1% at 12 years (Fig 1). There were no statistically significant differences in survival between patients undergoing a De Vega annuloplasty (55.2% ± 7.7%) and a segmental annuloplasty (42.7% ± 9.71%).

View larger version (18K): [in this window] [in a new window]   Fig 1. Actuarial survival curve.

Doppler studies performed in 154 survivors during the year 2000 showed a statistically significant reduction of the right ventricular size (36.0 ± 9.5 mm versus 31.7 ± 8.0 mm; p = 0.05) and the pulmonary artery systolic pressure (55.4 ± 16.8 mm Hg versus 47.8 ± 13.9 mm Hg; p = 0.01) compared with preoperative data. Postoperatively, tricuspid regurgitation had completely regressed or was 1+ in 78 patients (50.6%). Tricuspid regurgitation was 2+ in 69 patients (44.8%) and 3+ in the remaining 7 patients (4.5%). There were no statistically significant differences in the severity of tricuspid regurgitation at follow-up according to the cause of lesions or the procedures used for tricuspid valve repair.

The degree of residual tricuspid regurgitation was assessed in the 54 patients who died at follow-up. The last echocardiographic study (the closest to the date of death) was evaluated, and information was available for only 45 patients (76.3%). Tricuspid regurgitation was 3+ or 4+ in 12 (26.7%) and 9 (20%) patients, respectively. In this series, the degree of residual regurgitation after suture annuloplasty did not predict the risk of late death or the need of reoperation.

Reoperation
Twenty-seven patients (11.6%) required a valve reoperation. The reoperation was necessary because of isolated tricuspid dysfunction in 4 patients; mitrotricuspid dysfunction in 7; mitral, aortic, and tricuspid dysfunction in 1; and mitral-aortic dysfunction in 18. Indication of reoperation was always established in the presence of left valvular dysfunction or when there was a tricuspid regurgitation of 3+ or 4+ that could not be controlled with medication, with an acceptable right ventricular function. The cause of tricuspid dysfunction (n = 9) was a postannuloplasty insufficiency that was treated with valve replacement in 7 and a new valve repair in 2. In 1 patient a De Vega annuloplasty had been performed and in 8, a segmental annuloplasty. In the 28 patients with functional tricuspid insufficiency, 4 required a reoperation of the tricuspid valve (3.1%), and in the 104 patients with organic tricuspid disease, reoperation of the tricuspid valve was performed in 5 cases (4.8%; not significant).

Hospital mortality at reoperation was 18.5% (5 of 27). Preoperative tricuspid regurgitation grade of 3+ to 4+/4+ was the only significant risk factor (p = 0.033) for reoperation at the univariate analysis. After multivariate analysis, factors significantly associated with reoperation were the use of a biologic prosthesis (odds ratio, 3.25; 95% confidence interval, 0.83 to12.74) and grade of tricuspid insufficiency (odds ratio, 2.39; 95% confidence interval, 0.98 to 5.83). The actuarial curve for freedom from reoperation was 75.7% ± 7.3% at 12 years (Fig 2). Statistically significant differences in survival free from reoperation according to type of annuloplasty were not found.

View larger version (17K): [in this window] [in a new window]   Fig 2. Actuarial curve for freedom from reoperation.

At the follow-up closing date, 83.3% patients were in NYHA functional class I or II, 7.8% in class III, and 3.9% in class IV. The actuarial curve for freedom from valve-related complications was 39.0% ± 6.3% at 11 years (Fig 3), with no statistically significant differences between patients undergoing a De Vega annuloplasty (41.8% ± 8.3%) and a segmental annuloplasty (36.3% ± 9.1%).

View larger version (17K): [in this window] [in a new window]   Fig 3. Actuarial curve for freedom from valve-related complications.

	Comment

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

It should be noted that the decision concerning surgical treatment was made preoperatively according to echocardiographic and clinical data. Hemodynamic studies performed in a subgroup of patients for excluding coronary artery disease showed an adequate correlation with echocardiographic findings. The important role played by Doppler echocardiography in the preoperative investigation and follow-up of patients with tricuspid valve disease has also been emphasized by others [16, 17]. In our experience, perioperative transesophageal echocardiogram tends to underestimate the tricuspid lesion and for this reason was not taken into account. We also believe that this clinical examination is of little value in the assessment of immediate results of tricuspid valve repair. Although in the past patients with moderate functional tricuspid lesions and mild tricuspid lesions, either of functional or of organic cause, were not operated on because of a general belief of improvement after surgical correction of left-side valvular lesions [7], since 1987 (the year in which this study began) surgery was indicated in patients with grade 2+ tricuspid valve disease, including functional lesions, and in patients with grade 1+ lesions of organic cause if valvular stenosis was present. It is improbable to find an answer to the question of whether tricuspid valve lesions would be resolved after surgical correction of left-side valvular diseases, but taking into account that the De Vega annuloplasty is a safe and effective technique that does not excessively prolong the surgical time [18, 19] and that significant tricuspid regurgitation is common after mitral valve replacement [20], we performed suture annuloplasty to all tricuspid lesions graded 2+ or greater. This attitude is justified by recent experiences of other authors. Matsuyama and colleagues [21] observed that 16% of 174 patients who underwent mitral valve surgery without tricuspid valve surgery had progressive tricuspid regurgitation (3+ or more) after a mean follow-up of 8.2 years. In the multivariate analysis, preoperative tricuspid regurgitation of 2+ was a significant predictor of late tricuspid regurgitation. In another study, Henein and associates [22] showed that tricuspid regurgitation impaired the functional results of rheumatic mitral valve replacement, with greater long-term mortality in patients with echocardiographic evidence of severe tricuspid regurgitation.

On the other hand, early and late mortality rate is higher after tricuspid valve prosthetic replacement [23–25] (up to 35% in our series) compared with valve repair (approximately 10% in the more recent series) [26–28]. There are different techniques for ring and suture annuloplasty, but the De Vega method described in 1972 [18] has been widely accepted. There is a controversy regarding the use of a prosthetic ring to obtain greater durability of tricuspid repair and a low recurrence of regurgitation. On the one hand, in our experience it was observed at the end of the study that tricuspid regurgitation had completely disappeared or was mild in 95.5% of patients. Accordingly, suture annuloplasty was effective and reliable for treating tricuspid disease associated with left-side valvular disease. These findings are consistent with data reported by others. In a series of 195 De Vega annuloplasties performed in association with mitral or mitral-aortic valve procedures, annuloplasty failed in 4 patients (2%) [27]. By contrast, the study of McCarthy and coworkers [16], in which a series of 790 patients with tricuspid valve repair was analyzed, concluded that long-term results of the De Vega annuloplasty were less favorable than those obtained after the use of a prosthetic ring. In this study, severe tricuspid regurgitation was identified as a risk factor for reoperation, which is in agreement with the present findings.

In our experience, it was preferred to perform tricuspid valve repair using the suture annuloplasty techniques (the choice between the De Vega annuloplasty and segmental annuloplasty was made by the attending surgeon). During the 12 years of the study, only 9 of the 213 survivors (4.2%) required reoperation because of tricuspid valve dysfunction (linear incidence of 0.62 patients/y), in 5 of whom there was an associated dysfunction of the left heart. The use of the prosthetic ring (in 27 patients during the same period of time than the present study) was limited to very severe cases of tricuspid valve dysfunction with very large dilatations of the native ring, inadequate quality of the tissues, or reoperations as a result of valve dysfunction after initial tricuspid repair procedures.

Another important aspect to take into consideration, although data are incomplete, is that patients who died at follow-up showed a more severe residual valve insufficiency (grades 3+ and 4+; 32%) than those who survived (4.5%).

With regard to the long-term results after tricuspid valve surgery, the prognosis of multivalvular disease is poor. Studies reporting the experience of the surgical treatment of probably the last patients with rheumatic tricuspid lesions from the 1960s to the 1980s showed a very high hospital mortality (between 12% and 21%) and an actuarial survival between 15% and 33% at 15 years [1, 2], with no differences in the long-term results between prosthetic valve replacement and tricuspid valve repair. In these studies [1, 2], risk factors for late mortality included NYHA functional class IV, advanced age, pulmonary hypertension, larger tricuspid prosthesis size, and earlier date of surgery. In this respect, our study, which includes most patients operated on during the last decade of the past century, constitutes a modern experience. The actuarial survival was 50.5% ± 6.1% at 11 years, which is better than that obtained in previous studies in which the actuarial survival was lower than 40% at 10 years [1, 2, 17, 29, 30]. Although improvement of short-term and long-term patient survival is likely to be associated with advances in cardiac surgical practice, the present clinical experience sustains that the outcome of tricuspid valve surgery is suboptimal and continues to present the cardiac surgeon with a difficult challenge for some unresolved questions.

The performance of a concomitant tricuspid valve procedure in patients with multivalvular heart disease affects postoperative prognosis [8, 10, 31]. Risk factors for late mortality reported in this article included increased age, left ventricular dysfunction, and preoperative functional class IV. These factors, however, are traditional predictors of outcome in cardiac valve surgery and do not seem to explain the significant morbidity and mortality of tricuspid valve surgery. Tricuspid regurgitation associated with left-side lesions is a part of the right-side disease in which right ventricular dysfunction and pulmonary hypertension are probably determining factors of a worse prognosis.

Therefore, despite the use of modern technologic advances, this old disease that is going to disappear in our environment continues to be a poor prognostic factor in patients with associated mitral or combined mitral and aortic valve disease.

	Acknowledgments

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We thank Marta Pulido, MD, for editing the manuscript and for editorial assistance.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): José M. Bernal José M. Revuelta Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bernal, J. M. Articles by Revuelta, J. M. Search for Related Content PubMed PubMed Citation Articles by Bernal, J. M. Articles by Revuelta, J. M. Related Collections Related Article