Prosthetic replacement of tricuspid valve: bioprosthetic or mechanical

BACKGROUND: Tricuspid valve replacement is one of the most challenging operations in cardiac surgery. Selection of the suitable prosthesis is still debatable. METHODS: In our institution, between January 1980 and December 2000, 129 tricuspid valve replacements were performed in 122 patients (14.7%). Bioprosthetic valves were used in 32 patients, whereas 97 patients had mechanical valve implantation. Twenty-two percent of replacements were done on men. Mean age was 35.27+/-11.56 years. In all patients, initially an annuloplasty technique was tried. Tricuspid valve replacement was performed when annuloplasty was not sufficient. In most of the cases, tricuspid valve interventions were done under cardiopulmonary bypass and on a beating heart. RESULTS: Early mortality was 24.5%. Patients were followed for 2 to 228 months. Seven patients underwent reoperation because of tricuspid valve dysfunction (7.6%). Nine patients died during the follow-up period. Late mortality was 9.7%. Actuarial estimates of survival in 20 years of follow-up for all tricuspid prosthetic valves, mechanical valves, and bioprosthetic valves were 65.1%+/-9.3%, 68.3%+/-10.6%, and 54.8%+/-12.1%, respectively. For the bioprosthetic valve group, freedom from structural valve degeneration was 90%+/-5.5%; for the mechanical valve group, freedom from deterioration, endocarditis, and leakage was 97.8%+/-4.2%, and freedom from thromboembolism was 92.6%+/-6.9%. CONCLUSIONS: We found that there was no statistically significant difference between the two groups in terms of early mortality, re-replacement, and midterm mortality (p > 0.05). Nevertheless, we recommend low profile modern bileaflet mechanical valves for prosthetic replacement of the tricuspid valve, due to their favorable hemodynamic characteristics and durability.     

Early aortic bioprosthetic valve deterioration in an octogenarian

We experienced extremely early aortic bioprosthetic valve deterioration with leaflet calcification and stiffening 2 1/2 years after aortic valve replacement in a female octogenarian. We could not identify the possible reason for this devastating complication; however, daily calcium supplement consumption may play a role of acceleration of calcium deposition in the leaflets of implanted bioprosthetic heart valves.     

A rare presentation of tricuspid valve thrombus in a normal heart

A young woman presented with a presumptive diagnosis of tricuspid valve tumor in a structurally normal heart. She was recently started on oral progesterone for menorrhagia related to uterine fibroids. She underwent an excision of the mass attached to the tricuspid valve, which was found to be an organized thrombus. We suggest a clinical approach to this problem.     

Hypercholesterolemia is a risk factor for bioprosthetic valve calcification and explantation

OBJECTIVE: There are pathophysiologic similarities between calcification and atherosclerosis. We wished to determine whether risk factors for atherosclerosis were linked to bioprosthetic valve calcification and dysfunction. METHODS: We performed a retrospective cohort study on 144 patients at a single institution who had bioprosthetic aortic or mitral valves removed, serum cholesterol levels recorded, and valve calcification assessed on the basis of hematoxylin and eosin staining and radiography of the valve. We also performed case-control analysis of a group of 66 patients whose tissue valves were explanted and compared them with an age- and position-matched group of 66 patients with similar duration of implantation. We also compared mean serum cholesterol levels. RESULTS: In the retrospective cohort study cholesterol (P =.035), younger age at implantation (P =.014), and coronary artery disease (P =.017) were linked to calcification of the valve by means of univariate analysis. In stepwise multiple regression analysis only the mean serum cholesterol level was linked to calcification (P =.02). Sex, hypertension, smoking, diabetes, and implant position were not linked to calcification. In the case-control analysis the mean serum cholesterol level of the explanted valve group was significantly higher (189 vs 163 mg/dL, P <.0001) than that of the group whose valves did not require explantation. For those whose serum cholesterol levels were greater than 200 mg/dL, the odds ratio was 3.9 (95% confidence interval, 1.7-8.9) for valve explantation. CONCLUSIONS: Increased serum cholesterol level may be a risk factor for bioprosthetic valve calcification requiring explantation.     

Right ventricular reduction as an adjunct procedure in tricuspid valve repair

Functional tricuspid regurgitation secondary to mitral valve disease can not be attributed to the dilatation of the tricuspid annulus alone. Furthermore, geometrical changes of the right ventricle lead to tethering of the tricuspid valve leaflets and thereby to an incomplete leaflet coaptation. With this pathologic entity, conventional isolated tricuspid valve annuloplasty will presumably result in significant residual tricuspid regurgitation. The surgical goal should be the reduction of tricuspid annulus dilatation and annihilation of tethering forces on the tricuspid leaflets. In combination with conventional tricuspid valve annuloplasty, right ventricular reduction surgery, as demonstrated, may be effective in reaching these goals and hereby avoiding residual tricuspid regurgitation in this patient population.     

Tricuspid valve replacement with a mitral homograft in children with rheumatic tricuspid valvulopathy

OBJECTIVE: Tricuspid valve replacement in children is associated with a nonnegligible complication rate because of specific disadvantages of mechanical or biologic prostheses. The objective of this study was to examine the midterm clinical outcomes of tricuspid valve replacement with a mitral homograft in 8 children with unreparable rheumatic tricuspid valve involvement. METHODS: Between 1993 and 2003, tricuspid valve replacement with a mitral homograft was performed in 8 patients (2 male and 6 female patients; mean age, 14.2 years) with rheumatic tricuspid valve disease. All patients were in New York Heart Association class III or IV. In all patients with rheumatic valve disease, conservative operations had previously been performed on the tricuspid valve during concomitant left-sided surgical intervention. Mean follow-up was 56 +/- 12 months and was complete. RESULTS: There were no operative or late deaths. All patients were alive at the most recent follow-up contact and were in New York Heart Association functional class I or II. None of the patients required homograft-related reoperation. At the most recent echocardiograhic examination, 6 patients had trivial residual tricuspid regurgitation, and 2 had mild tricuspid regurgitation. None of the patients had maximal transvalvular tricuspid gradients greater than 2 mm Hg during their yearly follow-up visits. CONCLUSION: On the basis of our midterm results, tricuspid valve replacement with a mitral homograft in children seems to be a valuable alternative surgical option.     

Transatrial stent-valve implantation in a stenotic tricuspid valve bioprosthesis

A 69-year-old man presented with symptoms of right heart failure due to stenosis of a tricuspid valve bioprosthesis. Echocardiography revealed right atrial dilatation and an estimated tricuspid valve area of 0.4 cm2. Because of advanced poor general condition and comorbidities, he was found unfit for conventional reoperation. Instead, transcatheter transatrial stent-valve implantation through a right thoracotomy was scheduled. The procedure resulted in a markedly improved clinical condition and an increased valve area measured to 2.5 cm2. In conclusion, transcatheter transatrial stent-valve implantation in stenotic valves is technically feasible and may lead to substantial improvement of the clinical condition.     

Valve-on-valve technique for replacement of degenerated tricuspid bioprosthetic valve without explantation

A 73-year-old woman admitted to our hospital with shortness of breath and edema of the lower extremities was diagnosed with right ventricular failure stemming from tricuspid valve regurgitation. She had undergone mitral valve replacement (MVR) with a mechanical valve at the age of 51, and reoperative MVR with mechanical valve, tricuspid valve replacement (TVR) with bioprosthetic valve, and pacemaker implantation at the age of 63. Reoperative TVR was performed when the patient failed to respond to drug therapy. A beating heart cardiopulmonary bypass procedure was performed in which only the bioprosthetic valve leaflet was excised, and reoperative TVR was performed with a 27-mm OptiForm^TM mechanical mitral valve (Sulzer Carbomedics Inc., Austin, TX, USA) by the valve-on-valve technique. The operative course was uneventful. The technique used here appears to be an effective approach to reoperative TVR, in this instance making it possible to avoid the risks associated with excision of the old prosthesis.     

A novel approach of tricuspid valve repair: mitralization of tricuspid valve

Open in a separate window OBJECTIVESThis study presents the mid-term results of a novel tricuspid valve (TV) repair strategy defined as ‘mitralization of TV’ (resection and plication of the posterior leaflet, ring implantation, optional leaflet procedures) applied for the correction of tricuspid regurgitation (TR).METHODSBetween 2017 and 2020, a total of 22 patients underwent concomitant TV repair using mitralization of the TV. Fourteen of the patients had functional TR (2 of them had severe tethering), 5 patients had prolapse and 3 patients had rheumatic involvement.RESULTSThere was no in-hospital mortality. Moderate or severe TR was not observed in any patient in echocardiographic evaluations before discharge. The mean follow-up duration was 30.9 + 6.2 months. Moderate-to-severe TR-free survival was 100% in the second year and 94.7% in the third year.CONCLUSIONSMitralization of the TV is a safe and effective treatment modality in terms of its mid-term results. This new technique provides an innovative perspective for the treatment of TR, especially in complex TV pathologies.