Tricuspid valve surgery for functional tricuspid valve regurgitation associated with left-sided valvular disease.

OBJECTIVES: We have reviewed 260 patients who underwent initial tricuspid valve surgery for functional tricuspid valve regurgitation (TR) and analyzed independent predictors for early and late unfavorable results. MATERIALS AND METHODS: Between 1981 and 1998, 260 tricuspid valve operations were performed for functional TR. There were 94 males and 166 females with a mean age of 55 years. The tricuspid valve surgery procedures consisted of De Vega tricuspid annuloplasty in 240 patients, ring annuloplasty in four patients, and tricuspid valve replacement in 16 patients. The mean duration of follow-up was 7.8 years. RESULTS: Hospital mortality was 8.9% (23 patients). Late deaths occurred in 34 patients including cardiac-related late deaths in 26 patients. The survival rates were 83+/-2% at 5 years and 78+/-3% at 10 years. Late tricuspid valve reoperation was performed on 13 patients due to residual or recurrent TR in 12 patients and thrombosed tricuspid bileaflet mechanical valve in one patient. The tricuspid valve reoperation-free survival rate was 90+/-2% at 5 years and 84+/-3% at 10 years. The only predictor of hospital mortality was preoperative highly elevated right atrial pressure (P=0.01). Variables predictive of cardiac-related late death were preoperative New York Heart Association (NYHA) class IV (P=0.01) and poor left ventricular ejection fraction (LVEF) (P=0.02). Residual TR of more than grade 2+ early after tricuspid annuloplasty was a significant risk factor for late tricuspid valve reoperation (P=0.01). Preoperative TR of grade 4+ was predictive of early residual TR (P=0.04). CONCLUSIONS: Tricuspid valve surgery for functional TR can be performed with acceptable levels of early mortality. Cardiac-related late mortality after tricuspid surgery may be improved by earlier surgical treatment before NYHA class IV or deterioration of LVEF occurs. To prevent late tricuspid reoperation, it is important not to leave residual TR of grade 2+ or more after tricuspid annuloplasty.     

Tricuspid valve repair: durability and risk factors for failure

OBJECTIVES: To compare durability of tricuspid valve annuloplasty techniques, identify risk factors for repair failure, and characterize survival, reoperation, and functional class of surviving patients. METHODS: From 1990 to 1999, 790 patients (mean age 65 +/- 12 years, 51% New York Heart Association functional class III or IV, and mean right ventricular systolic pressure 56 +/- 18 mm Hg) underwent tricuspid valve annuloplasty for functional regurgitation using 4 techniques: Carpentier-Edwards semi-rigid ring, Cosgrove-Edwards flexible band, De Vega procedure, and customized semicircular Peri-Guard annuloplasty. Of these patients, 89% had concomitant mitral valve surgery. A total of 2245 follow-up transthoracic echocardiograms were retrieved. Tricuspid regurgitation was analyzed, and risk factors for worsening regurgitation were identified, by multivariable ordinal longitudinal methods. RESULTS: Tricuspid regurgitation 1 week after annuloplasty was 3+ or 4+ in 14% of patients. Regurgitation severity was stable across time with the Carpentier-Edwards ring (P =.7), increased slowly with the Cosgrove-Edwards band (P =.05), and rose more rapidly with the De Vega (P =.002) and Peri-Guard (P =.0009) procedures. Risk factors for worsening regurgitation included higher preoperative regurgitation grade, poor left ventricular function, permanent pacemaker, and repair type other than ring annuloplasty. Right ventricular systolic pressure, ring size, preoperative New York Heart Association functional class, and concomitant surgery were not risk factors. Tricuspid reoperation was rare (3% at 8 years), and hospital mortality after reoperation was 37%. CONCLUSIONS: Tricuspid valve annuloplasty did not consistently eliminate functional regurgitation, and across time regurgitation increased importantly after Peri-Guard and De Vega annuloplasties. Therefore, these repair techniques should be abandoned, and transtricuspid pacing leads should be replaced with epicardial leads.     

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

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.     

Tricuspid valve annuloplasty with a flexible prosthetic band

This study evaluates the application to the tricuspid valve of a flexible prosthetic band originally devised for mitral repair. Between March 2001 and May 2005, 53 consecutive patients (age 66.2+/-8.5 years) with significant tricuspid regurgitation and dilatation of the right-sided cardiac chambers underwent tricuspid valve annuloplasty with the band and concomitant mitral repair or replacement. Thirty-one patients (58.5%) were in NYHA class III or IV, and 33 (62.3%) had a history of right heart failure. Follow-up was 19.2+/-14.0 months. Three patients (5.7%) died before discharge, and one during follow-up. One late reoperation was required for mitral endocarditis. NYHA class decreased in survivors from 2.7+/-0.8 to 1.4+/-0.6 (P<0.0001), and the symptoms of right heart failure improved significantly after surgery. Tricuspid regurgitation was mild or absent in 44 survivors (89.8%) and moderate in 5 (10.2%). Regurgitation significantly decreased even in patients with risk factors for tricuspid repair failure or with persistent left ventricular dysfunction. The 4-year actuarial freedom from tricuspid regurgitation grade >1 was 88.7%. By univariable analysis, preoperative tricuspid regurgitation grade >2, right ventricular shortening fraction <35%, and permanent pacemaker were associated with the risk of recurrent moderate regurgitation, though only probably so (P=0.077, 0.061, and 0.097, respectively).     

Reoperations after tricuspid valve repair

OBJECTIVE: The objective was to analyze the short- and long-term results of patients with previous tricuspid valve repair who had valve dysfunction and required cardiac reoperations. METHODS: Between 1976 and 2002, 74 patients with a mean age of 53.8 +/- 12.2 years underwent valve reoperations for dysfunction of previous tricuspid valve repair. Mitral and tricuspid lesions were diagnosed in 40 patients (54%), triple valve disease (mitral, aortic, tricuspid) was diagnosed in 26 patients (35.1%), isolated tricuspid disease was diagnosed in 6 patients (8.1%), and aortic and tricuspid lesions were diagnosed in 2 patients (2.7%). Reoperations included tricuspid valve replacement in 43 patients (58.1%) and a new tricuspid valve repair procedure in the remaining 31 patients (41.9%). RESULTS: Hospital mortality (30-day or within first admission) was 35.1% (n = 26). In the multivariate analysis, risk factors for hospital mortality included body mass index less than 20 kg/m2 and greater than 24 kg/m2 , triple valve disease, use of intra-aortic balloon counterpulsation, and presence of postoperative complications. The follow-up was complete in 100% of patients, with a mean follow-up of 14.2 years (range 4 months to 26 years). The late mortality was 40.5% (n = 30). Predictors of late mortality were body mass index less than 20 kg/m2 , cardiac surgery before 1991, and development of dysfunction early after tricuspid valve repair. At the follow-up closing date, 19 patients are alive (25.7%). The actuarial survival was 11.8% +/- 4.9% at 26 years. CONCLUSIONS: Patients with failure of a tricuspid valve repair procedure requiring reoperation have a poor prognosis with a high mortality rate both in-hospital and in the long-term.     

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.     

应用彩色多普勒对二尖瓣置换术后三尖瓣功能的远期随访

目的应用彩色多普勒超声评价二尖瓣置换术后远期三尖瓣功能及形态变化。方法对接受二尖瓣置换术的903例病人术后三尖瓣功能进行了2～9年,平均(3.6±2.4)年的跟踪观察。所有病例术前均有不同程度的三尖瓣环扩大或关闭不全,其中未行三尖瓣成形术者201例;行Kay或改良DeVega成形术者686例;三尖瓣成形术同时加成形环者16例。结果未行三尖瓣成形术者术后2～3年有46例出现三尖瓣重度关闭不全;行Kay或改良DeVega成形术者,术后3～5年150例出现中重度三尖瓣关闭不全;三尖瓣成形术同时加成形环者仅1例术后2年出现三尖瓣轻-中度关闭不全。结论二尖瓣置换术后远期三尖瓣功能性关闭不全与三尖瓣环扩大、右心功能损害和严重肺动脉高压有关,三尖瓣环扩大是其重要的原因。对二尖瓣置换术者,手术中一旦发现有三尖瓣环扩大,即使无三尖瓣关闭不全,亦应行三尖瓣成形术,重度三尖瓣关闭不全、瓣环明显扩大者最好在环缩术的同时加成形环。     

Operative risk of reoperative aortic valve replacement

OBJECTIVE: The contemporary risk of reoperative aortic valve replacement is ill-defined. We therefore compared the recent early results of reoperative and primary aortic valve replacement in our institution. METHODS: Between January 1993 and January 2001, a total of 162 patients underwent reoperative aortic valve replacement with or without coronary artery bypass grafting, and 2290 underwent primary aortic valve replacement with or without coronary artery bypass grafting. The reoperative and primary groups were similar with regard to gender (37% female in both), preoperative New York Heart Association functional class (2.8 +/- 1 vs 2.8 +/- 1), and ejection fraction (58% +/- 15% vs 57% +/- 15%). Patients undergoing reoperative aortic valve replacement were younger than those undergoing primary aortic valve replacement (64 +/- 15 years vs 70 +/- 13 years, P < .001). Previous prostheses were xenografts in 77 patients (48%), homografts and autografts in 25 (15%), and mechanical prostheses in 60 (37%). Mean time to reoperation was 9.7 +/- 6.8 years. RESULTS: Early mortality for reoperative aortic valve replacement (8/162, 5%) was not statistically different from that for primary aortic valve replacement (71/2290, 3%, P = .20). Endocarditis was more common in the reoperative group (22% vs 3%, P < .001); when endocarditis was excluded from the analysis, early mortality was 3% in both groups. Multivariate predictors for early mortality were prosthetic valve endocarditis ( P < .001, odds ratio 9.8), advanced preoperative functional class ( P < .001, odds ratio 2.0), peripheral vascular disease ( P = .008, odds ratio 2.0), preserved left ventricular ejection fraction ( P = .004, odds ratio 0.98), and male gender ( P = .009, odds ratio 0.49). After adjustment for these factors, there was no difference in early mortality between the groups ( P = .095). CONCLUSION: The risk of reoperative aortic valve replacement is similar to that for primary aortic valve replacement. These data support the expanded use of bioprosthetic valves in younger patients.     

A novel technique for correction of severe tricuspid valve regurgitation due to complex lesions.

OBJECTIVES: Correction of tricuspid regurgitation due to complex lesions (not treatable with annuloplasty only) is associated with suboptimal results. To improve the efficacy of valve repair in this context, we developed a new surgical approach, which consists of stitching together the central part of the free edges of the leaflets producing a 'clover' shaped valve. Our preliminary experience with this novel technique is reported. METHODS: Between 2001 and 2003, 14 patients (mean age 57+/-17 years), with severe tricuspid regurgitation due to complex lesions, underwent valve repair with this novel approach in combination with annuloplasty. The aetiology of the disease was post-traumatic in five cases, degenerative in eight and secondary to dilated cardiomyopathy in one. Anterior leaflet prolapse/flail was present in most patients associated with posterior and/or septal leaflet prolapse or tethering. Annular and right ventricular dilatation was present in all cases. Mitral valve repair/replacement was concomitantly performed in nine patients. RESULTS: Hospital mortality was 7.1% (1/14). At follow-up extending to 22 months (mean 12+/-6.3), all survivors were asymptomatic. At the last echocardiogram tricuspid regurgitation was absent or mild in 13 patients and moderate in one. Mean tricuspid valve area and gradient were 4.2+/-0.4 cm(2) and 2.7+/-1.4 mmHg, respectively. CONCLUSIONS: Despite the short follow-up, this novel technique appears to be an easy, rapid and effective approach to correct severe tricuspid regurgitation due to complex lesions. Such a repair restored tricuspid valve competence, even in the presence of huge RV dilatation and pulmonary hypertension.     

Long-term follow-up after Carpentier-Edwards ring annuloplasty for tricuspid regurgitation

BACKGROUND: Use of flexible rings for tricuspid ring annuloplasty is becoming popular. This study was undertaken to evaluate Carpentier-Edwards (C-E) rigid ring annuloplasty for tricuspid regurgitation (TR), secondary to mitral valve disease and clinical outcome on a long-term basis. METHODS: From December 1985 to March 1996, 45 patients with secondary TR underwent C-E ring annuloplasty. Thirty-nine patients (95.1%) were in New York Heart Association (NYHA) functional class III or IV. The mean follow-up was 96.7+/-48.5 months or 362.6 patient-years. RESULTS: There were three in-hospital and nine late deaths that were not related to tricuspid annuloplasty. Actuarial survival at 10 years was 68.3%. Echocardiographic studies showed that TR was well controlled within grade 2+ in all survivors. Residual pulmonary hypertension (PH) was recognized in 9 of 21 patients (42.9%) with preoperative PH, however, no TR was seen in 6 patients. A TR grade of 2+ was observed in 3 patients. Thirty of the total survivors (96.8%) were in NYHA class I and II, but 1 patient was in NYHA class III. The actuarial rate of freedom from tricuspid valve reoperation after 10 years was 97.5%. CONCLUSIONS: C-E ring annuloplasty is acceptable for repair of secondary TR and improvement in clinical status on a long-term basis.     

Evaluation of long-term results of bicuspidalization annuloplasty for functional tricuspid regurgitation. A seventeen-year experience with 133 consecutive patients

Between 1968 and 1985, 133 consecutive patients underwent bicuspidalization annuloplasty for moderate to severe functional tricuspid regurgitation associated with mitral or combined mitral and aortic valve disease. Over this period, the incidence of tricuspid valve replacement was only 2.3% (3/136 patients). There were 18 early deaths (13.5%) in the entire series--three (5.0%) of 60 patients in the last 5 years of the study--and 10 late deaths (8.7%). Actuarial survival rate for the entire series, excluding early deaths, was 91.0% +/- 3.0% at 10 and 17 years. There were seven reoperations (6.1%) on the tricuspid valve, needed because of residual or recurrent mitral valve lesions after the initial operation. Actuarial rates of freedom from reoperation on the tricuspid valve were 93.6% +/- 3.0% (10 years) and 69.7% +/- 16% (17 years) for the entire series: 78% +/- 10% (15 years) for the open mitral commissurotomy plus tricuspid annuloplasty group (44 patients); 90% +/- 9.0% (15 years) for the mitral plus tricuspid annuloplasty group (10); 75.2% +/- 22% (17 years) for the mitral replacement plus tricuspid annuloplasty group (58); and 92.6% +/- 7.0% (16 years) for the combined aortic and mitral valve surgery plus tricuspid annuloplasty group (21). Ninety-eight percent of the survivors were in New York Heart Association class I or II postoperatively. Of 21 randomly selected patients investigated by pulsed Doppler echocardiography, 14 (67%) had no regurgitation or grade 1/4 tricuspid regurgitation and the remaining seven (33%) had grade 2/4 regurgitation postoperatively. Our experiences suggest that bicuspidalization annuloplasty can be a reliable method in the vast majority of patients with functional tricuspid regurgitation.     

继发性三尖瓣关闭不全的外科治疗进展

继发于左心系统瓣膜病变的三尖瓣关闭不全,多为三尖瓣瓣环扩大导致的功能性三尖瓣关闭不全,也有少数患者同时合并三尖瓣风湿性等器质性改变。对三尖瓣反流的处理,目前主张如果能通过瓣膜成形方法恢复三尖瓣瓣膜功能,应尽量行三尖瓣成形手术。三尖瓣成形方法主要包括线性成形和人工瓣环成形技术,但目前各种手术成形方法的适应证选择和临床应用尚无统一的标准,多年来一直是困扰心脏外科医师的难题和研究热点,是否需要同期行三尖瓣成形术,采用什么成形方法才能达到最佳的三尖瓣成形效果。因此,对继发性三尖瓣关闭不全患者三尖瓣病变程度的判定、矫治标准及手术方法等进行综述。     

Tricuspid valve repair. Operative and follow-up evaluation by Doppler color flow mapping

Severe tricuspid regurgitation may produce significant morbidity and mortality if not corrected, but commonly used methods of intraoperative assessment may be unreliable. Tricuspid regurgitation was evaluated by a new intraoperative technique, Doppler color flow mapping, in 85 patients before and after cardiopulmonary bypass. Regurgitation grade by intraoperative color Doppler mapping correlated well with right ventricular angiography (kappa value = 0.92, p less than 0.01; n = 8) and with preoperative color Doppler studies (kappa = 0.71, p less than 0.05; n = 51). The right atrial V wave correlated poorly with the severity of tricuspid regurgitation intraoperatively, both before (r = 0.30) and after (r = -0.05, p = no significant difference) cardiopulmonary bypass. Advanced (3+ or 4+) tricuspid regurgitation was found in 40% (21) of 52 patients requiring mitral valve repair or replacement. Tricuspid annuloplasty with a prosthetic ring provided a significant (greater than or equal to 2 grade) reduction in regurgitation severity in 94% (17/18; p less than 0.05). Without repair, tricuspid regurgitation decreased to a similar degree after mitral valve operations in 14% (5/36); only one of the five patients had advanced tricuspid regurgitation prepump. Fluid filling of the arrested right ventricle after the surgical procedure did not predict regurgitation severity (false negative rate 50%, 2/4; false positive rate 22%, 2/9). Regurgitation grade remained unchanged after the initial postpump study, up to 60 weeks postoperatively. In conclusion, color Doppler flow mapping provides more accurate intraoperative assessment of tricuspid regurgitation than the right atrial V wave or fluid filling of the right ventricle. This semiquantitative technique aids in the selection of patients appropriate for surgical repair of the tricuspid valve and is useful in judging the adequacy of tricuspid valve repair before chest closure. Advanced (3+ or 4+) tricuspid regurgitation is a common occurrence in patients undergoing mitral valve repair or replacement and rarely responds to conservative (nonoperative) management. Ring annuloplasty provides a highly effective and durable reduction in tricuspid regurgitation.     

Successful repair of traumatic tricuspid valve regurgitation

Isolated traumatic tricuspid valve regurgitation is an uncommon complication of blunt chest trauma. Tricuspid valve replacement has been ordinarily managed for this lesion. Herein, we report two cases of successful repair for traumatic tricuspid valve regurgitation, 11 and 40 years following blunt chest trauma, respectively. Tricuspid valve repairs were performed using an artificial chordae implantation with expanded polytetrafluoroethylene (CV-5) sutures and ring annuloplasty. Postoperative echocardiography revealed that the tricuspid valve regurgitation improved to mild and trivial respectively in two patients. They are presently doing well, 4 and 2 years after the repair, respectively.     

A review of surgery for acquired tricuspid valve disease, including an assessment of the stented semilunar homograft valve, and the results of operation for multivalvular heart disease

A total of 246 operations were performed in 230 patients for correction of acquired tricuspid valve disease. All but three of the patients had multivalvular heart disease. There was an 11% hospital mortality which fell to 7% in the later era (1973-82). Mortality was similar for tricuspid annuloplasty and tricuspid replacement and for double and triple valve surgery. On multivariate analysis the incremental risk factors for hospital death were extreme functional disability (Class V), being of Caucasian race, and having a high cardiothoracic ratio (CTR). Actuarial survival was 58% at 9 years postoperative. The incremental risk factors for late death were prior cardiac surgery, age at operation greater than or equal to 55 years, and advanced functional disability (Classes IV, V). The actuarial incidence of significant tricuspid incompetence following annuloplasty was 12% at 3 years, and following stented homograft semilunar valve replacement was 6% at 3 years and 24% at 8 years. Severe homograft valve incompetence was always associated with recurrent left-sided valve lesions or residual pulmonary hypertension. It is concluded that a homograft valve is a superior form of tricuspid valve replacement.     

Mitral valve repair in children with rheumatic heart disease

OBJECTIVE: The purpose of this study was to assess the long-term results of mitral valve repair in children with chronic rheumatic heart disease. METHODS: From January 1988 through December 2003, 278 children (153 male children) underwent mitral valve repair. Mean age was 11.7 +/- 2.9 years (range, 2-15 years). One hundred seventy-three children (62%) were in the New York Heart Association functional class III or IV. Congestive heart failure was present in 24 (8.6%). Reparative procedures included posterior collar annuloplasty (n = 242), commissurotomy (n = 187), cusp-level chordal shortening (n = 94), cusp thinning (n = 71), cleft suture (n = 65), and cusp excision or plication (n = 10). Associated procedures included atrial septal defect closure (n = 22), aortic valve repair/replacement (n = 13), and tricuspid valve repair (n = 3). RESULTS: Early mortality was 2.2% (6 patients). Preoperative left ventricular dysfunction was associated with greater mortality. Median follow-up was 56.5 months (mean, 58.9. +/- 32.3 months; range, 5 to 180 months). One hundred seventy-seven survivors (65%) had no or trivial mitral regurgitation. Sixteen patients (6%) required reoperation for valve dysfunction. There were 7 late deaths (2.6%). Actuarial, reoperation-free, and event-free survivals at a median follow-up of 56.5 months were 95.2% +/- 1.5%, 91.6% +/- 2.2%, and 55.9% +/- 3.5%, respectively; at 15 years, they were 95.2% +/- 1.5%, 85.9% +/- 5.9%, and 46.7% +/- 4.7%, respectively. CONCLUSION: Mitral valve repair in children with chronic rheumatic heart disease is feasible and provides acceptable long-term results.     

Triple valve repair for young rheumatic patients.

BACKGROUND: Facing young foreign polyvalvular rheumatic patients, for which long-term anticoagulation is not available, we have chosen to attempt triple valve repair procedures in order to avoid prosthetic implantation in this particular population suffering from triple valve disease. METHODS: Twenty-one young rheumatic patients (mean age:11+/-4 years) underwent triple valve repair procedures including cusp extension on the aortic valve aortic between September, 1992 and December, 2000. Valvular pathology characteristics according to Carpentier's classification included mitral insufficiency type III post+II ant (n=10), type III post (n=4), type II ant (n=2), mitral stenosis (n=5), type III aortic insufficiency (n=21), type I (n=13) and type III (n=8) tricuspid insufficiency. RESULTS: Firstly, the mitral valve disease were corrected using Carpentier's techniques of repair: prosthetic ring annuloplasty (n=16), commissurotomy (n=12), chord transposition (n=11) or shortening (n=4), papillary muscle sliding plasty (n=4) and pericardial patch leaflet enlargement (n=6). Secondly, aortic lesions were corrected using glutaraldehyde stabilized autologous pericardium triple cusps extension technique (n=21). Lastly, tricuspid repairs were always performed on beating hearts using commissurotomy (n=8), prosthetic ring (n=12) or other techniques (n=9) of annuloplasty. The operative mortality was 4.7% (one patient died). Echocardiograms before discharge showed grade I mitral insufficiency in seven patients and grade I aortic insufficiency in five patients. There was no late death during a mean follow-up of 51+/-31 months. Two patients underwent valvular redo surgery because of aortic and mitral plasty deterioration due to rheumatic disease progress. After 5 years, 90% of the patients were free from redo valvular surgery. CONCLUSIONS: In rheumatic patients, autologous pericardial patch extension of the aortic valve permitted widespread use of reconstructive surgery even in patients suffering from triple valve disease. Triple valve repair, in this particular challenging setting of patients, has provided satisfactory initial and mid-term results and could be considered as an interesting palliative surgical approach.     

Ebstein's anomaly: repair based on functional analysis.

OBJECTIVE: 'Classical' repair of Ebstein's anomaly is usually performed with transverse plication of the atrialized chamber. However, the anterior leaflet has restricted motion which is an important factor of the tricuspid valve insufficiency. We studied the long term results of mobilization of the anterior leaflet associated with longitudinal plication of the right ventricule. METHODS: From 1980 to July 2002, 191 patients (mean age 24.4+/-15 years (1-65)) were operated on. Anterior leaflet function was assessed on pre-op echocardiography and on surgical examination. Conservative surgery was possible in 187 patients (98%) and included mobilization of the anterior leaflet, longitudinal plication of the right ventricle and prosthetic annuloplasty in adults. Bidirectional cavo-pulmonary shunt was associated in 60 patients. Four patients had valve replacement. RESULTS: Hospital mortality occurred in 18 patients: 9% (95%CL: 6-15%) due to right ventricle (RV) failure in nine patients. Mean follow-up was 6.4 years (0.07-22). Actuarial survival was 82% at 20 years. Tricuspid valve insufficiency was 1 or 2+ in 80% of the cases. Reoperation occurred in 8% (16 patients). A successful second repair was obtained in ten patients. Electron beam computerized tomography (20 patients) demonstrated improved left ventricle ejection fraction 56-66% (P<0.05). Supraventricular tachycardia and pre-excitation syndromes were reduced from 23 to 5%. CONCLUSION: Conservative surgery is indicated for all symptomatic patients. The incidence of valve repair is high when leaflet mobilization is performed. Valve replacement can be avoided in most cases. Functional and hemodynamic results are excellent.     

Tricuspid valve operations in 530 patients. Twenty-five-year assessment of early and late phase events

From Jan. 1, 1961, through Dec. 31, 1987, 530 patients underwent an intracardiac operation that included a tricuspid valve procedure. The tricuspid valve was repaired in 351 patients (66%) and replaced in 179 (34%). Mean age was 56.9 years. Risk factors associated with tricuspid valve replacement included tricuspid stenosis (p = 0.02), jugular venous distention (p = 0.04), previous operation (p = 0.05), and angiographic severity of tricuspid valve incompetence (p less than 0.001). There were 78 hospital deaths (15%). Risk factors for hospital death included previous operation (p = 0.03), male gender (p = 0.03), hepatomegaly (p = 0.03), De Vega or Carpentier annuloplasty (repair group only), (p = 0.01), and older age at operation (p = 0.06). Ninety-eight percent of the patients were followed up. There were 185 late deaths (41%). The actuarial survival rate was 20% at 180 months. Risk factors for late death included male gender (p = 0.03), hepatomegaly (p = 0.04), and lack of postoperative warfarin therapy (p less than 0.001). Actuarial freedom from reoperation was 25.5% at 180 months. There was no difference in reoperation rates (p = 0.10) or survival (p = 0.42) whether the tricuspid valve had been repaired or replaced. We conclude that the requirement for surgical treatment of tricuspid valve insufficiency in patients with multivalvular disease constitutes a high risk group for cardiac surgery. Preoperative variables may predict the result of tricuspid valve replacement. Tricuspid valve replacement may be performed with the expectation of a low risk of valve-related events.     

Surgical treatment of tricuspid insufficiency in patients undergoing mitral valve replacement

During the past eight years, 46 of the 106 patients who underwent mitral valve replacement were associated with tricuspid insufficiency. No surgical correction was performed (14 cases) in cases of slight tricuspid insufficiency. Tricuspid annuloplasty (11 cases) or valve replacement (21 cases) was employed according to the severity of insufficiency. In the non-repair group, the mortality rate was fairly low (21 per cent), but the postoperative status was the least satisfactory by the NYHA classification. Tricuspid insufficiency was significantly reduced only in two of these 14 cases after the mitral valve replacement. In the tricuspid annuloplasty group, although the technique of tricuspid annuloplasty did not always correct insufficiency completely, only one patient died of residual insufficiency. The cardiac output measured with Minnesota Impedance Cardiograph increased postoperatively in proportion to stress in this group. In the tricuspid valve replacement group, cardiac catheterization studies revealed hemodynamic improvement at rest in all, but cardiac output during exercise remained unchanged or decreased in some cases. Now we consider that tricuspid insufficiency with advanced mitral valve disease, even of a slight degree, should be surgically treated and that annuloplasty has more obvious hemodynamic benefits than valve replacement.