By Sihar Deddy Siahaan

Surgeons encountering an organic tricuspid lesion in daily practice often try to avoid a valve replacement as much as possible, and generally prefer some sort of repair with or without using annuloplasty rings Interestingly, although the technique for tricuspid valve replacement is pretty straightforward when compared to various repair options which necessitates considerable skill and experience, there is continuing debate on some aspects of the valve replacement, such as the choice of the prosthesis type according to age and risk groups.

a.

Demographics Forty-two patients, 16 male (38%) and 26 female (62%);with a mean age of 33 15 (range: 770 years) underwent 42 tricuspid valve replacements between March 1987 and December 2004. The etiology of tricuspid valve disease was rheumatic in 27 (64%), Ebsteins anomaly in 13 (31%), and endocarditis in 2 (5%). b. Clinical presentation 10 pts were in New York Heart Association Class-II functional capacity (24%), 19 were in Class III (45%), and 13 were in class IV (31%) Dyspnea was present in 26 patients (62%), tachyarrhythmia in 25 (60%), congestive symptoms and signs in 25 (60%), cyanosis in 8 (19%) and fever in 2 (5%).

c. Procedure isolated tricuspid valve replacement 20 pts (48%) mitral and tricuspid replacement 17 pts (40%) Aortic ,mitral and tricuspid replacement 5 pts (12%) Tricuspid replacement device was mechanical (St. Jude or Carbomedics)in 15 patients (36%) and bioimplant (Carpentier-Edwards or St. Jude) in 27 (64%) A bioimplant was preferred in patients undergoing isolated tricuspid valve replacement with no previously implanted mitral or aortic mechanical valves, especially in the old age group, and for those in whom the anticoagulant therapy would be problematic

Follow-up The mean follow-up time was 5.6 years (up to 18.3 years, a total of 175 patient years) Three patients underwent reoperation for repeat tricuspid replacement during the follow-up,two for prosthetic valve thrombosis and one for bioprosthesis degeneration 2 years after the primary operation.
d.

Statistical analysis Means are presented standard deviation. Determinantsof mortality or complications were analyzed by Chi-square orFishers exact tests when applicable. Survival and complication-free survival estimates were expressed as KaplanMeier curve
e.

Early outcome Hospital mortality was 26% (11 patients, 8 females and 3 males, p = 0.48; mean age: 39.5 14.9; range 2170 years). The major cause for early mortality was right heart failure and low cardiac output syndrome The risk factors associated with perioperative mortality were, (1) Rheumatic etiology, (10 of 27; 37% vs only 1 of 13 patients of Ebsteins anomaly group; p = 0.05), (2) Reoperation ( 11%; p = 0.01) and (3) Elevated pulmonary artery pressure (exceeding 30 mmHg; 5.9%; p = 0.004).
a.

Early complications : low cardiac output requiring inotropic support in (50%) transient bradyarrhythmia in (19%), cardiac tamponade in 4 (9.5%). respiratory complications necessitating prolonge mechanical ventilatory support (4.8%), transient renal function impairment (2.4%) sepsis (2.4%)

 Perioperative

low cardiac output development was strongly associated with poor preoperative functional class,as it developed in 9 of the 19 patients in NYHA Class-III and 10 of the 13 patients in Class-IV, in contrast to only 2 of the 10patients in Class-II ( p = 0.007).

b. Long-term outcome Survivors were followed up for an average postoperative period of 5.6 5.5 years (up to 18.3 years, a total of 175 patient years). Nine patients died during postoperativefollow-up. Three patients underwent repeat tricuspid valve replacements The KaplanMeier survival estimates were 37 11% at 10 years (Fig. 1) and 30 11% at 15 years with an average survival was 8.5 1.41 years (all including operative mortality), and longest postoperative follow-up was 18 year

Risk factors influencing long-term outcome For the patients with elevated pulmonary artery pressure(exceeding 30 mmHg) the long-term survival was less favorable with a 10-year KaplanMeier survival rate of21%, in contrast to 54% in those with normal pulmonary artery pressures ( p = 0.01) (Fig. 2). survival rates did not differed between the different preoperative functional class groups in terms of statistical significance Another factor influencing the long-time survival was the underlying disease, as 10-year Kaplan Meier survival was 53% in patients of congenital origin (Ebstein) versus 41% in those of rheumatic origin (Fig.3)
c.

d. Reoperations and event-free survival Two patients underwent repeated tricuspid valve replacements due to prosthetic valve thrombosis in the mechanicalvalve group while another patient from bioprosthesis group underwent reoperation due to bioprosthesis degeneration 2 years after the primary operation In all these reoperations,tricuspid prosthesis was replaced by a bioprosthetic valve No statistically significant difference was detected between mechanical or bioprosthetic valves in regard to perioperative mortality, low cardiac output, long-term survival or event-free survival.

e. Functional capacity improvement A comparison between preoperative and postoperativefunctional capacity based on NYHA Classification is representedin Fig. 4.

tricuspid disease sustained long enough may cause extensive compromise both locally (valve apparatus and/or right ventricle) and systemically (hemodynamic effects on the end-organs, especially the liver). Our results are in accordance with this observation, with a relatively high operative mortality, and a 10-year survival of only 37% (including operative mortality). Ten-year event-free survival was 31% for the whole group, with no statistically significant difference between mechanical or bioprosthetic valves

 The

risk factors for early mortality were rheumatic etiology, reoperation and elevated pulmonary artery pressure.Low cardiac output developed more frequently in those with decreased functional capacity (NYHA Class III an IV),congestive symptoms and those of rheumatic origin. rheumatic etiology more frequently necessitates valve replacement instead of repair

 Some

authors advocate using bioprostheses in tricuspid position due to high thromboembolic complications following mechanical valve implants .Our results did not support this argument,probably because of the relatively low incidence of valve related events in our series.

 Some

authors advocate the use of biologic prostheses even in young patients because of limited life expectancy unrelated to the type of tricuspid prostheses at long-term followup.Others suggest that even greater care is needed to prevent valve thrombosis in mechanical valves, there is still a greater chance for reoperation in bioprosthetic valves

 All

these arguments above need to be more elucidated to go beyond being simple speculations. Nevertheless, the fact is that the short and long-term results after tricuspid valve replacement are poorer than those of left-sided replacements

Long-Term Survival - Our study indicated that about 50% of patients were alive 10 years after surgery - In our experience,late deaths have not been due to valve-related complications but have resulted mainly from continuing heart failure and its attendant morbidity - Surgical technique, including type of prosthesis, did not have any bearing on longterm survival in our experience. - It is possible that improved medical management may be a strategy to increase the long-term survival.

 Mechanical

or Bioprosthetic Valve -The choice of prosthesis for TVR remains controversial with some groups favoring mechanical,others biological,and some are indifferent .In our series the long-term survival was similar regardless of prosthesis type. Although we found a high incidence of anticoagulation-related bleeding in the mechanical group

-Because there is no clear superiority of one prosthesis over another, the decision should be individualized to the patient.

 Immediate-

and Long-Term Survival - There were 14 deaths (17%) in patients who underwent tricuspid valve replacement with bioprostheses and 3 deaths (20%) in patients with mechanical tricuspid valve replacement within 30 days of operation (p 0.7). Seven patients died of multiorgan failure, 5 of mediastinal bleeding at the time of operation, 4 of cardiogenic shock, and 1 after a stroke.

 Long-Term

Complications - One patient died of thrombosis of a tricuspid mechanical valve (CarboMedic) 2 years after the operation, and another patient underwent reoperation because of tricuspidvalve dysfunction 1 year after implantation of a Duromedic heart valve in the tricuspid position - Reoperative tricuspid valve replacement and the use of a bioprosthesis or a mechanical valve had no significant effect on mortality after operation.

 Comment

- 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

Repair of Ebsteins anomaly. Atrialized portion of the right ventricle is obliterated by tying of the sutures. Closure of the atrial septal defect. Placement of the suture for shortening of the tricuspid annulus in the area of the dysplastic and downward displaced posterior leafl et. After tying of the suture, a functionally monocuspid valve will be created. (According to Danielson et al. [28, 29])

 Tricuspid

valve repair is associated with better perioperative and long-term outcome than valve replacement The incidence of re-operation is low with no significant difference whether the tricuspid valve has been repaired or replaced When valve replacement is necessary we recommend the use of a biological prosthesis considering the poor long-term survival

 Tricuspid

valve replacement: Postoperative and long-term results Guido J. Van Nooten, MDa, Frank Caes, MDa, Yves Taeymans, MDb, Yves Van Belleghem, MDa, Katrien Franois, MDa, Dirk De Bacquer, MScb, Frank E. Deuvaert, MDc, Francis Wellens, MDc, Georges Primo, MDc Ghent and Brussels, Belgium Received for publication August 12, 1994. Accepted for publication Dec. 29, 1994. Address for reprints: Guido J. Van Nooten, MD, Cardiac Surgery Department, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium.

 Mild

increased PAP = 2.6 - 2.9 m/s (27-33 mmhg)

Moderate
Severe

increased PAP = 3.0 - 3.9 m/s (36-60 mmhg)

increased PAP = 4.0 (64 mmhg )

1/The normal tricuspid inflow velocity is less than 0.5 to 1 m/s, with a mean gradient less than 2 mm Hg. 2/The evaluation of tricuspid valve stenosis with Doppler echocardiography is similar to the method described for mitral stenosis , although the constant of 190 has been proposed of the PHT method . 3/Tricuspid stenosis is considered severe when the mean gradient is 7 mm Hg or more and PHT is 190 milliseconds or longer.