Tricuspid valve replacement: 25-year-experience at the Royal Adelaide Hospital

Abstract

Background: Patients requiring tricuspid valve replacement (TVR) often present with advanced symptoms and cardiac dysfunction. TVR is still an uncommon procedure but is associated with high morbidity and mortality. The aim of this study was to review our 25-year-experience with TVR and compare the pre-operative and early post-operative results with the available literature. Methods: A retrospective chart review was undertaken of all patients undergoing TVR between 1988 and 2013 at the D’Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital. Patient demographics, pre-operative clinical status, operative details, post-operative morbidity and 30-day mortality were analysed. A literature review was conducted using PubMed. Search terms included “tricuspid valve replacement” and “tricuspid valve surgery”, alone and in combination. Full text English publications regarding isolated TVR as well as TVR combined with other procedures were included. Reports describing tricuspid valve repair were not included in this review. Results: Between 1988 and 2013, 25 patients underwent tricuspid valve replacement at the D’Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital. The mean age was 55.9 ± 18 years, and 64% were female. Pre-operative New York Heart Association functional class were II (n=2, 8%), III (n=14, 56%) and IV (n=9, 36%). Aetiology for tricuspid dysfunction was rheumatic (44%), infective endocarditis (24%), carcinoid (8%), iatrogenic (8%), trauma (4%), dilated cardiomyopathy (4%) and pulmonary hypertension (4%). Pre-operative echocardiogram showed severe tricuspid stenosis in 16% (n=4) and severe tricuspid regurgitation in the remainder (n=21, 84%). Tricuspid leaflet morphology was deemed primary (n=11, 44%) or functional (n=14, 56%). Pre-operative right ventricular systolic function was normal (36%), mild impairment (20%), moderate impairment (24%), or severe impairment (16%). Left ventricular systolic function was normal in 23 cases, and moderately impaired in 2 cases (mean LVEF 60.8%). Pre-operative right heart dilatation was mild (24%), moderate (20%) or severe (48%). Mean pre-operative systolic pulmonary artery pressure was 46.3 ± 16.2 mmHg and mean pre-operative pulmonary capillary wedge pressure was 19.25 ± 7.4 mmHg. Seven patients (28%) had previous cardiac surgery. Three patients underwent isolated minimally invasive TVR via mini-thoracotomy, while the remaining 22 patients underwent TVR via median sternotomy, 7 patients as an isolated procedure and 15 patients combined with another procedure. Five patients underwent surgery as an emergency operation. Mean aortic cross clamp time was 78.3 minutes. Three cases were done with no aortic cross clamp. Mean cardiopulmonary bypass time was 122 min. A tissue prosthesis was used in 22 cases, and a mechanical prosthesis was used in 3 cases. Post-operative morbidity included pacemaker insertion (28%), pneumonia (40%), acute kidney injury requiring dialysis (48%), bleeding requiring return to theatre (8%), and stroke (8%). Thirty-day mortality was 32% (n= 8). Conclusion: Tricuspid valve replacement is rare but the procedure is associated with significant morbidity and mortality. The decision to operate can be challenging. Careful pre-operative assessment is crucial. Aetiology, clinical presentation and right heart and pulmonary vascular haemodynamics are major determinants of the outcome.