Bioprosthetic Tricuspid Valve Replacement Research Articles

May 2024 Medical Image of the Month: Hereditary Hemorrhagic Telangiectasia in a Patient on Veno-Arterial Extra-Corporeal Membrane Oxygenation

No abstract available. Manuscript truncated after 150 words. A 54-year-old man with a complex cardiac history, including Tetralogy of Fallot requiring Blalock-Taussig shunt in infancy, infundibular patch repair at age 7, and bioprosthetic tricuspid valve replacement at age 52, had ongoing frequent hospitalizations with decompensated right ventricular heart failure secondary to native pulmonary valve mixed stenosis plus regurgitation and left pulmonary artery stenosis. His case was further complicated by his history of hereditary hemorrhagic telangiectasia (HHT) with recurrent epistaxis and recent GI bleeds with multiple angiodysplastic lesions throughout the stomach, duodenum, and descending colon which were previously treated with argon plasma coagulation. The patient was admitted to our hospital in NYHA class IV heart failure receiving a continuous dopamine infusion and aggressive diuresis. Upon admission, a right heart catheterization demonstrated severe pulmonary valve regurgitation, left pulmonary artery stenosis, and systemic hypoxemia suggestive of an intrapulmonary shunt. Admission transthoracic echocardiogram demonstrated normal left ventricular ejection fraction of 55-60%, a …

Restricted Cusp Motion in Newly Implanted Tricuspid Bioprostheses: Incidence, Predictors, and Impact on Survival

ObjectiveThis study aimed to investigate the occurrence of restricted cusp motion (RCM) at the time of bioprosthetic tricuspid valve replacement (TVR) and analyzed associated risk factors and outcomes. MethodsThis study involved adult patients who underwent TVR with a bioprosthesis at our institution between 2012 and 2022. Bioprosthetic cusp motion was analyzed de-novo through a detailed review of intraoperative transesophageal echocardiograms (TEE). Two models of porcine valves were implanted, the Hancock II bioprosthesis (Medtronic, Inc, Minneapolis, Minnesota) and the St. Jude Epic bioprosthesis (St. Jude Medical, St. Paul, Minnesota). ResultsAmong the 476 patients who met the inclusion criteria, RCM was identified on the immediate post-bypass TEE in 150 (31.5%); there was complete immobility of the cusp in 63 patients (13.2%) and limited movement of a cusp in 87 patients (18.3%). In a multivariable logistic regression analysis, the Hancock II model (OR 6.15, p<0.001), a larger orifice area (per IQR increase, OR 1.58, p=0.017), a smaller body surface area (per IQR increase, OR 0.68, p=0.040), and a lower ejection fraction (per IQR increase, OR 0.60, p=0.033) were independently associated with having RCM. Cox regression adjusting for 15 covariates revealed that RCM at time of TVR was independently associated with an increased risk of mortality (HR 1.35, p=0.049). ConclusionsThis study revealed a high incidence of restricted cusp motion in bioprosthetic valves in the tricuspid position detected shortly post-implantation, which was associated with increased late mortality. To reduce the probability of restricted cusp motion, it is important to select the appropriate prosthesis model and size, particularly in small patients.

Failed bioprosthetic tricuspid valve replacement treated with transcatheter valve for valve repair

Tricuspid bioprosthetic valve failure may lead to right-sided heart failure and is traditionally managed with surgical valve replacement. However, the substantial mortality risk associated with reoperation for failed tricuspid bioprosthesis prompts the need for less invasive alternatives. Transcatheter valve-in-valve (TViV) implantation presents a promising minimally invasive option for patients with failing bioprosthetic valves. This case involves a 32-year-old man with a history of recurrent failed bioprosthetic tricuspid valves who underwent successful percutaneous TViV implantation using a 29 mm Edwards Sapien S3 valve, resulting in marked clinical and hemodynamic improvement. This case contributes essential insights to the limited literature on TViV in the tricuspid position, particularly in patients with complex surgical histories. The high procedural success rate and substantial improvement in valve function underscore the potential of TViV as an effective alternative to surgical replacement for failed tricuspid bioprosthetic valves. Keywords: Transcatheter tricuspid valve replacement; tricuspid valve-in-valve; bioprosthetic tricuspid valve; tricuspid valve stenosis

The Role of Transthoracic Echocardiography for Assessment of Mortality in Patients with Carcinoid Heart Disease Undergoing Valve Replacement

Patients with carcinoid heart disease (CHD) are referred for valve replacement if they have severe symptomatic disease or evidence of right ventricular (RV) failure and an anticipated survival of at least 12 months. Data are lacking, however, on the role of transthoracic echocardiography in predicting outcomes. We carried out a retrospective, single-centre cohort study of patients with a biopsy-confirmed neuroendocrine tumour (NET) and CHD undergoing valve replacement for severe valve disease and symptoms of right heart failure. The aim was to identify factors associated with postoperative mortality, both within one year of surgery and during long-term follow-up. Of 88 patients with NET, 49 were treated surgically (mean age: 64.4 ± 7.6 years; 55% male), of whom 48 had a bioprosthetic tricuspid valve replacement for severe tricuspid regurgitation; 39 patients had a pulmonary valve replacement. Over a median potential follow-up of 96 months (interquartile range: 56-125), there were 37 deaths, with 30-day and one-year mortality of 14% (n = 7) and 39% (n = 19), respectively. A significant relationship between RV size and one-year mortality was observed, with 57% of those with severe RV dilatation dying within a year of surgery, compared to 33% in those with normal RV size (p = 0.039). This difference remained significant in the time-to-event analysis of long-term survival (p = 0.008). RV size was found to reduce significantly with surgery (p < 0.001). Those with persisting RV dilatation (p = 0.007) or worse RV function (p = 0.001) on postoperative echocardiography had significantly shorter long-term survival. In this single-centre retrospective study of patients undergoing surgery for CHD, increasingly severe RV dilatation on preoperative echocardiography predicted adverse outcomes, yielding a doubling of the one-year mortality rate relative to normal RV size. These data support the possibility that early surgery might deliver greater long-term benefits in this patient cohort.

Early and long-term outcomes of bioprosthetic versus mechanical tricuspid valve replacement: A nationwide population-based study

ObjectivesWe compared early and long-term clinical outcomes of bioprosthetic versus mechanical tricuspid valve replacement in a nationwide study based on the database from the National Health Insurance Service. MethodsOf 1425 patients who underwent tricuspid valve replacement from 2003 to 2018, 1241 patients were enrolled after excluding retricuspid valve replacement, complex congenital heart disease, Ebstein anomaly, and age less than 18 years at operation. Bioprostheses (group B) and mechanical prostheses (group M) were used in 562 patients (45.3%) and 679 patients (54.7%), respectively. The median follow-up duration was 5.6 years. Propensity score matching was performed. Subgroup analysis was performed in patients aged 50 to 65 years. ResultsThere was no difference in operative mortality or postoperative complications between the groups. All-cause mortality was higher in group B (7.8 vs 4.6 per 100 patient-years, hazard ratio, 1.75, 95% confidence interval, 1.33-2.30, P < .001). The cumulative incidence of stroke was higher in group M (hazard ratio, 0.65, 95% confidence interval, 0.43-0.99, P = .043), whereas the cumulative incidence of reoperation was higher in group B (hazard ratio, 4.20, 95% confidence interval, 1.53-11.54, P = .005). In terms of the age-dependent hazard of all-cause mortality, group B demonstrated a higher hazard than group M below the age of 75 years, and it was statistically significant between 54 and 65 years of age. In the subgroup analysis, all-cause mortality was also higher in group B. ConclusionsMechanical tricuspid valve replacement demonstrated higher long-term survival than bioprosthetic tricuspid valve replacement. In particular, mechanical tricuspid valve replacement showed significantly higher overall survival between 54 and 65 years of age.

Long-Term Outcomes of Bioprosthetic and Mechanical Tricuspid Valve Replacement after Left-Sided Valves Surgery.

This study aimed to show the outcomes of isolated tricuspid valve replacement (ITVR) after left-sided valve surgery (LSVS). Patients who underwent ITVR after LSVS were divided into bioprosthetic tricuspid valve (BTV) and mechanical tricuspid valve (MTV) groups. Clinical data were collected and analyzed between groups. 101 patients were divided into BTV (n = 46) and MTV (n = 55) groups. The mean ages of the BTV and MTV groups were 63.4 ± 8.9 and 52.4 ± 7.6 years, respectively (P <0.01). There was no significant difference in 30-day mortality (BTV 10.9% vs. MTV 5.5%), early postoperative complications, and long-term tricuspid valve (TV)-related adverse events between these two groups. New-onset renal insufficiency was an independent risk factor for early mortality. Survival rates in the BTV group were 94.8% ± 3.6%, 86.5% ± 6.5%, and 54.2% ± 17.6% and in the MTV group were 96.0% ± 2.8%, 79.0% ± 7.4%, and 59.4% ± 14.8% at 1, 5, and 10 years, respectively (P = 0.826). The TV prosthesis selection in ITVR after LSVS seems to not affect 30-day mortality and early postoperative complications. Long-term survival and the occurrence of TV-related events were also comparable between these two groups.

Outcomes of isolated tricuspid valve replacement: a systematic review and meta-analysis of 5,316 patients from 35 studies.

Transcatheter tricuspid valve replacement (TTVR) is rapidly emerging as a therapeutic option amongst patients with secondary tricuspid regurgitation. Historical data from surgical tricuspid valve replacement (TVR) studies may serve as a benchmark for the development of TTVR trials. The aim of the study was to investigate the early and late outcomes following isolated surgical TVR. Multiple electronic databases were searched to identify studies on isolated surgical TVR. The prespecified primary endpoint was operative mortality; secondary endpoints were early and late outcomes. Overall estimates of proportions and incidence rates with 95% confidence intervals (CI) were calculated using random-effects models. Multiple sensitivity analyses accounting for baseline characteristics, country and the operative period were applied. Results: A total of 35 studies (5,316 patients) were included in this meta-analysis. The operative period ranged from 1974 to 2019. The overall rate of operative mortality was 12% (95% CI: 9-15), with higher mortality for patients who were operated on before 1995, who had prior cardiac surgeries, or who had liver disease. The most frequent clinical events were pacemaker implantation (10% [95% CI: 6-16]), bleeding (12% [95% CI: 8-17]), acute kidney injury (15% [95% CI: 9-24]) and respiratory complications (15% [95% CI: 12-20]). At follow-up analysis of the bioprosthetic TVR, there was an incidence rate per 100 person-years of 6 (95% CI: 2-13) for death and 8 (95% CI: 5-13) for recurrence of significant tricuspid regurgitation. This meta-analysis provides an overview of the historical clinical outcomes following isolated surgical TVR. These findings can support the development of future clinical trials in the tricuspid space by providing thresholds for clinical outcomes.

Prosthesis choice for tricuspid valve replacement: Comparison of clinical and echocardiographic outcomes

ObjectivesThere is limited evidence evaluating valve function and right heart remodeling after tricuspid valve replacement (TVR), as well as whether the choice of prosthesis has an impact on these outcomes. MethodsWe reviewed 1043 consecutive adult patients who underwent first-time TVR; 33% had previous aortic and/or mitral valve operations. Severe tricuspid valve regurgitation (TR) was the indication for surgery in 94% patients. A mechanical valve was used in 149 (14%) patients and a bioprosthetic valve in 894 (86%). Concomitant major cardiac procedures were performed in 57% of patients. ResultsThe median age of the cohort was 68.8 (range, 25-94) years, and 57% were female. Overall survival at 5 and 10 years was 50% and 31%, respectively. Adjusted survival and cumulative incidence of reoperation after TVR were similar in patients with bioprosthetic and mechanical valves. Overall, right ventricular (RV) function and dilation improved postoperatively with the estimated proportion of patients with moderate or greater RV systolic dysfunction/dilatation decreasing by around 20% at 3 years follow-up. After adjusting for preoperative degree of dysfunction/dilatation, valve type had no effect on late improvement in RV function and dilation. Bioprosthetic TVR was associated with greater rates of recurrence of moderate or greater TR over late follow-up. Overall, a slight decline in tricuspid valve gradients was observed over time. ConclusionsMechanical and bioprosthetic valves provide comparable survival, incidence of reoperation, and recovery of RV systolic function and size after TVR. Bioprosthetic valves develop significant TR over time, and mechanical valves may have an advantage for younger patients and those needing anticoagulation.

Successful One and One-half Ventricular Circulation with Bioprosthetic Tricuspid Valve Replacement and Total Chordal Preservation in a Patient with Ebstein’s Anomaly: A Video Presentation

AbstractEbstein’s anomaly is a rare congenital malformation of the right ventricle and tricuspid valve which is characterized by several features that can exhibit an infinite spectrum of malformation.The abnormalities include: i) adherence of the tricuspid leaflets to the underlying myocardium (failure of delamination); ii) anterior and apical rotational displacement of the functional tricuspid annulus (septal &gt; posterior &gt; anterior leaflet); iii) dilatation of the right atrioventricular junction (the true tricuspid annulus) with variable degrees of hypertrophy and thinning of the wall; iv) dilatation of the “atrialized” portion of the right ventricle; and v) redundancy, fenestration, and tethering of the anterior leaflet.

Percutaneous VDD leadless pacer implant post recent bioprosthetic tricuspid valve replacement for infective endocarditis

AbstractIn January 2020, the first Medtronic VDD leadless pacemaker Micra AV was approved by FDA to treat patients with advanced AV block, based on the encouraging results from the Micra Atrial tRacking using a Ventricular accELerometer 2 (MARVEL 2). There is reassuring data about safety and short‐term outcomes of traditional leadless pacemaker implant after recent surgical tricuspid valve replacement, but only few cases are reported in literature. No data was found regarding AV Micra implant safety and outcomes in patients following bioprosthetic tricuspid valve replacement as of today. Our patient is a 44‐year‐old gentleman with history of IV drug use who recently underwent tricuspid replacement with bioprosthesis for infective endocarditis complicated by postsurgical heart block, acute kidney insufficiency requiring hemodialysis, persistent bacteremia and candidemia, and progressive failure of the epicardial pacing wires. Given the elevated infective risk, the decision of attempting leadless pacer implant through the bioprosthetic valve was taken and our patient underwent successful Micra AV implant on postoperative day 30. To our knowledge, this is the first AV Micra placement following bioprosthetic tricuspid valve replacement. The uneventful procedure and the encouraging short‐term device follow‐up results seem to confirm the relative safety of this device in treating advanced atrioventricular conduction disorders in patients at elevated infective risk.

Minimally Invasive Valve Replacement for Late Tricuspid Regurgitation After Left-Sided Valve Surgery

Late severe tricuspid regurgitation after left-sided valve surgery can negatively affect long-term prognosis and quality of life. Because of extensive surgical trauma and poor right heart function, perioperative mortality after reoperation for tricuspid regurgitation historically remained high. A number of minimally invasive techniques were adopted at our center recently, including endoscopy-assisted right minithoracotomy, vacuum-assisted single femoral venous drainage without dissecting or snaring vena cava, direct right atriotomy through pericardium, and the beating-heart technique. Moreover, the tricuspid valves were replaced with bioprostheses in the majority of those patients at our center. The midterm outcomes of minimally invasive bioprosthetic tricuspid valve replacement were favorable.

Which is the best prosthesis in an isolated or combined tricuspid valve replacement?

The debate concerning the optimal choice of tricuspid position continues. We compared the long-term results of mechanical and biological prostheses in patients who underwent isolated or combined tricuspid valve replacement, at 2 major cardiac surgical centres in central China. From January 1999 to December 2018, 338 patients underwent tricuspid valve replacement. Patients were divided into an isolated group or a combined group according to whether their surgery was combined with a left heart valve surgery. Mechanical tricuspid valve replacement was performed in 142 patients (isolated group: 41 vs combined group: 101), and 196 patients underwent bioprosthetic tricuspid valve replacement (isolated group: 145 vs combined group: 51). Operative results, long-term survival and tricuspid valve-related events were compared. Early mortality in the combined group was higher (n = 6, 4%) than that in the isolated group (n = 3, 2%), but no significant difference was observed between the mechanical and biological subgroups. In the isolated group, there was a higher event-free rate in the biological subgroup than in the mechanical subgroup (P = 0.042) and a similar result was also observed for patients without Ebstein's anomaly (P = 0.039). In the combined group, no significant difference was observed (P = 0.98). Survival rates were similar between the mechanical and biological subgroups in both the isolated (P = 0.54) and combined (P = 0.81) groups. Mechanical valves in isolated tricuspid valve replacement were more prone to valve thrombosis and bleeding. Every decision regarding tricuspid valve prostheses should be individualized, but biological prostheses may be an optimal choice for patients, especially for patients without Ebstein's anomaly, in isolated tricuspid valve replacement.

Fifteen-Year Outcomes After Bioprosthetic and Mechanical Tricuspid Valve Replacement

This study was conducted to compare long-term clinical outcomes of mechanical and bioprosthetic tricuspid valve replacement (TVR). Two-hundred twenty-six TVR patients were enrolled; 120 patients underwent bioprosthetic TVR (BTV group) and 106 underwent mechanical TVR (MTV group). Early results and long-term clinical outcomes were compared. The median follow-up duration was 99 months (range, 1-295). Propensity score (PS) analyses including PS-adjusted Cox regression models and 1:1 PS matching were performed. Mean ages of the MTV and BTV groups were 50.5 ± 10.3 and 60.8 ± 12.0 years, respectively. There were no significant differences in early mortality (4.9% in total) and postoperative complications between the 2 groups. The overall survival and freedom from cardiac death in the MTV group were similar to those in the BTV group (reference, BTV group; hazard ratio [HR], 0.82 [95% confidence interval {CI}, 0.44-1.53] and 0.91 [95% CI, 0.44-1.87], respectively). The risk of a composite of thromboembolism and bleeding was significantly higher in the MTV group (HR, 2.35; 95% CI, 1.16-4.77; P= .018). However the tricuspid valve reoperation rate was significantly lower in the MTV group (HR, 0.11; 95% CI, 0.02-0.53; P= .007). Overall TV-related event rates in the MTV group were similar to those in the BTV group (HR, 0.79; 95% CI, 0.49-1.28). PS matching extracted 69 pairs. Comparative analyses of early- and long-term outcomes from the matched groups yielded similar findings to those from the entire patient groups. The outcomes of bioprosthetic TVR were comparable with those of mechanical TVR in terms of long-term survival and tricuspid valve-related events over a 15-year postoperative follow-up.

P700 TEE guidance of percutaneous closure the inlet and exit of ascending aorta pseudoaneurysm in a patient had triple valve replacement

Abstract Funding Acknowledgements none OnBehalf none Introduction Surgical treatment of ascending aortic pseudoaneurysms (AAPA) that develop following cardiac surgery carries significant morbidity and mortality. However, there are emerging reports of transcatheter closure of AAPA. To the best of our knowledge, this is the first reported case where the APA communicates with the left ventricle (LV) cavity with significant diastolic volume overload mimic severe aortic regurgitation. We added to the complications of APA, a fistulous communication with LV causing severe volume overload and heart failure. Case description: Thirty-two years old female underwent mechanical aortic and mitral valve replacement and bioprosthetic tricuspid valve replacement in April 2013. At October 2016, she started to have progressive shortness of breath. TEE revealed large ascending aorta pseudoaneurysm that communicates with LV cavity. Cardiac computed tomography (CT) with contrast revealed a sizeable noncoronary sinus of Valsalva pseudoaneurysm 47mm x 39mm. Surgical excision of the aneurysm decided, but the patient refused any surgical procedure. Percutaneous closure of the inlet and exit of the aneurysm discussed and accepted by the patient. The procedure of transcatheter aneurysm device closure performed successfully with TEE guidance (Figure). A: showed the aneurysm exit to the LV while D: showed its inlet from the aorta. The wire passed the aneurysm inlet at ascending aorta to its outlet in the LV (B). Six mm VSD device deployed closing the aneurysm exit to LV (C). Another 6mm VSD device deployed closing the aneurysm inlet (E). Transgastric long axis aorta view showed no more flow to LV. Midessophageal Short axis view showed no flow between ascending aorta and the aneurysm. Fluoroscopy injection inside the aneurysm (F), another two devices left inside the aneurysm (G). The patient was observed in the cardiac care unit (CCU) for two days, then discharged home in good condition. She was followed in the outpatient clinic after two weeks, and she is doing well with no more shortness of breath. Follow up echo after one year of the procedure showed a small remaining flow from the aneurysmal cavity to the left ventricle. (H and K) compares apical three-chamber view before and one year after closure. Discussion: Preprocedural CT and Intraprocedural TEE are mandatory in determining the size and location of AAPA. Also, the type and size of suitable devices for closure. Overall, the success rate for percutaneous closure is 80%, with a 12% device embolization rate and an 8% failure rate of the transcatheter technique to close the pseudoaneurysm, necessitating conversion to surgical closure. In most reported cases the AAPA had only communication with the aorta. In our case, the AAPA also communicates with the LV cavity that requires the closure of both communications. Conclusion: Percutaneous closure of the inlet and exit of AAPA with TEE guidance is feasible. Long term follow up is required in a large number of patients. Abstract P700 Figure: AAPA device closure

479 When 2 rights make a wrong

Abstract Background The presence of an intra-cardiac mass is always a cause for concern, with regards to not only aetiology, but also treatment of complications. We describe a case series of 2 right sided cardiac myxomas, where the first case described an unusual location for tumour occurrence, while the second case provided insights into complications of a cardiac myxoma. Methods The first case involved a 70 year old asymptomatic lady who was referred for an additional heart sound. A transthoracic echocardiogram (TTE) showed a large, mobile 1.5 X 1.2 cm mass, attached to the atrial surface of septal tricuspid valve leaflet, prolapsing in and out of the right sided chambers. This was confirmed on transoesophageal echocardiogram (TEE). Cardiac MRI (magnetic resonance imaging) showed a similar mass attached to the septal tricuspid leaflet with features consistent with a myxoma. She was referred to cardiothoracic surgery, and 2 lobulated tumours arising the septal tricuspid valve and adjacent posterior leaflet were seen. The tumours were resected and a bio-prosthetic tricuspid valve replacement implanted. Histology of the tumours showed myxomatous degeneration of tricuspid valve, consistent with cardiac myxoma. The second case was a 56 year old lady who had dyspnoea, pedal oedema and an elevated jugular venous pulse on examination. A TTE done showed a large 7 X 4 cm mass extending from the right atrium (RA) into the right ventricle (RV). The left ventricular ejection fraction was 35%. Cardiac MRI confirmed the presence of a large mass in the right ventricle that exerted pressure effects on the ventricular septum and RV anterior free wall. Intra-operatively, a large RA mass attached by a stalk to the fossa ovalis was seen. The mass was excised and histology was consistent with cardiac myxoma. A repeat transthoracic echocardiogram done 2 weeks later showed normalisation of the LVEF. See images below for more information. Conclusion While myxomas are the most common benign cardiac tumours, they occur less commonly in the right atrium, and much less so on the tricuspid valve. Clinical manifestations range from being completely asymptomatic, as in the 1st case, to non-specific constitutional symptoms such as fever or general malaise, and to life-threatening complications. These include embolism to the pulmonary circulation, causing sudden death, or to the systemic circulation through an intra-cardiac shunt, causing strokes. This risk is increased if the tumour is large, polypoidal and friable. Large tumours can also cause obstructive symptoms and heart failure. Thus timely diagnosis with multi-modality imaging tools, and definitive treatment with complete resection of the tumour are essential. Continued monitoring for recurrences of the tumour, which can occur in 1-5% of all cases, should be performed as well. Abstract 479 Figure. Right sided cardiac masses

Surgical treatment for tricuspid regurgitation after left-sided valve surgery

Late tricuspid regurgitation after left-sided valve surgery can negatively affect long-term prognosis. The surgical timing and strategy of tricuspid valve reoperation will have important impact on the surgical outcomes. However, there is no clear recommendations of the surgical timing for this condition in the current guidelines. Generally, tricuspid valve reoperation should be performed before irreversible right heart failure occurs. Although tricuspid valve repair is the first choice for tricuspid regurgitation, bioprosthetic tricuspid valve replacement might be a reliable alternative when tricuspid leaflets have severe rheumatic damage or right ventricle and tricuspid annulus significantly dilate. Combined minimally invasive surgical techniques, including right minithoracotomy approach, accessing the right atrium directly through the pericardium with limited dissection, peripheral cannulation strategy with the vacuum-assist single venous drainage technique and heart beating technique, can significantly decrease the operative mortality and postoperative bleeding. With development of interventional therapy, transcatheter tricuspid valve repair or replacement may become alternatives for tricuspid regurgitation after left-sided valve surgery in the future.

Short-term outcomes of minimally invasive reoperation for tricuspid regurgitation after left-sided valve surgery

Objective: To examine the short-term outcomes of minimally invasive reoperation for severe tricuspid regurgitation after left-sided valve surgery. Methods: From January 2015 to December 2018, a total of 89 patients with severe tricuspid regurgitation after left-sided valve surgery received reoperation in Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University were included in this study. There were 21 males and 68 females, aging of (56.4±7.9) years (range: 41 to 74 years). The interval between previous left-sided valve surgery and tricuspid reoperation was (14.1±6.1) years (range: 4 to 33 years). A combination of multiple minimally invasive techniques were adopted, including endoscopy-assist right minithoracotomy approach, peripheral cannulation strategy with the vacuum-assist single venous drainage technique, heart beating technique, and temporary percutaneous pacemaker implantation, with a concomitant enhancement in preoperative right cardiac function optimization. Results: All patients received minimally invasive isolated tricuspid valve replacement (n=81) or tricuspid valve repair (n=8). After the application of multiple minimally invasive techniques, the operative mortality rate was only 3.4% (3/89). The causes of death were progressive right heart failure with multiorgan failure (n=1) and low cardiac output associated with postoperative bleeding (n=2). Regarding to the perioperative complications, renal replacement therapy rate was 5.6% (5/89), permanent pacemaker implantation rate was 1.1% (1/89), and the incidence of stroke was 0. Mechanical ventilation time was 24(24) hours, ICU stay time was 2.5 (3.0) days (M(Q(R))). During the short-term follow-up, there were no case of severe tricuspid regurgitation, 2 cases of moderate regurgitation, 4 cases of mild-to-moderate regurgitation. Conclusions: For severe tricuspid regurgitation after left-sided valve surgery, the advanced minimally invasive techniques can significantly reduce the operative mortality and morbidity. Minimally invasive bioprosthetic tricuspid valve replacement is a reliable alternative for severe tricuspid regurgitation after left-sided valve surgery.

Bioprosthetic tricuspid valve stenosis: a case series

BackgroundBioprosthetic tricuspid valve stenosis is a late sequela of tricuspid valve replacement (TVR); however, detailed information regarding its clinical picture is lacking.Case summaryThirty-one patients with bioprosthetic TVR (mean age: 60.5 ± 16.6 years, male/female: 11/20) were followed-up for 79.5 ± 49.1 months (14–188 months). Eleven patients developed bioprosthetic tricuspid valve stenosis (mean tricuspid gradient >5 mmHg) at a median interval of 96 months (interquartile range: 61–114 months). The mean tricuspid gradient at the time of tricuspid valve stenosis diagnosis was 10.9 ± 3.9 mmHg. Although the mid-term tricuspid valve stenosis-free survival was favourable (92.4% at 60 and 78.7% at 84 months), it had declined steeply to 31.5% by 120 months. Ten out of 11 tricuspid valve stenosis patients showed signs of right heart failure (RHF) as manifested by oedema and elevated jugular venous pressure, requiring moderate-to-high doses of diuretics. Diastolic rumble was audible in 10 patients. Five of the 11 tricuspid valve stenosis patients required redo TVR as a result of refractory RHF. Examination of the five excised bioprostheses showed pannus in four, fusion of the commissure in three, native valve attachment in two, and sclerosis in one. Detailed clinical pictures and pathology of the explanted valves in three cases that underwent surgery are presented in this case series.DiscussionBioprosthetic tricuspid valve stenosis is not uncommon after 8 years. Tricuspid valve replacement performed at the second surgery was associated with a higher incidence of bioprosthetic tricuspid valve stenosis.

TCT-85 Contemporary Outcomes of Isolated Bioprosthetic Tricuspid Valve Replacement: A Benchmark for Transcatheter Tricuspid Valve Replacement

There is a growing interest in transcatheter therapies for tricuspid regurgitation (TTVR), with several dedicated systems in development. Contemporary outcomes of bioprosthetic tricuspid valve replacement (TVR) surgery can be used as a benchmark for TTVR until randomized trials in the field are

Bioprosthetic tricuspid valve replacement for tricuspid valve endocarditis secondary to infected endocardial pacemaker leads.

The purpose of this study was to present outcomes of bioprosthetic tricuspid valve replacement (TVR) in patients with tricuspid valve infective endocarditis (TVIE). From October 2001 to December 2015, 26 patients underwent a bioprosthetic TVR due to severe TVIE after endocardial pacemaker implantation. Staphylococcus species and Streptococcus species were the predominant microorganisms. Early 30-day hospital mortality was 0 (0%). There were three late deaths (11.5%), none cardiac related. At nine years, freedom from cardiac death was 100%. Mean follow-up was 5.7 ± 4.1 years (range, 1.3-14.2 years). There were two cases (7.7%) of cardiac redo operations related to recurrent infection. At nine years, freedom from valve-related redo operation was 92.3%. There was no thrombosis-embolism, bleeding, or other valve-related events. No peri-valve leak or vegetation was seen on the last echocardiographic examination. Bioprosthetic TVR can be performed with acceptable morbidity and mortality in severe tricuspid endocarditis due to infected endocardial pacemaker leads.