Patients Undergoing Tricuspid Valve Repair Research Articles

Right ventricular papillary muscle approximation to the septum as an adjunct technique during tricuspid valve repair in congenital heart surgery

ObjectiveTricuspid regurgitation is often caused by leaflet splaying from displaced papillary muscles or ventricular dilatation. Traditional annuloplasty may not address this mechanism. The present study describes a single institution's experience using right ventricular papillary muscle approximation for tricuspid valve repair. MethodsRight ventricular papillary muscle approximation consists of suturing the anterior papillary muscle to a point of the septum (septum or septal papillary muscle) that optimizes leaflet coaptation. We describe our technique and analyze clinical data of patients undergoing tricuspid valve repair with right ventricular papillary muscle approximation during congenital heart surgery between 2012 and 2021. ResultsRight ventricular papillary muscle approximation was performed as an adjunct procedure in 207 of 825 tricuspid valve repairs (25.1%). Discharge tricuspid regurgitation grade was mild tricuspid regurgitation or less in 153 patients (73.9%), and 140 patients (67.6%) had mild tricuspid regurgitation or less at a median latest follow-up of 3.2 years (interquartile range, 0.7-6.8). Thirty patients (14.5%) underwent 11 early tricuspid valve reinterventions (3 due to right ventricular papillary muscle approximation dehiscence) and 21 late tricuspid valve reinterventions. Estimated 5-year freedom from tricuspid valve reintervention was 84% (95% CI, 77.0-89.2). Systemic right ventricle physiology (odds ratio, 2.88, P = .048) and multiple mechanisms of tricuspid regurgitation (odds ratio, 7.35, P = .038) were significant predictors of tricuspid valve reintervention on multivariable analysis. ConclusionsTricuspid valve repair with right ventricular papillary muscle approximation demonstrates acceptable short-term durability, but similar to other tricuspid valve repair strategies is less durable in patients with systemic right ventricle pressure and multiple mechanisms of tricuspid regurgitation. Right ventricular papillary muscle approximation is a safe and effective adjunct technique that should be considered in patients with tricuspid regurgitation caused by leaflet splaying from displaced papillary muscles or right ventricle dilatation.

Tricuspid Valve Repair Can Restore the Prognosis of Patients with Hypoplastic Left Heart Syndrome and Tricuspid Valve Regurgitation: A Meta-analysis.

To date, evidence supporting the efficacy of tricuspid valve (TV) repair in interrupting the progression of systemic right ventricular (RV) adverse remodeling in hypoplastic left heart syndrome (HLHS) is conflicting. We conducted a systematic review and meta-analysis of scientific literature to assess the impact of TV repair in effectively modifying the prognosis of patients with HLHS.We conducted a systematic review of PubMed, Web of Science, and Scopus databases. A random-effect meta-analysis was performed and transplant-free survival, freedom from TV regurgitation, and TV reoperation data were reconstructed using the published Kaplan-Meier curves.Nine studies were included, comprising 203 HLHS patients undergoing TV repair and 323 HLHS controls. The estimated transplant-free survival at 1, 5, and 10 years of follow-up was 75.5% [95% confidence interval (CI) = 67.6-84.3%], 63.6% [95% CI = 54.6-73.9%], and 61.9% [95% CI = 52.7-72.6%], respectively. Transplant-free survival was comparable to HLHS peers without TV regurgitation (p = 0.59). Five-year freedom from recurrence of TV regurgitation and freedom from TV reoperation was 57% [95% CI = 46.7-69.7%] and 63.6% [95% CI = 54.5-74.3%], respectively. Younger age and TV repair at the time of Norwood operation increased the risk of TV regurgitation recurrence and the need for TV reoperation.Our meta-analysis supports the efficacy of TV repair in favorably modifying the prognosis of patients with HLHS and TV regurgitation, reestablishing a medium-term transplant-free survival which is comparable to HLHS peers. However, durability of surgery and long-term fate of TV and RV performance are still unclear.

Surgical Management of Ebstein’s Anomaly in Adults

Ebstein’s anomaly is a rare congenital anomaly of the tricuspid valve, which presents challenges to cardiac surgeons due to the spectrum of anatomical variation of the disease and the technical difficulty of valve repair. Given the evolving surgical techniques being implemented in repair, a review of regional results for surgery in Ebstein’s anomaly is important. This study aimed review surgical techniques being used in the management of Ebstein’s anomaly in adult patients and the outcomes of patients undergoing tricuspid valve repair, including the Cone repair, and tricuspid valve replacement for Ebstein’s anomaly in Australia and New Zealand. Outcome measures include postoperative survival and freedom from reoperation.

Contemporary Outcomes of Isolated Tricuspid Valve Surgery

IntroductionIsolated tricuspid valve (TV) surgery is uncommonly performed and has historically been associated with excessive operative mortality. We previously reported improved short-term outcomes at our center. Understanding contemporary outcomes of isolated TV surgery beyond the perioperative period is essential to properly benchmark outcomes of newer transcatheter interventions. MethodsPatients who underwent isolated TV surgery from 2007 to 2021 at a single institution were retrospectively reviewed. Survival was estimated using the Kaplan–Meier method and multivariable Cox proportional hazards regression modeling identified independent risk factors for all-cause mortality. ResultsAmong 173 patients undergoing isolated TV surgery, 103 (60%) underwent TV repair and 70 (40%) underwent TV replacement. Mean age was 60.3 ± 18.9 y and 55 (32%) were male. The most common etiology of TV disease was functional (46%). In-hospital mortality was 4.1% (7/173), with no difference between TV repair and replacement (P = 0.06). Overall survival at 1 y and 5 y was 78.3% (111/142) and 64.5% (53/82), respectively. After median (interquartile range) follow-up of 2.0 (0.6-4.4) y, patients undergoing TV repair experienced a higher unadjusted survival as compared to those undergoing TV replacement (log-rank P = 0.02). However, after adjusting for covariates, TV replacement was not an independent predictor of all-cause mortality (hazard ratio 1.40; 95% confidence interval, 0.71-2.76; P = 0.33). ConclusionsIsolated TV surgery can be performed with lower operative mortality than historically reported. Establishing survival benchmarks from TV surgery is important in the era of developing transcatheter interventions.

Insights from 3D Echocardiography in Hypoplastic Left Heart Syndrome Patients Undergoing TV Repair.

Tricuspid regurgitation (TR) in hypoplastic left heart syndrome (HLHS) is associated with morbidity and mortality. TR mechanisms and the impact of tricuspid valve repair (TVR) are unclear. We examined HLHS TR mechanisms, TVR's impact on tricuspid valve (TV), and features of poor TVR durability. We retrospectively compared 35 HLHS TVR cases and 35 age/stage-matched HLHS controls who do not undergo TVR. Pre-operative 3-dimensional echocardiography (3DE) assessed overall TV morphology (prolapse, normal, tethered), leaflet morphology, vena contracta area, and TR location. Two-dimensional echocardiography measured TV annulus diameter, RV fractional area change (RVFAC), sphericity, and TR grade at three time points (pre-op, early post-op, and latest follow-up). Pre-op, TVR group, and controls had no difference in age, RV function or shape, or TV dimension. TVR group most commonly had anterior leaflet prolapse followed by septal leaflet prolapse or tethering. TR jet arises centrally (63%) and anterior septally (26%). Posterior annuloplasty (69%), commissuroplasty (37%), and leaflet repair (37%) were surgical techniques commonly performed. At early post-op, TR grade and TV annulus decreased. At latest follow-up, TV annulus remained reduced; however, 50% had significant TR. 25% required TV reoperation. Larger vena contracta at TVR was associated with significant TR. HLHS patients undergoing TVR had more anterior leaflet prolapse and central TR. While TVR initially reduces annular size and TR grade, 50% redevelop significant TR despite maintained annular reduction. The association of greater TR severity prior to repair with post-op recurrence raises the consideration for earlier repair of TR in HLHS patients.

Early Right Ventricular Reverse Remodeling Predicts Survival After Isolated Tricuspid Valve Surgery

BackgroundThere are limited data on the impact of isolated tricuspid valve (TV) surgery on recovery of right ventricular (RV) function and RV reverse remodeling. MethodsAmong 223 patients who had isolated TV procedures between 2001 and 2017, 60 (27%) underwent TV repair and 163 (73%) received TV replacement. Indication for surgery was functional tricuspid valve regurgitation in 64%, lead induced in 18%, and primary leaflet dysfunction in 18%. RV reverse remodeling was assessed by echocardiography at a median of 11.3 months (interquartile range [IQR] 5.9-13.5) post-dismissal. ResultsMean age was 67.3 ± 13.7 years, and 57% were female. Overall 30-day mortality was 2.7%. After a median follow-up period of 9.5 years (IQR 3.6-12.9), adjusted Cox regression analysis revealed comparable survival for TV repair and replacement and identified older age, and presence of RV dysfunction (hazard ratio [HR] 1.84, 95% confidence interval [CI] 1.14-2.98; P = .01), as independent predictors of poor survival. Patients who exhibited RV reverse remodeling within 18 months postoperatively had significantly improved survival compared with those who did not (log-rank P = .005), and reverse remodeling was independently associated with improved survival (HR 0.42, 95% CI 0.24-0.74; P = .003). Lower preoperative right atrial pressure (odds ratio 0.83, 95% CI 0.73-0.94; P = .004) was predictive of early RV reverse remodeling. ConclusionsIsolated TV surgery can be performed with acceptable outcomes (early mortality 2.7%), and overall survival is best in patients who receive the operation before developing RV systolic dysfunction. Adjusted survival was similar for patients undergoing TV repair or replacement. Early reverse remodeling of RV after surgery is associated with survival benefit.

Abstract 14107: Early Right Ventricular Reverse Remodeling Predicts Long-term Survival After Isolated Tricuspid Valve Surgery

Introduction: There are limited data on the impact of isolated tricuspid valve (TV) surgery on recovery of right ventricular (RV) function and RV reverse remodeling. Methods: Among 223 patients who had isolated TV procedures between 2001 and 2017, 60 (27%) underwent TV repair and 163 (73%) received TV replacement. RV reverse remodeling was assessed by echocardiography at a median of 11.3 months (IQR 5.9-13.5) post dismissal. Kaplan-Meier analysis and the log-rank test were used to estimate and create survival curves. Cox proportional hazards analysis was performed to study the association of clinical and echocardiographic parameters with mortality. Results: Mean age was 67.3 ± 13.7 years, and 57% were female. Indication for surgery was functional TR in 64% (n=143) patients. Overall 30-day mortality was 2.7%. After a median follow-up period of 9.5 years (IQR 3.6-12.9) there were a total of 122 (54.7%) deaths. Adjusted Cox regression analysis revealed comparable survival for TV repair and replacement and identified older age, and presence of RV dysfunction (HR 1.84, 95% CI 1.14-2.98; P=0.01) as independent predictors of poor survival. Impact of early RV reverse remodeling on survival after TV surgery was evaluated in 90 patients; In 39 RV function and/or RV size recovered, but in 51 RV dysfunction and/or RV enlargement persisted or worsened. Patients who exhibited RV reverse remodeling had significantly improved survival compared to those who did not (Log-Rank P=0.005) and reverse remodeling was independently associated with improved survival (HR 0.42, 95% CI 0.24-0.74; P=0.003). In a multivariable analysis lower preoperative right atrial pressure (OR 0.83, 95% CI 0.73-0.94; P=0.004) was an independent predictor of early right heart reverse remodeling. Conclusions: Isolated TV surgery can be performed with acceptable outcomes, and overall survival is best in patients who receive the operation before developing severe RV systolic dysfunction. Adjusted survival was similar for patients undergoing TV repair or replacement. Reverse remodeling of RV during the first 18 months after surgery appears to provide survival benefit. Preoperative RA pressure is an independent determinant of postoperative RV remodeling.

The mid-term outcomes of minimally invasive plasty for severe tricuspid regurgitation after cardiac surgery

Objectives: To evaluate the efficacy of minimally invasive surgery in patients with late severe tricuspid regurgitation after cardiac surgery, and to evaluate the role of leaflets augmentation technique in tricuspid valvuloplasty. Methods: From January 2015 to June 2019, 85 patients undergoing tricuspid valve repair procedure with minimally invasive approach at Department of Cardiovascular Surgery, Guangdong provincial People's Hospital were enrolled. There were 22 males and 63 females, aging of (53.6±12.4) years (range: 15 to 75 years). The interval between the prior and current operations was (16.0±7.3) years (range: 0.2 to 35.0 years). The diameter of right atrium and right ventricle was (77.3±17.2) mm and (61.0±8.4) mm, respectively. Tricuspid regurgitation was severe or extremely severe, the tricuspid regurgitation area was (19.0±10.3) cm(2). All patients underwent minimally invasive tricuspid valvuloplasty or tricuspid valve replacement on beating-heart with totally endoscopic technique and port-access approach through right chest wall. The operations included tricuspid valve replacement and tricuspid valvuloplasty, the technique of tricuspid valvuloplasty including leaflets augmentation with patch, ring implantation, chordae tendineaes reconstruction, release of papillary muscle, edge to edge method, etc. Postoperative hospitalization days, the time of ICU stay, blood transfusion rate, ventilator time and the results of echocardiography were recorded. Follow-up was completed regularly by WeChat, telephone and outpatient visit. Results: Sixty-five patients underwent tricuspid valve repair, and 20 patients underwent tricuspid valve replacement because of prosthetic failure and plasty failure. Five patients died during hospitalization, with mortality rate 5.9%. One patient was transferred to local hospital for anti-infection treatment, the other 79 patients were discharged from hospital in well condition and followed-up. The postoperative hospitalization time was 7.0 (5.5) days (M(Q(R))) days, the mean ventilator time was 18.0 (16.2) hours, and the mean ICU stay time was 68.0 (75.5) hours. There were 35 patients without blood conduction transfusion, the transfusion rate was only 58.9% (50/85). Four cases of severe, 9 cases of moderate and 67 cases of mild to zero tricuspid regurgitation were examined before being discharged, with tricuspid regurgitation area of (2.8±3.5) cm(2) (range: 0 to 19.1 cm(2)). The follow-up time was 1 to 38 months. Two patients died during follow-up, one patient died from infective endocarditis and mitral perivalvular leakage, the other one died of intractable right heart failure. One patient was implanted with permanent pacemaker due to Ⅲ atrioventricular block. Valvular re-replacement was performed in 2 patients who were re-admitted for the artificial valve infection and mechanical valve obstruction. No re-operation of tricuspid valve. Conclusions: Totally endoscopic minimally invasive technique provided satisfactory surgical outcomes for critically sick patients with severe tricuspid regurgitation following cardiac surgery. The application of leaflets augmentation technique achieved ideal repair effect for previously unrepairable lesions.

Echocardiographic study of functional tricuspid regurgitation and results of tricuspid valve repair

BackgroundFunctional tricuspid regurgitation (FTR) is often neglected. No clear consensus has been reached on superiority of preoperative transthoracic (TTE) or intraoperative transesophageal echocardiography (TEE) in assessment of tricuspid regurgitation (TR) in rheumatic heart disease. There is still debate when to consider for surgical repair of FTR and its benefits. MethodsA total of 50 patients with rheumatic heart disease involving mitral, aortic or both valves with moderate and severe TR were included in the study. TR was assessed using preoperative TTE and intraoperative TEE. 36 out of 50 patients underwent tricuspid valve repair. Two patients died in postoperative period. Results of tricuspid valve repair were studied in 34 patients after six months of surgery. ResultsTTE was superior in assessing tricuspid annulus size, central jet area, vena contracta, right atrium size and right ventricle systolic pressure. Patients undergoing tricuspid valve repair had better quality of life with significant improvement in grade of dyspnea, angina, pedal edema and hepatomegaly. The annulus size, jet velocity and right ventricle systolic pressure were significantly lower in patients who underwent tricuspid valve repair. Tricuspid valve should be repaired in all cases of moderate to severe TR with significant annular dilation (>38 mm). ConclusionsFTR is better assessed by TTE compared to intraoperative TEE. Concomitant TR correction (even in moderate degree of TR with tricuspid annulus ≥ 38 mm) should be strongly considered at the time of left side valve surgery resulting in better quality of life.

Tricuspid valve repair with Dacron band versus DeVega or segmental annuloplasty. Hospital outcome and short term results.

BackgroundThe purpose of this study was to compare the hospital outcome and short term results of tricuspid valve (TV) repair with three repair techniques for functional tricuspid regurgitation (TR), namely, flexible Dacron band, DeVega and segmental annuloplasty.MethodsA total of 60 patients underwent TV repair at National Heart Institute from January 2013 to November 2014, of which 20 had DeVega procedure (DV), 20 had a segmental annuloplasty (SA) procedure and 20 had a Dacron band (DB) procedure. Concomitant procedures done for rheumatic left sided valve pathology consisted of mitral valve replacement in 70% of patients, and double valve replacement in 30% of patients. Clinical and echocardiographic follow-up data were obtained. Follow-up was 100% complete and was concluded after one year.ResultsAll demographic criteria and preoperative characteristics of the three studied groups were comparable except for preoperative right ventricular (RVEDD) size that was significantly bigger in Dacron band group as compared to the other two groups (3.18 ± 0.43 cm compared to 3.00 ± 0.33 cm (DV) and to 2.88 ± 0.35 cm (SA), p value of (0.045)). Similarly, all operative and postoperative criteria were comparable among the study groups. Noticeably, (RVEDD) size remodeled better postoperatively in (DB) group as compared to the other two groups, (2.54 ± 0.26 cm compared to 2.83 ± 0.311 cm (DV) and to 2.72 ± 0.29 cm (SA), mean difference values were group (0.64 ± 0.47 cm) for (DB) compared to (0.18 ± 0.29 cm) for (DV) or to (0.16 ± 0.45 cm) for (SA) with p value of 0.000. The majority of patients in each group did not have tricuspid regurgitation (TR) or mild degree (+1) of (TR) on discharge. After one year of follow-up, most of the patient had either no regurgitation or grade (+1 TR). Two patients (10%) in DV group and one patient (5%) in SA group had (+3 TR). There was no statistical significance in the incidence of hospital mortality, only one patient died in DB and one in DV group (5%) and no death happened after hospital mortality for the three groups after one year.ConclusionsThe three techniques are options to repair the tricuspid valve, however, placement of Dacron band in patients undergoing tricuspid valve repair is associated with better RV remodelling, and hence, a probable better right ventricular performance and better outcome of repair is expected. A higher number of patients are needed with longer follow up period to appreciate the effect on survival and rate of freedom from tricuspid regurgitation and re-intervention.

Outcomes of tricuspid annuloplasty with and without prosthetic rings: a retrospective follow-up study.

BackgroundThe efficacies of tricuspid valve repair, risk factors for treatment failure and postoperative quality of life have not been thoroughly evaluated in patients with tricuspid insufficiency associated with rheumatic heart disease (RHD). We therefore reviewed our experience with ring and non-ring tricuspid annuloplasty for the treatment of functional tricuspid insufficiency (TI) in RHD.MethodsThis retrospective, follow-up study involved 74 RHD patients who underwent either non-ring annuloplasty (De Vega procedure; 34 patients, 45.95 %) or ring annuloplasty (40 patients, 54.05 %) along with concurrent mitral or/and aortic valve replacement. Operation time, cardiopulmonary bypass time, aortic clamping time, intensive care unit stay and extubation time were recorded. Echocardiographic findings and Short Form (SF)-36 scores were compared between the two groups.ResultsIn hospital mortality and complications were similar in the two study groups (P = 0.6755). At 1 week, 1 month, 6 months, 1 year, 2 years and even longer after the operation, the Kaplan–Meier curve of freedom from mild and above recurrent TI showed significantly better efficacy in the ring annuloplasty group than the De Vega procedure group (log rank P = 0.0377). Risk factors for recurrent TI included high pulmonary artery systolic pressure (PASP) and non-ring annuloplasty (PASP: hazard ratio = 1.52; non-ring: hazard ratio = 1.42). The mental component summary score at 1 year after the operation did not significantly differ between the two groups (P = 0.6446), but the physical component summary score was significantly better in the ring annuloplasty group (P = 0.0037).ConclusionCompared with non-ring annuloplasty, ring annuloplasty was associated with improved survival, decreased TI recurrence and higher quality of life in RHD patients undergoing tricuspid valve repair combined with mitral and/or aortic valve replacement.

Do transvalvular pacemaker leads influence functional outcome after tricuspid ring annuloplasty?

The impact of permanent pacemaker (PPM) leads on functional outcome of tricuspid valve (TV) repair has not been clearly demonstrated. Therefore, controversy exists as to whether transvalvular PPM leads should be explanted and replaced by epicardial leads at the time of valve repair. This study evaluates the influence of PPM leads on functional outcome, TV-related reoperations and survival in patients undergoing TV repair for functional tricuspid regurgitation (TR). We retrospectively reviewed 415 consecutive patients who underwent TV ring annuloplasty at our institution from July 2007 to February 2013. In 112 patients (27%), a PPM was implanted either pre- or postoperatively. The follow-up is 94% complete (mean: 24.4 months; cumulative total 845 patient-years). The mean age was 70.2 ± 9.8 years and the mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 12.4%. Of note, 76.6% of the patients were in New York Heart Association class III or IV. Echocardiography documented moderate or severe TR in 96.4% of the patients, with a mean annulus diameter of 44.8 ± 5.4 mm. 95.4% of the patients underwent a combined procedure and 16.4% an urgent or emergent operation. The 30-day mortality was 7.5%. The preoperative TR grade was reduced from 2.47 ± 0.52 to 0.70 ± 0.54 (P < 0.001). At hospital discharge, residual ≥II TR was present in 7.1% of the patients. Freedom from recurrent ≥II TR at 5 years was 86.7 ± 3.2%. Upon uni- and multivariate analyses, the presence of a transvalvular PPM was not a risk factor for recurrent ≥II TR and late mortality. Freedom from TV-reoperations was 98.1 ± 0.8% at 5 years without significant difference between groups. The presence of a transvalvular PPM lead is not a risk factor for recurrent TR, TV-related reoperations and late mortality in patients undergoing ring annuloplasty for functional TR.

RESIDUAL TRICUSPID REGURGITATION FOLLOWING TRICUSPID VALVE REPAIR DURING CONCOMITANT VALVE SURGERY DOES NOT WORSEN OVERALL SURVIVAL

Significant debate exists about when to intervene for residual tricuspid regurgitation (TR) after repair during concomitant mitral or aortic valve procedures. All patients undergoing tricuspid valve repair (TVr) during aortic and/or mitral valve (AV, MV) operations at our institution from 2005

Tricuspid valve surgery: The past 10 years from the Nationwide Inpatient Sample (NIS) database

The purpose of this study was to examine the trends in tricuspid valve surgery over time. We used 10 years (1999-2008) of NIS data to examine the population of patients undergoing tricuspid valve repair or replacement (ICD-9-CM codes 35.14, 35.27, and 35.28). We identified 28,726 admissions for tricuspid valve surgery. The total number of tricuspid procedures more than doubled over the 10- year period (1712 cases in 1999 vs 4072 cases in 2008). Although the absolute number of repairs and replacements increased over time, the tricuspid repair rate increased whereas there was a corresponding decrease in tricuspid replacement rate. Isolated tricuspid valve surgery accounted for 20% of the total tricuspid cases, whereas tricuspid surgery as a concomitant procedure to other cardiac operations accounted for the remaining 80%. There was a trend toward increased use of tissue over mechanical valves for tricuspid replacement. Overall hospital mortality was 10.6%. Over time, mortality decreased significantly for both repair and replacement. Concomitant tricuspid replacement was associated with significantly higher hospital mortality than was isolated tricuspid replacement (16.1% vs 10.1%; P = .0001). There has been a dramatic increase in tricuspid interventions over time. This has been associated with an increase in tricuspid repair rates as well as use of bioprostheses for tricuspid replacement. The majority of tricuspid operations are performed concomitantly to other cardiac procedures. Mortality for tricuspid valve surgery remains considerable and significantly higher for replacement than for repair.

Repair of Rheumatic Tricuspid Valve Disease: Predictors of Very Long-Term Mortality and Reoperation

We examined predictors of reoperation and late mortality in patients undergoing tricuspid valve repair for rheumatic disease. Between 1997 and 2007, 299 consecutive patients (mean age 50.8 + or - 13.7 years) underwent surgical repair of the tricuspid valve for multivalvular organic rheumatic disease. A total of 184 patients was found to have mitral and tricuspid valve disease, 108 triple valve disease, 5 isolated tricuspid lesion, and 2 aortic and tricuspid valve disease. Prosthetic ring annuloplasty was performed in 78 patients, commissurotomy and ring annuloplasty in 82, isolated commissurotomy in 10, suture annuloplasty in 105, and commissurotomy and suture annuloplasty in 24. Thirty-day mortality was 7.4%. Previous valve surgery and reoperation for bleeding were risk factors for early death. Late mortality was 51.2%, in the majority of patients due to cardiac causes. There was a median follow-up of 16.4 years (range, 6 months to 34 years) and cumulative follow-up of 5,432 patients per year (96.7% complete). Age, New York Heart Association functional class IV and postclamping time were predictive factors for late mortality. At 25 years, the Kaplan-Meier survival was 26.6% + or - 4.2%. A total of 106 patients required valve reoperation. Age older than 40 years was a protective factor for reoperation. At 25 years, Kaplan-Meier freedom from reoperation was 35.0% + or - 5.3%. Repair of the tricuspid valve in patients with rheumatic valve disease can be performed with acceptable early results, but progression of rheumatic disease is associated with a high incidence of valve dysfunction and mortality in the long term.

When Should Prophylactic Maze Procedure Be Considered in Patients Undergoing Mitral Valve Surgery?

Some patients are at high risk for late atrial fibrillation (AF) after mitral valve surgery, even without a prior history of arrhythmias. We examined the incidence and predictors of late AF in patients with functional tricuspid regurgitation (TR) undergoing mitral valve repair. From March 1995 to December 2005, 573 patients (375 men) with severe mitral regurgitation owing to leaflet prolapse and functional TR underwent mitral valve repair; 75 patients (13%) had greater than mild TR preoperatively. We excluded patients with preoperative AF or other cardiac disease. We assessed late rhythm status, and results were expressed as a time-related event. A separate cohort of patients undergoing tricuspid valve repair was compared. Cumulative risk of late AF was 11% at 5 years and 23% at 10 years (>mild preoperative TR, 23% versus <mild TR, 9%; p = 0.0007). In a multivariable model, the risk of late AF was independently associated with advanced age (hazard ratio [HR], 1.05), left atrial size greater than 50 mm (HR, 1.06), greater than mild preoperative TR (HR, 2.3), and diabetes (HR, 4.8). Patients undergoing tricuspid valve repair (n = 25) had a similar risk of late AF at 5 years (tricuspid valve surgery, 18% versus no tricuspid valve surgery, 23%; p = 0.439). When analyzed as a time-dependent risk factor, patients with late AF had decreased late survival (HR, 4.01; p = 0.001). New, late-onset AF after mitral valve repair for leaflet prolapse is significantly increased in patients with greater degrees of preoperative TR, and late survival is subsequently decreased. To avoid the adverse consequences of late AF, the addition of surgical AF ablation may be warranted.

Right-Sided Valve Disease Deserves a Little More Respect

Historically, right-sided valvular disease has received less attention from clinicians and researchers than left-sided valve disease, in part because of a protracted latent asymptomatic period. Moreover, because tricuspid regurgitation (TR) is often due to left-sided valve disease and pulmonary regurgitation (PR) is often secondary to congenital cardiac disease, the underlying disorder rather than the valve lesion tends to dominate the clinical picture. It is increasingly recognized that right-sided valve disease is not benign and has a significant and independent impact on morbidity and mortality. Today, diagnostic techniques and appropriate management strategies for patients with right-sided valve disease are established and continually refined. In this era of increasing awareness and improved treatment options for patients with valve disease, it is important that clinicians consider the diagnosis of right-sided valve disease, understand its pathophysiology, choose appropriate confirmatory testing, and refer patients for timely intervention to prevent clinical deterioration with associated adverse consequences. This review examines the causes of right-sided valve disease and the latest diagnostic advances and treatment options for these often-neglected valve lesions. Patients with native right-sided valve disease are rarely affected by endocarditis, and indications for prophylaxis have recently changed.1 ### Tricuspid Regurgitation TR that is at least moderate in severity is most frequently “functional” in nature and by definition not related to primary tricuspid valve (TV) leaflet pathology but rather secondary to another disease process causing right ventricular (RV) dilatation, distortion of the subvalvular apparatus, tricuspid annular dilatation, or a combination of these. Furthermore, a moderate or greater degree of TR, regardless of primary origin, usually engenders additional TR as a result of the adverse hemodynamic consequence of RV volume overload. Causes of clinically significant TR are outlined in Table 1; 2 classic examples of primary tricuspid leaflet pathology are demonstrated in Figure 1. View this table: Table 1. Causes of TV …

Tricuspid Valve Repair With an Annuloplasty Ring Results in Improved Long-Term Outcomes

The purpose of this study was to compare the long-term results of tricuspid valve (TV) repair with or without an annuloplasty ring. 702 patients underwent TV repair at our institution (1978 to 2003), of which 493 had, predominantly, a De Vega procedure (no ring) and 209 had an annuloplasty ring (ring). TV pathology was functional (secondary) in 74% of patients. Concomitant procedures consisted of mitral valve surgery in 80% of patients, aortic valve surgery in 33%, and coronary bypass in 14%. Clinical and echocardiographic follow-up data were obtained. Follow-up was 99% complete and was 5.9+/-4.9 (mean+/-SD) years long. Ring patients were younger (55+/-14 versus 59+/-14 years; P=0.001) and less likely to have coronary artery disease (10% versus 17%; P=0.02), more likely to be female (75% versus 65%; P=0.01) and having had previous cardiac surgery (56% versus 42%; P=0.001). Operative times were similar between the 2 groups. Long-term survival, event-free survival and freedom from recurrent TR were significantly better in the ring group, and there was a trend toward fewer TV reoperations. Multivariable analysis demonstrated that the use of an annuloplasty ring was an independent predictor of long-term survival (hazard ratio [HR], 0.7; 95% confidence interval [CI], 0.5 to 1.0; P=0.03) and event-free survival (HR, 0.8; CI, 0.6 to 1.0; P=0.04). Placement of an annuloplasty ring in patients undergoing tricuspid valve repair is associated with improved survival and event-free survival.

Minimally invasive tricuspid operation using port access

Background. Port-access techniques performed through a right mini-thoracotomy have been extensively described for both the mitral and aortic valves. However, reports of tricuspid valve operations using the port-access approach are rare. A technique for minimally invasive tricuspid valve operation using port access is described. Methods. Port-access approach was applied to 33 consecutive patients undergoing tricuspid valve repair or replacement. Results. Twelve percent (4 of 33) underwent tricuspid replacement and 88% underwent repair (28 of 33). Perioperative mortality was 6% (2 of 33) and conversion to median sternotomy was 3% (1 of 33). Conclusions. Port-access tricuspid operations are both feasible and safe with a low conversion rate to conventional median sternotomy.

Hepatic portal venous flow in patients undergoing tricuspid valve surgery.

To determine the changes of flow in the hepatic artery and portal vein of patients undergoing tricuspid valve repair together with mitral valve replacement. Non-randomised parallel group study. Tertiary referral centre. 18 patients with mitral valve disease with or without tricuspid regurgitation (age range 46-73; six men) and six patients with coronary artery disease and normal left ventricular function (women age range 39-78; four men). Mitral valve replacement with or without modified De Vega repair of the tricuspid valve or coronary artery bypass surgery. Flow in the hepatic artery and portal vein as measured by duplex Doppler flowmetry before and two to four weeks after operation. Preoperative hepatic artery flow was less in patients with mitral valve disease than in patients with coronary artery disease (162.7(13.1) ml.min-1 v 242.5(6.6) ml.min-1, p < 0.05). Portal vein perfusion was significantly reduced only in patients with associated tricuspid regurgitation compared with (844(83) ml.min-1 v 1422(64) ml.min-1 p < 0.05). Hepatic perfusion was unaltered after operation in patients undergoing coronary artery bypass surgery (p > 0.05). Flow in the hepatic artery and portal vein was improved only in patients undergoing mitral valve replacement with associated tricuspid valve repair (p < 0.05). Abnormalities of hepatic perfusion can be measured non-invasively in all patients with mitral valve disease but especially in those with associated tricuspid regurgitation needing valve repair. These abnormalities improved two to four weeks after mitral valve surgery and tricuspid valve repair, suggesting that measurement of portal flow might be a useful means of assessing the severity of tricuspid regurgitation.