Patients Underwent Tricuspid Valve Surgery Research Articles

Tricuspid valve repair for severe tricuspid regurgitation due to pacemaker leads.

Tricuspid valve regurgitation due to pacemaker leads is a well-known complication. Although some reports have suggested that pacemaker leads should be surgically explanted, strongly adhered leads cannot always be removed. The aim of this study was to describe our tricuspid valve repair techniques with pacemaker leads left in situ. Our retrospective study investigated 6 consecutive patients who required tricuspid valve surgery for severe regurgitation induced by pacemaker leads. From the operative findings, we identified 3 patterns of tricuspid valve and pacemaker lead involvement. In 3 patients, the leads were caught in the chordae, in 2 patients, tricuspid regurgitation was caused by lead impingement on the septal leaflet, and in 3 patients, tricuspid valve leaflets had been perforated by the pacemaker leads. During surgery, all leads were left in situ after being separated from the leaflet or valvular apparatus. In addition, suture annuloplasty was performed for annular dilatation in all cases. In one patient, the lead was reaffixed to the annulus after the posterior leaflet was cut back towards the annulus, and the leaflet was then closed. There was one hospital death due to sepsis. The degree of tricuspid regurgitation was trivial in all surviving patients at discharge. During a mean follow-up of 21 months, one patient died from pneumonia 20 months after tricuspid valve repair. In patients undergoing tricuspid valve surgery due to severe tricuspid regurgitation caused by pacemaker leads, the leads can be left in situ after proper repair with annuloplasty.

Optimal Surgical Ablation of Atrial Tachyarrhythmias During Correction of Ebstein Anomaly

Ebstein anomaly (EA) is commonly associated with atrial flutter or fibrillation (AFl/F), which adversely affects outcome. Surgical ablation of AFl/F during surgery for EA has been shown to be effective, but the optimal lesion set remains unknown. Between 1995 and 2010, 86 patients had corrective surgery for EA and concomitant maze procedure for associated AFl/F. Median age at operation was 40 years (range, 1 to 72 years), and 49 patients (60%) were male. Preoperative AFl/F was paroxysmal in 43 patients (50%). All patients who had diagnosis of or treatment for accessory pathways and reentrant tachycardia were excluded from this analysis. All patients underwent tricuspid valve surgery for EA and concomitant maze procedure, including right-sided maze (RSM) in 62 patients (72%) and biatrial maze (BAM) in 24 patients (28%). Early mortality occurred in 3 patients (3.5%). During median follow-up of 52 months (range, 3 months to 17 years), overall freedom from AFl/F without antiarrhythmic medications was 79% (RSM, 80% versus BAM, 76%; p = 0.97). Although there was no difference in rhythm outcome between RSM and BAM for patients with paroxysmal AFl/F (p = 0.08), there was a trend toward higher freedom from AF without antiarrhythmic medications in patients with persistent AFl/F for BAM (86%) versus RSM (71%; p = 0.053). Overall, there were no late strokes, and 84% were free from sodium warfarin anticoagulation. Overall, surgical ablation of preoperative AFl/F is effective in patients undergoing surgery for EA. Although rhythm outcome of RSM and BAM did not differ in patients with preoperative paroxysmal AFl/F, those with persistent or permanent AFl/F may benefit from a biatrial lesion set.

Transvalvular Pacemaker Leads Increase the Recurrence of Regurgitation After Tricuspid Valve Repair

The impact of a transvalvular pacemaker lead on the progression of tricuspid regurgitation (TR) after tricuspid valve (TV) repair has not been clearly demonstrated. The aim of this study was to evaluate the presence of a transvalvular pacemaker lead as a risk factor for TR after TV repair in a large patient cohort. A retrospective review included 791 patients who underwent TV repair at our institution from 1977 to 2008. All patients bearing a transvenous pacemaker implanted either preoperatively or within 30 days of surgery were categorized in the "PACE" group (n=176), the remaining patients were categorized in the "NO PACE" group (n=615). Mean age was 61±11 years, and 575 patients (73%) were female. Mean follow-up was 5.8±5.5 years. Operative mortality was 13%. At discharge, TR severity was 3+ or greater in 10% and 15% of patients in the PACE and NO PACE groups, respectively (p=0.19). Multivariate analysis using a Cox regression model identified the presence of a transvenous pacemaker as an independent risk factor for recurrence of TR 2+ or greater (hazard ratio [HR] 1.60, p=0.008) and TR 3+ or greater (HR 1.47, p=0.046) at last follow-up. The presence of a transvenous pacemaker was also a significant independent predictor of late mortality (HR 2.12, p=0.02). In patients undergoing tricuspid valve surgery, the presence of a transvenous pacemaker implanted either preoperatively or within 30 days of surgery is associated with a significantly increased risk of persistent or recurrent TR at late follow-up.

Simplified model for end-stage liver disease score predicts mortality for tricuspid valve surgery.

The model for end-stage liver disease score (MELD = 3.8*LN[total bilirubin] + 9.6*LN[creatinine] + 11.2*[PT-INR] + 6.4) predicts mortality for tricuspid valve surgery. However, the MELD is problematic in patients undergoing warfarin therapy, as warfarin affects the international normalized ratio (INR). This study aimed to determine whether a simplified MELD score that does not require the INR for calculation could predict mortality for patients undergoing tricuspid valve surgery. Simplified MELD score = 3.8*LN[total bilirubin] + 9.6*LN[creatinine] + 6.4. A total of 172 patients (male: 66, female: 106; mean age, 63.8 ± 10.3 years) who underwent tricuspid replacement (n = 18) or repair (n = 154) from January 1991 to July 2011 at a single centre were included. Of them, 168 patients in whom the simplified MELD score could be calculated were retrospectively analysed. The relationship between in-hospital mortality and perioperative variables was assessed by univariate and multivariate analysis. The rate of in-hospital mortality was 6.4%. The mean admission simplified MELD score for the patients who died was significantly higher than for those surviving beyond discharge (11.3 ± 4.1 vs 5.8 ± 4.0; P = 0.001). By multivariate analysis, independent risk factors for in-hospital mortality included higher simplified MELD score (P = 0.001) and tricuspid valve replacement (P = 0.023). In-hospital mortality and morbidity increased along with increasing simplified MELD score. Scores <0, 0-6.9, 7-13.9 and >14 were associated with mortalities of 0, 2.0, 8.3 and 66.7%, respectively. The incidence of serious complications (multiple organ failure, P = 0.005; prolonged ventilation, P = 0.01; need for haemodialysis; P = 0.002) was also significantly higher in patients with simplified MELD score ≥ 7. The simplified MELD score predicts mortality in patients undergoing tricuspid valve surgery. This model requires only total bilirubin and creatinine and is therefore applicable in patients undergoing warfarin therapy.

Surgical outcomes of severe tricuspid regurgitation: predictors of adverse clinical outcomes

BackgroundAlthough recent studies contributed to an improved understanding of the prognosis of patients undergoing tricuspid valve (TV) surgery, the data are limited to certain causes of tricuspid regurgitation (TR) or...

Increased risk of acute kidney injury in patients undergoing tricuspid valve surgery

We aimed to determine which patients undergoing tricuspid valve (TV) surgery are at increased risk for acute kidney injury (AKI). We reviewed 951 patients [mean age 67 ± 13 years, 573 (60%) female] having TV surgery between 2000 and 2007. Analysis focused on clinical outcome; AKI was defined by the consensus RIFLE criteria (risk, injury, failure). Surgical procedures included isolated TV surgery in 224 (24%) and TV surgery in conjunction with another cardiac operation in 727 (76%) patients. TV surgery involved redo surgery in 395 (42%). The incidence of postoperative AKI was 30% (n = 285), and 75 (7.9%) of these patients required renal replacement therapy. AKI stratified by increased RIFLE class was associated with worse postoperative outcomes (prolonged intubation, length of hospital stay and mortality; P < 0.001 for each variable). For patients with AKI, odds ratio for mortality was 4.2 [95% confidence interval (CI) 3.2-5.4, P < 0.001; area under receiver operating curves 0.85 (95% CI 0.80-0.91)], and 2.3 (95% CI 1.9-2.9, P < 0.001) for prolonged intubation for each increase in RIFLE class. Independent risk factors for AKI were older age, male gender, previous surgery, preoperative anaemia, length of cardiopulmonary bypass and TV replacement. Importantly, preoperative creatinine and pulmonary artery pressure were not independently associated with AKI. TV surgery carries a high incidence of postoperative AKI that is associated with adverse outcome. The use of the RIFLE criteria allows comparison with prior studies and is an important predictor of early mortality. The estimation of patient risk for AKI should be based on multivariable prediction.

Tricuspid valve surgery beating heart or with cross clamp - is there a difference?

Objectives: Few studies have focused on the outcomes of tricuspid valve (TV) surgery in beating-heart technique vs. cross-clamping. Methods: Retrospective analysis of 121 patients undergoing TV surgery with isolated tricuspid valve repair or replacement in beating-heart technique (n=65) or with cross-clamp (n=56). Mean patient age was 59.3±15.9 years, 44.6% were male, and average logEuroSCORE was 11.6±11.2%. 47.9% of the operations were redos. Follow up was 98% complete with a mean duration of 30±36 months. Results: Overall thirty day mortality was 7.4%, 5-year survival was 71.0% for patients operated in beating-heart technique and 74.9% for patients operated with cross-clamp. During follow up eight patients underwent TV reoperation resulting in a 5-year event-free rate of 86.7% for patients operated in beating-heart technique and 87.7% for patients operated with cross-clamp. Conclusions: Postoperative results after TV surgery are good and comparable for patients operated in beating heart technique or with cross-clamp.

Model for End-Stage Liver Disease Predicts Mortality for Tricuspid Valve Surgery

Patients undergoing tricuspid valve surgery have a mortality of 9.8%, which is higher than expected given the complexity of the procedure. Despite liver dysfunction seen in many patients with tricuspid disease, no existing risk model accounts for this. The Model for End-Stage Liver Disease (MELD) score accurately predicts mortality for abdominal surgery. The objective of this study was to determine if MELD could accurately predict mortality after tricuspid valve surgery and compare it to existing risk models. From 1994 to 2008, 168 patients (mean age, 61 +/- 14 years; male = 72, female = 96) underwent tricuspid repair (n = 156) or replacement (n = 12). Concomitant operations were performed in 87% (146 of 168). Patients with history of cirrhosis or MELD score 15 or greater (MELD = 3.8*LN [total bilirubin] + 11.2*log normal [international normalized ratio] + 9.6*log normal [creatinine] + 6.4) were compared with patients without liver disease or MELD score less than 15. Preoperative risk, intraoperative findings, and complications including operative mortality were evaluated. Statistical analyses were performed using chi(2), Fisher's exact test, and area under the curve (AUC) analyses. Patients with a history of liver disease or MELD score of 15 or greater had significantly higher mortality (18.9% [7 of 37] versus 6.1% [8 of 131], p = 0.024). To further characterize the effect of MELD, patients were stratified by MELD alone. No major differences in demographics or operation were identified between groups. Mortality increased as MELD score increased, especially when MELD score of 15 or greater (p = 0.0015). A MELD score less than 10, 10 to 14.9, 15 to 19.9, and more than 20 was associated with operative mortality of 1.9%, 6.8%, 27.3%, and 30.8%, respectively. By multivariate analysis, MELD score of 15 or greater remained strongly associated with mortality (p = 0.0021). The MELD score predicted mortality (AUC = 0.78) as well as the European System for Cardiac Operative Risk Evaluation logistic risk calculator (AUC = 0.78, p = 0.96). The MELD score predicts mortality in patients undergoing tricuspid valve surgery and offers a simple and effective method of risk stratification in these patients.

Outcomes of Tricuspid Valve Repair and Replacement: A Propensity Analysis

The purpose of this study was to compare operative mortality and long-term outcome of patients undergoing tricuspid valve replacement versus tricuspid valve repair. From February 1986 to July 2006, 315 patients underwent tricuspid valve surgery including 93 replacements (72 biologic, 21 mechanical) and 222 repairs. To control for selection bias and varying comorbidities, a matched cohort of patients undergoing repair versus replacement was selected using propensity score analysis (68 patients in each group). In the propensity-matched cohorts, operative mortality was similar for tricuspid valve replacement (13% +/- 4%) and repair (18% +/- 5%; p = 0.64). Intensive care unit length of stay was similar between cohorts (replacement, 4 days; repair, 3 days; p = 0.45), but the replacements had a significantly longer hospital lengths of stay (9 days versus 6 days; p = 0.01). In the replacement cohort, survival was 85% at 1 year, 79% at 5 years, and 49% at 10 years. In the repair cohort, survival rates were similar with 80% at 1 year, 72% at 5 years, and 66% at 10 years (p = 0.66 versus replacement). Surgical treatment of tricuspid valve disease, regardless of the operative approach, is associated with significant early and late mortality. However, there is no difference favoring tricuspid valve repair over replacement. Thus, we should not hesitate to consider tricuspid valve replacement for patients in whom we believe there is a reasonable chance for recurrence of regurgitation after repair.

Complete transposition of the great arteries: surgical concepts for patients with systemic right ventricular failure following intraatrial repair.

One of the most serious late complications of the intraatrial baffle procedure (Mustard or Senning correction) in patients suffering from transposition of the great arteries, (TGA) is the late systemic right ventricular failure. Nearly all patients presenting with right ventricular dysfunction have severe associated tricuspid regurgitation. The surgical options for these patients include tricuspid valve reconstruction or replacement, staged conversion to the arterial switch operation and orthotopic heart transplantation. Review of 189 operative survivors who underwent the Mustard or Senning operation for TGA between 1970 and 1993 in our institution revealed 12 patients (6.3%) who died from severe systemic right ventricular dysfunction (mean follow-up 16+/-3.5 years), which was the most common cause of late death. All of them had concomitant severe tricuspid regurgitation. 7 patients (3.7%) died from sudden cardiac death. The actuarial survival at 10 years is 93% for simple TGA and 85% for TGA associated with ventricular septum defect or coarctation. At our institution, 4 adolescent or adult patients underwent tricuspid valve surgery; tricuspid valve replacement was performed in 2 patients and valve repair in 2 patients. In the mid-term follow-up, 2 of these patients died. Two additional patients underwent orthotopic heart transplantation, and one died on the waiting list. Staged conversion from the Senning/Mustard atrial repair to the arterial switch operation was initially reported by Mee. The procedure for pulmonary artery banding starts with inducing left ventricular reconditioning with subsequent arterial switch. The mortality of this two-staged procedure was as high as 20% to 30% in our early experience, and some of the candidates underwent heart transplantation. Tricuspid valve repair or replacement do not improve right ventricular function in patients with a failing right ventricle following the Mustard/Senning operation. Staged conversion to arterial switch may improve right ventricular function by decreasing the work load of the right ventricle and provides anatomic repair with left ventricle-to-aorta continuity. Orthotopic heart transplantation is the only alternative if the left ventricle does not respond to pulmonary artery banding.

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.

Natural history of tricuspid valve endocarditis: A two dimensional echocardiographic study

Sixteen patients with tricuspid valve endocarditis were studied to define (1) what clinical or echocardiographic subsets are at risk for complications or need for tricuspid valve surgery, and (2) the long-term two dimensional echocardiographic course of tricuspid vegetations. There were 18 episodes of tricuspid endocarditis in the 16 patients; 12 patients had a history of intravenous drug abuse. Staphytococcus aureus was the most common infecting organism (11 patients). Persistent infection, cardiomegaly or radiography and right-sided heart failure were present in all patients undergoing tricuspid valve surgery and in none of the medically treated patients.Echocardiographic studies demonstrated tricuspid vegetations in 10 patients by M mode and in all 16 by two dimensional technique. Vegetation size, right ventricular enlargement and abnormal septal motion were not of prognostic significance. Two dimensional echocardiographic measurements of vegetation size correlated with surgical pathologic measurements in the four patients who underwent surgery. Serial two dimensional echocardiographic studies were available in eight patients a mean of 10.6 (range 2 to 19.5) months after the initial study: Vegetations had decreased in size or disappeared in seven patients and were essentially unchanged in one patient.It is concluded that (1) two dimensional echocardiography increases the detection of tricuspid valve vegetations and accurately estimates their size; (2) persistent Infection, cardlomegaly and right-sided heart failure identify a subgroup of patients with tricuspid endocarditis who may have increased risk; (3) no M mode or two dimensional echocardiographic feature is a predictor of outcome; and (4) tricuspid valve vegetations tend to resolve with time.