Postoperative Tricuspid Regurgitation Research Articles

Role of Tricuspid Valve Repair for Moderate Tricuspid Regurgitation during Minimally Invasive Mitral Valve Surgery

The aim of this study was to investigate the impact of short- and mid-term survival of tricuspid valve (TV) repair versus conservative therapy in patients with preoperative moderate functional tricuspid regurgitation (TR) undergoing minimally invasive mitral valve (MV) surgery. Between January 2002 and December 2009, a total of 430 patients with pure mitral regurgitation and concomitant moderate TR underwent minimally invasive MV surgery for mitral regurgitation at the Leipzig Heart Center without (n = 336; group A) and with (n = 94; group B) TV surgery. Mean age was 66.7 ± 10.3 years, mean LVEF was 58.0 ± 13.8%, and 206 patients (47.9%) were male. Average logEuroSCORE was 12.4 ± 11.4%. Follow-up was on average 4.6 ± 2.4 years and 97% completed. Predischarge echocardiography showed no or mild TR in 51.1% of patients in group A versus 84.2% of patients in group B (p < 0.01). Overall 30-day mortality was 2.8% with no differences between both groups. Five-year survival was 82.9 ± 4.1% for patients with TV repair versus 85.0 ± 2.2% for patients without TV repair (p = 0.1) and it was 85.7 ± 3.3% in patients with moderate and more postoperative TR versus 90.1 ± 2.5% in patients with less than moderate postoperative TR (p = 0.08). Five-year freedom from TV-related reoperation was 98.8 ± 0.7% for patients in group A versus 98.9 ± 0.1% for patients in group B (p = 0.8). Patients undergoing MV surgery with moderate functional TR do not experience increased perioperative complication rates when a concomitant TV repair is performed. Our observations, combined with those of other groups, support current recommendations to perform concomitant TV repair in such patients, particularly if tricuspid annular dilation is present.

Proposal of a Novel Index for Selection of Optimal Annuloplasty Ring Size for Tricuspid Annuloplication

Optimal ring size in tricuspid annuloplasty (TAP) surgery to treat functional tricuspid regurgitation (TR) was investigated because optimal ring size remains undefined. Sixty seven patients who underwent TAP at our institution were retrospectively studied. Tricuspid Annuloplasty Ring size Index (TARI) was defined as implanted tricuspid annuloplasty ring size divided by body surface area (BSA). Different TARI cut-off values were tested to determine which value produced the greatest difference in TR improvement (TRI=preoperative minus postoperative TR grade) between patients with TARI smaller (group S) and larger (group L) than the cut-off. Group S was also subdivided by ring type: Cosgrove rings (SC) and MC3 rings (SM). TARI and TRI were negatively correlated (r=-0.307). A TARI threshold of 18.9 mm/m(2) produced the greatest and most significant difference (P<0.0005) in TRI. Defining groups S and L using this threshold, TRI was significantly greater for group S (1.77 ± 0.80) than for group L (0.97 ± 0.83); P <0.0005. There was no difference in TRI between groups SC and SM. A novel index TARI that normalizes tricuspid annuloplasty ring size by BSA was developed. Choosing ring size to make TARI <18.9 mm/m(2) is likely to be better than setting an upper limit of absolute ring size in the surgical treatment of TR.

Assessment of functional tricuspid regurgitation using 320-detector-row multislice computed tomography: Risk factor analysis for recurrent regurgitation after tricuspid annuloplasty

Functional tricuspid regurgitation (TR) often develops secondary to left heart disease. Tricuspid annuloplasty (TAP) is usually the treatment of choice for significant TRs, but recurrence of TR after surgery can occur. Previous studies have not clearly demonstrated the cause of the recurrent TR after TAP. By using an electrocardiogram-gated 320-detector-row multislice computed tomography (CT), we sought to delineate the morphologic cause of the incompetent tricuspid valve and identify the risk factors for recurrent TR. From August 2010 to September 2011, 35 patients underwent preoperative CT of the tricuspid valve. The distance between each commissure, the tethering angle of each leaflet, and the tethering height were measured. TAP using a rigid annuloplasty ring was performed in 22 patients. Risk factors for recurrent TRwere determined by multivariate analyses. End-diastolic and end-systolic tricuspid valve annular diameters (TVAD) correlated significantly with preoperative TR severity (R(2), 0.2734-0.4287; P<.05). However, compared with TVAD, tethering angles and height showed stronger correlation with preoperative TR severity (R(2): tethering angles, 0.5769-0.6810; tethering height, 0.6854). Multivariate analysis revealed that tethering height was an independent risk factor of postoperative recurrent TR (P=.0069). TVAD, tethering angles, and tethering height correlated significantly with preoperative TR severity. The tethering height of the tricuspid valve showed significant correlation with recurrent TR.

Abstract 9902: Tricuspid Valve Annuloplasty with Edge-to-Edge Repair is Effective Strategy for Management of Functional Tricuspid Regurgitation

Introduction: Tricuspid valve (TV) annuloplasty is recommended for management of functional tricuspid regurgitation (TR); however, residual TR occurs up to 25% of patients after surgery. For management of mitral regurgitation, edge-to-edge repair is accepted as effective procedure. Hypothesis: TV annuloplasty with edge-to-edge repair is more effective for management of functional TR than isolated TV annuloplasty. Methods: We analyzed 216 patients who underwent isolated TV annuloplasty and 75 patients who underwent TV annuloplasty with edge-to-edge repair. Echocardiography was performed to assess response to surgery and cardiac function and geometry 21 ± 5 days before and 6 ± 4 days after surgery. Severity of TR was assessed by maximal jet area in the right atrium. Residual TR was defined as maximal TR jet area &gt;5 cm 2 after surgery. Results: There was no significant difference in preoperative functional TR jet area between patients who underwent isolated TV annuloplasty and those who underwent TV annuloplasty with edge-to-edge repair (Table). Patients who underwent isolated TV annuloplasty showed significantly greater TV annulus diameter and lower right ventricular fractional area shortening than those who underwent TV annuloplasty with edge-to-edge repair. In both groups, TR jet area was significantly decreased after surgery. Patients who underwent TV annuloplasty with edge-to-edge repair showed significantly lower postoperative TR jet area as compared with those who underwent isolated TV annuloplasty although mean postoperative TR jet areas were &lt;5 cm 2 in both groups. Patients who underwent TV annuloplasty with edge-to-edge repair showed significantly less residual TR as compared with those who underwent isolated TV annuloplasty. Conclusions: TV annuloplasty with edge-to-edge repair is effective procedure for management of functional TR and may be superior to isolated TV annuloplasty.

La anuloplastia de De Vega. Perspectiva histórica

AbstractDe Vega annuloplasty. A historical perspectiveForty years ago Norberto G. Vega developed the suture annuloplasty that bears his name and which, since then, has been extensively used throughout the world with satisfactory long-term results. Various modified techniques have been introduced, trying to improve it, but little information has been published on those surgical patients. Within a few months of publication of the De Vega annuloplasty, a debate began that persists today about the best surgical alternative for the treatment of significant tricuspid insufficiency, the prosthetic ring versus suture annuloplasty, despite being scientifically proven that there is a significant distortion in the mobility and dynamics of the different components of the valve when using a prosthetic ring, as compared with the De Vega annuloplasty, which respects the normal valve physiology. During these decades, the indications for de Vega annuloplasty have expanded to treat congenital heart diseases, organic and traumatic tricuspid lesions, and even as a prophylactic alternative to prevent postoperative tricuspid regurgitation after heart transplantation and ventricular assist devices implantation. international guidelines are still cautious in recommending new indications and the best surgical approach for repair or replacement so there is no general consensus on tricuspid valve surgery. Certainly in the future, answers will be found to some still unresolved questions about this exciting and often forgotten tricuspid valve.

Clinical and echocardiographic outcomes after surgery for severe isolated tricuspid regurgitation

Few studies have investigated the outcomes after surgical correction of severe isolated tricuspid regurgitation. The medical records of 51 consecutive patients (aged 55.8 ± 12.9 years, 25 male) who underwent tricuspid valve surgery at the Asan Medical Center between September 1996 and July 2010 were evaluated retrospectively. All patients had severe isolated tricuspid regurgitation but no significant left-sided cardiac disease or history of heart surgery. Tricuspid valve repair (n = 37, 72.5%) or replacement (n = 14, 27.5%) was performed. Replacement involved mechanical (n = 4) or bioprosthetic valves (n = 10). One early death occurred (2.0%). During a median follow-up period of 47.4 months (interquartile range, 10.4-61.4 months), 9 late deaths, 3 readmissions for congestive heart failure, 2 heart transplantations, and 1 tricuspid valve reoperation occurred. Overall and event-free survivals at 5 years were 83.5% ± 5.4% and 77.3% ± 6.1%, respectively. In the multivariable Cox regression analysis, preoperative hemoglobin (P = .045), serum bilirubin (P = .008), estimated glomerular filtration rate (P = .045), and systolic right ventricular dimension (P = .047) were significant and independent determinants of clinical outcome. On serial echocardiographic evaluations (median follow-up period, 28.5 months; interquartile range, 18.9-68.7 months), moderate-to-severe tricuspid regurgitation was detected in 21 patients (41%). Severe tricuspid regurgitation after tricuspid valve repair or bioprosthetic valve replacement was a significant predictor of poor event-free survival, even after adjustment for preoperative risk factors (P = .036). In the present cohort, preoperative anemia, renal/hepatic dysfunction, right ventricular dilatation, and significant postoperative tricuspid regurgitation were associated with poor outcomes. Timely surgery is advisable in patients with severe isolated tricuspid regurgitation before the development of anemia, organ dysfunction, or right ventricular dilatation.

Some issues about the decision-making process for tricuspid valve repair

Congratulations to Roshanali and colleagues1Roshanali F. Saidi B. Mandegar M.H. Yousefnia M.A. Alladdini F. Echocardiographic approach to the decision-making process for tricuspid valve repair.J Thorac Cardiovasc Surg. 2010; 139: 1483-1487Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar for their valuable study, “Echocardiographic Approach to the Decision-Making Process for Tricuspid Valve Repair,” which appeared in the June 2010 issue. Functional tricuspid regurgitation develops secondary to the annular dilation as a result of enlargement of the right ventricular cavity, which in turn is related to the increase in pulmonary arterial pressure secondary to left ventricular pathology. This physiopathology does not coincide with the view provided by Roshanali and colleagues' original Figure 1,1Roshanali F. Saidi B. Mandegar M.H. Yousefnia M.A. Alladdini F. Echocardiographic approach to the decision-making process for tricuspid valve repair.J Thorac Cardiovasc Surg. 2010; 139: 1483-1487Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar because elongation of the leaflets and chordae is seen in regurgitation. The absence of coaptation depth among the data given in their original Table 1 supports our claim.1Roshanali F. Saidi B. Mandegar M.H. Yousefnia M.A. Alladdini F. Echocardiographic approach to the decision-making process for tricuspid valve repair.J Thorac Cardiovasc Surg. 2010; 139: 1483-1487Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar The criterion for pericardial patch use is unclear, although preoperative tricuspid annular diameter is given in their original Table 1.1Roshanali F. Saidi B. Mandegar M.H. Yousefnia M.A. Alladdini F. Echocardiographic approach to the decision-making process for tricuspid valve repair.J Thorac Cardiovasc Surg. 2010; 139: 1483-1487Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar The ring size and the method of reduction of annular diameter are unclear as well. We think that—at least in this study—the correlation between the degree of postoperative tricuspid regurgitation and pulmonary arterial pressure should be investigated. The number of patients in this study is adequate for such statistical analysis. Reevaluation of the data therefore could yield important results. Echocardiographic approach to the decision-making process for tricuspid valve repairThe Journal of Thoracic and Cardiovascular SurgeryVol. 139Issue 6PreviewCommonly used procedures to repair functional tricuspid regurgitation have a high failure rate. The present study was designed to lower this failure rate by reducing leaflet tethering via pericardial patch augmentation when the preoperative probability of recurrence was high. Full-Text PDF

Clinical Impact of Concomitant Tricuspid Valve Procedures During Left Ventricular Assist Device Implantation

Almost 50% of patients referred for implantable left ventricular assist device (LVAD) have significant tricuspid regurgitation (TR). Preoperative TR is associated with negative outcomes but the clinical benefit of concomitant tricuspid valve procedures has not been extensively studied. One hundred fifteen patients, undergoing implantable LVADs, were identified as having significant TR by echocardiography prior to their surgical procedure. Patients underwent either LVAD alone (n = 81) versus LVAD plus concomitant tricuspid procedures (n = 34) (29 annuloplasty ring repairs and 5 bioprosthetic replacements.) Preoperative characteristics and hemodynamics, as well as TR severity and clinical outcomes were retrospectively determined from chart and database review and compared for the two groups. Preoperative characteristics and hemodynamics were similar for the two groups. Postoperative TR was markedly reduced for the group undergoing concomitant procedures versus LVAD alone. A temporary right ventricular assist device was required for only one of the 34 cases in which concomitant tricuspid procedures were performed; for patients undergoing LVAD alone, 8 of 81 required right ventricular assist devices. Mean duration of postoperative inotrope utilization was increased for the LVAD alone group versus the group with concomitant tricuspid procedures (10.0 vs 8.0 days, respectively, p = 0.04). The incidence of postoperative renal dysfunction was increased for the LVAD alone group (39%) versus concomitant procedures (21%) (p = 0.05). The LVAD alone group also had a greater mean postimplant length of hospitalization versus the concomitant procedures group (26.0 vs 19.0 days, p = 0.02). Finally, there was a trend toward improved survival for the group with concomitant tricuspid procedures versus LVAD alone. For patients with significant TR undergoing implantable LVAD procedures, concomitant tricuspid procedures are associated with improved early clinical outcomes.

Factors for development of late significant tricuspid regurgitation after mitral valve replacement: the impact of subvalvular preservation

Development of late significant tricuspid regurgitation (TR) after successful mitral valve replacement (MVR) is not infrequent. The impact of different aetiologies or diverse surgical procedures has not been adequately investigated. We studied the influence of subvalvular preservation techniques during MVR on the incidence of late TR. A total of 801 patients with grade ≤ 2+/4+ preoperative TR underwent MVR without associated tricuspid procedures from January 1994 to August 2008. In 595 patients, only posterior mitral leaflet preservation was performed (group A). In the remaining 206 patients, both anterior and posterior leaflets were retained (group B). Postoperative development of significant TR was defined as a TR increase by more than one grade from preoperative or final TR grade ≥ 3+/4+ at follow-up. The global incidence of postoperative significant TR was 8.6%, with higher incidence in females (9.4% vs 6.7%, p=0.12), rheumatic disease (9.7% vs 6.5%, p=0.07), patients with previous AF (11.8% vs 3.8%, p<0.001) and, especially, in group A (10.8% vs 2.4%, p<0.001). The Maze procedure was protective in patients with AF (the incidence with and without associated Maze was 6.7% vs 13.2%, p=0.04). Preoperative left-atrial diameters were higher in patients with postoperative development of TR (56 ± 9 mm vs 51 ± 12 mm, p=0.01). Group A (p=0.04) and preoperative atrial fibrillation (p=0.001) were significant predictors of late postoperative TR. Late functional TR decreased free survival from chronic heart failure. Several clinical and operative factors are associated with the development of significant TR after MVR. Although early surgical intervention for TR may be recommended in selected patients, complete subvalvular preservation of the mitral valve and routine surgical ablation of atrial fibrillation can significantly reduce its incidence.

Echocardiographic approach to the decision-making process for tricuspid valve repair

Commonly used procedures to repair functional tricuspid regurgitation have a high failure rate. The present study was designed to lower this failure rate by reducing leaflet tethering via pericardial patch augmentation when the preoperative probability of recurrence was high. Between 2001 and 2007, 210 patients with severe functional tricuspid regurgitation underwent tricuspid valve repair at the Day General Hospital. With respect to the type of repair, the patients were randomly divided into 4 groups: (1) De Vega in 52 patients; (2) ring annuloplasty in 53 patients; (3) De Vega and, if indicated by the preoperative tethering index (tethering distance > 8 mm or tethering area > 16 mm(2)), pericardial patch augmentation in 53 patients; and (4) ring annuloplasty and, if indicated by the preoperative tethering index (tethering distance > 8 mm or tethering area > 16 mm(2)), pericardial patch augmentation in 52 patients. The results of 1-month and 1-year postoperative tricuspid regurgitation were evaluated. Fifteen patients in group 3 and 15 patients in group 4 met the criterion for the complementary procedure. Postoperative tricuspid regurgitation was different between the groups (P < .05): 16.0% and 28.0% of patients in the De Vega group, 8.0% and 14.0% of patients in the ring annuloplasty group, 4.0% and 10.0% of patients in the De Vega + pericardial patch augmentation group, and 2.0% and 8.0% of patients in the ring annuloplasty + pericardial patch augmentation group had postoperative tricuspid regurgitation at 1-month and 1-year follow-up, respectively. An assessment of preoperative tricuspid valve tethering to select patients suitable for augmentation contributes to a good surgical outcome in patients with severe functional tricuspid regurgitation.

Right Ventricular Reduction as an Adjunct Procedure in Tricuspid Valve Repair

Functional tricuspid regurgitation secondary to mitral valve disease can not be attributed to the dilatation of the tricuspid annulus alone. Furthermore, geometrical changes of the right ventricle lead to tethering of the tricuspid valve leaflets and thereby to an incomplete leaflet coaptation. With this pathologic entity, conventional isolated tricuspid valve annuloplasty will presumably result in significant residual tricuspid regurgitation. The surgical goal should be the reduction of tricuspid annulus dilatation and annihilation of tethering forces on the tricuspid leaflets. In combination with conventional tricuspid valve annuloplasty, right ventricular reduction surgery, as demonstrated, may be effective in reaching these goals and hereby avoiding residual tricuspid regurgitation in this patient population.

Abstract 2065: Uncorrected Moderate Tricuspid Regurgitation Impacts Late Survival In Patients Undergoing Mitral Valve Replacement

Introduction: Little is known regarding the evolution and clinical impact of moderate tricuspid regurgitation (TR) in patients undergoing mitral valve replacement (MVR). This natural history study was conducted to determine: the predictors of TR progression and the impact of TR progression on late survival. Methods: Between 1989 and 2005, 352 patients (mean age 63.5 ± 12.4y) who underwent mitral valve replacement with contemporary prostheses (mechanical/bioprostheses = 70%/30%) were followed for the evaluation of their concomitant tricuspid regurgitation (mean grade 2.0+ at mitral surgery). These patients did not undergo concomitant tricuspid valve repair or replacement. Concomitant coronary artery bypass grafting (CABG) was performed in 34% of patients, with a mean of 2.1 grafts. Clinical and echocardiographic follow-up was 100% complete and averaged 5.7 ± 3.9 years. Parametric and semi-parametric techniques were used to determine predictors of outcomes. Results: Thirty-day mortality was 2.2%. Postoperative progression of TR was noted in 36% of patients. Multivariate predictors of TR progression included female gender (odds ratio (OR) 10.3; p=0.03) and right ventricular systolic pressures ≥ 50 mmHg preoperatively (OR 8.1; p=0.05). Atrial fibrillation, concomitant CABG, the degree of preoperative mitral regurgitation, and mitral prosthesis size were not predictive of TR progression. TR progression in patients whose TR was 2+ or more at the time of initial surgery was associated with significantly decreased late survival (hazard ratio 3.7; p=0.05). Conclusions: Based on these data, it appears that if TR is not surgically corrected at time of MVR, it may progressively worsen over time in a sizable proportion of patients. In patients with TR 2+ or more at the time of MVR, TR progression is associated with decreased late survival. It therefore appears indicated to repair TR of grade 2+ or more at the time of mitral surgery, particularly in female patients and in patients with right ventricular systolic pressures of 50 mmHg or more, which are both predictive of postoperative TR progression.

Echocardiographic Follow-up of Tricuspid Annuloplasty with a New Three-Dimensional Ring in Patients with Functional Tricuspid Regurgitation

A new tricuspid valve (TV) annuloplasty system, the MC3 ring, includes a three-dimensional structure designed to remodel the TV annulus and preserve physiologic annular function. We investigated the early- and mid-term outcomes of TV annuloplasty with the MC3 ring. A total of 136 patients with functional tricuspid regurgitation (TR) had two-dimensional echocardiography before and 5 +/- 5 days after TV annuloplasty with the MC3 ring. Twenty-eight patients were followed for more than 1 year after surgery. Echocardiography was used to assess response to surgical therapy, including measures of cardiac function and geometry and identification of factors predisposing one to recurrent TR. TR severity was improved early after surgery (P < .001). At 5 days after surgery, 16% had TR graded greater than moderate; among patients followed more than 1 year, this figure was 14%. Postoperative TR severity was associated with preoperative TR severity and tethering height. TV annuloplasty with the new physiologic MC3 ring is effective for the management of TR and may be superior to conventional techniques. However, patients with extensive leaflet tethering (>1.0 cm) require additional maneuvers to ensure valve competence.

Determinants of Recurrent or Residual Functional Tricuspid Regurgitation After Tricuspid Annuloplasty

The durability of tricuspid valve (TV) repair by annuloplasty is limited. Identification of mechanisms of recurrent or residual tricuspid regurgitation (TR) after annuloplasty is necessary to improve results of TV repair. The purpose of this study was to investigate echocardiographic determinants of mid-term outcome after TV annuloplasty. This study consisted of 39 patients with functional TR who had echocardiography preoperatively, early postoperatively (5+/-2 days), and >1 year (20+/-6 months) after TV annuloplasty. Detailed echocardiographic measurements were performed, including TR severity, TV annular dimension, TV leaflet displacement, left ventricular (LV) function, and right ventricular (RV) function and pressures. Preoperative leaflet tethering height and area predicted early and mid-term outcome of annuloplasty. Early postoperative LV ejection fraction and TR severity influenced degree of TR >1 year after surgery. In addition, increased RV pressure was related to worse TR during late follow-up. Although TV tethering is an important determinant of recurrent or residual TR, LV and RV function and pressures impact repair durability. These factors identify patients at risk for repair failure; such individuals require development of additional surgical strategies to improve results of tricuspid valve repair and close surveillance after surgery.

Progression of Tricuspid Regurgitation After Repaired Functional Ischemic Mitral Regurgitation

Despite correction of left-sided cardiac lesions, associated functional tricuspid regurgitation (TR) that was surgically ignored can persist. It can also appear de novo. The aim of this study was to analyze TR in a group of patients who underwent successful revascularization and mitral valve repair (MVRep) for functional ischemic mitral regurgitation (MR). Among 124 consecutive patients with MVRep, 70 left the operating room with MR < or =1+ and had a preoperative and follow-up transthoracic echocardiograph. Moderate or greater MR or TR was considered significant. Twenty-one patients (30%) had TR before surgery, and only 9 had TR repaired. The postoperative incidence of residual TR was not significantly different whether the tricuspid valve had been repaired (4 of 9 [44%]) or surgically ignored (8 of 12 [67%]). At last follow-up, 34 patients (49%) had significant TR. The incidence of TR increased from 25% at <1 year to 53% between 1 and 3 years and 74% at >3 years. Absence or presence of recurrent MR did not significantly affect TR (14 of 22 [64%] with MR versus 20 of 48 [42%] with no MR). Preoperative and postoperative tricuspid annulus size in patients with late TR was significantly larger than in patients without TR. Functional TR is frequently associated with functional ischemic MR. After MVRep, close to 50% of patients have TR. The incidence of postoperative TR increases with time. Preoperative tricuspid annulus dilation might be a predictor of late TR.

Evolution of repaired and non-repaired tricuspid regurgitation in rheumatic mitral valve surgery without severe pulmonary hypertension.

The aim of this study was to evaluate the usefulness of repairing significant tricuspid regurgitation (> or = grade 2) without severe pulmonary hypertension (< or = 50 mm Hg). Between 1993 and June 2001, 88 consecutive patients were operated on for rheumatic mitral valve disease associated with significant tricuspid regurgitation and without severe pulmonary hypertension. The severity of the tricuspid valve disease was assessed by echocardiography. Sixty-three patients had severe (> or = grade 3) tricuspid regurgitation (Group I), and 25 patients had moderate (grade 2) tricuspid regurgitation (Group II). There was no hospital mortality. six patients died during follow-up. The overall actuarial survival rate for 8 years was 92.1% +/- 3.1%. Cox proportional hazard regression analysis showed that age ( p = 0.006) and pulmonary complication ( p = 0.01) were associated with increased late mortality. Freedom from death was similar in both groups at 8 years (93.1% +/- 3.3% versus 88% +/- 8%, p = 0.7). Severe postoperative tricuspid regurgitation (> or = grade 3), caused by the failure of tricuspid repair or leaving the valve untouched, impaired long-term survival after surgery, and actuarial survival was 96.1% +/- 2.7% and 83% +/- 7.8% at 7 years ( p = 0.048), respectively. Severe tricuspid regurgitation, functional or organic, should be corrected at the time of mitral valve surgery, whereas untouched functional moderate tricuspid regurgitation improves after mitral valve surgery.

Operative classification of thromboembolic disease determines outcome after pulmonary endarterectomy

Objective: We sought to determine whether type and location of thromboembolic disease in the pulmonary vascular tree predicts the hemodynamic result and clinical outcome in patients undergoing pulmonary endarterectomy. Methods: From 1998 to 2000, 202 patients with pulmonary hypertension and pulmonary vascular resistance ranging from 194 to 2950 dynes-s-cm−5 underwent pulmonary endarterectomy. Preoperative and postoperative tricuspid valve function, pulmonary artery pressure, and pulmonary vascular resistance were determined by means of transthoracic echocardiography and measurements with a Swan-Ganz catheter (Edwards Lifesciences, Irvine, Calif), respectively. Patients underwent intraoperative classification of thromboembolism as follows: type 1 (76 patients), fresh thrombus in the main-lobar pulmonary arteries; type 2 (81 patients), intimal thickening and fibrosis proximal to the segmental arteries; type 3 (38 patients), disease within distal segmental arteries only; and type 4 (7 patients), distal arteriolar vasculopathy without visible thromboembolic disease. Results: Overall perioperative mortality was 4.5% (9/202 patients). By means of univariate analysis, patients with type 3 or 4 disease (distal pulmonary vasculopathy) had more residual postoperative tricuspid regurgitation (P <.0001), higher postoperative pulmonary artery systolic pressure (P <.0001), and greater postoperative pulmonary vascular resistance (P <.0001) compared with that seen in patients with type 1 or 2 disease, in whom thromboembolic disease was more surgically accessible. Factors such as severity of preoperative tricuspid regurgitation, patient age, and circulatory arrest time had no correlation with postoperative hemodynamic improvement. Patients with distal thromboembolic disease (type 3-4) had higher perioperative mortality, required longer inotropic support, and had longer hospital stays compared with patients with type 1 or 2 thromboembolic disease. Conclusion: The degree of improvement in pulmonary hypertension and tricuspid regurgitation after pulmonary endarterectomy is determined by the type and location of pulmonary thromboembolic disease. Classification of thromboembolism is useful for predicting patient outcome after pulmonary endarterectomy.J Thorac Cardiovasc Surg 2002;124:1203-11

Tricuspid valve detachment for transatrial closure of ventricular septal defects.

Tricuspid leaflet detachment improves visualization and accuracy of closure of ventricular septal defects via the transatrial route. Between July 1998 and March 2001, surgical correction was performed in 296 cases of isolated ventricular septal defect, 215 cases of tetralogy of Fallot, and 16 cases of double-outlet right ventricle. Of these, 132 patients (79 with isolated ventricular septal defect, 49 with tetralogy of Fallot, and 4 with double-outlet right ventricle) underwent transatrial repair with temporary detachment of tricuspid leaflets for ventricular septal defect closure. The septal leaflet was detached in most cases, with anterior or posterior leaflets being detached when indicated. Median duration of intensive care was 3.6 days, and median hospital stay was 7 days. There was no incidence of tricuspid regurgitation attributable to leaflet detachment, as confirmed by postoperative echocardiography. Reoperation was not required for a residual defect or tricuspid regurgitation. The benefits of temporary leaflet detachment for transatrial repair of various difficult defects far outweigh the risk of postoperative tricuspid regurgitation.

Long-Term Follow-Up of Rheumatic Patients Undergoing Left-Sided Valve Replacement With Tricuspid Annuloplasty—Validity of Preoperative Echocardiographic Criteria in the Decision to Perform Tricuspid Annuloplasty

Between September 1989 and December 1991, modified De Vega tricuspid annuloplasty was performed in 43 patients who survived surgery for mitral or mitral plus aortic valve replacement. The preoperative indications for tricuspid annuloplasty were moderate to severe tricuspid regurgitation (TR) in 33 patients and mild or no TR but with a dilated tricuspid annulus (≥30 mm) as measured by 2-dimensional echocardiography at end-diastole in 10 patients. The mean age was 31 ± 13 years. The mean duration of follow-up was 57 ± 18 months. Overall long-term mortality was 12%. On Doppler color flow mapping, postoperative severe TR was present in 1 patient and moderate TR in 4 patients at latest follow-up. The tricuspid annulus diameter decreased from 37 ± 5 mm preoperatively to 24 ± 6 mm at latest follow-up. During the study period, an additional 77 patients underwent mitral valve replacement or double valve replacement, but without tricuspid annuloplasty. Within this group, 38 patients had a preoperative tricuspid annulus diameter of ≥30 mm, and 5 of these patients (13%) developed moderate or severe TR in the postoperative period, which may have been prevented had clinicians adhered to the preoperative indications for tricuspid annuloplasty. Thus, preoperative echocardiographically documented moderate or severe TR or a tricuspid annulus diameter of ≥30 mm are valid indications for performing tricuspid annuloplasty; modified De Vega tricuspid annuloplasty is a durable procedure in rheumatic patients; it appears that reducing the diastolic tricuspid annulus diameter to 24 mm is adequate to prevent residual TR in the long term.

Orthotopic heart transplantation with bicaval and pulmonary venous anastomoses

We present our experience with an alternative technique for orthotopic heart transplantation. It consists of total excision of the recipient's atria, with the donor's heart implantation performed using bicaval end-to-end anastomoses as well as pulmonary venous anastomoses. Forty consecutive patients receiving transplants in this fashion were compared with 64 patients who underwent orthotopic transplantation with the standard technique. The incidence of postoperative tricuspid regurgitation was reduced in patients receiving transplants with the new surgical approach ( p = 0.003). In addition, the need for pacemaker implantation for severe bradyarrhythmia in the early (0 to 6 weeks) posttransplantation period ( p = 0.003) was eliminated. Although not statistically significant, there was a trend in the reduction of postoperative mitral regurgitation in patients who received transplants by the modified technique. Based on this experience, we believe this modified technique for orthotopic heart transplantation has an anatomic and physiologic advantage that may improve long-term hemodynamic results.