Tricuspid Ring Annuloplasty Research Articles

Surgical repair of massive dilatation of the right atrium with tricuspid regurgitation

BackgroundMassive dilatation of the right atrium with tricuspid regurgitation is frequently diagnosed by accidental recognition of an enlarged cardiac silhouette during routine chest radiography. Although some patients are asymptomatic, enlargement of the right atrium can cause secondary tricuspid regurgitation due to dilatation of the tricuspid annulus, associated with arrhythmias and thrombus formation leading to pulmonary embolism, stroke, and, rarely, sudden death due to left ventricular compression.Case presentationA 76-year-old woman was followed up due to atrial fibrillation and tricuspid regurgitation for 8 years. A follow-up echocardiogram showed progressive dilatation of the right atrium. Because of the development of shortness of breath, right atrial plication and tricuspid valve repair were performed. Tricuspid annuloplasty was performed on the beating heart with the use of a 28-mm Carpentier-Edwards Physio tricuspid annuloplasty ring. Plication of the enlarged right atrium was performed at the interatrial septum, the free right atrium wall including the appendage, and the space between the inferior vena cava and the tricuspid ring. Closure of the left atrial appendage was performed from outside to prevent left atrial thrombus formation. Postoperative X-ray and computed tomography showed reduced cardiac silhouette and right atrial volume. The patient was discharged uneventfully and returned for follow-up visits with improved symptoms.ConclusionsAn adult case of massive dilatation of the right atrium of unknown etiology is reported. The patient’s symptoms were relieved by our operative procedure.

Automated Titanium Fasteners Versus Hand-Tied Knots: A Randomized Controlled Trial

The relative benefits of automated titanium fasteners (LSI Solutions, Victor, NY) have not been examined in patients undergoing sternotomy. The aim of this study was to assess the time and cost required for suture fixation with the automated device versus conventional hand tying in sternotomy for mitral or tricuspid ring annuloplasty. Fifty patients scheduled to undergo primary mitral or tricuspid, or both, ring annuloplasty-based valve repair operation by a single surgeon were randomly assigned to receive either conventional hand-tied knots or automated titanium fasteners, with 25 patients in each group. The primary outcome variable was the time required to affix the annuloplasty device to the valve annulus. The times taken to affix a mitral annuloplasty band or ring were 6.1 ± 0.9 min for manual tying versus 3.1± 0.4 min for automated fasteners (p < 0.0001); when calculated per annuloplasty stitch, the values were 22 ± 2 s versus 12 ± 1.1 s, respectively (p < 0.0001). The corresponding values for tricuspid annuloplasty were 4.2 ± 1.2 min (hand tying) versus 2.2 ± 0.3 min (automated fasteners) (p= 0.0005), and the times for each suture were 20 ± 2.1 s versus 13 ± 2 s, respectively (p= 0.0004). The use of the automated fastener had no significant impact on aortic cross-clamp time or cardiopulmonary bypass duration. Total cost associated with annuloplasty fixation with automated titanium fasteners (device cost in addition to operating room time cost) was significantly higher than with hand tying ($1,190 ± 374 vs $164 ± 60; p < 0.0001). Using the automated fastener to facilitate annuloplasty fixation through a sternotomy resulted in a small procedural time savings (average of 10 s/stitch) that had no overall impact on cardiopulmonary bypass or cross-clamp times but added an average cost of $1,026 to the operation.

Tricuspid valve surgery: repair and replacement.

The tricuspid valve has historically received less attention than any other cardiac valve with regard to pathophysiology and surgical management. The tricuspid valve is part of a complex functional apparatus that includes the right atrium, right ventricle, and pulmonary circulation. Functional tricuspid regurgitation is the most common tricuspid valve disease and it occurs secondary to dilatation of tricuspid annulus and/or tethering of valve leaflets from right ventricular dilatation and dysfunction. However, recent expansion in the use of right-sided transvenous devices such as pacemakers and implantable defibrillators has been met with a parallel increase in the risk of organic tricuspid disease. Recent data suggest that tricuspid regurgitation is not benign, and many patients will benefit from intervention at the time of left-sided valve surgery, or early in isolated tricuspid valve disease. This review describes the various surgical options and strategies in the treatment of common tricuspid valve diseases. Current American and European guidelines advocate for a more proactive surgical approach in the treatment of tricuspid regurgitation and/or annular dilatation at the time of left-sided valve surgery. Tricuspid annuloplasty is the preferred technique given its superior long-term outcomes. This renewed interest in surgical repair has been ushered by the development of a newer generation of tricuspid annuloplasty rings, as well as technological strides in transcatheter therapies which now extend to include tricuspid pathologies in otherwise inoperable patients with advanced tricuspid disease and cardiomyopathy. Tricuspid disease is not a benign entity. An aggressive approach to surgical management as well as prophylactic interventions are becoming more widely adopted. Aggressive tricuspid surgery however, remains an area of controversy in cardiac surgery, although surgical repair remains the gold standard for functional tricuspid regurgitation with replacement reserved for advanced or organic tricuspid disease. Transcatheter therapy is primarily directed toward non-surgical patients and is not included in this review.

Early Clinical Outcomes of Tricuspid Valve Repair with a Tri-Ad Annuloplasty Ring in Comparison with the Outcomes Using an MC3 Ring.

BackgroundWe evaluated the early clinical outcomes of tricuspid valve annuloplasty (TAP) with the Tri-Ad annuloplasty ring for functional tricuspid regurgitation (TR).MethodsFrom January 2015 to March 2017, 36 patients underwent TAP with a Tri-Ad ring for functional TR. To evaluate the early clinical outcomes of TAP with the Tri-Ad ring, we conducted a propensity score-matched analysis comparing the Tri-Ad and MC3 tricuspid annuloplasty rings (n=34 in each group). The follow-up duration was 11.0±7.07 months.ResultsThere was 1 case of operative mortality (2.8%) and no cases of late mortality. Postoperative complications occurred in 15 patients (41%), including acute kidney injury in 6 patients (16%), bleeding requiring reoperation in 4 patients (11%), and low cardiac output syndrome in 4 patients (11%). There were no ring-related complications, such as atrioventricular block or ring dehiscence. The TR grade decreased significantly (from 2.03±1.06 to 1.18±0.92, p<0.01), as did the systolic pulmonary artery pressure (from 43.53±13.84 to 38.00±9.72 mm Hg, p=0.03). There were no cases of severe residual TR, but moderate TR was observed in 3 patients, all of whom had severe TR preoperatively. Severe preoperative TR was also associated with moderate in the univariate analysis (p<0.01). In the propensity score-matched analysis comparing the Tri-Ad and MC3 rings, there was no significant difference in early clinical outcomes.ConclusionTAP with the Tri-Ad ring corrected functional TR effectively and provided good early clinical and echocardiographic results without ring-related complications. However, severe preoperative TR was associated with moderate or severe residual TR in the immediate postoperative period. A follow-up study is necessary to confirm the stability of this procedure.

PP-415 - Tricuspid Valve Repair: An Old Disease, a Modern Experience

Tricuspid valve (TV) is ‘forgotten’ or ‘enigmatic’ valve. After the surgery of left side valve disease, the longterm follow-up results revealed that the remaining tricuspid regurgation (TR) was not improved but sometimes got worse. We reported our results of tricuspid repair in this study. In Cardiovascular Surgery Clinic of Medical Faculty of Bezmialem Vakif Univercity, from September 2012 to December 2017, 100 patients (male:female 44:56, with a mean age of 61 ± 8.4 for female and; 59 ± 12,6 for male, respectively) underwent tricuspid valve annuloplasty. Operation was performed for functional TR in 98 patients (98%), TV endocarditis in 1 patient (1%), and organic TV disease in 1 patient (1%). The TR was grade II or III in 26 patients (26%) and grade IV in 74 patients (74%). In all patients, 3D-rigid ring was used (29 Carpentier-Edwards Physio Tricuspid annuloplasty ring in 29 patient, and Medtronic Contour 3D ring in 71 patient). Concomitant procedures performed Mitral Repair (48 patients), Mitral valve replacement (MVR) (16 patients), Aort valve replacement (AVR) and Mitral valve replacement (MVR) (16 patients), AVR and MR (7 patients), ASD closure (5 patients), ASD closure + Mitral Repair and Pulmonary valve repair (1 patient), VSD closure (1 patient), Mitral repair and Aort valve repair (1 patient), Mitral repair and Asendan aort replacement (1 patient), Mitral repair and David operation (1 patient), Bentall and CABG (1 patient) Tricuspid Valvotomy (1 patient), İsolated Tricuspid Annuloplasty (1 patient). Hospital mortality was 4 (4%) patients. On early postoperative echocardigraphy evaluation, there was no TR in 68 patients (68%), and mild TR was present in 32 (32%). In functional TR associated with left-sided cardiac valve diseases, TAP might be performed concomitantly, without prolonging operation time significantly and causing additional morbidity.

Serial Changes of Transmitral and Transtricuspid Pressure Gradients After Simultaneous Mitral and Tricuspid Ring Annuloplasty

Although flexible-ring annuloplasty is more inclined to increase the transmitral gradient over time, its effect on the tricuspid annulus is unknown. This study was conducted to evaluate serial changes in mean pressure gradient (mPG) across tricuspid and mitral valves after simultaneous dual implantation of flexible bands. Seventy-one (71) patients (median age, 61.6 years; IQR: 50.8-69.0 years) underwent simultaneous mitral/tricuspid annuloplasties using St. Jude Tailor rings. Serial mPGs across mitral and tricuspid valves were evaluated at three postoperative time points: predischarge, 3 years, and 5 years. To gauge the effects and clinical outcomes of prophylactic intervention, patients were categorised as tricuspid regurgitation (TR)≥moderate or TR<moderate. The median follow-up period was 125 months (IQR: 109-137 months). Unlike transmitral mPG, which increased over time (predischarge, 2.94; 3 years, 3.61; 5 years, 3.87; p<0.0005), transtricuspid mPG did not change (predischarge, 1.65; 3 years, 1.69; 5 years, 1.69; p=0.906). Preoperative TR grade had no impact on serial changes in transtricuspid mPG (TR≥moderate, p=0.542; TR<moderate, p=0.608). Three observed late recurrences of TR≥moderate degree displayed TR≥moderate at baseline, and overall mortality was higher in the TR≥moderate group (p=0.01). Flexible-band annuloplasty did not promote stenosis of tricuspid valves at mid-term follow-up. These findings confirm the safety of prophylactic tricuspid annuloplasty (via flexible band) as an adjunct to mitral annuloplasty.

Early Clinical Outcomes of Tricuspid Ring Annuloplasty Using the New Three-dimensional Annuloplasty Ring, Tri-Ad

We evaluated the early clinical outcomes of tricuspid ring annuloplasty using the Tri-Ad ring and compared the results of the Tri-Ad ring with those of MC3 ring, a widely used three-dimensional (3D) ring. From 2007 to 2017, 227 patients underwent tricuspid ring annuloplasty (TAP) for functional tricuspid regurgitation using the new 3D ring, Tri-Ad. In total, 191 patients underwent TAP with a MC3 ring and 36 patients underwent TAP with a Tri-Ad ring. Tri-Ad rings have been used since January 2015. Propensity score-matched analysis was performed (n = 36 in each group). Mean ± SD duration of follow-up was 67 ± 37 months. Operative mortality occurred in nine patients and postoperative complications in 39, which included atrial fibrillation (n = 9), low cardiac output syndrome (n = 15), and bleeding requiring reoperation (n = 15). There were no significant differences in operative mortality and postoperative complications (p = .650 and p = .423, respectively). In the Tri-Ad group, both tricuspid regurgitation grade and systolic pulmonary artery pressure significantly decreased compared with its preoperative values in predischarge echocardiography (from 2.00 ± 1.19 mmHg to 1.17 ± 0.81 mmHg [p < .001] and from 43.11 ± 13.21 mmHg to 38.58 ± 8.61 mmHg [p < .001], respectively). There were no ring-related complications, such as atrioventricular block or ring dehiscence during follow-up in Tri-Ad group. In matched patients, there were no significant differences in in-hospital mortality, postoperative complications, or tricuspid valve-related events (p = .310, p = .502, and p = .1.00, respectively). The Tri-Ad ring, a new 3D ring, showed comparable early clinical outcomes and echocardiographic results to the MC3 ring. However, a long-term follow-up study is required to confirm the safety and efficacy of this new device.

Evaluation of Outcomes of Tricuspid Valve Flexible Ring Annuloplasty with Left Sided Heart Valve Surgery

Evaluation of Outcomes of Tricuspid Valve Flexible Ring Annuloplasty with Left Sided Heart Valve Surgery

Long-term results of annuloplasty in trivial-to-mild functional tricuspid regurgitation during mitral valve replacement: should we perform annuloplasty on the tricuspid valve or leave it alone?

The benefits of concomitant tricuspid annuloplasty (TAP) for non-significant functional tricuspid regurgitation (TR) during mitral valve replacement (MVR) are controversial. We evaluated the long-term outcomes-particularly the long-term tricuspid valve (TV) functional outcomes-of MVR with or without tricuspid ring annuloplasty. From 2004 to 2014, 256 patients (56.4 ± 12.1 years) with trivial or mild functional TR who underwent MVR were enrolled. Eighty-two patients underwent concomitant tricuspid ring annuloplasty (TAP group), and 174 patients did not undergo the TV procedure (nTAP group). Propensity score-matched analysis was performed (n = 72 in each group). The follow-up duration was 77.4 ± 42.4 months. The early clinical outcomes were similar between the 2 groups before and after propensity score matching with an early mortality rate of 3.5% (9 of 256). No patients experienced ring-related complications during follow-up. Eleven (6.3%) patients developed significant TR (≥moderate) in the nTAP group, while no patients developed significant TR in the TAP group. There were no significant differences in overall survival between the 2 groups before or after matching. However, propensity score-matched analysis revealed that the freedom from significant TR aggravation and freedom from TV-related event rates were significantly higher in the TAP group than in the nTAP group (P = 0.047 and P = 0.043, respectively). Patients with untreated trivial or mild functional TR accompanied by mitral valve disease can develop significant TR during follow-up. TV ring annuloplasty can be performed without complications and can be beneficial for patients with trivial or mild functional TR who are undergoing MVR.

Midterm follow up after Ebstein's anomaly repair augmented with tricuspid annuloplasty ring

BackgroundEbstein's anomaly is a malformation of the tricuspid valve and right ventricle that is characterized by a spectrum of features including; failure of delamination, apical displacement of the functional annulus, dilation of the true tricuspid annulus and an atrialized portion of the right ventricle. The aim of this study was to assess the mid-term results of Ebstein's anomaly repair reinforced with annuloplasty ring. MethodsThis retrospective Cohort study was done including 47 patients with Ebstein's anomaly who underwent complete surgical repair. After completing the repair; the neo-tricuspid annulus was reinforced using a ring either Afksendiyos Kalangos bio-ring (Kalangos' ring, Bioring®, Lonay. Switzerland) or Carpentier-Edwards Physio ring with an average diameter of 27.6 ± 3.11 mm. Resultsat time of operation, The Mean age was 18.3 ± 12.3 years (range 1–38 years) and mean body weight was 40.6 Kg ±21.4. The mean O2 Saturation was 94.04% ± 7.2% while the mean PG across TV was 22.21 ± 8.72 mmHg. Reoperation was required for two patients (4.24%). In-hospital mortality was reported in one case (2.12%) while the overall mortality was (4.24%). After a mean of 5.81 ± 2.79 years follow up there were marked improvements of the severity of tricuspid regurge (TR) and the class of NYHA. ConclusionsAugmentation of the tricuspid valve repair with annuloplasty ring can be performed with low mortality and morbidity. Early and mid-term follow-up showed clinical improvement in the majority of patients, low incidence of reoperations, and no need for tricuspid valve replacement (TVR).

Innovations in tricuspid valve intervention.

Tricuspid valve disease has received much less attention in terms of intervention. The main reason for this is the widely held belief that treatment of left-sided valve disease leads to resolution of functional tricuspid regurgitation. Recent data show that tricuspid regurgitation is not benign and that many patients will benefit from intervention at the time of left-sided valve surgery, or in isolated tricuspid disease. This review describes the latest surgical and interventional options and strategies. Latest valve guidelines now recommend a more aggressive surgical approach to the treatment of moderate or severe tricuspid regurgitation, with annuloplasty being the preferred technique. Guidelines now also promote treatment of isolated significant tricuspid dilatation even without significant regurgitation, as a prophylactic strategy to prevent disease progression. This renewed interest in surgical repair has been accompanied by development of newer tricuspid annuloplasty rings. For patients in whom surgery would be high risk, transcatheter therapies are emerging as a promising alternative. Various repair devices have reported early experience. Recent surgical and transcatheter innovations in the treatment of tricuspid valve disease are promising and have the potential of removing the stigma of the tricuspid valve as the 'forgotten valve'.

Medtronic Duran AnCore versus Edwards MC3 rings for tricuspid annuloplasty.

Ring annuloplasty is now regarded as the standard surgical technique for the correction of tricuspid regurgitation (TR). However, comparative research on the durability of commercially available annuloplasty rings is limited. We reviewed early and late surgical results of tricuspid annuloplasty using the Duran AnCore and Edwards MC3 rings. From our institutional prospective cardiac surgical database, we identified 581 adult patients (55.9 ± 12.9 years) undergoing tricuspid ring annuloplasty using either a Duran AnCore ( n = 370; Duran group) or an Edwards MC3 ring ( n = 211; MC3 group) from January 2001 through December 2012. Survival rates, valve-related outcomes and late tricuspid functions were compared between the 2 groups. Propensity score analysis was conducted to adjust for selection bias. The degree of TR assigned preoperatively was mild in 128 (22.0%), moderate in 205 (35.3%), and severe in 248 patients (42.7%), with a higher prevalence of severe TR in the Duran group than in the MC3 group (46.5% vs 36.0%; P = 0.014). Over an observation period of 47.0 months, 46 patients developed significant TR (≥ moderate). After propensity score matching, there were no significant differences in the risks of early mortality ( P = 0.36), early complications ( P > 0.99) and recurrence of significant TR ( P = 0.33). Both the Duran and the MC3 rings showed comparable safety and tricuspid valve durability for tricuspid valve annuloplasty.

Comparison of outcomes of tricuspid annuloplasty with 3D-rigid versus flexible prosthetic ring for functional tricuspid regurgitation secondary to rheumatic mitral valve disease.

Annuloplasty bands and rings are widely used for repairing functional tricuspid regurgitation (FTR). However, the question regarding which is the ideal annuloplasty device remains unclear. The aim of this study was to compare the efficacy and mid-term durability of tricuspid ring annuloplasty for FTR secondary to rheumatic mitral valve disease using flexible Cosgrove-Edwards band and the rigid Edwards MC3 ring (Edwards Lifesciences, LLC, Irvine, CA, USA). We retrospectively collected the clinical data of those who underwent mitral valve replacement (MVR) in concomitant with tricuspid ring annuloplasty from 2009 to 2013. The flexible band was used in 46 patients (flexible group), and the 3D rigid ring was used in 60 patients (rigid group). Echocardiographic evaluation of tricuspid function was performed preoperatively and postoperatively. The grade of TR was significantly improved compared to preoperative values in two groups. There was no significant difference regarding postoperative TR grade between the two groups at 1 week and 2-3 months but there was statistical significant difference at postoperative 6-12 months, and 2-3 years. During the follow up period, 25 of 46 patients (54.3%) in flexible group and 22 of 60 patients (30.3%) in rigid group developed recurrent TR. Freedom from recurrent TR in flexible group is significant lower than rigid group in each postoperative follow up period. These findings suggest that 3D rigid ring annuloplasty might be more effective for tricuspid ring annuloplasty in FTR in mid-term postoperative periods when compared to flexible band.

Right ventricular infarction caused by tricuspid ring annuloplasty

Injury to the right coronary artery (RCA) is a rare complication of tricuspid annuloplasty. We report a patient who developed right ventricular (RV) infarction, because of tricuspid annuloplasty, and review management options.

Retrospective Study to Compare Ring Annuloplasty and Suture Annuloplasty in Tricuspid Valve Diseases

The Tricuspid regurgitation may be primary or secondary to left sided heart disease Residual tricuspid regurgitation is seen after tricuspid valve annuloplasty(TVA) - both ring and suture anuloplasty. A study was conducted in KEM Hospital as to validate the benefits of ring annuloplasty over suture anoloplasty. 80 patients undergoing MVR and TVA were studied. Of these 50 patients underwent MVR with ring annuloplasty and 30 underwent MVR with DeVegas annuloplasty. 2DECHO was done pre and postoperatively to determine pulmonary artery systolic pressure(PASP), grade of tricuspid regurgitation (TR), LV ejection fraction(LVEF) and tricuspid annulus. 82% of patients of ring annuloplasty group had reduction in PASP postoperatively compared to 56% in DeVegas annuloplasty . Grade of TR improved from moderately severe TR to mild TR in 86% in the ring annuloplasty group compared to53% in DeVegas annuloplasty group. 58% of patients of ring annuloplasty had maintained LV function postoperatively compared to 46% of patients in DeVegas annuloplasty.The mean tricuspid annulus showed reduction from preoperative annulus size of 37.72 to 27.5 in ring annuloplasty group and from 37.9to 27.13 in DeVegas annuloplasty group. Tricuspid ring annuloplasty is a better and durable repaire compared to suture annuloplasty for secondary TR. Aggressive management of secondary TR such as this could hopefully decreas the occurence of late TR following previous left sided valve surgery

Undersized Rigid Nonplanar Annuloplasty: The Key to Effective and Durable Repair of Functional Tricuspid Regurgitation

Previous clinical experiences have demonstrated high early and late recurrence rates after repair of functional tricuspid regurgitation (TR). We investigated the results of functional TR repair with undersized rigid nonplanar annuloplasty rings. From January 2007 to December 2013, 216 consecutive patients with moderate or greater functional TR were treated with undersized (size 26 mm or 28 mm) rigid nonplanar annuloplasty rings. The mean age was 69 ± 13 years. There was a previous history of cardiac operation in 25% (54 of 216 patients). Tricuspid regurgitation was graded as severe in 47% (102 of 216) and moderate in 53% (114 of 216). Concomitant operations included mitral valve procedures in 92% (198 of 216), coronary artery bypass grafting in 21% (45 of 216), aortic valve procedures in 9% (20 of 216), and cryomaze procedures in 35% (76 of 216). Size 26 mm rings were used in 38% of patients (81 of 216), and size 28 mm in 62% (135 of 216). The perioperative mortality rate was 6% (14 of 216). On predischarge echocardiography, TR grade was none or mild in 94% (176 of 187 patients), moderate in 4% (7 of 187), and severe in 2% (4 of 187). At a mean follow-up of 33.0 ± 24.0 months, TR grade was none or mild in 81% of patients (130 of 160), moderate in 16% (26 of 160), and severe in 2% (4 of 160). There were no reoperations for recurrent TR, and no patients have had tricuspid stenosis or annuloplasty ring dehiscence. Treatment of functional TR with undersized (26 mm or 28 mm) nonplanar rigid annuloplasty rings is safe and highly effective, with a near absence of recurrent severe TR at midterm follow-up.

Complex Tricuspid Valve Repair in Patients With Pacer Defibrillator–Related Tricuspid Regurgitation

Tricuspid valve regurgitation in patients with heart failure or in those undergoing complex cardiac operations is associated with increased morbidity and mortality. We report our results with a technique of repairing the tricuspid valves while retaining the pacer defibrillator lead. Patients had tricuspid valve repairs that included repositioning of the pacer defibrillator lead, approximation of septal and inferior/posterior leaflets in a modified cleft repair, and implantation of a tricuspid annuloplasty ring. This procedure was performed in more than 42 patients with good success.

Right atrial pseudomyxoma originated from junction between right atrial wall and tricuspid ring annuloplasty

We present diagnostic echocardiography results of a patient with intracardiac mass who had undergone primary ASD closure and tricuspid valve annuloplasty after being diagnosed with atrial septal defect and tricuspid failure. The atrial mass originated from free right atrial wall junction and tricuspid ring annuloplasty. Typical morphology of intracardiac mass which was considered to be myxoma during preoperative period was found to be an organized thrombus.

Conduction disorders after tricuspid annuloplasty with mitral valve surgery: Implications for earlier tricuspid intervention

ObjectiveTricuspid valve repair has been recently advocated in patients undergoing mitral valve surgery who have mild to moderate secondary tricuspid regurgitation. However, the incidence of heart conduction disorders after combined mitral valve and tricuspid valve interventions has not been evaluated. We sought to analyze the incidence of permanent pacemaker implantations and heart conduction disorders in patients undergoing mitral valve surgery with and without tricuspid valve annuloplasty. MethodsIn 2011 and 2012, among 201 consecutive patients referred to the Hôpital Européen Georges Pompidou for isolated nonischemic mitral valve disease, 113 underwent an isolated mitral valve procedure (group 1) and 88 had a concomitant tricuspid valve ring annuloplasty (group 2). ResultsPatients' mean age was 59.7 ± 16.5 years in group 1 and 60.7 ± 14.9 years in group 2 (P = .5). Mean crossclamp time and bypass time were 78 ± 35 minutes and 105 ± 47 minutes in group 1 and 92 ± 36 minutes and 128 ± 50 minutes in group 2, respectively (P = .001 and .005, respectively). Operative mortality was 3% (2.7% in group 1 and 3.2% in group 2, P = .4). Incidence of high-grade heart conduction disorders lasting more than 3 days postoperatively was 14.5% in group 1 and 41.2% in group 2 (P = .001). At 3 years, freedom from permanent pacemaker implantation was 99% ± 2% in group 1 and 94.1% ± 5% in group 2 (P = .02). For the entire cohort, longer crossclamp time (P = .02) and tricuspid ring annuloplasty (hazard ratio, 3.8; P = .001) were independent predictors of heart conduction disorders. ConclusionsThe need for permanent pacemaker implantation is increased after concomitant tricuspid ring annuloplasty in the setting of mitral valve surgery. A clinical period of observation up to 14 days after postoperative heart conduction disorders should be observed before recommending permanent pacemaker placement.

0026 : Transfemoral tricuspid valve-in-valve and valve-in-ring implantation using the Edwards SAPIEN XT valve: one-year follow-up

Redo tricuspid surgery may be at high risk or even contraindicated in patients with comorbidities. Transcatheter valve implantation (TVI) has been recently reported in this setting. The aim of this study was to evaluate the early and 1-year outcomes of TVI with Edwards SAPIEN XT valves in failed tricuspid bioprostheses (BP) and ring annuloplasty (RA). TVI was performed in 6 patients for failed tricuspid surgical valves (3 BP, 3 RA). Median patient age was 58 years, all were in New York Heart Association (NYHA) class≥III and 5 out of 6 had previously undergone at least 2 cardiac interventions. The procedure was successful in the 3 patients with BP and 2 with RA; one patient had a moderate paravalvular regurgitation at the level of the open portion of a rigid incomplete ring. Otherwise, regurgitation was absent in 3 patients, trace in 1 and mild in 1. The transvalvular gradient decreased from 8 mmHg at baseline to 4 mmHg at day 7. At 1-year follow-up, survival was 100%. Tricuspid gradients remained stable in all but 1 patient, as well as regurgitation grades. Only 1 patient was in NYHA class III, 2 were in class II and 3 in class I. Transfemoral TVI with SAPIEN XT valves after failed tricuspid surgery is feasible in selected high-risk patients, with good early and 1-year hemodynamic and clinical results. However, RA may raise issues due to their oval shape and open configuration.