Triple Valve Surgery Research Articles

Invited Commentary

Triple-valve surgery remains a surgical challenge despite improvement in surgical techniques, namely, the more frequent use of tricuspid and mitral valve repair and better intensive care unit patient care. This report by Pagni and colleagues [1] summarizes their experience with 131 patients who underwent triple-valve surgery, mainly repair of the mitral and tricuspid valves and replacement of the aortic valves.

Clinical Outcome After Triple-Valve Operations in the Modern Era: Are Elderly Patients at Increased Surgical Risk?

Despite modern advances in surgical care, triple-valve surgery (TVS) remains a challenge and carries a mortality of 10% to 20%. No validated risk score is available for TVS, and the effect of advanced age is unknown. This study examined our results in the modern era with the aim of identifying perioperative predictors of adverse outcomes. Between 1997 and 2013, 131 patients (mean age, 67.2±13.4 years) underwent TVS at our institution. Sixty-eight patients (51.9%) were aged 70 years and older. The most common etiology for aortic and mitral disease was degenerative (77.1%), rheumatic (10%), and endocarditis or prosthetic-related, or both, in the rest. Tricuspid valve disease was functional in 96%. New York Heart Association functional class III/IV was present in 69.4%, and 24% had had previous cardiac operations. One or more concomitant cardiac procedures were performed in 77 patients (58.8%), including coronary revascularization in 54. All aortic procedures were replacements, 14 patients required a prosthetic root conduit and 7 thoracic aorta replacement. Mitral replacements were used in 55%, repairs in 45%, and 96.2% of tricuspid procedures were repairs. Univariate and multivariate analyses were used to determine predictors of adverse outcomes. The 30-day and hospital mortality was 10.6% (n=14). Major complications occurred in 70 (53.4%). Univariate analysis identified New York Heart Association functional class III/IV (p=0.04), preoperative renal failure requiring dialysis (p=0.04), urgent operation (p=0.04), intraaortic balloon pump placement (p=0.02), and postoperative low cardiac output (p<0.0001) as predictors for early death. Proximal aortic operations, urgent operation, and New York Heart Association class IV correlated with increased early mortality (p<0.04) in patients aged 70 and older in addition to their decreased overall survival and decreased likelihood of discharge to home. Overall actuarial survival at 1, 5, and 10 years was 84.5%, 75%, and 45%, respectively. TVS remains a surgical challenge in the modern era. Despite a trend of increasing age and surgical risk, the early mortality rate and long-term survival remain respectable. Advanced age is associated with increased perioperative risk, but age per se should not be a contraindication for TVS.

Incidence of cerebrovascular accidents in patients undergoing minimally invasive valve surgery

Minimally invasive valve surgery has been associated with increased cerebrovascular complications. Our objective was to evaluate the incidence of cerebrovascular accidents in patients undergoing minimally invasive valve surgery. We retrospectively reviewed all the minimally invasive valve surgery performed at our institution from January 2009 to June 2012. The operative times, lengths of stay, postoperative complications, and mortality were analyzed. A total of 1501 consecutive patients were identified. The mean age was 73 ± 13 years, and 808 patients (54%) were male. Of the 1501 patients, 206 (13.7%) had a history of a cerebrovascular accident, and 225 (15%) had undergone previous heart surgery. The procedures performed were 617 isolated aortic valve replacements (41.1%), 658 isolated mitral valve operations (43.8%), 6 tricuspid valve repairs (0.4%), 216 double valve surgery (14.4%), and 4 triple valve surgery (0.3%). Femoral cannulation was used in 1359 patients (90.5%) and central cannulation in 142 (9.5%). In 1392 patients (92.7%), the aorta was clamped, and in 109 (7.3%), the surgery was performed with the heart fibrillating. The median aortic crossclamp and cardiopulmonary bypass times were 86 minutes (interquartile range [IQR], 70-107) minutes and 116 minutes (IQR, 96-143), respectively. The median intensive care unit length of stay was 47 hours (IQR, 29-74), and the median postoperative hospital length of stay was 7 days (IQR, 5-10). A total of 23 cerebrovascular accidents (1.53%) and 38 deaths (2.53%) had occurred at 30 days postoperatively. Minimally invasive valve surgery was associated with an acceptable stroke rate, regardless of the cannulation technique.

Triple valve surgery: A single center experience in 464 patients

Objectives: Triple valve disease is well known, however surgical therapy is challenging. We herein report our experience of patients undergoing triple valve surgery.

Minimally invasive triple valve surgery through partial upper sternotomy: Early results are promising

Minimally invasive triple valve surgery through partial upper sternotomy: Early results are promising

P113 * Clinical outcomes following double and triple valve surgery in Hong Kong

P113 * Clinical outcomes following double and triple valve surgery in Hong Kong

Outcome of triple valve surgery: a single centre experience

Outcome of triple valve surgery: a single centre experience

Surgical treatment of double and triple heart valve disease through a limited single-access right minithoracotomy

Heart valve disease can be extensive and may include double (mitral-aortic, mitral-tricuspid), or triple (mitral, aortic, and tricuspid) valvular regurgitation. The surgical correction of significant valvular regurgitation usually consists of the repair or replacement of all valves affected by a pathologic process. The median full-length sternotomy still serves as a classic approach for single, double, and triple valve operations in most patients. Here, we present a minimally invasive approach for the surgery of double and triple heart valve disease through a limited single-access right minithoracotomy in the 3rd intercostal space, with central aortic and percutaneous venous cannulation. A total of 48 double valve procedures were performed in our department using this technique. The minimally invasive approach through a right single-access thoracotomy has become our choice for all isolated mitral valve, and for most isolated aortic valve, replacement procedures. Triple valve surgery was performed in six cases and was feasible in all selected patients.

Triple Björk-Shiley valve: More than 30 years of asymptomatic functioning: To the memory of late academic Prof. Isidor Papo and the 45th anniversary of the first valve implantation in Yugoslavia

The Björk-Shiley Delrin (BSD) tilting disc heart valve was first clinically used in 1969. A triple BSD valve replacement has not been quite common, because of high postoperative risk and complications, but there have been several cases with different postoperative course. The first implantation of artificial valve in Yugoslavia was done by Prof. Isidor Papo, in 1965. We presented patient with more than 30 years of successful triple (aortic, mitral and tricuspid) BSD valve functioning. This is a rare case of a triple BSD valve long-term functioning and, as far as we know, the case of the longest period of successful functioning of the triple BSD valves. In March 1977, a 34-year-old female with severe congestive heart failure of the New York Heart Association (NYHA) functional class IV was admitted to the Military Medical Academy, Belgrade, for triple valve (aortic, mitral and tricuspid) surgery with BSD mechanical valves. Complicated surgery was done well. Sixteen months later the patient was diagnosed with infective endocarditis caused by Enterobacter spp. that was isolated from blood cultures. The patient was successfully cured. After that the patient had no cardiovascular symptoms and regular physical and echocardiographic examinations used to reveal satisfactory cardiovascular function. The patient died more than 30 years after the surgery due to a terminal phase of uterine carcinoma. Although BSD valves were withdrawn from clinical use long time ago, there are still some rare cases of their successful functioning, mostly due to the precise surgical technique and regular follow-up by the cardiologists.

Triple heart valve surgery through a right antero-lateral minithoracotomy

Triple valve surgery remains a complex intervention, with prolonged cardiopulmonary bypass (CPB) and cross-clamp times. A median sternotomy is the standard approach in the surgical treatment of multiple valve disease. In this report, we attempt to describe our approach for the correction of the triple heart valve disease through a right antero-lateral minithoracotomy, because avoiding sternotomy can bring less wound infections, faster recovery and a shorter hospital stay. The right minithoracotomy in the 3rd intercostal space was applied in two patients and a feasibility of either repair or replacement with a good field exposure to access the aortic, mitral and tricuspid valves without any particular difficulties was verified.

Redo Valvular Surgery in Elderly Patients

Elderly patients older than the age of 75 constitute 13% of the population that undergoes cardiac surgery at our institution and represent the fastest growing population in Ontario. We have witnessed an increasing proportion of elderly patients being referred for repeat surgical intervention for valvular heart disease. We determined the perioperative and long-term outcomes in elderly patients undergoing redo cardiac valve surgery. A retrospective review of our institutional database identified 112 patients aged 75 years or older (mean age, 78 +/- 3 years; range, 75 to 89 years) who underwent redo valve surgery between 1990 and 2004. All patients presented with a previous surgical intervention on the valve of interest. The mean follow-up was 5 +/- 4 years and was 100% complete. Eighty-eight patients (79%) had isolated valve surgery at their primary operation whereas 24 patients (21%) had concomitant coronary artery bypass grafting at the time of their initial valve surgery. At reoperation, 74 patients (66%) underwent single valve surgery (40 aortic valve, 34 mitral valve), 33 patients (29.5%) required double valve surgery, and 5 patients (4.5%) had triple valve surgery. Thirty-three patients (29.5%) required concomitant coronary artery bypass grafting, among whom 14 patients had a previous coronary artery bypass graft surgery. There were 12 operative (10.7%) and 47 late deaths (42%). Cardiovascular events were the cause of death in 32 patients (54% of all deaths). Overall survival at 5 years was 67% +/- 5%. The freedom from valve-related mortality and morbidity was 86% +/- 4% at 5 years. Mean intensive care eunit stay was 3.7 +/- 4.5 days, and postoperative hospital stay was 15 +/- 12 days. Redo valvular surgery in an elderly cohort can be performed with acceptable morbidity and mortality. Although 5-year survival is lower than that observed with a younger patient population, it is still likely higher than expected survival without surgical intervention. Despite increased resource utilization, elderly patients should be offered redo surgical intervention for valvular heart disease.

Short- and Long-Term Results of Triple Valve Surgery: A Single Center Experience

Triple valve surgery is usually complex and carries a reported operative mortality of 13% and 10-yr survival of 61%. We examined surgical results based on our hospital's experience. A total of 160 consecutive patients underwent triple valve surgery from 1990 to 2006. The most common aortic and mitral valve disease was rheumatic disease (82%). The most common tricuspid valve disease was functional regurgitation (80%). Seventy-four percent of the patients were in New York Heart Association (NYHA) class III and IV. Univariate and multivariable analyses were performed to identify predictors of early and late survival. Operative mortality was 6.9% (n=11). Univariate factors associated with mortality included old age, preoperative renal failure, postoperative renal failure, pulmonary complications, and stroke. Of them, postoperative renal failure and stroke were associated with mortality on multivariable analysis. Otherwise, neither tricuspid valve replacement nor reoperation were statistically associated with late mortality. Survival at 5 and 10 yr was 87% and 84%, respectively. Ninety-two percent of the patients were in NYHA class I and II at their most recent follow-up. Ten-year freedom from prosthetic valve endocarditis was 97%; from anticoagulation-related hemorrhage, 82%; from thromboembolism, 89%; and from reoperation, 84%. Postoperative renal failure and stroke were significantly related with operative mortality. Triple valve surgery, regardless of reoperation and tricuspid valve replacement, results in acceptable long-term survival.

Outcome in Triple Valve Surgery: Our Experience

Shahid Gangalal National Heart Centre does about 1200 cardiac operations per year. Valve Surgery especially for rheumatic valves comprises about half of the operations performed every year. Over 1500 valve surgeries have already been performed in the centre since 2002 till date. We present our experience on triple valve surgery.

Quadruple valve replacement for acute endocarditis

A 76-year-old man presented with symptoms of heart failure, fever, and fatigue. His medical history included chronic renal and factor XIII insufficiency, diverticulosis, and chronic obstructive pulmonary disease. Transesophageal echocardiography showed endocarditis of the aortic, tricuspid, and pulmonary valves with severe insufficiency (Figure 1), and moderate mitral insufficiency with suspected vegetations (Figure 2).Figure 2Severe endocarditis of the tricuspid valve (1) and suspected endocarditis of the mitral valve with moderate insufficiency (2). LA, Left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Cardiac catheterization was normal. Broad-spectrum antibiotic coverage was initiated with ampicillin, gentamycin, and imipenem. After 10 days of conservative therapy, the patient underwent surgery because of ongoing symptoms of heart failure. A median sternotomy and standard cannulation were performed. Moderate hypothermia and antegrade blood cardioplegia were administered. Because of large vegetations (>1 cm) on all 4 valves, no reconstructive surgery was possible. The mitral valve was replaced (31-mm Epic, St Jude Medical, Minneapolis, Minn), followed by the tricuspid valve (33-mm Epic), the pulmonary valve (27-mm Freestyle, Medtronic Inc, Minneapolis, Minn), and the aortic valve (23-mm Epic). Because of third-degree arteriovenous block, a pacemaker lead (Medtronic Kappa) was attached epimyocardially and tunneled under the costal margin. The intraoperative course was otherwise uneventful, and the patient was weaned from cardiopulmonary bypass with small doses of inotropes. Postoperative bleeding required blood transfusion, coagulation factors, and recombinant activated factor VII. Blood and aortic valve cultures revealed Enterococcus faecalis and Gemella morbillorum. Postoperative treatment was prolonged because of intracerebral bleeding with resultant left-sided hemiplegia, persistent upper gastrointestinal bleeding resulting in a Billroth II operation, and hemodialysis. Predischarge echocardiography showed excellent function of all 4 prosthetic valves. At 3 months follow-up, the patient is in rehabilitation and generally good health with gradually resolving neurologic symptoms. Heart valve replacement for endocarditis is a relatively common operation, but the current case is notable for 2 reasons: (1) Endocarditis was caused by simultaneous infection with E. faecalis and G. morbillorum, and (2) all cardiac valves were replaced in 1 operation. To the best of our knowledge, the current report is the first to describe successful quadruple valve replacement for acute endocarditis. E. faecalis is known to cause endocarditis, as is G. morbillorum, but a simultaneous infection with both organisms has been described only once.1Abboud R. Friart A. Two cases of isolated tricuspid endocarditis following colonic intervention.Acta Clin Belg. 1995; 50: 242-245PubMed Google Scholar Infection with E. faecalis can be extensive, as reported by Krake and colleagues2Krake P.R. Zaman F. Tandon N. Native quadruple-valve endocarditis caused by Enterococcus faecalis.Tex Heart Inst J. 2004; 31: 90-92PubMed Google Scholar in a patient with involvement of all cardiac valves. The patient in this case report did not undergo surgical treatment and subsequently died of sepsis.2Krake P.R. Zaman F. Tandon N. Native quadruple-valve endocarditis caused by Enterococcus faecalis.Tex Heart Inst J. 2004; 31: 90-92PubMed Google Scholar Involvement of all 4 heart valves can be observed with in other pathologic processes. Chiappini and colleagues3Chiappini B. Noirhomme P. Verhelst R. El Khoury G. Quadruple valve involvement in a patient with severe carcinoid heart disease.J Card Surg. 2006; 21: 599-600Crossref PubMed Scopus (4) Google Scholar reported on a patient with severe dysfunction of all valves secondary to carcinoid spread from the ileum. Their patient underwent valve replacement (tricuspid, pulmonary) and valve repair (aortic, mitral) with a good recovery. Hossack and colleagues4Hossack K.F. Hopeman A.R. Sutherland 3rd, E.W. Long-term follow-up of a patient with quadruple valve replacement.Tex Heart Inst J. 1987; 14: 315-317PubMed Google Scholar also reported on a patient with rheumatic involvement of all valves treated with repeated operations, with a good long-term outcome. These 2 cases demonstrate that quadruple valve surgery can be successfully performed. Although the addition of pulmonary valve replacement adds to the complexity of the operation, previous investigators have demonstrated good long-term results with triple valve surgery.5Alsoufi B. Rao V. Borger M.A. Maganti M. Armstrong S. Feindel C.M. et al.Short- and long-term results of triple valve surgery in the modern era.Ann Thorac Surg. 2006; 81: 2172-2178Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar Our patient made a good recovery from a large and complex operation, despite several severe comorbidities before surgery and his complicated postoperative course. We think his recovery justifies such aggressive surgical therapy in selected patients with quadruple valve disease. Replacement of all 4 heart valves in 1 operation is feasible in selected patients. Even in patients with endocarditis, a satisfactory outcome can be achieved.

Triple valve surgery – early- and long-term results of 194 consecutive patients

Triple valve surgery – early- and long-term results of 194 consecutive patients

Valvulitis Requiring Triple Valve Surgery as an Initial Presentation of Systemic Lupus Erythematosus

Cardiac involvement is common in systemic lupus erythematosus. Classically, the term "verrucous endocarditis" was used to describe the noninfective vegetations seen on pathological inspection of heart valves. The wide use of echocardiography has led to increased frequency of detection of valve abnormalities, most commonly leaflet thickening. The vast majority of patients with systemic lupus erythematosus and valvular involvement are asymptomatic, with only a small minority progressing to hemodynamically significant pathology, generally after long disease duration. We report a patient with systemic lupus erythematosus and associated antiphospholipid syndrome, whose first presentation of disease consisted of severe, symptomatic valvular regurgitation of the mitral, aortic, and tricuspid valves requiring triple valve surgery.

Primary triple valve surgery for advanced rheumatic heart disease in Mainland China: a single-center experience with 871 clinical cases

Triple valve surgery (TVS) is still of choice for advanced rheumatic heart disease (RHD), which has been associated with reported poor early and late outcomes. We describe the short- and long-term results after TVS in last two decades in Mainland China. From January 1985 to January 2005, a total of 871 patients (217 men, 654 women), with mean age of 42+/-11 years, underwent primary TVS for isolated advanced RHD. All patients received replacement procedures in mitral and aortic position (845 mechanical, 26 bioprosthetic), and 840 patients received repair procedures and the other 31 received replacement procedures in tricuspid position (9 mechanical, 22 bioprosthetic). Preoperative, perioperative, and postoperative data were retrospectively analyzed and risk factors affecting early and late survival were evaluated. The 30-day hospital mortality was 8% (n=71). Presence of ascites, New York Heart Association (NYHA) class IV and lower left ventricular ejection fraction (LVEF) were identified as independent risk factors for hospital mortality. Overall long-term survival rate was 71%+/-3% at 5 years, and 59%+/-5% at 10 years. The cardiac survival rate was 75%+/-3% at 5 years and 63%+/-4% at 10 years. The event-free survival rate at 5 years and 10 years was 61%+/-6% and 41%+/-13%, respectively. Multivariate analysis revealed advanced age, NYHA class IV and lower LVEF were associated with increased late mortality. The freedom from thromboembolism and anticoagulation-related hemorrhage at 10 years was 90%+/-4% and 81%+/-5%, respectively. Of the 508 patients still alive, 376 (74%) were in NYHA class I and II. Primary TVS for advanced RHD appears to offer satisfactory short- and long-term results with excellent symptomatic improvement. Cardiac-related late mortality following TVS may be improved by early surgical treatment before NYHA class IV or deterioration of LVEF occurs.

Triple-Valve Procedures: Impact of Risk Factors on Midterm in a Rheumatic Population

We aimed to determine the influence of preoperative, intraoperative, and postoperative variables on short and midterm results in patients undergoing triple-valve surgery. Between September 1989 and December 2003, 157 patients underwent triple-valve surgery with mechanical prosthetic valves. Preoperative, operative, and postoperative data were retrospectively analyzed and risk factors affecting hospital mortality and short and midterm survival were evaluated. The hospital mortality was 2.5%. Multivariate analysis revealed that New York Heart Association functional class IV, low left ventricular ejection fraction (< 0.35) and increased left ventricular end diastolic diameter (> 50 mm Hg) were associated with increased short and midterm mortality. The freedom rate from reoperation and thromboembolic complications at 5 years were 93% +/- 4% and 81% +/- 7%, respectively. In echocardiographic assessments, significant decrease in left ventricular end-diastolic and end-systolic diameters (53.1 +/- 8.3 vs 50.1 +/- 7.1, p = 0.002 and 35.3 +/- 7.4 vs 32.6 +/- 7.2, p = 0.002) was observed. Triple-valve surgery offers satisfactory short and midterm results and prevents ventricular dilatation. Mortality significantly decreases if surgery is performed before left ventricle functions deteriorate.

Short- and Long-Term Results of Triple Valve Surgery in the Modern Era

Triple valve surgery is usually complex and carries a reported operative mortality of 25% and 10-year survival of 40%. We examined surgical results in the modern era. A total of 174 consecutive patients, mean age 58 +/-12 years underwent triple valve surgery from 1990 to 2004. The most common aortic and mitral valve disease was rheumatic disease (61%), followed by prosthetic valve dysfunction (22%). Tricuspid valve disease was functional regurgitation in 72% of patients. Ninety-four percent of patients were in New York Heart Association class III and IV, and 60% had had previous cardiac operations. The aortic valve procedures consisted of 160 replacements and 14 repairs, the mitral valve procedures, 153 replacements and 21 repairs, and the tricuspid valve procedures, 12 replacements and 162 repairs. Univariate and multivariable analyses were performed to identify predictors of early and late survival. Operative mortality was 13% (n = 22). Univariate factors associated with mortality included urgent surgery, shock, tricuspid valve replacement, preoperative renal failure, and peripheral vascular disease. Survival at 5 and 10 years was 75% and 61%, respectively. Seventy-three percent of patients were in New York Heart Association class I and II at their most recent follow-up. Ten-year freedom from thromboembolism was 88%, from anticoagulation-related hemorrhage, 83%, from endocarditis, 96%, and from cardiac reoperation, 92%. Patients with advanced rheumatic valve disease and prosthetic valve dysfunction are at risk for requiring triple valve surgery. Compared with historic reports, the results of triple valve surgery, primary and reoperative, have improved. Although early mortality is high, long-term and event-free survival are comparable with that of patients undergoing single valve replacement.

Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients

Background Stroke remains a devastating complication after cardiac surgical procedures despite advances in perioperative monitoring and management. The purpose of this study was to determine the predictors of stroke in a large, contemporary cardiac surgery population. Methods Prospective data on 16,184 consecutive patients undergoing cardiac surgery (coronary artery bypass grafting [CABG], n = 8,917; beating heart CABG, n = 1,842; aortic valve surgery, n = 1,830; mitral valve surgery, n = 708; double or triple valve surgery, n = 381; CABG and valve surgery, n = 2,506) between April 1996 and August 2001 were subjected to univariate and multivariate analysis. Stroke was defined as any new permanent (manifest stroke) or temporary neurologic deficit or deterioration (transient ischemic attack or prolonged reversible ischemic neurologic deficit) and was confirmed by computed tomography or magnetic resonance imaging whenever possible. Results Overall incidence of stroke was 4.6% and varied between surgical procedures (CABG 3.8%; beating-heart CABG 1.9%; aortic valve surgery 4.8%; mitral valve surgery 8.8%; double or triple valve surgery 9.7%; CABG and valve surgery 7.4%). Of 63 patient-specific and treatment variables, 54 were found to have a significant univariate association with postoperative stroke. Multivariable analysis revealed 10 variables that were independent predictors of stroke: history of cerebrovascular disease, peripheral vascular disease, diabetes, hypertension, previous cardiac surgery, preoperative infection, urgent operation, CPB time more than 2 hours, need for intraoperative hemofiltration, and high transfusion requirement. Beating heart CABG was associated with a lower incidence of stroke in this multivariable analysis. Conclusions Identification of predictors for stroke is important for understanding the pathogenesis of this devastating complication as well as for developing preventative strategies. Although retrospective analyses can be subject to selection bias we believe beating heart CABG is associated with a lower incidence of stroke and may therefore improve patient outcomes.