Underwent Tricuspid Valve Surgery Research Articles

Clinical outcomes after tricuspid surgery : The role of previous cardiac surgery.

The aim of our study was to assess the outcomes of surgical treatment for severe tricuspid regurgitation according to whether cardiac surgery had been performed before the tricuspid valve intervention. Between 1996 and 2013, 201 consecutive patients with severe tricuspid regurgitation underwent tricuspid surgery at our center. Patients were classified according to whether or not they had undergone previous cardiac surgery, which 33% of the sample had. Perioperative as well as long-term morbidity and mortality were analyzed. Mean patient age was 62.3years. 32.8% underwent suture annuloplasty, 41.3% underwent ring annuloplasty, 15.4% received a bioprosthesis, and 10.4% received a mechanical prosthesis. There were no significant differences in perioperative mortality between the group that had not undergone previous cardiac surgery and the group that had (12.7% vs. 17.9%, respectively; p= 0.32). The long-term mortality rate (median follow-up time: 53months) was 43.3%. Long-term survival curves showed no significant differences between the two groups (p= 0.884), and previous cardiac surgery was not a predictive factor for long-term mortality (hazard ratio= 1.211; p= 0.521). In a series of patients who underwent tricuspid valve surgery, no significant differences were observed in perioperative mortality or in long-term survival according to whether or not subjects had undergone previous cardiac surgery.

The path to surgery in carcinoid heart disease: a retrospective study and a multidisciplinary proposal of a new algorithm

Background: Development of carcinoid heart disease (CHD) is the major negative prognostic factor in patients with the carcinoid syndrome. The only effective treatment is valve replacement. However, the selection of candidates and determination of optimal timing remain unclear. Considerable variability in local screening and treatment strategies exist. Methods: In this single-centre study, we retrospectively analysed the diagnostic process and outcome of all CHD patients who underwent valve surgery between 2000 and 2016. We propose a new CHD screening and management algorithm. Results: All patients (n = 15), mean age 64 ± 7, underwent tricuspid valve surgery. In 14 of them (93%) an additional valve was replaced. In only a minority of patients (27%) CHD diagnosis was established by screening. Survival after 1, 3, 12 and 24 months was 93%, 80%, 53% and 33%, respectively. Causes of death included infections and critical illness immediately postoperatively, and tumour progression and right heart failure in the longer term. There was a trend (p = .099) towards better preoperative right ventricular function in the patients who survived more than 12 months postoperatively (TAPSE 20 mm ± 4) compared to those who died between 3 to 12 months after surgery (TAPSE 16 mm ± 1). The former group had a shorter mean interval from diagnosis of the carcinoid syndrome to cardiac diagnosis than the latter (13 vs. 105 months, p = .014). Conclusion: Mortality after valve replacement for CHD remains high. A probably underestimated cause is late referral for cardiac surgery. We propose a systematic, multidisciplinary approach to all carcinoid syndrome patients.

Tricuspid valve surgery in implantable cardiac electronic device-related endocarditis: Repair or replace?

The aim of this study was to investigate lead endocarditis-related tricuspid valve regurgitation, to identify underlying causes, and to report our surgical approaches to tricuspid valve endocarditis. Between March 2010 and August 2016, medical records of a total of 43 patients (23 males, 20 females; mean age: 63.2±13.6 years; range 48 to 72 years) who underwent tricuspid valve surgery for severe tricuspid regurgitation caused by lead endocarditis, which was previously placed as an implantable cardiac electronic device were reviewed. We removed all systems including infected leads and generators, revised infected wounds and tissues, performed tricuspid valve surgery for lead endocarditis, and applied long-term intravenous antibiotic regimen for the culprit agent, as confirmed by the culture. Of 43 patients, 18 underwent tricuspid valve repair and 25 underwent tricuspid valve replacement for lead endocarditisrelated severe tricuspid valve regurgitation. During followup (range, 2 to 62 months), two patients required temporary mechanical support due to postoperative acute right heart failure, while eight patients died due to sepsis (n=6; 14%) and stroke (n=2; 4.6%) in the early postoperative period. The remaining patients showed significant improvement in signs and symptoms of heart failure. Our study results suggest that incompetent experience and inaccurate decision for valve repair may result in delayed valve replacement and prolonged operation time.

Periprocedural and perioperatory management of patients with tricuspid valve disease.

Tricuspid regurgitation (TR) is a common valvular lesion which may affect morbidity and mortality. It can be related to an intrinsic abnormality of the tricuspid valve leaflets (organic) or secondary to annular dilatation (functional). Often organic and functional TR coexist in the same patient. A long-standing TR is associated with ascites, congestive hepatopathy, peripheral edema, renal failure, and abdominal fullness which significantly affect the outcome. In particular, the perioperative course may be complicated due to both the presence of comorbidities and the development of a severe postoperative right ventricle (RV) dysfunction. In fact, the TR may conceal a preoperative RV dysfunction due to a backflow in in the right atrium, which becomes overt only after the tricuspid valve (TV) repair/replacement (afterload mismatch). In light of this, an appropriate medical treatment before surgery may improve the performance of the RV, maximizing the result of the elective surgical therapy. The perioperative optimization should reduce the right atrial and ventricle overload, decrease the pulmonary vascular resistances, improve RV contractility and treat aggressively the arrhythmias. In doing so, the following rules should be considered: careful fluid administration, β1-agonists favored over α-agonists to treat hemodynamic instability, and maintenance of a normal-to-elevated heart rate. Since the TV repair/replacement needs mechanical ventilation in both open and percutaneous surgery, a careful volume and pharmacological management should be adopted to counteract the detrimental effect of the mechanical ventilation on the top of an already dysfunctional RV. In fact, in the context of RV failure the cardiac output is strictly dependent on the preload and the increase of the intrathoracic pressure, reducing the venous return, may lead to acute heart failure. The intraoperative administration of volume and vasoactive drugs, titrated on the basis of the transesophageal echocardiography, permit to support the RV intraoperatively. Paracorporeal mechanical hemodynamic support should be always available as "bail out" in the event of intractable RV failure. In conclusion the patients undergoing TV surgery are complex and only a detailed anesthesiologic and surgical workup may decrease the perioperative mortality and morbidity.

Six-month outcome after transcatheter edge-to-edge repair of severe tricuspid regurgitation in patients with heart failure.

Severe tricuspid regurgitation (TR) is common in patients with right-sided heart failure (HF) and causes substantial morbidity and mortality. Treatment options beyond medical therapy are limited for high-risk patients. Transcatheter edge-to-edge tricuspid valve (TV) repair showed procedural safety and short-term efficacy. Impact on mid-term outcome is unclear. This dual-centre observational study evaluates the mid-term safety, efficacy and clinical outcome after edge-to-edge TV repair for severe TR in patients with HF. Overall, 50 patients with right-sided HF and severe TR were treated with the transcatheter edge-to-edge repair technique; 14 patients were treated for isolated TR and 36 patients for combined mitral regurgitation (MR) and TR. At 6-month follow-up (available for 98% of patients), a persistent reduction of at least one echocardiographic TR grade was achieved in 90% of patients and New York Heart Association class improved in 79% of patients. The 6-minute walk distance increased by 44% (+84 m, P < 0.001), the median N-terminal pro-B-type natriuretic peptide decreased by 30% (from 3625 to 2526 pg/mL, P = 0.002), and the quality of life score improved by 16% (decrease of 6 points in the Minnesota Living with Heart Failure Questionnaire score, P = 0.056). The improvements were comparable in patients undergoing isolated TR or combined MR and TR treatment. During follow-up, 8 patients died, 14 were hospitalized for worsening of HF, 2 underwent TV surgery, and 2 received a second TV clip procedure. Transcatheter edge-to-edge TV repair for severe TR is safe and effective in reducing TR. It appears to be associated with improved clinical outcome in the majority of patients.

Sudden death in patients with Ebstein anomaly.

Ventricular dysfunction or structural alteration of either ventricle is a well-established risk factor for sudden death (SD). Ebstein anomaly (EA) can present with both right and left heart abnormalities; however, predictors of SD have not been described. We therefore sought to characterize the incidence and risk factors of SD among a large cohort of patients with EA. All EA patients who underwent evaluation at a high-volume institution over a 4-decade period were retrospectively reviewed. Clinical variables, cardiovascular surgical procedure(s), and cause of death were recorded. Sudden death incidence from birth and following tricuspid valve (TV) surgery were estimated using the Kaplan-Meier method. Cox regression analysis was used to identify clinical and surgical predictors of SD. The cohort comprised of 968 patients [mean age 25.3 years, 41.5% male; 79.8% severe EA, 18.6% accessory pathway, 0.74% implantable cardioverter-defibrillator (ICD) placement]. The 10-, 50-, and 70-year cumulative incidences of SD from birth were 0.8%, 8.3%, and 14.6%, respectively. Prior ventricular tachycardia [hazard ratio (HR) 6.37, P < 0.001)], heart failure (HR 5.64, P < 0.001), TV surgery (HR 5.94, P < 0.001), syncope (HR 2.03, P = 0.019), pulmonic stenosis (HR 3.42, P = 0.001), and haemoglobin > 15 g/dL (HR 2.05, P = 0.026) were multivariable predictors of SD. In a similar subgroup analysis of patients who underwent TV surgery, all of the above factors except syncope were significantly associated with post-operative SD on multivariable analysis. Patients with EA are at significant risk for SD. Key clinical SD predictors identified can aid in risk stratification and potentially guide primary prevention ICD implantation.

De Vega tricuspid valve annuloplasty - a rightly neglected surgical technique?

IntroductionThere is a lot of discussion about the best surgical technique for tricuspid valve (TV) regurgitation in patients undergoing an operation for primary mitral valve disease.AimTo review and compare our results and experiences regarding the two main surgical strategies: tricuspid valve annuloplasty with a prosthetic ring (RING group) and suture annuloplasty (De Vega group).Material and methodsWe reviewed 570 patients who underwent TV surgery between 2000 and 2016 with either ring annuloplasty (RING group: n = 490 (85.9%)) or De Vega suture annuloplasty (De Vega group: n = 69 (12.1%)). The aetiology of TV insufficiency was secondary in 96.3% (538/559) of the patients, but 47.6% of the patients with primary aetiology had endocarditis of the permanent pacemaker stimulating wires.ResultsThe age of the two study groups was similar (p = 0.6589), with a mean age of 66.7 years for the ring annuloplasty group and 67.9 years for the De Vega suture technique. The overall 30-day mortality was 10.9% (n = 61) (RING group n = 58 (11.8%) and De Vega group n = 3 (4.3%)). Ten years after TV surgery with either ring annuloplasty or the De Vega suture technique, 5.8% of patients in both study groups presented with a recurrence of severe tricuspid regurgitation ≥ 3.ConclusionsOutcomes of tricuspid valve repair did not differ in terms of long-term stability and durability between the two evaluated techniques.

Outcome of tricuspid valve surgery in the presence of permanent pacemaker

ObjectivesGiven the paucity of available literature, we sought to evaluate the mechanisms of tricuspid regurgitation and the outcomes of tricuspid valve surgery in the presence of permanent pacemakers. MethodsWe retrospectively reviewed the records of 622 adult patients who underwent tricuspid valve surgery in the presence of permanent pacemakers between January 1993 and December 2013. Those with prosthetic tricuspid valve or tricuspid valve endocarditis and those undergoing concomitant heart transplant were excluded (n = 23). Patients were divided into 2 etiologic groups: pacemaker-associated tricuspid regurgitation (n = 349, 58%) and pacemaker-induced tricuspid regurgitation (n = 249, 42%). One patient was not categorized, because permanent pacemaker involvement was unknown. ResultsMean age was 69.5 ± 12.0 years; 312 patients (52%) were female. In pacemaker-associated tricuspid regurgitation, the most common cause was functional (n = 304, 87%). The most common mechanism leading to pacemaker-induced tricuspid regurgitation was restricted leaflet mobility (n = 101, 41%), followed by adherent leaflet to the leads (n = 93, 37%), leaflet perforation (n = 30, 12%), scarring of leaflets (n = 19, 8%), and chordal entrapment (n = 18, 7%). The most common leaflet involved was septal leaflet (n = 182, 73%). Tricuspid valve repair (n = 215, 62%) was higher in the pacemaker-associated tricuspid regurgitation group. In multivariable analysis, pacemaker-induced tricuspid regurgitation was found to be protective with improved survival (hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.68-0.98). Other independent risk factors of mortality included tricuspid valve replacement (HR, 1.50; 95% CI, 1.20-1.87), nonelective surgery (HR, 1.66; 95% CI, 1.33-2.08), diabetes (HR, 1.37; 95% CI, 1.09-1.73), severe tricuspid regurgitation (HR, 1.42; 95% CI, 1.04-1.95), and older age when there was a concomitant aortic valve surgery (HR, 1.44; 95% CI, 1.15-1.79). ConclusionsSeveral mechanisms lead to pacemaker-induced tricuspid regurgitation. Pacemaker-induced tricuspid regurgitation when compared with pacemaker-associated tricuspid regurgitation carries a better prognosis with improved survival.

Severity of tricuspid regurgitation is associated with long-term mortality

ObjectivesTo determine the association between intraoperative/presurgical grade of tricuspid regurgitation (TR) and mortality, and to determine whether surgical correction of TR correlated with an increased chance of survival compared with patients with uncorrected TR. MethodsThe grade of TR assessed by intraoperative transesophageal echocardiography (TEE) before surgical intervention was reviewed for 23,685 cardiac surgery patients between 1990 and 2014. Cox proportional hazard regression models were used to determine association between grade of TR and the primary endpoint of all-cause mortality. Association between tricuspid valve (TV) surgery and survival was determined with Cox proportional hazard regression models after matching for grade of TR. ResultsKaplan-Meier survival curves demonstrated a relationship between all grades of TR. Multivariable analysis of the entire cohort demonstrated significantly increased mortality for moderate (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.1-1.4; P < .0001) and severe TR (HR, 2.02; 95% CI, 1.57-2.6; P < .0001). Mild TR displayed a trend for mortality (HR, 1.07; 95% CI, 0.99-1.16; P = .075). After matching for grade of TR and additional confounders, patients who underwent TV surgery had a statistically significant increased likelihood of survival (HR, 0.74; 95% CI, 0.61-0.91; P = .004). ConclusionsOur study of more than 20,000 patients demonstrates that grade of TR is associated with increased risk of mortality after cardiac surgery. In addition, all patients who underwent TV surgery had a statistically significantly increased likelihood of survival compared with those with the same degree of TR who did not undergo TV surgery.

Impact of Isolated Tricuspid Valve Repair on Right Ventricular Remodelling in an Adult Congenital Heart Disease Population.

Surgical repair of isolated congenital tricuspid valve (TV) disease is rare with no well-defined indication and outcomes. Moreover, the role of right ventricle (RV) in this context has not yet been investigated. We sought to assess the impact of congenital TV repair on cardiac remodelling and clinical-functional status and the importance of the RV function in an adult congenital heart disease (ACHD) population. From January 2005 to December 2015, 304 patients underwent TV surgery in our centre. Of these, 27 (ACHD) patients had isolated TV repair. Patients were evaluated with preoperative and postoperative transthoracic echocardiogram. Survival rate has been investigated with a mean clinical follow-up (FU) of 3.7 ± 2.3 years, whereas the mean echocardiographic FU was 2.9 ± 1.8 years. The clinical and functional status of patients showed a statistically significant improvement after the surgical repair in terms of New York Heart Association class (66.7 vs 7.4%; p < 0.01), clinical signs of heart failure (29.6 vs 7.4%; p < 0.01), and left ventricular function (14.8 vs 7.4%; p < 0.01). The RV and right atrium diameter were significantly reduced after surgery (5.15 ± 1.21 vs 4.32 ± 1.16; p < 0.01) and (44.7 ± 16.7 vs 26.7 ± 9.2; p < 0.01), respectively. The degree of postoperative pulmonary hypertension was also significantly reduced (40.7 vs 7.4%; p < 0.01). The survival rate was 96.3% at 1 year and 93.7% at 5 years. One patient (3.7%) had early failure of the tricuspid repair requiring a reoperation. Isolated TV repair for adult congenital disease significantly improved patients' clinical and functional status and allowed right ventricular remodelling and functional improvement.

Comparison of Results of Tricuspid Valve Repair Versus Replacement for Severe Functional Tricuspid Regurgitation

The optimal decision regarding whether to repair or replace the tricuspid valve (TV) remains controversial in patients with very severe functional tricuspid regurgitation (TR). We sought to compare clinical outcomes of TV repair versus replacement for very severe TR associated with severe TV tethering. We included 96 consecutive patients (20 men, 58 ± 11years of age) who had both severe tethering of TV and very severe functional TR and consequently underwent TV surgery during left-sided valve surgery. TV repair was performed on 79 patients (repair group), whereas 17 patients underwent TV replacement (replacement group). The primary end point of the study was defined as the composite of operative mortality, cardiac death, repeat TV surgery, and hospitalization due to congestive heart failure during follow-up. The 2 groups had similar baseline clinical, echocardiographic, and operative characteristics, but operative mortality was significantly higher in the replacement group than in the repair group (p= 0.008). During a median follow-up of 87months, 19 patients (24%) in the repair group and 8 (47%) in the replacement group attained the composite end point, and TV replacement was independently associated with end points in the Cox proportional hazards analysis after adjustment with propensity score (hazard ratio 4.033, 95% CI 1.470 to 11.071; p= 0.007). In conclusion, compared with TV repair, replacement was associated with higher operative mortality and worse long-term clinical outcomes in patients with very severe functional TR. Repair should be the preferred surgical option even for severe TR associated with more advanced tethering and right ventricular dilatation.

Abstract 11678: Tricuspid Valve Repair Versus Replacement for Very Severe Functional Tricuspid Regurgitation

Introduction: The optimal decision regarding whether to repair or replace the tricuspid valve (TV) remains controversial in patients with very severe functional tricuspid regurgitation (TR). Objectives: We sought to compare clinical outcomes of TV repair versus replacement for very severe TR associated with severe TV tethering. Methods: We included 96 consecutive patients (20 men, 58±11 years of age) who had both severe tethering of TV and very severe functional TR, and consequently underwent TV surgery during left-sided valve surgery. TV repair was performed on 79 patients (repair group), whereas 17 patients underwent TV replacement (replacement group). The primary end-point of the study was defined as the composite of operative mortality, cardiac death, repeat TV surgery and hospitalization due to congestive heart failure during follow-up. Results: The two groups had similar baseline clinical, echocardiographic and operative characteristics, but operative mortality was significantly higher in the replacement group than in the repair group (P=0.008). During a median follow-up of 87 months, 19 (24%) patients in the repair group and 8 (47%) in the replacement group attained the composite end point, and the estimated 10-year event-free survival rate was significantly higher in the repair group (75 ± 6%) than in the replacement group (43 ± 2%) (P = 0.019). TV replacement was independently associated with end points in the Cox proportional hazards analysis after adjustment with propensity score (hazard ratio, 4.033; 95% CI, 1.470 to 11.071; P=0.007). Conclusions: Compared with TV repair, replacement was associated with higher operative mortality and worse long-term clinical outcomes in patients with very severe functional TR. Repair should be the preferred surgical option even for severe TR associated with more advanced tethering and right ventricular dilatation.

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

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

Tricuspid Valve Surgery in Patients with Isolated Tricuspid Valve Endocarditis: Analysis of Perioperative Parameters and Long-Term Outcomes.

Background The aim of this study was to evaluate the perioperative characteristics and the short- and mid-term outcomes in patients undergoing tricuspid valve (TV) surgery for isolated TV endocarditis. Patients and Methods A total of 56 patients with isolated TV endocarditis underwent TV surgery at a single center between June 1995 and February 2012. Mean age of patients was 53.8 ± 17.1 years, 39 (69.6%) being male. The mean left ventricular ejection fraction was 60.4 ± 13.6% and 13 (23.2%) patients had diabetes mellitus. Average logistic EuroSCORE was 19.4 ± 17.0%. Mean follow-up was 4.7 ± 3.8 years. Results Microbiological investigations revealed positive blood cultures in 89.1% of patients and positive intraoperative swabs in 51.9%. The most common pathogen (42.9%) isolated was Staphylococcus aureus, followed by coagulase-negative staphylococcus (17.9%). Discussion A history of intravenous drug abuse (IVDA) was recorded in 11 patients (19.6%), of which 8 patients additionally had hepatitis C. A total of 15 patients (26.8%) had a permanent pacemaker/implantable cardioverter-defibrillator in situ. TV replacement was performed in 22 patients (39.3%) and TV repair was performed in 34 patients (60.7%). Overall 30-day mortality was 12.5%. Five-year survival was 63.9 ± 7.2% (95% confidence interval [CI]: 64.0-137.5 months). Freedom from reoperation for recurrent TV endocarditis was 91.7 ± 4.0% (95% CI: 152.3-179.3 months) at 5 years. Conclusion Blood culture is the most important tool to detect the causative pathogen causing IE of TV. The high risk of hepatitis C in patients with IVDA and IE of the TV should be mentioned.

Optimal Surgical Ablation of Atrial Tachyarrhythmias During Correction of Ebstein Anomaly

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

Right ventricular functions measured by cardiac magnetic resonance imaging in patients who underwent tricuspid valve surgery: implication for patients' outcome

Poster: ECR 2015 / C-1797 / Right ventricular functions measured by cardiac magnetic resonance imaging in patients who underwent tricuspid valve surgery: implication for patients’ outcome by: J.-W. Kang, W. J. Choi, D. H. Yang, T.-H. Lim; Seoul/KR

One and a half ventricle repair in association with tricuspid valve repair according to "peacock tail" technique in patients with Ebstein's malformation and failing right ventricle.

The aim of this study was to evaluate the outcome in a series of patients with Ebstein's anomaly and a failing right ventricle (RV) undergoing tricuspid valve (TV) repair and bidirectional Glenn cavopulmonary anastomosis (BDG). Between January 2006 and September 2013, 11 consecutive patients diagnosed with severe forms of Ebstein's anomaly and a failing RV underwent TV surgery and BDG. The mean age was 16.5 ± 7 years. Most frequently found symptoms were cyanosis, dyspnea, and arrhythmias. The azygos or hemiazygos veins were left open. The TV was repaired using the "peacock tail" technique, which consisted of total detachment of the anterior and posterior leaflets of the TV and rotation in both directions reimplanting them to the true annulus. The mean follow-up was 3.8 ± 2.4 years (range three months to six years). Hospital mortality was 9% (one patient). TV repair was possible in 10 patients. None of the patients had AV block postoperatively. At one year after surgery, the indexed RV and RA diameter were reduced significantly versus the preoperative data (p = 0.003 and p < 0.001). The mean TVR and indexed TV area were 1.2 ± 0.42 and 1.6 ± 0.6 (mm/m2), significantly lower than preoperatively (p = 0.001 and p = 0.008, respectively). The mean NYHA functional class, SaO2 , and cardiothoracic ratio were significantly improved. The peacock tail technique for TV repair in combination with BDG in patients with Ebstein's malformation and depressed RV function results in TV preservation, a low incidence of recurrent regurgitation, favorable functional status and RV function, and resolution of cyanosis.

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

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

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

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

Surgical Treatment for Isolated Tricuspid Valve Endocarditis

Systematic long-term data on tricuspid valve (TV) endocarditis are limited. The aim of this study was to investigate the outcome of surgery for isolated TV endocarditis. A total of 637 patients who underwent TV surgery between June 1996 and September 2012 at Hannover Medical School were retrospectively investigated. Of the 637 patients, 33 (14 female, mean age, 49 ± 21 years) underwent isolated TV surgery for endocarditis: biological TV replacement, n=14; mechanical TV replacement, n=4; TV reconstruction, n=15. A total of 28 cases were associated with i.v. drug abuse (n=14) or pacemaker infection (n=14). Staphylococcus (S.) aureus was the most common microorganism detected on preoperative blood culture. Mean follow-up was 6.0 ± 4.1 years (83% completed). Three patients (9%) died during the first 30 postoperative days. Survival at 1, 5 and 10 years was 88%, 73%, and 73%, respectively. Freedom from reoperation was 100%, 95%, and 88%, respectively. During follow-up New York Heart Association class improved significantly, and echocardiography identified remaining TV insufficiency grade ≥ II° only in 2 patients. Statistical analysis identified advanced age, logistic EuroSCORE and positive blood culture for S. aureus as significant risk factors for long-term mortality. Isolated TV endocarditis is strongly associated with i.v. drug abuse or pacemaker infection. Long-term outcome is acceptable, independent of the surgical procedure.