VALVULAR HEART DISEASE
Clinical and Anatomic Observations in Patients Having Mitral Valve Replacement for NIitral Sfen&s and Simultaneous Tricuspid Valve Replacement Erik A. Eways, BS,* and William C. Roberts, MD
Certain clinical and morphologic findings are described in 67 patients (aged 23 to 76 years [mean 521; 55 women [S?%]) who had mitral valve replacement for mitral stenosis (with or without associated regurgitation), and simultaneous tricuspid valve replacement for pure tricuspid regurgitation (58 patients) or tricuspid stenosis (all with associated regurgitation; 9 patients). Of the 66 patients with pure tricuspid regurgitation, 21 had anatomically normal and 37 had anatomically abnormal (diffusely fibrotic leaflets) tricuspid valves. Among these 58 patients, no clinical or hemodynamic variable was useful before surgery in distinguishing the group without from that with anatomically abnormal tricuspid valves. All 9 patients with stenotic tricuspid valves had anatomically abnormal tricuspid valves. The latter group had a lower average right ventricular systolic pressure (tricuspid valve closing pressure) than those with pure tricuspid regurgitation, and none had severe pulmonary arterial hypertension (present in 20 [30%] of the 66 patients with pure tricuspid regurgltation). (Am J Cardiol1991;68:1367-1371)
From the Pathology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland. Manuscript received June 17, 1991; revised manuscript received July 12, 1991, and accepted July 15. Address for reprints: William C. Roberts, MD, Building 10, Room 2N258, National Institutes of Health, 9000 Rockville Pike, Bethesda, Maryland 20892. *Sophomore medical student, George Washington University School of Medicine and Health Sciences, Washington, D.C.
significant percentageof patients with primary mitral valve diseasehave tricuspid valve dysfunction. Consequently, some patients undergoing mitral valve replacementor repair operations for primary mitral diseasealso have tricuspid valve replacement or other operative procedures performed on the right-sided atrioventricular valve. Among surgeonswho perform many cardiac valve operations yearly, some rarely replace the tricuspid valve and others do so relatively frequently. If the tricuspid valve is stenotic, the decisionis relatively easy; if it is purely regurgitant, the decisionis more difficult. In the latter circumstance,the tricuspid valve leaflets may be anatomically abnormal, normal or virtually normal. In this report we focus on the frequency and type of structural abnormality of the tricuspid valve in patients having simultaneous replacement of both mitral and tricuspid valvesfor mitral stenosis and tricuspid valve dysfunction (either pure regurgitation or stenosis[with or without regurgitation]).
A
METHODS Patients studied: In the Surgery Branch of the Na-
tional Heart, Lung, and Blood Institute from September 1963 to December 1989, a total of 113 patients >20 years of age underwent simultaneous replacement of the native mitral and tricuspid valves without aortic valve replacement at any time. Of the 113 patients, 11 were excluded from further analysis because a peak systolic pressuregradient between the left ventricle and a systemicartery >lO mm Hg was present.Another 18 patients were excluded because either the operatively excised tricuspid and mitral valves were not available for reexamination or photographs of these operatively excised valves were unavailable. Of the remaining 84 patients, 67 had mitral stenosisand 17 had pure mitral regurgitation. This report focuses on the 67 patients with mitral stenosis.Thirty-two (48%) of the 67 patients previously had valvular commissurotomy operations: mitral valve only (28 patients), tricuspid valve only (2), and both mitral and tricuspid valve commissurotomy (2). None of the 67 patients had a previous anuloplasty procedure on either the tricuspid or mitral valve. MITRAL AND TRICUSPID VALVE REPLACEMENT
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Year of operation and surgeon: The 67 valve replacement operations were performed by 6 different surgeons during the following time periods: 1963 to 1965 (1 patient); 1966 to 1970 (13); 1971 to 1975 (20); 1976 to 1980 (16); 1981 to 1985 (10); and 1986 to 1989 (7). Classifications and definitions: The clinical records of all 67 patients were reviewed. The operatively excisedvalveshad all beenexamined and classifiedinitially by WCR. Of the 134 operatively excised valves in the 67 patients, 62 were reexamined, and photographs of the other 72 were examined. The original description of the operatively excisedvalve by WCR was reviewed in all 67 patients. The patients were divided into 3 groups on the basis of valvular function and structure (Table I). The leaflets in all stenotic valves (both mitral and tricuspid) were diffusely fibrotic, and the mitral leaflets were often focally calcified. Calcific depositswere absent in all stenotic tricuspid valves. Nonstenotic, purely regurgitant tricuspid valves consideredanatomically abnormal were also diffusely fibrotic, but their orifices were nonstenotic. Tricuspid valves consideredanatomically normal were free of diffuse leaflet or chordal thickening; somehad small focal leaflet thickenings involving 1 or 2 leaflets. (These focal thickenings were considered consequencesof increasedright ventricular systolic or closing pressure on the leaflets.) All patients with mitral stenosiswere considered to have rheumatic heart disease. Mitral and tricuspid stenoseswere confirmed in all patients by cardiac catheterization before surgery. All 67 patients had right- and left-sided cardiac catheterization during the 6 weeks preceding simultaneous replacement of the native mitral and tricuspid valves.
RESULTS
Certain clinical, hemodynamic and morphologic findings in the 67 patients (55 women [X2%]) are listed in Table I, and somevalves are illustrated in Figures 1 to 5. Of the 67 patients, 9 (14%) had associatedtricuspid valve stenosis(group 3) and, consequently,anatomically abnormal tricuspid valves; 58 (86%) had pure tricuspid valve regurgitation, 21 (3 1%) with anatomically normal (group 1) and 37 (55%) with anatomically abnormal tricuspid valves(group 2). No significant differencesamong the 3 groups were observedbefore surgery in mean right atria1 pressure,average right atria1 peak V wave, percentageof patients with peak right ventricular systolic pressure 540 mm Hg, peak left ventricular systolic pressure, percentage of patients with peak left ventricular systolic pressure>140 mm Hg, average peak systemic arterial systolic pressure,and mean and averageV wave in the pulmonary artery wedgeposition or left atrium. Patients in group 3 (mitral and tricuspid 1368
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stenoses)had lower average peak right ventricular sys- DISCUSSION The present study focuseson structural alterations tolic pressureand percentageof patients with right venin operatively excisedtricuspid valves in patients having tricular systolic pressures>70 mm Hg than those in mitral valve replacementbecauseof mitral stenosis.Pathe other 2 groups had.
FIGURE 1. Operatively excised stenotii mitral valve (a and b), and purely regurgitant and anatomically normal tricuspid valve (c) in 5%year-old woman (S74-5134). Mean diastolic gradient across mitral valve was 18 mm Hg. Right ventricular pressure was So/7 mm Hg, and left ventricular pressure was 124/S mm Hg.
fibrotic tricuspid valve (d) in 6!% FIGURE 2. Operatively excised stenotic mitral valve (a to c) and purely regurgitant, diisely year-old man (S74-5046). Right ventricular pressure was 120/27 mm Hg, and left ventricular pressure was 100/25 mm Hg. The mitral valve is calcified.
MITRAL AND TRICUSPID VALVE REPLACEMENT
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tients whose indication for mitral valve replacement was pure mitral regurgitation were excluded from this study. Of the 67 patients having stenotic mitral valves replaced, the leaflets and chordae tendineae of all mitral valves were diffusely fibrotic with or without calcif-
ic deposits.1,2The operatively excisedtricuspid valvesin these patients were anatomically normal in 21 patients (3 1%) and anatomically abnormal (diffusely fibrotic) in 46 (69%). The tricuspid valves in the latter 46 patients were purely regurgitant in 37 (80%) and stenotic
FIGURE 3. Operatively excised stenotic mitral vaive (a and b) and diffusely fibrotic purely regurgitant tricuspid valve (c) in !54year-old man (S66-2439). Right ventricular pressure was 65/10 mm Hg, and left ventricular pressure was 110/12 mm Hg.
FIGURE 4. Operatively excised stenotic mitral valve (a) and diffusely fibrotic mildiy stenotic tricuspid valve (b) in IS-year-old woman (S71-3034). Right ventricular pressure was 38/l 1 mm Hg, and left ventricular pressure was 146/14 mm Hg.
FIGURE 5. Operatively excised stenotic mitral valve (a to c) and stenotii tricuspid valve (dj in 39.year-old woman (S745057) whose right ventricular pressure was 45/15 mm Hg and whose left ventricular pressure was 1 IO/IS mm Hg. Radiograph (c) shows only small deposit of calcium in 1 mitral leaflet.
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(mean right atria1 to right ventricular mean diastolic gradient ranged from 3 to 11 mm Hg [average= 61) with or without associatedregurgitation in 9 (20%). When a cardiac valve (tricuspid or any other cardiac valve) is stenotic, the valve leaflets are diffusely fibrotic or extensively calcified (i.e., anatomically abnorma1).2,3Among patients with mitral stenosis severe enough to warrant a mitral valve operation, associated tricuspid valve stenosisis infrequent (14% in the present study). This percentage, however, is much less if the analysis does not focus exclusively on patients having simultaneous replacementof both the mitral and tricuspid valves.In the study by Roberts2focusing on necropsy patients with fatal valvular heart disease(some of whom had had cardiac operations and some of whom had not), 434 (43%) of 1,010 patients L 15 years of age had mitral stenosis with or without associatedmitral regurgitation. Of the 434 patients, mitral stenosiswas not associatedwith aortic valve dysfunction or tricuspid stenosisin 189 (44%); it was combined with aortic stenosisin 152 (35%) with pure aortic regurgitation in 65 (13%) with both aortic and tricuspid stenosesin 24 (6%) and with tricuspid stenosis alone in 4 ( 1%). Therefore, if the 176 patients with associatedaortic stenosis (24 of whom also had tricuspid stenosis)and the 65 with pure aortic regurgitation were excluded from the necropsy study (as they were in the present study), only 4 (2%) of the remaining 193 patients with mitral stenosishad associatedtricuspid valve stenosis.2 Among patients with mitral stenosissevereenough to warrant a mitral valve operation, a significant percentage of them will also have some degree of pure tricuspid regurgitation. Of the 67 patients with replaced stenotic mitral valves in the present study, 58 (86%) had purely regurgitant tricuspid valves and 9 ( 14%) had stenotic tricuspid valves. The 58 purely regurgitant tricuspid valves were anatomically abnormal in 37 patients (64%) and anatomically normal in 21 (36%). We found only 1 previously published report with which our observations could be meaningfully compared. Hauck et al4 examined operatively excised tricuspid valves in 248 patients with mitral stenosis, and 163 (66%) of them had purely regurgitant tricuspid valves and 85 (34%) had stenotic tricuspid valves.Of the 163 patients with purely regurgitant tricuspid valves, the tricuspid
leaflets and chordae tendineae were anatomically normal in 54 (22%) and diffusely fibrotic in 194 (78%). The patients reported by Hauck and associatesand by us underwent valve replacementduring similar time periods (1963 to 1989). Comparison of these 2 studies indicates that the patients with mitral stenosisundergoing replacement of both mitral and tricuspid valves at the Mayo Clinic (Hauck et al) had a higher frequency of associatedtricuspid valve stenosisand, therefore, a lower frequency of pure tricuspid regurgitation than those having similar therapy at the National Institutes of Health (present study). Tricuspid valve replacement is performed less frequently today than during the 1960s and 1970s when 50 patients (75%) describedin the present study underwent valve replacement operations. Justifying tricuspid valve replacementin the presenceof tricuspid valve stenosis is much easier than justifying tricuspid valve replacement in the presenceof pure tricuspid valve regurgitation associatedwith mitral stenosis.When the tricuspid leaflets and chordae are anatomically normal, as they were in 21 (3 1%) of the 67 patients described herein, we believethat most surgeonstoday would rarely replace the tricuspid valve. When the tricuspid valve is purely regurgitant but the leaflets are diffusely fibrotic, the decision of replacementversusanuloplasty (with ring) is more difficult. Unfortunately, in the present study none of the clinical or hemodynamic variables analyzed (Table I) was useful in distinguishing before surgery patients with purely regurgitant anatomically normal tricuspid valves from those with purely regurgitant anatomically abnormal ones.
REFERENCES 1. Lachman AS, Roberts WC. Calcific deposits in stenotic mitral valves. Extent and relation to age, sex, degree of stenosis, cardiac rhythm, previous commissurotomy and left atria1 body thrombus from study of 164 operatively-excised valves. Circuhtion 1978;57:808-815. 2. Roberts WC. Morphologic features of the normal and abnormal mitral valve. Am J Cardiol 1983;51:1005-1028. 3. Olson LJ, Subramanian R, Ackermann DM, Orszulak TA, Edwards WD. Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. Mayo Clinic Proc 1987;62:22-34. 4. Hawk AJ, Freeman DP, Ackermann DM, Danielson GK, Edwards WD. Surgical pathology of the tricuspid valve: a study of 363 cases spanning 25 years. Mayo C/in Proc 1988;63:851-863.
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1371
Clinical and Anatomic Observations in Patients Having Mitral Valve Replacement for NIitral Sfen&s and Simultaneous Tricuspid Valve Replacement Erik A. Eways, BS,* and William C. Roberts, MD
Certain clinical and morphologic findings are described in 67 patients (aged 23 to 76 years [mean 521; 55 women [S?%]) who had mitral valve replacement for mitral stenosis (with or without associated regurgitation), and simultaneous tricuspid valve replacement for pure tricuspid regurgitation (58 patients) or tricuspid stenosis (all with associated regurgitation; 9 patients). Of the 66 patients with pure tricuspid regurgitation, 21 had anatomically normal and 37 had anatomically abnormal (diffusely fibrotic leaflets) tricuspid valves. Among these 58 patients, no clinical or hemodynamic variable was useful before surgery in distinguishing the group without from that with anatomically abnormal tricuspid valves. All 9 patients with stenotic tricuspid valves had anatomically abnormal tricuspid valves. The latter group had a lower average right ventricular systolic pressure (tricuspid valve closing pressure) than those with pure tricuspid regurgitation, and none had severe pulmonary arterial hypertension (present in 20 [30%] of the 66 patients with pure tricuspid regurgltation). (Am J Cardiol1991;68:1367-1371)
From the Pathology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland. Manuscript received June 17, 1991; revised manuscript received July 12, 1991, and accepted July 15. Address for reprints: William C. Roberts, MD, Building 10, Room 2N258, National Institutes of Health, 9000 Rockville Pike, Bethesda, Maryland 20892. *Sophomore medical student, George Washington University School of Medicine and Health Sciences, Washington, D.C.
significant percentageof patients with primary mitral valve diseasehave tricuspid valve dysfunction. Consequently, some patients undergoing mitral valve replacementor repair operations for primary mitral diseasealso have tricuspid valve replacement or other operative procedures performed on the right-sided atrioventricular valve. Among surgeonswho perform many cardiac valve operations yearly, some rarely replace the tricuspid valve and others do so relatively frequently. If the tricuspid valve is stenotic, the decisionis relatively easy; if it is purely regurgitant, the decisionis more difficult. In the latter circumstance,the tricuspid valve leaflets may be anatomically abnormal, normal or virtually normal. In this report we focus on the frequency and type of structural abnormality of the tricuspid valve in patients having simultaneous replacement of both mitral and tricuspid valvesfor mitral stenosis and tricuspid valve dysfunction (either pure regurgitation or stenosis[with or without regurgitation]).
A
METHODS Patients studied: In the Surgery Branch of the Na-
tional Heart, Lung, and Blood Institute from September 1963 to December 1989, a total of 113 patients >20 years of age underwent simultaneous replacement of the native mitral and tricuspid valves without aortic valve replacement at any time. Of the 113 patients, 11 were excluded from further analysis because a peak systolic pressuregradient between the left ventricle and a systemicartery >lO mm Hg was present.Another 18 patients were excluded because either the operatively excised tricuspid and mitral valves were not available for reexamination or photographs of these operatively excised valves were unavailable. Of the remaining 84 patients, 67 had mitral stenosisand 17 had pure mitral regurgitation. This report focuses on the 67 patients with mitral stenosis.Thirty-two (48%) of the 67 patients previously had valvular commissurotomy operations: mitral valve only (28 patients), tricuspid valve only (2), and both mitral and tricuspid valve commissurotomy (2). None of the 67 patients had a previous anuloplasty procedure on either the tricuspid or mitral valve. MITRAL AND TRICUSPID VALVE REPLACEMENT
1367
Year of operation and surgeon: The 67 valve replacement operations were performed by 6 different surgeons during the following time periods: 1963 to 1965 (1 patient); 1966 to 1970 (13); 1971 to 1975 (20); 1976 to 1980 (16); 1981 to 1985 (10); and 1986 to 1989 (7). Classifications and definitions: The clinical records of all 67 patients were reviewed. The operatively excisedvalveshad all beenexamined and classifiedinitially by WCR. Of the 134 operatively excised valves in the 67 patients, 62 were reexamined, and photographs of the other 72 were examined. The original description of the operatively excisedvalve by WCR was reviewed in all 67 patients. The patients were divided into 3 groups on the basis of valvular function and structure (Table I). The leaflets in all stenotic valves (both mitral and tricuspid) were diffusely fibrotic, and the mitral leaflets were often focally calcified. Calcific depositswere absent in all stenotic tricuspid valves. Nonstenotic, purely regurgitant tricuspid valves consideredanatomically abnormal were also diffusely fibrotic, but their orifices were nonstenotic. Tricuspid valves consideredanatomically normal were free of diffuse leaflet or chordal thickening; somehad small focal leaflet thickenings involving 1 or 2 leaflets. (These focal thickenings were considered consequencesof increasedright ventricular systolic or closing pressure on the leaflets.) All patients with mitral stenosiswere considered to have rheumatic heart disease. Mitral and tricuspid stenoseswere confirmed in all patients by cardiac catheterization before surgery. All 67 patients had right- and left-sided cardiac catheterization during the 6 weeks preceding simultaneous replacement of the native mitral and tricuspid valves.
RESULTS
Certain clinical, hemodynamic and morphologic findings in the 67 patients (55 women [X2%]) are listed in Table I, and somevalves are illustrated in Figures 1 to 5. Of the 67 patients, 9 (14%) had associatedtricuspid valve stenosis(group 3) and, consequently,anatomically abnormal tricuspid valves; 58 (86%) had pure tricuspid valve regurgitation, 21 (3 1%) with anatomically normal (group 1) and 37 (55%) with anatomically abnormal tricuspid valves(group 2). No significant differencesamong the 3 groups were observedbefore surgery in mean right atria1 pressure,average right atria1 peak V wave, percentageof patients with peak right ventricular systolic pressure 540 mm Hg, peak left ventricular systolic pressure, percentage of patients with peak left ventricular systolic pressure>140 mm Hg, average peak systemic arterial systolic pressure,and mean and averageV wave in the pulmonary artery wedgeposition or left atrium. Patients in group 3 (mitral and tricuspid 1368
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stenoses)had lower average peak right ventricular sys- DISCUSSION The present study focuseson structural alterations tolic pressureand percentageof patients with right venin operatively excisedtricuspid valves in patients having tricular systolic pressures>70 mm Hg than those in mitral valve replacementbecauseof mitral stenosis.Pathe other 2 groups had.
FIGURE 1. Operatively excised stenotii mitral valve (a and b), and purely regurgitant and anatomically normal tricuspid valve (c) in 5%year-old woman (S74-5134). Mean diastolic gradient across mitral valve was 18 mm Hg. Right ventricular pressure was So/7 mm Hg, and left ventricular pressure was 124/S mm Hg.
fibrotic tricuspid valve (d) in 6!% FIGURE 2. Operatively excised stenotic mitral valve (a to c) and purely regurgitant, diisely year-old man (S74-5046). Right ventricular pressure was 120/27 mm Hg, and left ventricular pressure was 100/25 mm Hg. The mitral valve is calcified.
MITRAL AND TRICUSPID VALVE REPLACEMENT
1369
tients whose indication for mitral valve replacement was pure mitral regurgitation were excluded from this study. Of the 67 patients having stenotic mitral valves replaced, the leaflets and chordae tendineae of all mitral valves were diffusely fibrotic with or without calcif-
ic deposits.1,2The operatively excisedtricuspid valvesin these patients were anatomically normal in 21 patients (3 1%) and anatomically abnormal (diffusely fibrotic) in 46 (69%). The tricuspid valves in the latter 46 patients were purely regurgitant in 37 (80%) and stenotic
FIGURE 3. Operatively excised stenotic mitral vaive (a and b) and diffusely fibrotic purely regurgitant tricuspid valve (c) in !54year-old man (S66-2439). Right ventricular pressure was 65/10 mm Hg, and left ventricular pressure was 110/12 mm Hg.
FIGURE 4. Operatively excised stenotic mitral valve (a) and diffusely fibrotic mildiy stenotic tricuspid valve (b) in IS-year-old woman (S71-3034). Right ventricular pressure was 38/l 1 mm Hg, and left ventricular pressure was 146/14 mm Hg.
FIGURE 5. Operatively excised stenotic mitral valve (a to c) and stenotii tricuspid valve (dj in 39.year-old woman (S745057) whose right ventricular pressure was 45/15 mm Hg and whose left ventricular pressure was 1 IO/IS mm Hg. Radiograph (c) shows only small deposit of calcium in 1 mitral leaflet.
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(mean right atria1 to right ventricular mean diastolic gradient ranged from 3 to 11 mm Hg [average= 61) with or without associatedregurgitation in 9 (20%). When a cardiac valve (tricuspid or any other cardiac valve) is stenotic, the valve leaflets are diffusely fibrotic or extensively calcified (i.e., anatomically abnorma1).2,3Among patients with mitral stenosis severe enough to warrant a mitral valve operation, associated tricuspid valve stenosisis infrequent (14% in the present study). This percentage, however, is much less if the analysis does not focus exclusively on patients having simultaneous replacementof both the mitral and tricuspid valves.In the study by Roberts2focusing on necropsy patients with fatal valvular heart disease(some of whom had had cardiac operations and some of whom had not), 434 (43%) of 1,010 patients L 15 years of age had mitral stenosis with or without associatedmitral regurgitation. Of the 434 patients, mitral stenosiswas not associatedwith aortic valve dysfunction or tricuspid stenosisin 189 (44%); it was combined with aortic stenosisin 152 (35%) with pure aortic regurgitation in 65 (13%) with both aortic and tricuspid stenosesin 24 (6%) and with tricuspid stenosis alone in 4 ( 1%). Therefore, if the 176 patients with associatedaortic stenosis (24 of whom also had tricuspid stenosis)and the 65 with pure aortic regurgitation were excluded from the necropsy study (as they were in the present study), only 4 (2%) of the remaining 193 patients with mitral stenosishad associatedtricuspid valve stenosis.2 Among patients with mitral stenosissevereenough to warrant a mitral valve operation, a significant percentage of them will also have some degree of pure tricuspid regurgitation. Of the 67 patients with replaced stenotic mitral valves in the present study, 58 (86%) had purely regurgitant tricuspid valves and 9 ( 14%) had stenotic tricuspid valves. The 58 purely regurgitant tricuspid valves were anatomically abnormal in 37 patients (64%) and anatomically normal in 21 (36%). We found only 1 previously published report with which our observations could be meaningfully compared. Hauck et al4 examined operatively excised tricuspid valves in 248 patients with mitral stenosis, and 163 (66%) of them had purely regurgitant tricuspid valves and 85 (34%) had stenotic tricuspid valves.Of the 163 patients with purely regurgitant tricuspid valves, the tricuspid
leaflets and chordae tendineae were anatomically normal in 54 (22%) and diffusely fibrotic in 194 (78%). The patients reported by Hauck and associatesand by us underwent valve replacementduring similar time periods (1963 to 1989). Comparison of these 2 studies indicates that the patients with mitral stenosisundergoing replacement of both mitral and tricuspid valves at the Mayo Clinic (Hauck et al) had a higher frequency of associatedtricuspid valve stenosisand, therefore, a lower frequency of pure tricuspid regurgitation than those having similar therapy at the National Institutes of Health (present study). Tricuspid valve replacement is performed less frequently today than during the 1960s and 1970s when 50 patients (75%) describedin the present study underwent valve replacement operations. Justifying tricuspid valve replacementin the presenceof tricuspid valve stenosis is much easier than justifying tricuspid valve replacement in the presenceof pure tricuspid valve regurgitation associatedwith mitral stenosis.When the tricuspid leaflets and chordae are anatomically normal, as they were in 21 (3 1%) of the 67 patients described herein, we believethat most surgeonstoday would rarely replace the tricuspid valve. When the tricuspid valve is purely regurgitant but the leaflets are diffusely fibrotic, the decision of replacementversusanuloplasty (with ring) is more difficult. Unfortunately, in the present study none of the clinical or hemodynamic variables analyzed (Table I) was useful in distinguishing before surgery patients with purely regurgitant anatomically normal tricuspid valves from those with purely regurgitant anatomically abnormal ones.
REFERENCES 1. Lachman AS, Roberts WC. Calcific deposits in stenotic mitral valves. Extent and relation to age, sex, degree of stenosis, cardiac rhythm, previous commissurotomy and left atria1 body thrombus from study of 164 operatively-excised valves. Circuhtion 1978;57:808-815. 2. Roberts WC. Morphologic features of the normal and abnormal mitral valve. Am J Cardiol 1983;51:1005-1028. 3. Olson LJ, Subramanian R, Ackermann DM, Orszulak TA, Edwards WD. Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. Mayo Clinic Proc 1987;62:22-34. 4. Hawk AJ, Freeman DP, Ackermann DM, Danielson GK, Edwards WD. Surgical pathology of the tricuspid valve: a study of 363 cases spanning 25 years. Mayo C/in Proc 1988;63:851-863.
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