BEST EVIDENCE TOPIC – ADULT CARDIAC
Interactive CardioVascular and Thoracic Surgery 20 (2015) 114–119 doi:10.1093/icvts/ivu326 Advance Access publication 26 September 2014
Does concomitant tricuspid annuloplasty increase perioperative mortality and morbidity when correcting left-sided valve disease? Tie-Yuan Zhu, Jian-Gang Wang and Xu Meng* Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China * Corresponding author. Division of Cardiac Surgery, Beijing Anzhen Hospital, No. 2 Anzhen Road, Chaoyang District, Beijing 100029, China. Tel: +86-10-64456984; fax: +86-10-64453010; e-mail: [email protected] (X. Meng). Received 23 March 2014; received in revised form 30 August 2014; accepted 4 September 2014
Abstract A best evidence topic in adult valvular surgery was written according to a structured protocol. The question addressed was ‘Does concomitant tricuspid annuloplasty increase the perioperative mortality and morbidity when correcting left-sided valve disease?’ A total of 561 papers were found using the reported search, of which 12 presented the best evidence to answer the clinical question. The authors, country, journal, date of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Among these 12 papers, there were nine retrospective studies, two cohort studies and one randomized controlled trial (RCT). Overall, additional tricuspid valve (TV) repair takes more time during operations, particularly with a ring annuloplasty method. The mean aortic cross-clamping times were 57–83 min without associated tricuspid repair and 62–100 min with, and cardiopulmonary bypass times without and with repair were 82–124 and 90–174 min, respectively. A study of 624 patients who had undergone isolated mitral valve (MV) surgery and MV surgery plus TV repair showed more female and atrial fibrillation patients in the tricuspid valve plasty (TVP) group, but no increase in the 30-day mortality was found. One RCT, presenting similar patient baseline characteristics, also found no difference in the hospital mortality rates between the TVP group and the non-TVP group. Another 10 studies also demonstrated no statistically significant differences in perioperative mortality. In a cohort study of 311 patients undergoing MV repair with or without tricuspid annuloplasty, postoperative complications, such as bleeding, stroke, pacemaker, haemofiltration and myocardial infarction, all showed no statistically significant differences in the two groups. One study retrospectively analysed a large number of patients undergoing either isolated left-sided valve surgery or a concomitant TV repair, and there were no statistically significant differences regarding major complications (bleeding, pacemaker, respiratory insufficiency, and renal failure). Moreover, another three studies also found no statistically significant differences in terms of bleeding, pacemaker, wound infection, neurological deficit, pericardial effusion, low cardiac output syndrome and dialysis. In conclusion, there is good evidence to support that tricuspid annuloplasty is a low-risk procedure and concomitant TV repair does not significantly increase the perioperative mortality and morbidity when correcting left-sided valve disease. Keywords: Tricuspid valve • Tricuspid valve insufficiency • Tricuspid annuloplasty
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
(TR), while another doctor argues that it is not necessary and that additional tricuspid repair will increase the perioperative risk. You believe that tricuspid annuloplasty is a low-risk procedure; however, you want to find some evidence to support this.
THREE-PART QUESTION
SEARCH STRATEGY
In [patients with tricuspid regurgitation combined with left-sided valvular diseases] does [concomitant tricuspid annuloplasty compared with isolated left-sided valve surgery] increase [ perioperative mortality and morbidity]?
Medline from 1950 through March 2013 using the PubMed interface: [(Title/Abstract) mitral valve repair OR (Title/Abstract) mitral valve replacement OR (Title/Abstract) mitral valve surgery OR (Title/Abstract) left-sided valve surgery] AND [(Title/Abstract) tricuspid valve repair OR (Title/Abstract) tricuspid annuloplasty].
INTRODUCTION
CLINICAL SCENARIO SEARCH OUTCOME During the preoperative case discussion meeting for a 50-year old female patient who has a mild-to-moderate tricuspid regurgitation apart from her rheumatic mitral lesion, one surgeon suggests aggressive treatment for the secondary tricuspid regurgitation
A total of 561 papers were found using the reported search, from which 12 represented the best evidence on this topic and are summarized in Table 1.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
T.-Y. Zhu et al. / Interactive CardioVascular and Thoracic Surgery
115
Table 1: Best evidence papers Author, date, journal and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
Dreyfus et al. (2005), Ann Thorac Surg, UK [2]
NTVP = 163 patients TVP = 148 patients (De Vega = 4 and ring = 144)
30-day mortality
3 (1.8%) vs 1 (0.6%), P = 0.36
Prospective cohort study
Cohort study (level 2b)
Demographics: Isolated MV repair Female: 60 vs 60 (P = 0.5) Age (years): 61.2 vs 58.5 (P = 0.11) AF: 43 vs 48 (P = 0.24) NYHA class: 2.5 vs 2.6 (P = 0.29) EF (%): 59.6 vs 61.4 (P = 0.051) NTVP = 499 patients TVP = 125 patients (De Vega = 28 and ring = 85, ring + valve plasty = 12)
5 vs 8, P = 0.33 1 vs 1, P = 0.94 5 vs 1, P = 0.13
Myocardial infarction Haemofiltration Sternitis
4 vs 1, P = 0.21 4 vs 2, P = 0.48 3 vs 4, P = 0.61
CPB time (min)
120 ± 40 vs 140 ± 43 (P
Interactive CardioVascular and Thoracic Surgery 20 (2015) 114–119 doi:10.1093/icvts/ivu326 Advance Access publication 26 September 2014
Does concomitant tricuspid annuloplasty increase perioperative mortality and morbidity when correcting left-sided valve disease? Tie-Yuan Zhu, Jian-Gang Wang and Xu Meng* Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China * Corresponding author. Division of Cardiac Surgery, Beijing Anzhen Hospital, No. 2 Anzhen Road, Chaoyang District, Beijing 100029, China. Tel: +86-10-64456984; fax: +86-10-64453010; e-mail: [email protected] (X. Meng). Received 23 March 2014; received in revised form 30 August 2014; accepted 4 September 2014
Abstract A best evidence topic in adult valvular surgery was written according to a structured protocol. The question addressed was ‘Does concomitant tricuspid annuloplasty increase the perioperative mortality and morbidity when correcting left-sided valve disease?’ A total of 561 papers were found using the reported search, of which 12 presented the best evidence to answer the clinical question. The authors, country, journal, date of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Among these 12 papers, there were nine retrospective studies, two cohort studies and one randomized controlled trial (RCT). Overall, additional tricuspid valve (TV) repair takes more time during operations, particularly with a ring annuloplasty method. The mean aortic cross-clamping times were 57–83 min without associated tricuspid repair and 62–100 min with, and cardiopulmonary bypass times without and with repair were 82–124 and 90–174 min, respectively. A study of 624 patients who had undergone isolated mitral valve (MV) surgery and MV surgery plus TV repair showed more female and atrial fibrillation patients in the tricuspid valve plasty (TVP) group, but no increase in the 30-day mortality was found. One RCT, presenting similar patient baseline characteristics, also found no difference in the hospital mortality rates between the TVP group and the non-TVP group. Another 10 studies also demonstrated no statistically significant differences in perioperative mortality. In a cohort study of 311 patients undergoing MV repair with or without tricuspid annuloplasty, postoperative complications, such as bleeding, stroke, pacemaker, haemofiltration and myocardial infarction, all showed no statistically significant differences in the two groups. One study retrospectively analysed a large number of patients undergoing either isolated left-sided valve surgery or a concomitant TV repair, and there were no statistically significant differences regarding major complications (bleeding, pacemaker, respiratory insufficiency, and renal failure). Moreover, another three studies also found no statistically significant differences in terms of bleeding, pacemaker, wound infection, neurological deficit, pericardial effusion, low cardiac output syndrome and dialysis. In conclusion, there is good evidence to support that tricuspid annuloplasty is a low-risk procedure and concomitant TV repair does not significantly increase the perioperative mortality and morbidity when correcting left-sided valve disease. Keywords: Tricuspid valve • Tricuspid valve insufficiency • Tricuspid annuloplasty
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
(TR), while another doctor argues that it is not necessary and that additional tricuspid repair will increase the perioperative risk. You believe that tricuspid annuloplasty is a low-risk procedure; however, you want to find some evidence to support this.
THREE-PART QUESTION
SEARCH STRATEGY
In [patients with tricuspid regurgitation combined with left-sided valvular diseases] does [concomitant tricuspid annuloplasty compared with isolated left-sided valve surgery] increase [ perioperative mortality and morbidity]?
Medline from 1950 through March 2013 using the PubMed interface: [(Title/Abstract) mitral valve repair OR (Title/Abstract) mitral valve replacement OR (Title/Abstract) mitral valve surgery OR (Title/Abstract) left-sided valve surgery] AND [(Title/Abstract) tricuspid valve repair OR (Title/Abstract) tricuspid annuloplasty].
INTRODUCTION
CLINICAL SCENARIO SEARCH OUTCOME During the preoperative case discussion meeting for a 50-year old female patient who has a mild-to-moderate tricuspid regurgitation apart from her rheumatic mitral lesion, one surgeon suggests aggressive treatment for the secondary tricuspid regurgitation
A total of 561 papers were found using the reported search, from which 12 represented the best evidence on this topic and are summarized in Table 1.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
T.-Y. Zhu et al. / Interactive CardioVascular and Thoracic Surgery
115
Table 1: Best evidence papers Author, date, journal and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
Dreyfus et al. (2005), Ann Thorac Surg, UK [2]
NTVP = 163 patients TVP = 148 patients (De Vega = 4 and ring = 144)
30-day mortality
3 (1.8%) vs 1 (0.6%), P = 0.36
Prospective cohort study
Cohort study (level 2b)
Demographics: Isolated MV repair Female: 60 vs 60 (P = 0.5) Age (years): 61.2 vs 58.5 (P = 0.11) AF: 43 vs 48 (P = 0.24) NYHA class: 2.5 vs 2.6 (P = 0.29) EF (%): 59.6 vs 61.4 (P = 0.051) NTVP = 499 patients TVP = 125 patients (De Vega = 28 and ring = 85, ring + valve plasty = 12)
5 vs 8, P = 0.33 1 vs 1, P = 0.94 5 vs 1, P = 0.13
Myocardial infarction Haemofiltration Sternitis
4 vs 1, P = 0.21 4 vs 2, P = 0.48 3 vs 4, P = 0.61
CPB time (min)
120 ± 40 vs 140 ± 43 (P
