Clinical Application of Current Techniques and Treatment in Cardiology Adv. Cardiol., vol. 17, pp. 199-207 (Karger, Basel 1976)
Indications for and Results of Tricuspid Valve Replacemene NICHOLAS
T.
KOUCHOUKOS
and LARRY W.
STEPHENSON
Department of Surgery, University of Alabama Medical Center, Birmingham, Ala.
Replacement of the tricuspid valve is generally reserved for patients with far advanced rheumatic valvular disease, usually involving the mitral and aortic valves as well, and less frequently for patients with isolated disease of the tricuspid valve. Controversy still exists regarding the relative merits of tricuspid valve replacement and reconstructive procedures (annuloplasty) in patients with rheumatic or functional tricuspid regurgitation. This report will not attempt to resolve this controversy, but will document our experience with tricuspid valve replacement in 87 patients during a 7.S-year period.
Materials and Methods
1 This research was supported in part by Program Project Grant HL 11,310, National Heart and Lung Institute, Bethesda, Md.
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
Between February 1967 and August 1974, 87 patients had replacement ofthe tricuspid valve at the University of Alabama Medical Center. During this same period, 17 patients underwent annuloplasty for tricuspid incompetence, and two patients had a commissurotomy for tricuspid stenosis. The hemodynamic lesions of the tricuspid valve requiring replacement are shown in table I. The ages of the patients ranged from 5 to 75 years with a mean of 46 years, and 59 of the patients (68%) were females. 37 previous cardiac procedures (17 closed, 20 open) were performed in 28 of the patients. Isolated tricuspid valve replacement was performed in only eight patients and for a variety of causes. The remainder of the procedures were associated with replacement of other valves for rheumatic valvular disease (table II). 60 patients were functional class III (New York Heart Association classification) preoperatively and the remaining 27 were class IV.
200
KOUCHOUKOS/STEPHENSON
Table 1. Hemodynamic lesions requiring tricuspid valve replacement Hemodynamic lesion
Number of patients
Incompetence Stenosis and incompetence Stenosis
S4 32 32 87
Total
Table II. Etiology of tricuspid valvular disease requiring valve replacement Number of patients Isolated tricuspid valve replacement Ebstein's malformation With associated ventricular septal defect Traumatic tricuspid incompetence With associated right atrial myxoma With associated cardiomyopathy Rheumatic disease with previous mitral valve replacement Multiple valve replacement Rheumatic valvulitis Aortic and tricuspid
Totals
8 2 2 2 2 2
2 79 4
Mitral and tricuspid
39
Aortic mitral and tricuspid
36 87
Standard cardiopulmonary bypass employing a bubble oxygenator (Bentley-Temtrol), moderate hemodilution and flows of 2.0-2.21/min/m2 were employed. The operative technique varied according to the valves replaced. For operations in which the aortic valve was replaced, direct coronary perfusion was used. For all other procedures, periods of myocardial ischemic arrest not exceeding 15-20 min at perfusion temperatures of 28-32 or 30-40 min after profound internal and external myocardial cooling, were employed. In general, the severity of the tricuspid valvular disease was assessed by digital examination through the right atrial appendage just before beginning cardiopulmonary bypass. If the degree of regurgitation was severe (grade S or 6 on a scale of 0-6) or there was severe structural damage of the valve, valve replacement was performed. In all other cases without significant tricuspid stenosis, the severity of the incompetence was again assessed in a similar way after insertion of the mitral and/or aortic prostheses just after
discontinuation of cardiopulmonary bypass. If the incompetence was moderate or severe
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
oe,
Indications for and Results of Tricuspid Valve Replacement
201
Table III. Prosthetic devices employed for tricuspid valve replacement Prosthetic valve Starr-Edwards model 6120 (Silastic ball) Starr-Edwards models 6300,6310-6320 (cloth-covered, metallic ball) Braunwald-Cutter (cloth-covered, silastic ball) Bjork-Shiley (disc) Porcine xenograft (preserved, stented) Totals
Number of patients
33
25 9 16
4 87
(grade 3-6) at that time, tricuspid valve replacement (or annuloplasty in a small number of cases) was performed. As noted in table I, both stenosis and incompetence or pure stenosis of the tricuspid valve were present in 33 of the 87 patients requiring valve replacement. The prosthetic devices used to replace the tricuspid valve are shown in table III. Anticoagulation with warfarin sodium was begun on the second postoperative day in all patients except those receiving porcine xenografts and in children and young adults under 18 years of age. Digitalis and diuretic therapy were employed when indicated. Follow-up information was obtained by examination by the surgical staff or the referring physicians and telephone contact with the patient. The date of last inquiry was December 12, 1974. Three patients were lost to follow-up. The mean duration of follow-up was 32 months and ranged from 4 to 94 months. Survival data were analyzed by the life table method.
Hospital Mortality There were 19 hospital deaths (22%). All of the deaths occurred in patients having mitral and tricuspid or triple valve replacement (table IV). The preoperative functional class influenced the hospital mortality (table V). For 60 patients who were functional class III preoperatively, the mortality was 17% (ten patients), and for 27 patients who were class IV, it was 33% (nine patients). 16 of the 19 hospital deaths were associated with severely impaired cardiac performance and low cardiac output postoperatively. In five of these patients, significant myocardial necrosis was found at autopsy. This probably resulted from inadequacies of myocardial perfusion during the operative
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
Results
202
KOUCHOUKOSjSTEPHENSON
Table IV. Hospital mortality following tricuspid valve replacement Number of patients
Valve replaced
Hospital deaths n
8
%
Tricuspid Aortic and tricuspid Mitral and tricuspid Aortic, mitral and tricuspid
4 39 36
0 0
0 0
11
Totals
87
19
28 22 22
8
Table V. Hospital mortality following tricuspid valve replacement according to preoperative functional class (New York Heart Association classification) Functional class
III IV
Number of patients
Hospital deaths
n
%
60
10
27
9
17 33
Table VI. Causes of late death following tricuspid valve replacement cause of death
Number of patients
Cardiac arrhythmia Cardiac failure Myocardial infarction Prosthetic endocarditis Intracranial hemorrhage
6 4
Totals
2 14
procedure. The other three hospital deaths resulted from neurologic injury, complete heart block, and a bleeding diathesis. Previous cardiac procedures, either open or closed, did not influence the hospital mortality.
late deaths were cardiac in origin, one resulted from prosthetic endocarditis,
and two were secondary to bleeding associated with anticoagulation therapy.
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
Late Mortality There have been 14 late deaths (16%) from 2 to 36 months following operation. The causes of late death are shown in table VI. Eleven of the 14
203
Indications for and Results of Tricuspid Valve Replacement
100.0 (81) 90.0
80.0
...J
ex:
~
>
60.0
0:::
:::l
Vl
SO.O
>--
z
w
u
0:::
w
Q..
40.0
~"I
·"1 10.0
O.O~
I •• ,
.,.""
••
!
••••
,
,,' I I I '
•
!
«I
,
I.,
I,
"
' , I,
""'" I
c
MONTHS AFTER OPERATION Fig. 1. Cumulative survival rate following tricuspid valve replacement in 87 patients. Number of patients exposed to risk is given in parentheses.
Complications Complete heart block developed in three patients postoperatively and was fatal in one. Four patients developed serious arrhythmias in the postoperative period resulting in cardiac standstill, but all were successfully resuscitated and discharged from the hospital. Prosthetic endocarditis occurred in two patients following discharge from the hospital and was fatal in one. Documented malfunction of the tricuspid prosthesis resulting in death, arrhythmias, or tricuspid incompetence has not been observed. There has been a low incidence of thromboembolic episodes (4%) among the surviving patients. Two patients have died of intracranial hemorrhage related to anticoagulant therapy.
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
The cumulative survival rate for the entire group of patients is shown in figure 1. The cumulative survival rates for the patients grouped according to the preoperative functional class are shown in figure 2. The differences in survival between the class III and class IV patients were statistically significantly different at and beyond 3 years.
204
KOUCHOUKOSjSTEPHENSON
100.0
1m (60) llll':(27)
90.0
-I
cr > >
It::
::>
1I)
SO.O
I-
Z
!J.J U It:: !J.J IL
'10.0
JtSE
30.0
20.0 10.0
0.0
~
2
2
o
~
0
cj
0
~
(;)
~
MONTHS AFTER OPERATION
Fig. 2. Cumulative survival rates following tricuspid valve replacement according to preoperative functional class. Number of patients exposed to risk is given in parentheses. o = Class III patients; 6. = class IV patients.
The hospital mortality of 22% for patients requiring replacement of the tricuspid valve is higher than that for combined aortic and mitral valve replacement in our institution (28 of 228 patients or 12%) and for isolated mitral [1] or aortic [2] valve replacement. Although lower hospital mortality rates have been reported from some centers with tricuspid annuloplasty as compared to tricuspid valve replacement [3-5], this was not observed in our series, since the mortality for tricuspid annuloplasty in combination with replacement of other valves was 25% (two of eight patients). The number of patients, however, is. small. In most series reporting the use of annuloplasty and valve replacement, annuloplasty has not totally supplanted valve replacement, and the mortality rates following valve replacement have generally been higher [3-5]. In our own experience, the preoperative functional disability of the patient significantly affected the hospital and late mortality
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
Discussion
205
rates (fig. 2). This has also been observed following isolated mitral valve replacement [1]. Clearly, a number of patients who present with severe tricuspid incompetence in association with other valvular disease have significant depression of myocardial function preoperatively, which affects both the early and long-term results. At least 75% of the late deaths in this series were related to myocardial dysfunction. It is noteworthy that none of the patients requiring isolated tricuspid valve replacement died in the postoperative period. In patients undergoing other valve replacements, the decision to replace or repair the tricuspid valve when there is moderate or severe tricuspid incompetence must be weighed against the possible detrimental effects of leaving the incompetence uncorrected. There is little disagreement among surgeons that correction of the tricuspid regurgitation is required in such cases, since the operative mortality and incidence of low cardiac output postoperatively are appreciably less with correction than without. Presently, there is no definitive answer as to which procedure (valve replacement or annuloplasty) is more effective in this circumstance. Tricuspid valve replacement is carried out even by those individuals who use tricuspid annuloplasty extensively, since annuloplasty cannot always be accomplished successfully. It is of interest that the operative mortality is higher when valve replacement is performed as compared to annuloplasty under these conditions [3-5]. Comparison of annuloplasty and valve replacement in patients with comparable degrees of tricuspid incompetence and preoperative myocardial dysfunction should provide the answer to this difficult question. Our current practice in deciding on the necessity for correction of tricuspid incompetence at the time of other valve replacement is to assess the tricuspid valve through the atrial appendage prior to beginning cardiopulmonary bypass. If there is evidence of severe structural damage to the valve or severe tricuspid incompetence and annular dilatation, valve replacement is performed. If there are minimal or no structural abnormalities of the valve and minimal tricuspid incompetence, the valve is generally not replaced or repaired. If the tricuspid incompetence is moderate, the incompetence is again assessed after the other valves have been replaced and cardiopulmonary bypass has been discontinued. If there is still moderate or severe tricuspid incompetence, the right atrium is opened and, if an adequate annuloplasty can be performed, this is carried out. If not, the valve is replaced. While this method of assessing and treating tricuspid incompetence may not be perfect, it provides, in our opinion, a reasonable approach to the surgical management of tricuspid valve disease.
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
Indications for and Results of Tricuspid Valve Replacement
KOUCHOUKOS/STEPHENSON
206
Summary A review of our experience with tricuspid valve replacement over a 7.5-year period is presented. Isolated disease of the tricuspid valve was encountered infrequently (8 of 87 patients) and was due to a variety of causes. In the remaining cases, the tricuspid disease was associated with rheumatic valvular disease of the mitral and/or aortic valves. The hospital mortality for the entire group of patients was 22%, and the late mortality during a mean follow-up period of 32 months was 16%. Operative and late mortality were clearly affected by the severity of myocardial dysfunction present preoperatively. Problems related to the prosthetic valves and to anticoagulant therapy were relatively few. Our present indications for replacement of the tricuspid valve are presented. Earlier operative intervention in patients with tricuspid valvular disease should improve the early and longterm results.
Acknowledgements The authors are indebted to Drs. JOHN W. KIRKLIN, ROBERT B. KARP, and ALBERT D. PACIFICO for allowing us to include patients operated upon by them and to Dr. EUGENE BLACKSTONE for the statistical analyses.
References
2
3
4
5
ALLEN, W.B.; KARP, R.B., and KoucHouKos, N.T.: Mitral valve replacement. Archs Surg., Chicago 109: 642-646 (1974). KARP, R.B.; KIRKLIN, J.W.; KOUCHOUKOS, N.T., and PACIFICO, A.D.: Comparison of three devices to replace the aortic valve. Circulation 49/50: suppl. 3, pp. 163-169 (1974). CARPENTIER, A.; DELOCHE, A.; HANANIA, G.; FORMAN, J.; SELLIER, P.; PIWNICA, A., and DUBOST, C.: Surgical management of acquired tricuspid valve disease. J. thorac. cardiovasc. Surg. 67: 53-65 (1974). BoYD, A.D.; ENGELMAN, R.M.; ISOM, O.W.; REED, G.E., and SPENCER, F.C.: Tricuspid annuloplasty: five and one-half years' experience with 78 patients. J. thorac. cardiovasc. Surg. 68: 344-351 (1974). TURNIER, E.; KAy, J.H.; MENDEZ, A.M., and ZUBIATE, P.: Surgical management of tricuspid insufficiency. Abstract. Circulation 49/50: suppl. 3, p.43 (1974).
Prof. N.T. KOUCHOUKOS, MD, Department of Surgery, University of Alabama Medical Center, University Station, Birmingham, AL 35294 (USA)
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
2
Indications for and Results of Tricuspid Valve Replacemene NICHOLAS
T.
KOUCHOUKOS
and LARRY W.
STEPHENSON
Department of Surgery, University of Alabama Medical Center, Birmingham, Ala.
Replacement of the tricuspid valve is generally reserved for patients with far advanced rheumatic valvular disease, usually involving the mitral and aortic valves as well, and less frequently for patients with isolated disease of the tricuspid valve. Controversy still exists regarding the relative merits of tricuspid valve replacement and reconstructive procedures (annuloplasty) in patients with rheumatic or functional tricuspid regurgitation. This report will not attempt to resolve this controversy, but will document our experience with tricuspid valve replacement in 87 patients during a 7.S-year period.
Materials and Methods
1 This research was supported in part by Program Project Grant HL 11,310, National Heart and Lung Institute, Bethesda, Md.
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
Between February 1967 and August 1974, 87 patients had replacement ofthe tricuspid valve at the University of Alabama Medical Center. During this same period, 17 patients underwent annuloplasty for tricuspid incompetence, and two patients had a commissurotomy for tricuspid stenosis. The hemodynamic lesions of the tricuspid valve requiring replacement are shown in table I. The ages of the patients ranged from 5 to 75 years with a mean of 46 years, and 59 of the patients (68%) were females. 37 previous cardiac procedures (17 closed, 20 open) were performed in 28 of the patients. Isolated tricuspid valve replacement was performed in only eight patients and for a variety of causes. The remainder of the procedures were associated with replacement of other valves for rheumatic valvular disease (table II). 60 patients were functional class III (New York Heart Association classification) preoperatively and the remaining 27 were class IV.
200
KOUCHOUKOS/STEPHENSON
Table 1. Hemodynamic lesions requiring tricuspid valve replacement Hemodynamic lesion
Number of patients
Incompetence Stenosis and incompetence Stenosis
S4 32 32 87
Total
Table II. Etiology of tricuspid valvular disease requiring valve replacement Number of patients Isolated tricuspid valve replacement Ebstein's malformation With associated ventricular septal defect Traumatic tricuspid incompetence With associated right atrial myxoma With associated cardiomyopathy Rheumatic disease with previous mitral valve replacement Multiple valve replacement Rheumatic valvulitis Aortic and tricuspid
Totals
8 2 2 2 2 2
2 79 4
Mitral and tricuspid
39
Aortic mitral and tricuspid
36 87
Standard cardiopulmonary bypass employing a bubble oxygenator (Bentley-Temtrol), moderate hemodilution and flows of 2.0-2.21/min/m2 were employed. The operative technique varied according to the valves replaced. For operations in which the aortic valve was replaced, direct coronary perfusion was used. For all other procedures, periods of myocardial ischemic arrest not exceeding 15-20 min at perfusion temperatures of 28-32 or 30-40 min after profound internal and external myocardial cooling, were employed. In general, the severity of the tricuspid valvular disease was assessed by digital examination through the right atrial appendage just before beginning cardiopulmonary bypass. If the degree of regurgitation was severe (grade S or 6 on a scale of 0-6) or there was severe structural damage of the valve, valve replacement was performed. In all other cases without significant tricuspid stenosis, the severity of the incompetence was again assessed in a similar way after insertion of the mitral and/or aortic prostheses just after
discontinuation of cardiopulmonary bypass. If the incompetence was moderate or severe
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
oe,
Indications for and Results of Tricuspid Valve Replacement
201
Table III. Prosthetic devices employed for tricuspid valve replacement Prosthetic valve Starr-Edwards model 6120 (Silastic ball) Starr-Edwards models 6300,6310-6320 (cloth-covered, metallic ball) Braunwald-Cutter (cloth-covered, silastic ball) Bjork-Shiley (disc) Porcine xenograft (preserved, stented) Totals
Number of patients
33
25 9 16
4 87
(grade 3-6) at that time, tricuspid valve replacement (or annuloplasty in a small number of cases) was performed. As noted in table I, both stenosis and incompetence or pure stenosis of the tricuspid valve were present in 33 of the 87 patients requiring valve replacement. The prosthetic devices used to replace the tricuspid valve are shown in table III. Anticoagulation with warfarin sodium was begun on the second postoperative day in all patients except those receiving porcine xenografts and in children and young adults under 18 years of age. Digitalis and diuretic therapy were employed when indicated. Follow-up information was obtained by examination by the surgical staff or the referring physicians and telephone contact with the patient. The date of last inquiry was December 12, 1974. Three patients were lost to follow-up. The mean duration of follow-up was 32 months and ranged from 4 to 94 months. Survival data were analyzed by the life table method.
Hospital Mortality There were 19 hospital deaths (22%). All of the deaths occurred in patients having mitral and tricuspid or triple valve replacement (table IV). The preoperative functional class influenced the hospital mortality (table V). For 60 patients who were functional class III preoperatively, the mortality was 17% (ten patients), and for 27 patients who were class IV, it was 33% (nine patients). 16 of the 19 hospital deaths were associated with severely impaired cardiac performance and low cardiac output postoperatively. In five of these patients, significant myocardial necrosis was found at autopsy. This probably resulted from inadequacies of myocardial perfusion during the operative
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
Results
202
KOUCHOUKOSjSTEPHENSON
Table IV. Hospital mortality following tricuspid valve replacement Number of patients
Valve replaced
Hospital deaths n
8
%
Tricuspid Aortic and tricuspid Mitral and tricuspid Aortic, mitral and tricuspid
4 39 36
0 0
0 0
11
Totals
87
19
28 22 22
8
Table V. Hospital mortality following tricuspid valve replacement according to preoperative functional class (New York Heart Association classification) Functional class
III IV
Number of patients
Hospital deaths
n
%
60
10
27
9
17 33
Table VI. Causes of late death following tricuspid valve replacement cause of death
Number of patients
Cardiac arrhythmia Cardiac failure Myocardial infarction Prosthetic endocarditis Intracranial hemorrhage
6 4
Totals
2 14
procedure. The other three hospital deaths resulted from neurologic injury, complete heart block, and a bleeding diathesis. Previous cardiac procedures, either open or closed, did not influence the hospital mortality.
late deaths were cardiac in origin, one resulted from prosthetic endocarditis,
and two were secondary to bleeding associated with anticoagulation therapy.
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
Late Mortality There have been 14 late deaths (16%) from 2 to 36 months following operation. The causes of late death are shown in table VI. Eleven of the 14
203
Indications for and Results of Tricuspid Valve Replacement
100.0 (81) 90.0
80.0
...J
ex:
~
>
60.0
0:::
:::l
Vl
SO.O
>--
z
w
u
0:::
w
Q..
40.0
~"I
·"1 10.0
O.O~
I •• ,
.,.""
••
!
••••
,
,,' I I I '
•
!
«I
,
I.,
I,
"
' , I,
""'" I
c
MONTHS AFTER OPERATION Fig. 1. Cumulative survival rate following tricuspid valve replacement in 87 patients. Number of patients exposed to risk is given in parentheses.
Complications Complete heart block developed in three patients postoperatively and was fatal in one. Four patients developed serious arrhythmias in the postoperative period resulting in cardiac standstill, but all were successfully resuscitated and discharged from the hospital. Prosthetic endocarditis occurred in two patients following discharge from the hospital and was fatal in one. Documented malfunction of the tricuspid prosthesis resulting in death, arrhythmias, or tricuspid incompetence has not been observed. There has been a low incidence of thromboembolic episodes (4%) among the surviving patients. Two patients have died of intracranial hemorrhage related to anticoagulant therapy.
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
The cumulative survival rate for the entire group of patients is shown in figure 1. The cumulative survival rates for the patients grouped according to the preoperative functional class are shown in figure 2. The differences in survival between the class III and class IV patients were statistically significantly different at and beyond 3 years.
204
KOUCHOUKOSjSTEPHENSON
100.0
1m (60) llll':(27)
90.0
-I
cr > >
It::
::>
1I)
SO.O
I-
Z
!J.J U It:: !J.J IL
'10.0
JtSE
30.0
20.0 10.0
0.0
~
2
2
o
~
0
cj
0
~
(;)
~
MONTHS AFTER OPERATION
Fig. 2. Cumulative survival rates following tricuspid valve replacement according to preoperative functional class. Number of patients exposed to risk is given in parentheses. o = Class III patients; 6. = class IV patients.
The hospital mortality of 22% for patients requiring replacement of the tricuspid valve is higher than that for combined aortic and mitral valve replacement in our institution (28 of 228 patients or 12%) and for isolated mitral [1] or aortic [2] valve replacement. Although lower hospital mortality rates have been reported from some centers with tricuspid annuloplasty as compared to tricuspid valve replacement [3-5], this was not observed in our series, since the mortality for tricuspid annuloplasty in combination with replacement of other valves was 25% (two of eight patients). The number of patients, however, is. small. In most series reporting the use of annuloplasty and valve replacement, annuloplasty has not totally supplanted valve replacement, and the mortality rates following valve replacement have generally been higher [3-5]. In our own experience, the preoperative functional disability of the patient significantly affected the hospital and late mortality
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
Discussion
205
rates (fig. 2). This has also been observed following isolated mitral valve replacement [1]. Clearly, a number of patients who present with severe tricuspid incompetence in association with other valvular disease have significant depression of myocardial function preoperatively, which affects both the early and long-term results. At least 75% of the late deaths in this series were related to myocardial dysfunction. It is noteworthy that none of the patients requiring isolated tricuspid valve replacement died in the postoperative period. In patients undergoing other valve replacements, the decision to replace or repair the tricuspid valve when there is moderate or severe tricuspid incompetence must be weighed against the possible detrimental effects of leaving the incompetence uncorrected. There is little disagreement among surgeons that correction of the tricuspid regurgitation is required in such cases, since the operative mortality and incidence of low cardiac output postoperatively are appreciably less with correction than without. Presently, there is no definitive answer as to which procedure (valve replacement or annuloplasty) is more effective in this circumstance. Tricuspid valve replacement is carried out even by those individuals who use tricuspid annuloplasty extensively, since annuloplasty cannot always be accomplished successfully. It is of interest that the operative mortality is higher when valve replacement is performed as compared to annuloplasty under these conditions [3-5]. Comparison of annuloplasty and valve replacement in patients with comparable degrees of tricuspid incompetence and preoperative myocardial dysfunction should provide the answer to this difficult question. Our current practice in deciding on the necessity for correction of tricuspid incompetence at the time of other valve replacement is to assess the tricuspid valve through the atrial appendage prior to beginning cardiopulmonary bypass. If there is evidence of severe structural damage to the valve or severe tricuspid incompetence and annular dilatation, valve replacement is performed. If there are minimal or no structural abnormalities of the valve and minimal tricuspid incompetence, the valve is generally not replaced or repaired. If the tricuspid incompetence is moderate, the incompetence is again assessed after the other valves have been replaced and cardiopulmonary bypass has been discontinued. If there is still moderate or severe tricuspid incompetence, the right atrium is opened and, if an adequate annuloplasty can be performed, this is carried out. If not, the valve is replaced. While this method of assessing and treating tricuspid incompetence may not be perfect, it provides, in our opinion, a reasonable approach to the surgical management of tricuspid valve disease.
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
Indications for and Results of Tricuspid Valve Replacement
KOUCHOUKOS/STEPHENSON
206
Summary A review of our experience with tricuspid valve replacement over a 7.5-year period is presented. Isolated disease of the tricuspid valve was encountered infrequently (8 of 87 patients) and was due to a variety of causes. In the remaining cases, the tricuspid disease was associated with rheumatic valvular disease of the mitral and/or aortic valves. The hospital mortality for the entire group of patients was 22%, and the late mortality during a mean follow-up period of 32 months was 16%. Operative and late mortality were clearly affected by the severity of myocardial dysfunction present preoperatively. Problems related to the prosthetic valves and to anticoagulant therapy were relatively few. Our present indications for replacement of the tricuspid valve are presented. Earlier operative intervention in patients with tricuspid valvular disease should improve the early and longterm results.
Acknowledgements The authors are indebted to Drs. JOHN W. KIRKLIN, ROBERT B. KARP, and ALBERT D. PACIFICO for allowing us to include patients operated upon by them and to Dr. EUGENE BLACKSTONE for the statistical analyses.
References
2
3
4
5
ALLEN, W.B.; KARP, R.B., and KoucHouKos, N.T.: Mitral valve replacement. Archs Surg., Chicago 109: 642-646 (1974). KARP, R.B.; KIRKLIN, J.W.; KOUCHOUKOS, N.T., and PACIFICO, A.D.: Comparison of three devices to replace the aortic valve. Circulation 49/50: suppl. 3, pp. 163-169 (1974). CARPENTIER, A.; DELOCHE, A.; HANANIA, G.; FORMAN, J.; SELLIER, P.; PIWNICA, A., and DUBOST, C.: Surgical management of acquired tricuspid valve disease. J. thorac. cardiovasc. Surg. 67: 53-65 (1974). BoYD, A.D.; ENGELMAN, R.M.; ISOM, O.W.; REED, G.E., and SPENCER, F.C.: Tricuspid annuloplasty: five and one-half years' experience with 78 patients. J. thorac. cardiovasc. Surg. 68: 344-351 (1974). TURNIER, E.; KAy, J.H.; MENDEZ, A.M., and ZUBIATE, P.: Surgical management of tricuspid insufficiency. Abstract. Circulation 49/50: suppl. 3, p.43 (1974).
Prof. N.T. KOUCHOUKOS, MD, Department of Surgery, University of Alabama Medical Center, University Station, Birmingham, AL 35294 (USA)
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 3:08:42 AM
2
