Original Cardiovascular
Tricuspid Valve Repair for the Poor Right Ventricle: Tricuspid Valve Repair in Patients with Mild-toModerate Tricuspid Regurgitation Undergoing Mitral Valve Repair Improves In-Hospital Outcome Alicja Zientara1 Michele Genoni1 Omer Dzemali1
Kirk Graves1
1 Department of Cardiac Surgery, Stadtspital Triemli, Zürich,
Switzerland
Dragan Odavic1
Helen Löblein1
Achim Häussler1
Address for correspondence Alicja Zientara, MD, Department of Cardiac Surgery, Stadtspital Triemli, Birmensdorferstrasse 497, Zürich 8063, Switzerland (e-mail: [email protected]).
Abstract
Keywords
► tricuspid valve ► mitral valve surgery ► heart failure
received September 25, 2014 accepted after revision November 28, 2014
Background Tricuspid regurgitation (TR) in patients undergoing surgery for mitral valve (MV) increases morbidity and mortality, especially in case of a poor right ventricle. Does repair of mild-to-moderate insufficiency of the tricuspid valve (TV) in patients undergoing MV surgery lead to a benefit in early postoperative outcome? Methods A total of 22 patients with mild-to-moderate TR underwent MV repair and concomitant TV repair with Tri-Ad (Medtronic ATS Medical Inc., Minneapolis, Minnesota, United States) and Edwards Cosgrove (Edwards Lifesciences Irvine, California, United States) rings. The severity of TR was assessed echocardiographically by using colorDoppler flow images. The tricuspid annular plane systolic excursion (TAPSE) was under 1.7 cm. Additional procedures included coronary artery bypass (n ¼ 9) and maze procedure (n ¼ 15). The following parameters were compared: postoperative and peak dose of noradrenaline (NA), pre/postoperative systolic pulmonary pressure (sPAP), extubation time, operation time, cross-clamp time, cardiopulmonary bypass (CPB) time, pre/postoperative ejection fraction (EF), intensive care unit (ICU)-stay, hospital stay, cell saver blood transfusion, intra/postoperative blood transfusion, and postoperative TR. Results The mean age was 67 14.8 years, 45% were male. Mean EF was 47 16.2%, postoperative 52 12.4%. sPAP was 46 20.1 mm Hg preoperatively, sPAP was 40.6 9.4 mm Hg postoperatively, NA postoperatively was 12 10 μg/min, NA peak was 18 11 μg/min, operation time was 275 92 minutes, CPB was 145 49 minutes, ICU stay was 2.4 2.4 days, hospital stay was 10.8 3.5 days, cell saver blood transfusion was 736 346 mL, intraoperative transfusions were 2.5 1.6. Two patients needed postoperative transfusions. A total of 19 patients were extubated at the 1st postoperative day, 2 patients at the 2nd day, and 1 at the 4th postoperative day. Two patients required a pacemaker. No reintubation, no in-hospital mortality, and one reoperation because of bleeding complications. Conclusion Correction of mild-to-moderate TR at the time of MV repair does maintain TV function and avoid right ventricular dysfunction in the early postoperative period improving the clinical outcome.
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1399783. ISSN 0171-6425.
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Thorac Cardiovasc Surg
Zientara et al.
Introduction Significant tricuspid regurgitation (TR) in patients undergoing surgery for mitral valve (MV) does increase their morbidity and mortality. Numerous studies focus on detailed criteria for the decision of tricuspid valve (TV) repair during MV surgery, especially concerning 1 year and late outcome. Different echocardiographic and hemodynamic parameters were analyzed and weighed regarding the indication for operation. The progression of the TR is well known and documented. Nath et al found that moderate and severe TR increases the 1year mortality regardless of sPAP degree.1 Calafiore et al reported an impairment of midterm survival and functional status, if a moderate or functional TR stays untreated.2 In 2005, Dreyfus et al reported a series of 148 patients with MV repair where an intraoperative TV annular diameter > 70 mm was used as a criterion for TV repair regardless of the preoperative TR grade. TR increased more than two grades in 48% of the patients in the no-TV repair group and only in 2% of the TV repair group. No correlation has been found between preoperative tricuspid annular dilatation and regurgitation grade.3 Porter et al outlined that among patients who underwent MV replacement without TV surgery, 67% developed late TR.4 The experience of TR progression and the tendency of tricuspid annular dilatation over the years were documented by other authors.5–7 Repair of mild-to-moderate TR was performed by Kim et al, who investigated 236 patients with rheumatic mitral disease and demonstrated that TV repair leads to freedom from significant TR at 5 years (92.9% 2.9%). Postoperative moderate-to-severe TR was significantly associated with the composite of death and cardiac-related complications.8 Benedetto et al focused on the dilated annulus over 40 mm and performed prophylactic TV annuloplasty in patients showing less than moderate ( þ 2) TR at preoperative echocardiography during MV repair. The comparison of the two groups (with/without TR repair during MV repair) demonstrated in the 12-month follow-up that TR repair was associated with a reduced rate of tricuspid regurgitation progression, improved right ventricular (RV) remodeling, and better functional outcomes.9 Underlined by these results, the correction of mild-tomoderate TR in case of a left-sided operation is included as a Class IIa (evidence C) recommendation in the European guidelines of valvular heart disease in the presence of annulus dilatation over 40 mm or over 21 mm/m2.10 The latest guidelines published in 2014 by the American College of Cardiology also support these landmarks as a Class IIa (evidence B) recommendation for correction of mild-to-moderate TR. In addition, the risk factors for further TR progression are listed and identified as pulmonary hypertension, atrial fibrillation, and prior evidence of right heart failure and RV dysfunction and remodeling.11 In fact, there are no specific reports describing the outcome of TV repair or replacement in the setting of right ventricular failure or poor right ventricular function. The early postoperative period demonstrates the most vulnerable phase for hemodynamic stabilization at intensive Thoracic and Cardiovascular Surgeon
care unit (ICU) after MV surgery finding the balance between catecholamines and volume management. There are no current data or reports available concerning the short-time outcome at ICU, which can be decisive for the course of the patient and the later outcome. We know that the correction of mitral insufficiency does not correct functional TR automatically. Treatment of the mitral lesion alone decreases the afterload but does not correct tricuspid annular dilatation, preload, or right ventricular function. The aim of our observational study was to retrospectively analyze our data concerning short-time outcome and ICU parameters in patients after TV repair following mild-tomoderate TR in the presence of poor RV function and MV repair. Therefore, we defined the criteria for our clinical practice by separating the classical combination for TV repair of dilated annulus (> 40 mm) plus pulmonary hypertension (> 45 mm Hg) plus echocardiographic TR grade (TR > 2þ), favoring a more aggressive approach towards TV surgery to improve postoperative management at ICU.
Methods Patients and Study Design We performed a retrospective review of 22 patients (45% male, mean age 67 years [ 14.8]) with mild-to-moderate functional TR that underwent first-time MV repair and concomitant TV repair with Tri-AD (Adams Tricuspid Annuloplasty Ring, Medtronic) and Edwards Cosgrove rings (Annuloplasty System, Edwards Lifesciences) from January 2010 to September 2012. The baseline characteristics are listed in ►Fig. 1. Patients with organic TV disease were not included in this study. The severity of TR was assessed by using color-Doppler flow images in transthoracic echocardiography. As a parameter of poor RV function, the tricuspid annular plane systolic excursion (TAPSE) was under 1.7 cm in all 22 patients preoperatively. Additional procedures included coronary artery bypass in 9 patients and maze procedure in 15 patients. The following parameters were compared: postoperative doses and peak doses of noradrenaline (NA), pre/postoperative systolic pulmonary arterial pressure (sPAP), extubation time, operation
Fig. 1 Baseline characteristics of the patients.
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TV Repair for the Poor Right Ventricle
TV Repair for the Poor Right Ventricle
Surgical Technique and Criteria for Tricuspid Valve Repair Our indication for TV repair at the time of MV repair was more aggressive than current American and European guidelines and included patients with mild-to-moderate TR (TI [tricuspid valve insufficiency] < 2 þ ). We did not only orientate to the combination of classical recommended criteria (elevated sPAP þ TI > 2 þ echocardiographically þ annulus > 40 mm) but also focused on every criterion separately. All patients were operated via a full median sternotomy under cardiopulmonary bypass at normothermia. Double venous cannulation was used. Myocardial protection consisted of antegrade cardioplegia (Bretschneider). Patients with an indication for revascularization underwent coronary artery bypass grafting first. Patients with a history of atrial fibrillation or flutter and a left atrium diameter over 40 mm underwent left and right atrial lesion set of the Maze procedure by means of mono- and/or bipolar radiofrequency. The MV was approached through a standard right atriotomy and transseptal approach. MV reconstruction was conducted using standard Carpentier techniques. Mitral annuloplasty was routinely performed using a flexible ring (Edwards Carpentier Physio [Edwards Lifesciences, Irvine, California, United States]). Ring size was determined by means of standard measurement of the surface of the anterior leaflet. For the TV annuloplasty, we used Tri-Ad and Cosgrove Edwards rings. Transesophageal echocardiography was used to confirm the competence of the repair.
Results The mean age was 67 years ( 14.8), 45% were male. All patients underwent successful MV repair. Mean EF was 47% ( 16.2), postoperative 52% ( 12.4). sPAP was 46 mm Hg ( 20.1) preoperatively, sPAP was 40.6 mm Hg ( 9.4) postoperatively, NA postoperatively was 12 μg/min ( 10), NA peak was 18 μg/min ( 11), operation time was 275 minutes ( 92), CPB time was 145 minutes ( 49), ICU stay was 2.4 days ( 2.4), hospital stay was 10.8 days ( 3.5), cell saver blood
was 736 mL ( 346), blood transfusion was 2.5 ( 1.6) intraoperatively. Two patients needed blood transfusion after operation. A total of 19 patients were extubated at the 1st postoperative day, 2 patients at the 2nd day, and 1 patient at the 4th postoperative day after reoperation because of bleeding complications. Two patients required a permanent pacemaker for heart block. No reintubation, no in-hospital mortality, one reoperation because of bleeding complications. A total of 14 patients had no sign of TR, 7 patients had mild TR, and 1 patient had moderate TR at the discharge echocardiogram. The perioperative parameters are listed in ►Fig. 2.
Discussion Functional TR is a common finding in patients with mitral regurgitation. More than one-third of the patients with mitral stenosis have at least moderate TR.12,13 Until recently, surgical avoidance of TV repair was easily accepted in patients with functional TR, on the basis of the incorrect concept that TR would disappear once the primary left heart disease had been treated.14 The physiopathology and the treatment of this condition have been neglected for several years. Over the past few years, many investigators have reported evidence in favor of a more aggressive surgical approach to functional TR.3,15,16 The presence of severe functional TR following MV repair is associated with adverse morbidity and mortality.17 In case of a dilatation of the tricuspid annulus, there is growing evidence that favors repair. Several studies have demonstrated that annuloplasty of the TV based on tricuspid dilatation improves functional status independent of the degree of TR and may improve RV remodeling.18 The late TR occurs from progression of seemingly insignificant TR untreated at the time of initial mitral surgery or from failure of a previously performed tricuspid annuloplasty. The favored technique remains the reconstruction with an annuloplasty ring, which shows a significantly improved long-term survival, event-free survival, and survival free of recurrent TR compared with De Vega suture annuloplasty.19 The early postoperative period at ICU is the crucial time frame for the patient to achieve hemodynamic stabilization by volume management and catecholamines. Physiologically, a poor right ventricle in addition to a normal left ventricular (LV) function demonstrates a challenge for the medical treatment at the ICU. A combination of elevated RV afterload
Fig. 2 (a) Cumulative hospital stay and days on ICU. (b) Amount of noradrenaline (μg/min) at ICU, perioperative peak-dose, and postoperative dose at ICU. (c) Operation time and CPB time. (d) Comparison between pre and postoperative ejection fraction without significant differences. CPB, cardiopulmonary bypass; ICU, intensive care unit; LV, left ventricular; NA, noradrenaline.
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time, cross-clamp time, cardiopulmonary bypass (CPB) time, pre/postoperative ejection fraction (EF), ICU stay, hospital stay, cell saver blood, blood transfusion intra/postoperatively, and postoperative TR grade.
Zientara et al.
Zientara et al.
due to volume loading and depressed RV contractile function may lead to right heart failure in the acute phase of cardiac stabilization. Sudden increases in the RV pressure might be poorly tolerated in the early postoperative course after cardiac operation. Even when the RV contractile function is initially normal, severe RV pressure overload can cause a progressive and persistent decline in RV function, likely due to activation of endogenous proteases or induction of apoptosis.20 In the further course, RV dysfunction may progress in the absence of a new identifiable insult to the heart. The most common cause of RV dysfunction is chronic left-sided heart failure.21 Once right heart failure develops, elevated intrathoracic pressure from ventilator therapy may exacerbate it postoperatively.20 The use of inotropic agents, for example, dobutamine, might support the weak right ventricle, while the left ventricle might react with an obstruction and a consecutive low output. In addition, ventricular interdependence plays an important role in the pathophysiology of RV failure in the acute setting. RV dilatation and pressure overload cause a leftward shift of the septum, changing LV geometry. RV dilatation may also increase the constraining effect of the pericardium. These changes contribute to the low-cardiacoutput state by decreasing LV distensibility and preload.22 Although functional TR may occur in the setting of elevated pulmonary pressures, the most important determinant of the severity of functional TR is the magnitude of tricuspid annular dilatation.23 TV regurgitation itself leads to further RV dilatation and dysfunction, more TV annular dilatation and tethering, which might be forced by volume load.24 Our hypothesis was that a surgical correction of mild-to-moderate functional TR at the time of MV repair may prevent RV dysfunction in the early postoperative period and result in simplified volume management at the ICU by avoiding the clinical manifestations of RV failure defined by fluid retention, low cardiac output, and atrial or ventricular arrhythmias.21 Recognizing that the dilated annulus does not simply revert back to a normal size, a more liberal approach towards TV repair was established in the recent European and American guidelines.10,11 This is the first observational report describing the in-hospital outcome of TV repair in the setting of poor RV function after MV repair. Concentrating on the time horizon, we demonstrated in our series a short ICU stay and hospital stay. Our documented data at ICU gives a view and good impression of the patients’ outcome after our operating strategy. The operation time shows an acceptable time frame supporting that additional TV repair can be performed in a timely and safe manner in combination procedures and adds little time and complexity to MV surgery.3,19,25 The classical arguments against systematic repair of functional TR are that it may resolve after correction of left heart disease, prolonged duration of cardiopulmonary bypass, and cross-clamp time, and that annuloplasty may introduce incremental risks, such as AV block. With our data, we could disprove these arguments. Intraoperative blood transfusions and the transfusion of cell saver blood were in an acceptable normal range. The postoperative and peak doses of NA were in a lower range and Thoracic and Cardiovascular Surgeon
could be easily reduced. Almost all patients could be transferred to the normal ward on the 1st or 2nd postoperative day. Focusing on the aforementioned long time results that are supported by former studies the direct TV repair during the initial MV repair avoids the necessity of a risky reoperation because of progressive TR.
Limitations and Future Investigations This observational report entails some limitations beginning with the retrospective and nonrandomized nature of the available data. Obviously, the measurement of the RV function preoperatively depends on differential loading conditions and may lead to inaccurate echocardiographic assessment. Nevertheless, indices of RV function, such as the tricuspid annular plane systolic excursion, may allow a more routine inclusion in risk stratification models in future.21 The postoperative course of RV parameters should be followed by predetermined intervals at ICU. Moreover, as mentioned in the current guidelines concerning valvular heart disease, risk factors for further TR progression, such as pulmonary hypertension, atrial fibrillation, prior evidence of right heart failure and RV dysfunction and remodeling, should be noted and have to be respected concerning the decision for TV repair.
Conclusion Correction of mild-to-moderate functional TR at the time of MV repair may prevent RV dysfunction in the early postoperative period and result in simplified volume management at the ICU, while avoiding the clinical manifestations of RV failure which are defined by fluid retention, low cardiac output, and atrial or ventricular arrhythmias. Additional TV repair can be performed in a timely and safe manner in combination procedures. The arguments against systematic repair of functional TR such as prolonged duration of cardiopulmonary bypass and cross-clamp time, and the risk of AV block could be disproved by our data. A more aggressive management of secondary TR such as this could decrease the occurrence of late TR following previous MV surgery, especially because of the poor outcome of additional TV repair years after the left-sided surgery. Recommended criteria for TV repair (annular dilatation, TR 2þ, increased sPAP) should not only be seen as a combination but evaluated separately in patients with poor RV function (TAPSE < 1.7 cm). Whether the surgical correction of TR in left heart disease can definitively improve short clinical outcomes by simplifying ICU management should be addressed by prospective clinical trials, including further echocardiographic parameters and a larger number of patients.
References 1 Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation
on long-term survival. J Am Coll Cardiol 2004;43(3):405–409 2 Calafiore AM, Gallina S, Iacò AL, et al. Mitral valve surgery for
functional
mitral
regurgitation:
should
moderate-or-more
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TV Repair for the Poor Right Ventricle
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tricuspid regurgitation be treated? A propensity score analysis. Ann Thorac Surg 2009;87(3):698–703 Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg 2005;79(1):127–132 Porter A, Shapira Y, Wurzel M, et al. Tricuspid regurgitation late after mitral valve replacement: clinical and echocardiographic evaluation. J Heart Valve Dis 1999;8(1):57–62 Matsuyama K, Matsumoto M, Sugita T, Nishizawa J, Tokuda Y, Matsuo T. Predictors of residual tricuspid regurgitation after mitral valve surgery. Ann Thorac Surg 2003;75(6):1826–1828 Matsunaga A, Duran CMG. Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation. Circulation 2005;112(9, Suppl):I453–I457 Song H, Kim MJ, Chung CH, et al. Factors associated with development of late significant tricuspid regurgitation after successful left-sided valve surgery. Heart 2009;95(11):931–936 Kim JB, Yoo DG, Kim GS, et al. Mild-to-moderate functional tricuspid regurgitation in patients undergoing valve replacement for rheumatic mitral disease: the influence of tricuspid valve repair on clinical and echocardiographic outcomes. Heart 2012; 98(1):24–30 Benedetto U, Melina G, Angeloni E, et al. Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery. J Thorac Cardiovasc Surg 2012;143(3): 632–638 Vahanian A, Alfieri O, Andreotti F, et al; ESC Committee for Practice Guidelines (CPG); Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS). Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg 2012;42(4):S1–S44 Nishimura RA, Otto CM, Bonow RO, et al. AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129(23): e521–643 Sagie A, Freitas N, Chen MH, Marshall JE, Weyman AE, Levine RA. Echocardiographic assessment of mitral stenosis and its associated
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valvular lesions in 205 patients and lack of association with mitral valve prolapse. J Am Soc Echocardiogr 1997;10(2):141–148 Boyaci A, Gokce V, Topaloglu S, Korkmaz S, Goksel S. Outcome of significant functional tricuspid regurgitation late after mitral valve replacement for predominant rheumatic mitral stenosis. Angiology 2007;58(3):336–342 Braunwald NS, Ross J Jr, Morrow AG. Conservative management of tricuspid regurgitation in patients undergoing mitral valve replacement. Circulation 1967;35)4, Suppl):I63–I69 Chan V, Burwash IG, Lam BK, et al. Clinical and echocardiographic impact of functional tricuspid regurgitation repair at the time of mitral valve replacement. Ann Thorac Surg 2009;88(4):1209–1215 Lee JW, Song JM, Park JP, Lee JW, Kang DH, Song JK. Long-term prognosis of isolated significant tricuspid regurgitation. Circ J 2010;74(2):375–380 Pinney SP. The role of tricuspid valve repair and replacement in right heart failure. Curr Opin Cardiol 2012;27(3):288–295 Shah PM, Raney AA. Tricuspid valve disease. Curr Probl Cardiol 2008;33(2):47–84 Tang GH, David TE, Singh SK, Maganti MD, Armstrong S, Borger MA. Tricuspid valve repair with an annuloplasty ring results in improved long-term outcomes. Circulation 2006;114(1, Suppl): I577–I581 Greyson CR. Right heart failure in the intensive care unit. Curr Opin Crit Care 2012;18(5):424–431 Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricular failure. Circulation 2008;117(13):1717–1731 O’Rourke RA, Dell’Italia LJ. Diagnosis and management of right ventricular myocardial infarction. Curr Probl Cardiol 2004;29(1): 6–47 Sagie A, Schwammenthal E, Padial LR, Vazquez de Prada JA, Weyman AE, Levine RA. Determinants of functional tricuspid regurgitation in incomplete tricuspid valve closure: Doppler color flow study of 109 patients. J Am Coll Cardiol 1994;24(2):446–453 Shiran A, Sagie A. Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism, and management. J Am Coll Cardiol 2009;53(5):401–408 Singh SK, Tang GH, Maganti MD, et al. Midterm outcomes of tricuspid valve repair versus replacement for organic tricuspid disease. Ann Thorac Surg 2006;82(5):1735–1741, discussion 1741
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TV Repair for the Poor Right Ventricle
Tricuspid Valve Repair for the Poor Right Ventricle: Tricuspid Valve Repair in Patients with Mild-toModerate Tricuspid Regurgitation Undergoing Mitral Valve Repair Improves In-Hospital Outcome Alicja Zientara1 Michele Genoni1 Omer Dzemali1
Kirk Graves1
1 Department of Cardiac Surgery, Stadtspital Triemli, Zürich,
Switzerland
Dragan Odavic1
Helen Löblein1
Achim Häussler1
Address for correspondence Alicja Zientara, MD, Department of Cardiac Surgery, Stadtspital Triemli, Birmensdorferstrasse 497, Zürich 8063, Switzerland (e-mail: [email protected]).
Abstract
Keywords
► tricuspid valve ► mitral valve surgery ► heart failure
received September 25, 2014 accepted after revision November 28, 2014
Background Tricuspid regurgitation (TR) in patients undergoing surgery for mitral valve (MV) increases morbidity and mortality, especially in case of a poor right ventricle. Does repair of mild-to-moderate insufficiency of the tricuspid valve (TV) in patients undergoing MV surgery lead to a benefit in early postoperative outcome? Methods A total of 22 patients with mild-to-moderate TR underwent MV repair and concomitant TV repair with Tri-Ad (Medtronic ATS Medical Inc., Minneapolis, Minnesota, United States) and Edwards Cosgrove (Edwards Lifesciences Irvine, California, United States) rings. The severity of TR was assessed echocardiographically by using colorDoppler flow images. The tricuspid annular plane systolic excursion (TAPSE) was under 1.7 cm. Additional procedures included coronary artery bypass (n ¼ 9) and maze procedure (n ¼ 15). The following parameters were compared: postoperative and peak dose of noradrenaline (NA), pre/postoperative systolic pulmonary pressure (sPAP), extubation time, operation time, cross-clamp time, cardiopulmonary bypass (CPB) time, pre/postoperative ejection fraction (EF), intensive care unit (ICU)-stay, hospital stay, cell saver blood transfusion, intra/postoperative blood transfusion, and postoperative TR. Results The mean age was 67 14.8 years, 45% were male. Mean EF was 47 16.2%, postoperative 52 12.4%. sPAP was 46 20.1 mm Hg preoperatively, sPAP was 40.6 9.4 mm Hg postoperatively, NA postoperatively was 12 10 μg/min, NA peak was 18 11 μg/min, operation time was 275 92 minutes, CPB was 145 49 minutes, ICU stay was 2.4 2.4 days, hospital stay was 10.8 3.5 days, cell saver blood transfusion was 736 346 mL, intraoperative transfusions were 2.5 1.6. Two patients needed postoperative transfusions. A total of 19 patients were extubated at the 1st postoperative day, 2 patients at the 2nd day, and 1 at the 4th postoperative day. Two patients required a pacemaker. No reintubation, no in-hospital mortality, and one reoperation because of bleeding complications. Conclusion Correction of mild-to-moderate TR at the time of MV repair does maintain TV function and avoid right ventricular dysfunction in the early postoperative period improving the clinical outcome.
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1399783. ISSN 0171-6425.
Downloaded by: University of Florida. Copyrighted material.
Thorac Cardiovasc Surg
Zientara et al.
Introduction Significant tricuspid regurgitation (TR) in patients undergoing surgery for mitral valve (MV) does increase their morbidity and mortality. Numerous studies focus on detailed criteria for the decision of tricuspid valve (TV) repair during MV surgery, especially concerning 1 year and late outcome. Different echocardiographic and hemodynamic parameters were analyzed and weighed regarding the indication for operation. The progression of the TR is well known and documented. Nath et al found that moderate and severe TR increases the 1year mortality regardless of sPAP degree.1 Calafiore et al reported an impairment of midterm survival and functional status, if a moderate or functional TR stays untreated.2 In 2005, Dreyfus et al reported a series of 148 patients with MV repair where an intraoperative TV annular diameter > 70 mm was used as a criterion for TV repair regardless of the preoperative TR grade. TR increased more than two grades in 48% of the patients in the no-TV repair group and only in 2% of the TV repair group. No correlation has been found between preoperative tricuspid annular dilatation and regurgitation grade.3 Porter et al outlined that among patients who underwent MV replacement without TV surgery, 67% developed late TR.4 The experience of TR progression and the tendency of tricuspid annular dilatation over the years were documented by other authors.5–7 Repair of mild-to-moderate TR was performed by Kim et al, who investigated 236 patients with rheumatic mitral disease and demonstrated that TV repair leads to freedom from significant TR at 5 years (92.9% 2.9%). Postoperative moderate-to-severe TR was significantly associated with the composite of death and cardiac-related complications.8 Benedetto et al focused on the dilated annulus over 40 mm and performed prophylactic TV annuloplasty in patients showing less than moderate ( þ 2) TR at preoperative echocardiography during MV repair. The comparison of the two groups (with/without TR repair during MV repair) demonstrated in the 12-month follow-up that TR repair was associated with a reduced rate of tricuspid regurgitation progression, improved right ventricular (RV) remodeling, and better functional outcomes.9 Underlined by these results, the correction of mild-tomoderate TR in case of a left-sided operation is included as a Class IIa (evidence C) recommendation in the European guidelines of valvular heart disease in the presence of annulus dilatation over 40 mm or over 21 mm/m2.10 The latest guidelines published in 2014 by the American College of Cardiology also support these landmarks as a Class IIa (evidence B) recommendation for correction of mild-to-moderate TR. In addition, the risk factors for further TR progression are listed and identified as pulmonary hypertension, atrial fibrillation, and prior evidence of right heart failure and RV dysfunction and remodeling.11 In fact, there are no specific reports describing the outcome of TV repair or replacement in the setting of right ventricular failure or poor right ventricular function. The early postoperative period demonstrates the most vulnerable phase for hemodynamic stabilization at intensive Thoracic and Cardiovascular Surgeon
care unit (ICU) after MV surgery finding the balance between catecholamines and volume management. There are no current data or reports available concerning the short-time outcome at ICU, which can be decisive for the course of the patient and the later outcome. We know that the correction of mitral insufficiency does not correct functional TR automatically. Treatment of the mitral lesion alone decreases the afterload but does not correct tricuspid annular dilatation, preload, or right ventricular function. The aim of our observational study was to retrospectively analyze our data concerning short-time outcome and ICU parameters in patients after TV repair following mild-tomoderate TR in the presence of poor RV function and MV repair. Therefore, we defined the criteria for our clinical practice by separating the classical combination for TV repair of dilated annulus (> 40 mm) plus pulmonary hypertension (> 45 mm Hg) plus echocardiographic TR grade (TR > 2þ), favoring a more aggressive approach towards TV surgery to improve postoperative management at ICU.
Methods Patients and Study Design We performed a retrospective review of 22 patients (45% male, mean age 67 years [ 14.8]) with mild-to-moderate functional TR that underwent first-time MV repair and concomitant TV repair with Tri-AD (Adams Tricuspid Annuloplasty Ring, Medtronic) and Edwards Cosgrove rings (Annuloplasty System, Edwards Lifesciences) from January 2010 to September 2012. The baseline characteristics are listed in ►Fig. 1. Patients with organic TV disease were not included in this study. The severity of TR was assessed by using color-Doppler flow images in transthoracic echocardiography. As a parameter of poor RV function, the tricuspid annular plane systolic excursion (TAPSE) was under 1.7 cm in all 22 patients preoperatively. Additional procedures included coronary artery bypass in 9 patients and maze procedure in 15 patients. The following parameters were compared: postoperative doses and peak doses of noradrenaline (NA), pre/postoperative systolic pulmonary arterial pressure (sPAP), extubation time, operation
Fig. 1 Baseline characteristics of the patients.
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TV Repair for the Poor Right Ventricle
TV Repair for the Poor Right Ventricle
Surgical Technique and Criteria for Tricuspid Valve Repair Our indication for TV repair at the time of MV repair was more aggressive than current American and European guidelines and included patients with mild-to-moderate TR (TI [tricuspid valve insufficiency] < 2 þ ). We did not only orientate to the combination of classical recommended criteria (elevated sPAP þ TI > 2 þ echocardiographically þ annulus > 40 mm) but also focused on every criterion separately. All patients were operated via a full median sternotomy under cardiopulmonary bypass at normothermia. Double venous cannulation was used. Myocardial protection consisted of antegrade cardioplegia (Bretschneider). Patients with an indication for revascularization underwent coronary artery bypass grafting first. Patients with a history of atrial fibrillation or flutter and a left atrium diameter over 40 mm underwent left and right atrial lesion set of the Maze procedure by means of mono- and/or bipolar radiofrequency. The MV was approached through a standard right atriotomy and transseptal approach. MV reconstruction was conducted using standard Carpentier techniques. Mitral annuloplasty was routinely performed using a flexible ring (Edwards Carpentier Physio [Edwards Lifesciences, Irvine, California, United States]). Ring size was determined by means of standard measurement of the surface of the anterior leaflet. For the TV annuloplasty, we used Tri-Ad and Cosgrove Edwards rings. Transesophageal echocardiography was used to confirm the competence of the repair.
Results The mean age was 67 years ( 14.8), 45% were male. All patients underwent successful MV repair. Mean EF was 47% ( 16.2), postoperative 52% ( 12.4). sPAP was 46 mm Hg ( 20.1) preoperatively, sPAP was 40.6 mm Hg ( 9.4) postoperatively, NA postoperatively was 12 μg/min ( 10), NA peak was 18 μg/min ( 11), operation time was 275 minutes ( 92), CPB time was 145 minutes ( 49), ICU stay was 2.4 days ( 2.4), hospital stay was 10.8 days ( 3.5), cell saver blood
was 736 mL ( 346), blood transfusion was 2.5 ( 1.6) intraoperatively. Two patients needed blood transfusion after operation. A total of 19 patients were extubated at the 1st postoperative day, 2 patients at the 2nd day, and 1 patient at the 4th postoperative day after reoperation because of bleeding complications. Two patients required a permanent pacemaker for heart block. No reintubation, no in-hospital mortality, one reoperation because of bleeding complications. A total of 14 patients had no sign of TR, 7 patients had mild TR, and 1 patient had moderate TR at the discharge echocardiogram. The perioperative parameters are listed in ►Fig. 2.
Discussion Functional TR is a common finding in patients with mitral regurgitation. More than one-third of the patients with mitral stenosis have at least moderate TR.12,13 Until recently, surgical avoidance of TV repair was easily accepted in patients with functional TR, on the basis of the incorrect concept that TR would disappear once the primary left heart disease had been treated.14 The physiopathology and the treatment of this condition have been neglected for several years. Over the past few years, many investigators have reported evidence in favor of a more aggressive surgical approach to functional TR.3,15,16 The presence of severe functional TR following MV repair is associated with adverse morbidity and mortality.17 In case of a dilatation of the tricuspid annulus, there is growing evidence that favors repair. Several studies have demonstrated that annuloplasty of the TV based on tricuspid dilatation improves functional status independent of the degree of TR and may improve RV remodeling.18 The late TR occurs from progression of seemingly insignificant TR untreated at the time of initial mitral surgery or from failure of a previously performed tricuspid annuloplasty. The favored technique remains the reconstruction with an annuloplasty ring, which shows a significantly improved long-term survival, event-free survival, and survival free of recurrent TR compared with De Vega suture annuloplasty.19 The early postoperative period at ICU is the crucial time frame for the patient to achieve hemodynamic stabilization by volume management and catecholamines. Physiologically, a poor right ventricle in addition to a normal left ventricular (LV) function demonstrates a challenge for the medical treatment at the ICU. A combination of elevated RV afterload
Fig. 2 (a) Cumulative hospital stay and days on ICU. (b) Amount of noradrenaline (μg/min) at ICU, perioperative peak-dose, and postoperative dose at ICU. (c) Operation time and CPB time. (d) Comparison between pre and postoperative ejection fraction without significant differences. CPB, cardiopulmonary bypass; ICU, intensive care unit; LV, left ventricular; NA, noradrenaline.
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time, cross-clamp time, cardiopulmonary bypass (CPB) time, pre/postoperative ejection fraction (EF), ICU stay, hospital stay, cell saver blood, blood transfusion intra/postoperatively, and postoperative TR grade.
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due to volume loading and depressed RV contractile function may lead to right heart failure in the acute phase of cardiac stabilization. Sudden increases in the RV pressure might be poorly tolerated in the early postoperative course after cardiac operation. Even when the RV contractile function is initially normal, severe RV pressure overload can cause a progressive and persistent decline in RV function, likely due to activation of endogenous proteases or induction of apoptosis.20 In the further course, RV dysfunction may progress in the absence of a new identifiable insult to the heart. The most common cause of RV dysfunction is chronic left-sided heart failure.21 Once right heart failure develops, elevated intrathoracic pressure from ventilator therapy may exacerbate it postoperatively.20 The use of inotropic agents, for example, dobutamine, might support the weak right ventricle, while the left ventricle might react with an obstruction and a consecutive low output. In addition, ventricular interdependence plays an important role in the pathophysiology of RV failure in the acute setting. RV dilatation and pressure overload cause a leftward shift of the septum, changing LV geometry. RV dilatation may also increase the constraining effect of the pericardium. These changes contribute to the low-cardiacoutput state by decreasing LV distensibility and preload.22 Although functional TR may occur in the setting of elevated pulmonary pressures, the most important determinant of the severity of functional TR is the magnitude of tricuspid annular dilatation.23 TV regurgitation itself leads to further RV dilatation and dysfunction, more TV annular dilatation and tethering, which might be forced by volume load.24 Our hypothesis was that a surgical correction of mild-to-moderate functional TR at the time of MV repair may prevent RV dysfunction in the early postoperative period and result in simplified volume management at the ICU by avoiding the clinical manifestations of RV failure defined by fluid retention, low cardiac output, and atrial or ventricular arrhythmias.21 Recognizing that the dilated annulus does not simply revert back to a normal size, a more liberal approach towards TV repair was established in the recent European and American guidelines.10,11 This is the first observational report describing the in-hospital outcome of TV repair in the setting of poor RV function after MV repair. Concentrating on the time horizon, we demonstrated in our series a short ICU stay and hospital stay. Our documented data at ICU gives a view and good impression of the patients’ outcome after our operating strategy. The operation time shows an acceptable time frame supporting that additional TV repair can be performed in a timely and safe manner in combination procedures and adds little time and complexity to MV surgery.3,19,25 The classical arguments against systematic repair of functional TR are that it may resolve after correction of left heart disease, prolonged duration of cardiopulmonary bypass, and cross-clamp time, and that annuloplasty may introduce incremental risks, such as AV block. With our data, we could disprove these arguments. Intraoperative blood transfusions and the transfusion of cell saver blood were in an acceptable normal range. The postoperative and peak doses of NA were in a lower range and Thoracic and Cardiovascular Surgeon
could be easily reduced. Almost all patients could be transferred to the normal ward on the 1st or 2nd postoperative day. Focusing on the aforementioned long time results that are supported by former studies the direct TV repair during the initial MV repair avoids the necessity of a risky reoperation because of progressive TR.
Limitations and Future Investigations This observational report entails some limitations beginning with the retrospective and nonrandomized nature of the available data. Obviously, the measurement of the RV function preoperatively depends on differential loading conditions and may lead to inaccurate echocardiographic assessment. Nevertheless, indices of RV function, such as the tricuspid annular plane systolic excursion, may allow a more routine inclusion in risk stratification models in future.21 The postoperative course of RV parameters should be followed by predetermined intervals at ICU. Moreover, as mentioned in the current guidelines concerning valvular heart disease, risk factors for further TR progression, such as pulmonary hypertension, atrial fibrillation, prior evidence of right heart failure and RV dysfunction and remodeling, should be noted and have to be respected concerning the decision for TV repair.
Conclusion Correction of mild-to-moderate functional TR at the time of MV repair may prevent RV dysfunction in the early postoperative period and result in simplified volume management at the ICU, while avoiding the clinical manifestations of RV failure which are defined by fluid retention, low cardiac output, and atrial or ventricular arrhythmias. Additional TV repair can be performed in a timely and safe manner in combination procedures. The arguments against systematic repair of functional TR such as prolonged duration of cardiopulmonary bypass and cross-clamp time, and the risk of AV block could be disproved by our data. A more aggressive management of secondary TR such as this could decrease the occurrence of late TR following previous MV surgery, especially because of the poor outcome of additional TV repair years after the left-sided surgery. Recommended criteria for TV repair (annular dilatation, TR 2þ, increased sPAP) should not only be seen as a combination but evaluated separately in patients with poor RV function (TAPSE < 1.7 cm). Whether the surgical correction of TR in left heart disease can definitively improve short clinical outcomes by simplifying ICU management should be addressed by prospective clinical trials, including further echocardiographic parameters and a larger number of patients.
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