229
Tricuspid Valve Replacement: Factors Influencing Early and Late Mortality T. K. Kaul and J. L. Mercer Region al Adult Card iothoracic Surgical Cen tre , Broad gr een Hosp ital. Liverp ool. Un ited Kingd om
Seventy four patients underw en t tricuspi d valve replacem en t (TVHI. between 1968 an d 1983 . 93 % were female, mean age was 44 ± 4 yea rs . Tricuspid va lve was rep laced wit h a mechanical prosth esis in 52 and a bioprosthesis in 22 patients. Fifty seven patients und erw ent primary TVR and 17 und erwent a second a ry TVR followin g a mean interval of 41 ± 2 months (SEMI following a pr evious mitral or tri cusp id valve opera tion. Preoperatively 86% pat ien ts were in NYHA class III- IV a nd congestive cardiac failure (CHF). Ea rly mort a lity for prim ary lVR wa s 36.8% and 35.2 % for sec ondary TVR. Early mortality has been sig nificantly reduced sin ce the introduction of ca rdioplegic protection for the ass ocia ted valve lesions . Early mort ality was significa ntly influenced by the redu ced preoperat ive values of FVC and FEV\ in patients with long sta ndi ng mitra l valve disease a nd by rai sed preoperative levels of plasma bilir ubin an d alkaline phosp hate in patient s with Cfl F. Risk ofthro mbotic occlus ion a nd late deaths rem ained high duri ng the first yea r after TVHwit h a mech an ical prosth esis. Key word s
Tricuspid valve rep lacemen t - Congestive cardiac fa ilure Mechanical cardiac valve th rombo sis
Introdu ction The a ppropriate man agement of tricuspi d valve disease remains controversial. However. the gen era l principles in dealing with tricuspid valve dysfunction is to avoid tricuspid valve replacement if possible. Preserving tricuspid valve by a conse rvative proc edu re is ideal. results are encouraging with a low mortality and morbid ity (1,15), whereas tr icuspid valve replacement (TVRl is still assoc iated with high mortality and morbidity despit e imp rovement in pr e- and postoperative man agement (11, 16, 19). A grea ter numb er of tricuspid valve replacements were perform ed earlier in this series when the value of various meth ods of tr icuspid a nnuloplasty was not clea rly established. We have stud ied the risk factors which may have influenced mo rtality ofthe patients who underw ent TVR in our unit. Materi als and Methods Seventy-four patien ts und erw ent TVR betw een 196 6 a nd 1983. 93% were female an d their ages wer e in the ra nge 22 -66 yea rs (mea n 44 ± 4 yea rs). TVR was usually per formed wit h othe r va lve
Thorac. cardiovasc. Surgeon 38 (1990) 229-235 © Georg Thieme Verlag Stuttgart - New York
Trikuspida lklappen ersatz - welch e Fakturen heeinf'lussen die Frtih - und die Spatle ta llta t? Es wird uber 74 Patlenten im Alter von 22 bis 66 Ja hren ben chtet , die zwisc hen 1966 und 1983 eine n Tr ikuspidalklappener satz (TKE) erhic lten. Bei 57 Patient en wu rde ein prt rna rer TKE vorgen omm en im Zusammenha ng mit eine m a nde re n Klappen eingrtff meistens In "" 34) gleichzeitig mit eine m Mitralklap pen ersatz. Hei 17 Pat ienten handeh e es sich urn e inen se kundaren TKE. 52ma l wurde eine mechani sch e und 22mal eine biologische Klappe implantiert. Bis 1978 wu rden 33 Patient en ohne Kardioplegie. dana ch 41 Patien ten mit Kardioplegie operie rt. Die Fruhletalita t betrug nach pr ima rem TKE 36 .8 %. na ch sekundarem TKE 35.2 %. Die Fruhl etalit at war sig nilikant durch schlecht ere respi rat oris che Funktlonswerte (FEV,) und schlechte re Leberfu nktionswerte (Ser um· Bilirubin und alkalische Phosph atase) beet nflufn . was Pa tienten mit einem la nge Zeit bestchen den Mltr alvitlum betraf Nac h EinfU hru ng der Kard ioplegie kon nle die Fruhletalitat sign ifikan t gcsen kt werde n. Die Autorcn pladi er en au fgru nd ihrcr Ergeb nisse und untcr Bcriicksichtigun g der elnsc hlag igen Literatur ftlr an uloplastl sche Eing rifTe an de r Trikuspidalklapp e (Devega-Anulopl astik. Carpe ntier -Ring] wa nn imme r cs mogltch ist. Der Klappenersat z sollte nu r dan n vorge nomme n word en . wen n cin e a bso lute Indikation bcst eht. In diesen Fallen sollte man der Biopr cth ese den Vorz ug geb en .
repl acements or pro cedu res . the deta ils of ope ra tive procedures performed are summa rised in Tables 1 a nd 2. Mech ani cal prostheses were used in 52 pati ents (7 1.4 %) and bioprosth eses wer e
used in 22128.6%1 patients. Operati ons we re carried out using ca rdiopulmona ry bypass thr ough a median ste rno tomy with moderate hypothermia . Before 1978 myoca rdium was pr otected duri ng ischae mic arrest with continu ous coronary perfu sion in patients who und erw ent a concom lta nt aortic valve rep laceme nt. but in the rema ining pat ients mitral
Table 1 Primarytricuspid valve replacement: operative procedures, early & latedeaths n
Early deaths
l ate deaths
Simultaneous MVR + TVR Triplevalve replacement Open mitralvalvotomy + TVR Closure ofASD + TVR
34 19 3
10
9
4 2
1
2 nil
1 1
Total
57
21
8
Early mortality doublevalve vs triplevalve: no significant difference
Received for Publi cation : October 9 . t 989
Downloaded by: Universite Laval. Copyrighted material.
Summary
T. K. Kaul. 1. L. M ercer
Thom e. ear diol'as c. Surgeo1l38 (1 990) Table 2
valve surgical procedur es were performed with ischae mic arrest and moder ate hypothermi a (Phase ll. Since September 1978 cold crystalloid cardioplegia and surface cooling were used (Phase 11). Anterior and posterior leaflets of the tricuspid valve were excised leaving a 0,5 cm cufT. Prostheses were sutured with continuous 210 prolene or ethibond sutures and interrupted sutures were used in th e region of sep tal leaflet to avoid injury to the conduction system. Anticoagulant therap y was continued life-long in patients with a mecha nical prosthesis and was discontinued after 6 month s in pat ients who received a bioprosth esis. Primary TVH was performed in 57 patients and seconda ry TVR (TVH at a reoper ation) was per formed on 18 occasions in 17 patients at a mean interval of 42 ± 2 month s (SEM) following an open heart procedur e. One month after TVR there were 47 surv ivors (Group I) and 27 non survivors (early mortalities) (Group Ill. Tricuspid valve replacement was per formed either isolated or along with the other cardiac procedure s. All Starr-Edwards. Beall-Lent icular an d 13 of the Bjork-Shiley proth eses were implanted during the phas e I, and 19 biopro sth eses during the phase II. Bioprostheses were used for 10 secondar y TVH. The eflcct of vario us preoperat ive demographic , clinical, and haemodynam ic variabl es and respir atory. hepatic. and renal function on early mort ality was studied. Their values in Group I and Group (I patients, as well as in th ose who und erwent primary or secondary TVR were compared. The eITect of dichotomous variables (primary vs secondary: mechani cal vs bioprostheses) on early morta lity dur ing phase I an d phase II was exa mined, Multivari ate regressional analysis was used to demonst rate the influence of various preoperative variables on the early mort ality. The critical values of the factors which significantly influenced early mortal ity were determ ined , Long-term survival (more tha n one year) in relation to the replacement prostheses used and the inter val after Tv lt was examined, particularly in relation to the valve related complications egothrombosis. anticoagulation, endocarditi s, and primar y tissue failure.
Secondarytricuspid valvereplacement: operativeprocedures, early
& late deaths n
Early deaths
Late deaths
6
4
MVR+ TVR AVR+ MVR + TVR
10 1
2 nil
nil nil nil
Total
17
6
nil
IsolatedTVR
Early mortality isolatedTVR vs MVR + TVR: significant difference (p < 0.05)
Table 3
Preoperative clinicalfindings: primary and secondaryTVR
Age (years)
M/F Duration of valvular heart disease (years) Previous surgery Closed mitral valvotomy MVRor open mitral valvotomy NYHAclass II III- IV Diuretic therapy < 80 mg lasixlday > 80 mg lasix/day
Primary TVR(n- 57)
Secondary TVR(n - 17)
44 ± 1.l 2/ 55
53 ± 1.3 2/15
7.8 ± 0.9
12.1 2 ± l '
82.4%
100% 100%'
nil
17.5% 82.5%
nil
33.3% 66.7
nil
100%
100%
NYHA: New York Heart Association. • significant difference (p < 0.05)
Primary TVR n - 57
SecondaryTVR n - 17
Haemodynamic findings (mmHg)
RA RVEDP MPA LA LVEDP
13 ± 9± 45 ± 22 ± 11.2 ±
Tricuspid valve gradient in pureTS
TR (I + to 4 +)
~S]
17 ± 12 ± 52 ± 18 ± 9.8 ±
4.5 ± 0.5(n -ll ) 2.5 ± 0.3 (n - 14) [ 56 ± 08 ]
TR Malfunctioning tricuspid (mechanical) prostheses Respiratory Function FVC(L) FEVI( L) FEV/FVC% MBC(U min) Hepatic Function Serum Bilirubin (nmol/ L) SerumAlkaline phos.(U/L) Renal Function Blood urea (mmol/ L) Creatineclearance (mglmin)
RA RVEDP
0.8 0.4 2 1.2 1.2
0.97" 1.2 4.8 1.7 2
4.3(n - 2) 3.8 ± 0.4 (n - 8)
(n- 32)
nil
2.26 ± 0.2 n -6
nil
1.83 ± 1.27 ± 71 ± 50 ±
0.06 0.04 3% 38
1.52 ± 0.8' 1.1 1 ± 0.03' 58 ±4% 42 ± 7
25 ± 2 129 ± 8
21.8± 3 11O ±1O
10± 0.4 102 ± 6
9± 2 11 6 ± 2.8
'"
Rightatrial Right ventricular end TS · diastolic pressure MPA Main pulmonary artery TR LA ". Left atrial FVC LVEDP FEV) Left ventricular end diastolic pressure MBC · • significant difference (p < 0.05) primaryvs. secondaryTVR
Tricuspid stenosis Tricuspid regurgitation Forced vital capacity Forced expiratory volume Maximum breath ingcapacity
Table 4 Preoperative haemodynamic findings,respiratory, hepatic and renal function
Downloaded by: Universite Laval. Copyrighted material.
230
Thorac . cardioo"sc. Surgeoll 38 (19 90)
Tricuspid Valve Replacem ent: Factors Influencing Early and Late Mortality
Table 5 Preoperativeclinical findings: survivors andearlymortalities
Results ar e expressed as mean ± SEM, pair ed data ar e com pared by using students paire d ' t' test. Coxregression analysis. chi-squa re test, and actuarial analysis were used to show the influence of predictable variables on the post-operative surviva l.
Resu lts Early mortality was 36.8% (29.9 -43.8 %, 70% Cl) a fter prim ar y and 35.2% (24%-46 .8 %,70 % Cl) after secondary TVIl (non-significant differ ence). Early mortality was not influenced by the number of the valves replaced (Table 1), but was higher when TVR alon e was performed for severe right hear t decompensation (Table 2). The pati ents who underwent secondary TVIl wer e at higher risk due to carSurvivors
Survivors n = 47
Early mortalities
M/ F
48 ± 1.8 3/44
52 ± 1.2 1126
Durationof valvular heart disease (years)
8 ± 0.7
10 ± 1
Previous surgery Closed mitral valvotomy MVR or open mitralvalvotomy
63.8% 23.4%
100% 22.20%
NYHAciass II III- IV
21.3% 78.7%
nil
27.6%
nil
72.4%
100%
n ~ 27 Age (years)
Diuretic therapy < 80 mg lasix/day > 80 mg lasixlday
• significantdifference (p < 0.05) in NYHA-c1ass distribution
Table 6
Preoperative haemodynamic findings, respiratory, hepatic andrenal function: Survivors vs. earlymortalities after
Early mortalities n ~ 27
n ~ 47
100 %'
TVR Downloaded by: Universite Laval. Copyrighted material.
Statistical anatusis
Haemodynamic findings (mmHg)
RA RVEDP MPA LA LVEDP Tricuspid valve gradient in pureTS
TR (1+- 4+)
:S ] TR
Malfunctioning tricuspid (mechanical) prostheses
231
11 ± 11 ± 28 ± 17 ± 10 ±
13 ± 0.6 10 ± 2.1 38.5 ± 2 23 ± 3 12 ± 0.8 5±0 .5(n ~
I I)
2.8 ± 0,3 (n ~ 12) 5.8 ± 0.2] (n ~ 24) [ 2.2± 0.3
0.8 2.8 1.2 3.4
0.8
3.8 ± 0.4 In ~ 9) 2.9 ± 0.2 In ~ 10) 5.2 ± 0.3] [ 2,3 ± 0.1
(n ~
81
n ~3
Respiratory Function
FVC(L) FEV, (L) FEV,/FVC %
1.9 7 ± 0.11 1.33 ± 0.08
MBC (L/min)
52 ± 3
72 ± 2.8%
1.6 ± Ll 7 ± 68 ± 46 ±
0.12' 0.06'
2% 2
Hepatic Function Serum Bilirubin (nmol/ l) Serum Alkaline phos. (U/l)
20 ± 1.96 104 ± 64
27±2.1160 ± 31'
Renal Function Blood urea (mmoll l ) Creatine clearance (mglmin)
7.6 ± 0.4 114 ± 4
11.5 ± 1.2 92 ± 2
Abbreviationssame as in Table 4. • significantdifference (p < 0.05)primary vs. secondaryTVR
diac reoperations (Table 3) and a greater imp airment of their right heart and respiratory function (Tabl e 4). Preoper ative vari ables in Group I (survi vors) and Group II (early mort alities) have been compare d in Tabl es 5 and 6. All Group II pati ents wer e in NYHA Class Ill-IV, as compa red to 78% in Group I (p < 0.05, Tabl e 5). The differ ences between the haemod ynamic findin gs between th e two groups wer e not significant, but FVC an d FEV! we re significantl y lower , and the peak plasm a bilirubin and alkaline phosph ate highe r in Group II (Table 6). The effect of these vari abl es on early mort ality a nd their predicted critical values in this seri es are shown in Figs. 1-4 . Besides these variables. multivariate ana lysis pointed to sever e tricuspid regurgitation and lack of cardioplegic protection having a significant influen ce on the early mortality (Table 7). A significant redu ction in the early mortality during pha se II was du e to ca rdioplegic protection , despite a
Table 7 Factors influencingearly mortality (multivariate analysis) p Preoperative Variables
Age > 60 % Sex(female) NYHA class
TR FVC FEV, Bilirubin Alkaline phosphate
RA, RVED P, MPA LA, LVEDP, TS Intraoperative variables
Abbreviationssame as in Table 4
No cardioplegia Triple valve replacement Mechanical prostheses
< 0.05 < 0.05 < 0.001 < 0.001 < 0.001 < 0.001 0.05 > 0.05 < 0.0001 > 0.05 > 0.05
T. K. Kaul. J. L. Mercer
Thom e. eardiovase . Su rgeoll 38 (1990)
a: 100
>
I-
'" 100
...> .,.~
·
~ 80 ~
::.
80
~
-e 0
1:
0 M
:s
50
C
:s "
~
40
'"
no. of deaths
no. of patients
12
20
FVC 1.6
'E
•
60
'"c
u
20
< t.5
200
>
150
plasma alkaline phosphate
plasma bilirubin j,l mol/ L
Fig. 3
5 16
:.5
p < 0.01
11
90
e
20
20
no. of patients
60
M
-c
'"
no. of deaths
alk . pho s. U/ L
80
·•
::.•
'·"••
100
... ::•
...
60
2.5
Effect of pre-operative FEV 1 on early mortality afterTVR
>
>
e
22 p < 0 .05 35
1.5 2 FEV 1 in Li ters
3
Fig. 1 Effectof pre-operative FVC on early morta lityafter TVR
M
patients
5 16
>f'. 20
FV C in liters
.,.s
no. of
"
ec o.oi
2.5
no. of death s
Effect of pre-operative peak Bilirubinonearly mortality afterTVR
Fig. 4
> 350 Ull
Effect of pre-operativepeakAlkaHne Phosphateonearlymortalityafter
TYR
PrimaryTVR SecondaryTVR Mechanical prostheses Primary Secondary Bioprostheses Primary Secondary
Phase I Nocardioplegia(n - 33) Early %(95%CII deaths
Phase II Cardioplegic protection (n - 41) Early %(95%CI) deaths
14129 2/ 4
30%- 64% 1%- 99%
'"7 128 "4/13
9%-41% 5%-55%
14/29 011
30%-64% 0%
"""111 6 0/9
4.7%-8.5% 0%
nil 2/3
13%-90%
Primary (21/57, 24.3 %-49.3 %1 vs secondary (6/ 17, 12.4%- 58.1 %1N.S. Mechanical (17152, 20.7 %-45.4%) vsbioprostheses (10122, 25%- 65%1N.S. • p < 0.05;••• p < 0.001;CI - Confidence limits; rn/n ratio Number of deaths
6/ 12 21%-78 % 2/ 5 3%-82.3% (Replacementof amechanical prosthesis)
J %(95%cu 0
Number at risk
Table 8 Effect of dlchotomatous variables on early mortality
Downloaded by: Universite Laval. Copyrighted material.
23 2
Thorac . cardiollasc . Su rgeon 38 (199OJ
Tricuspid Valve Replacement: Factors Influencing Early and Late Mort ality
Table9 Tricuspidvalve replacement (replacement prosthesis, early &latedeaths)
Prosthesis
SE
as
B
H
CE
IS
Number used Primary Secondary
13
29 5
3 nil
10 81+1)
nil 2
2 nil
Total 57 Total 17
2
Earlydeaths Primary Secondary late deaths Primary Secondary
6
9 nil
2
4
2 nil
nil
233
nil nil
6 4
nil nil
nil nil
Total 21 Total 6
nil nil
2 nil
nil nil
nil nil
Total 8 Total nil
Replacement prosthesesforsecondary TVR: Replacement of Beall lenticular prosthesis (I) SE Failed annoluplasty(II BS Failedannuloplasty (41 + Epicardial PacingSystem Persistant TR following MVR (I)" CE Clotted It) ClottedBeall (I ) Hancock T. Valvotomy2" Clotted 12} + II)" Persistant TRafter MVR (3)" Replacement of BS prosthesis' SE: Starr Edward, BS: BjorkShirey, B: Beall, H; Hancock, CE: Carpentier Edwards, IS: lonescuShiley. • Early Deaths.
as
grea ter number of high -risk Isecondary TVR) a nd more complex procedu res (e.g. replacement of malfunctionin g mechanical prostheses) per formed duri ng this period ITable 8). Patient survival in relation to the replacement pr osth eses used is summar ised in Table 9. All Sta rrEdwa rds prosth eses wer e used during phase I and ea rly mortality was also influenced by inadequ ate myocardial protection. Ha ncock bioprostheses were mainly used during phase II and ea rly deat hs in these patie nts was due to a gross deran gement of their preoperative hepatic and
Table10 Causesof early &late deathsafterTVR PrimaryTVR n
Secondary TVR n
Causesof early deaths Congestive cardiac failure Myocardial infarction Cerebral infarction Arrhythmias & AV. Block Detached mitral prosthesis Haemorrhage Septicaemia
1 2 1 nil 1
nil
Total
21
6
2
nil
Causesof late deaths Earlycompletethromboticocclusionof BS prosthesis Earlypartialthromboticocclusionof BS prosthesiswith multiplepulmonary emboli l atethromboticocclusionof BS prosthesiswithmultiplepu lmonary emboli Overanticoagulationinpatientswith SEprosthesis Prosthetic valve endocard itisin patientswithHancock bioprosthesis
Total SE:Starr-Edwards, BS: Blerk-Shlley.
t5
3
1
nil nil nil nil
respiratory function. The mean preoperative bilirubin 1101 ± 8 nmol/L), alkaline phosph ate IU5 ± 4 Ll/ L), FVC (1.6 ± 0.1 L) a nd FEV, (1.5 ± 0.1 L) of the ea rly mortalities who received a Han cock bioprosthesis were well beyond their pred icted critical values in this ser ies. The mai n cause or mode of early death in this series was congestive cardiac failur e an d most of the late deaths 16/ 8) wer e due to the complications which developed following the implantation of a mechanical prosthesis ITab le 10). Patient long-ter m survival in relation to the replacement prostheses and the time interva l after TVR is shown in Figs. 5 and 6 respectively. The prob ability of death with in 12 months due to the thrombotic occlusion of a mechanical prosthesis was 1) % (3.5%-14.5 %,70 % Cl}, This occurred in the patients who remained in congestive cardiac failure des pite successful valve replacement. There was no ea rly or late failure of the bioproth eses used, but there were 2 valve-related deaths due to endocarditis (12. 1 and 60 months). Four patients who developed delayed conduction defect following the implantation ofa Bjork-Shiley prost hesis, received a permanent epica rdial pacing system.
3
nil nil
2
nil
2
nil
8
nil
Discussion In the ea rly yea rs ofthis series TVII was conside red idea lfor a complete restoration oftricuspid valve function, especially in patients with severe right hea rt failure. During this period, conservative procedu res (De Vega's annuloplasty, tricuspid valvotomy) were used only in more favourab le cas es owing to the possibility of imperfect results from over or und er correction 14, 14). However, in view of a high mortality associated with TVR a nd more consistan t and sa tisfactory long-term results with the conservative procedures, a gra dual cha nge in the tr eatment policy was persued. During the latter part of this series, in accord with othe r authors conservative procedur es IDe Vega's ann uloplasty and Carpetier' s flexible ring a nnulplas ty) were used more liberally; prim ary TVII was performed only for severe mixed organic tricuspid valve lesions, an d seconda ry TVR
Downloaded by: Universite Laval. Copyrighted material.
as
t: K. Kaul. J. L. Mercer
Thom e. eardiol'ase. Surgeofl38 (1990) 100 ; -
90
~
0.2
80
n "
.~
"-
70
l.I)
:1'-
~
6 3%
0.1
26
70%
55" '-;:;::;5""
50
---,
.""
*
no auve
3. _ 26 22· 12 l~· 6 6m
23 11 5 1
22
22
10
* 8S • BIO 4 "' SE
•5
10
monthsafter TV R
1 J
2
~..,%----~-------37" 35"
30
no. o f deaths
1
6
2
12
1
60
1 1
120 180
0.001 5
20
10
15
20
years after TVR
yean
Fig. 5 Actuarial survival after TVR inrelationtoreplacement prosthesis (including early mortality). 3 BEAl l : no mortahties
Fig. 6
was perfor med for (a ) th romb otic occlusion ofa mechani cal prosthesis in tricuspid position, (b) failed conse rvative procedures, and (c) persistant tricuspid regurgitation despite success ful mitral valve replacement (5, 6, 9, 10, 15). Despite cardioplegic protection, operative morta lity during phase II has remained high at 26.8 % (9,1%- 44,5% , 95 % CIl, due to a greater complexity of the operative pr ocedures (reoperat ions) perform ed in high-risk pati ent s. Long-term survival after TVRhas generally remain ed poor: repo rted act ua rial survival rate (including ea rly mortality) at 10 years has rang ed between 35%-45 %, irr espective of the nature of the replacemenl prostheses used (3, 5, 8). It has been possible to achieve similar survival rates after the conserva tive procedures De Vega's a nnulopasty, Carpentier's ring a nnuloplasty, and Kay' s annuloplasty (5, 8). Tricuspid a nnuloplas tic procedures have been generally used for the correction of modera te to severe functional tricuspid regurgitation, but they have also been successfully used in selected cases with mixed tricuspid valve lesions and also in patients with severe right heart failure (1, 5). Recent reports indicate that an excellent long-ter m pr eservation of tricuspid valve function is possible, even in patients with severe right failure, with De Vega's annuloplasty and Carpentier's ring a nnuloplasty (I , 15). Therefore it has been recommended that whenever possi ble conse rvative procedures should be used initially, an d TVR shou ld be reserved for its absolute indications (1), The choice of replacement prosthesis is a lso difficult for the tr icuspid position. Mechani cal prostheses, e.g. StarrEdwa rds (5, 12), Bjo rk-Shiley (3, 13) and St. Jud e prostheses (17), have functioned satisfactorily for over 10 years in the tricuspid position. However ba ll-and- cage prosth esis
is not ideal in the tricuspid position, as the cage of the pr osthesis conforms poorly to the wedge-sha ped cavity of the right ventricle an d the ball movement may be restricted by the subvalvular appa ratu s. Thrombotic occlusion of both ball-a nd-cage and disc prostheses is a major disadvant age in tricuspid position and may occur in up to 20 % of the mechan ical prostheses (2, 18). We have observed an ea rly thrombotic occlusion (within 1 yea r) of a Bjork-Shiley prosthesis in 13 % (6.1 %-20. 1%, 70 % CIl survivors in tricuspid position , despit e adequat e anticoagu lation. In this seri es this complication occurred in the patients who remained in ca rdiac failure, despite successful valve replacement. In view of the high risk of mechanical valve thrombosis and pro blems related with ant icoagu lation it is onlylogical to use a bioprosthesis in the tricuspid position. Some limitat ions of bioprostheses in patients with low cardiac output have been described (7), but in most of the series they have functioned satisfactorily duri ng their expected life time (8). Late morta lity may be redu ced or averted by an elective seconda ry TVR,
Probability of death after TVR in relationto timeintervalafter TVR
Acknowledgement
The authors gratefully acknowledge secretarial help of Mrs. Norma Sill.
Downloaded by: Universite Laval. Copyrighted material.
234
Tricusp id Val ve Replacement: Factors Influencing Early and Late Mort ality
• Ab e. T.. M. Tukamoto. M. Yanagiya. M. Mo rlkau-a. N. Wa tanabe. and S. Komatsu: De Vega' s annuloplasty for acqui red tr icuspid
l
3
4
5
1'1
7
8
q
10
disea se: Early and late results in 110 patients. Ann . Thora c. Surg . 48 (1989) 670-676 Hache . fl. J.• A H. L. From . A R. Castaneda. C. R. Jorqe rson. and Y. Wang : Late thrombotic obstruction with Star r-Edwa rds prosthesis. ChesI6 1{1972 )613-6 16 8j ,,,k. v. 0.. A Henz. a ndA Pet erffya : Cana mechan ical hear t valve be used in tricusp id position? Experience with Bj erk-Shiley tilting disc valve in 70 patien ts. Eur. Heart J. 1 (1980155 -61 Chidam baram. M.. S. A Abdulali, B. G. Ba ciga. and M. lones cu. Long-term results of De Vega tricuspid an nuloplasty. Ann. Thorac. Surg. 43 (1987) 185- 188 Cohanog lu. A . and A Starr: Tricuspid valve su rgery: Indications. methods and results. Cardiovasc. Clinic (valvular Ileart Disease) 16 (1986) 1', 2 375- 387 Grondin . P.. G. Lap age. Y. Costanguay. and C. Me ere: The tri cusp id valve: A surgical challenge. J. Thorac. Cardiovasc. Surg . 53 (1967) 7-20 ltorotoitz. M. S.: Porcine heterografts in tricus pid position . Am. J . Ca rdio\. 42 (1978) 691 Kay . G. L.. S. Morita. M . Mendez. A Zubiate, and J. II. Kay : Tricuspid regurgitation ass ociated with mitra l valve disease: Repair and replacement. Ann. Thorac. Surg. 48 (1989) 593-595 Klep etk oto, lV.. M . Kticpe ra. G. Kren ik: H. Magom etsch nig. J. M iczoc n. C. Muller. and E. Domanig: Functional tricusp id insufficiency: conservative or operative management . Thorac Ca rdlovasc . Surgeon 33 (1985) 167 - 172 King. fl. M.. H. V.Sc haff. G. K. Danielson. B. J. Gersh. 1: A. Ors zu tak; J. M. A chier. F. J. Puga. and J. fl. Plut h: Surge ry for tr icuspid regurgitation late after mitral valve replacement. Circulation 70 (1984) Suppl. L 193 -19 7
w: Step henson: Indications and resu lts of tricus pid valve replacement. Adv. Cardiel. 17 (19761 199 - 206 12 Ma cmanus. Q.. G. Grunkem eir. and A. Starr: Late results of tripl e valve replacem en t: a 14 year review. Ann. Thorac . Surg . 25(1 978) 402-406 13 Mestres. C. A. . A/gual. and M. Mur tr a: The Bjork-Shiley tilting disc valve in tricusp id position, 10 year experience. Scand . J. Thora c. Cardiovasc. Surg. 17 (1983) 197- 199 .4 Plu th. J. fl.. and F. ll. Ellis : Tricuspid ins ufficiency in patients und ergoing mitral valve replacement. J . Thorac. Cardiovasc. Surg. 58 (1969) 484-491 15 Riv era, R.. E. Dur an. andM. Aj uria: Carpentier's flexible ring vers us De Vega 's annulcplasty:A prospective randcmised study. J . Thorac. Ca rdiovasc. Surg. 89 (19851196- 203 11'1 Scnfeilppo. P. M .• E. R. Giuliani, G. K.Dunielson . fl./J. Walla ce. I': R. Pluth . and D. w: McGoon: Tricuspid valve prosthetic replacemen t. ear ly and late results with Starr -Edwards prosthesis. J. Thorac. Cardiovasc. Surg. 71 (1976) 441 -445 17 Singh. A. K.. I-: D. Christian. and D. O. Wi lliams: Follow up asse ssment ofSt. Jud e medical prosthetic valve in tricuspid position. Ann . Thora c. Surg. 37 (1984) 324-327 18 Tho rburn . P.. J . J . Morga n. M. X. S na nhan. and V. P. Chang : Longterm resu lts ofTVRand the prob lem of prostheti c valve thrombosis. Am. J. Cardio\. 51 (1983) 1128-11 32 Iq Yur cha k. P. M.. W M. Daqeu. and M . J. Buckley: Predictors of surviva l after tricuspid valve su rgery. Am. J . Cardiel. 54 09841 137- 141 11
235
Kouchoukos . N. T..and L.
Mr. T. K. Kaul
Royal Devon a nd Exeter Ilospital Iw onfordl Barr ack Road Exeter. EX2 SDW U. K.
Downloaded by: Universite Laval. Copyrighted material.
Referen ces
Thom e. eardi0l1ose. S urgeo1l38 ( 1990)
Tricuspid Valve Replacement: Factors Influencing Early and Late Mortality T. K. Kaul and J. L. Mercer Region al Adult Card iothoracic Surgical Cen tre , Broad gr een Hosp ital. Liverp ool. Un ited Kingd om
Seventy four patients underw en t tricuspi d valve replacem en t (TVHI. between 1968 an d 1983 . 93 % were female, mean age was 44 ± 4 yea rs . Tricuspid va lve was rep laced wit h a mechanical prosth esis in 52 and a bioprosthesis in 22 patients. Fifty seven patients und erw ent primary TVR and 17 und erwent a second a ry TVR followin g a mean interval of 41 ± 2 months (SEMI following a pr evious mitral or tri cusp id valve opera tion. Preoperatively 86% pat ien ts were in NYHA class III- IV a nd congestive cardiac failure (CHF). Ea rly mort a lity for prim ary lVR wa s 36.8% and 35.2 % for sec ondary TVR. Early mortality has been sig nificantly reduced sin ce the introduction of ca rdioplegic protection for the ass ocia ted valve lesions . Early mort ality was significa ntly influenced by the redu ced preoperat ive values of FVC and FEV\ in patients with long sta ndi ng mitra l valve disease a nd by rai sed preoperative levels of plasma bilir ubin an d alkaline phosp hate in patient s with Cfl F. Risk ofthro mbotic occlus ion a nd late deaths rem ained high duri ng the first yea r after TVHwit h a mech an ical prosth esis. Key word s
Tricuspid valve rep lacemen t - Congestive cardiac fa ilure Mechanical cardiac valve th rombo sis
Introdu ction The a ppropriate man agement of tricuspi d valve disease remains controversial. However. the gen era l principles in dealing with tricuspid valve dysfunction is to avoid tricuspid valve replacement if possible. Preserving tricuspid valve by a conse rvative proc edu re is ideal. results are encouraging with a low mortality and morbid ity (1,15), whereas tr icuspid valve replacement (TVRl is still assoc iated with high mortality and morbidity despit e imp rovement in pr e- and postoperative man agement (11, 16, 19). A grea ter numb er of tricuspid valve replacements were perform ed earlier in this series when the value of various meth ods of tr icuspid a nnuloplasty was not clea rly established. We have stud ied the risk factors which may have influenced mo rtality ofthe patients who underw ent TVR in our unit. Materi als and Methods Seventy-four patien ts und erw ent TVR betw een 196 6 a nd 1983. 93% were female an d their ages wer e in the ra nge 22 -66 yea rs (mea n 44 ± 4 yea rs). TVR was usually per formed wit h othe r va lve
Thorac. cardiovasc. Surgeon 38 (1990) 229-235 © Georg Thieme Verlag Stuttgart - New York
Trikuspida lklappen ersatz - welch e Fakturen heeinf'lussen die Frtih - und die Spatle ta llta t? Es wird uber 74 Patlenten im Alter von 22 bis 66 Ja hren ben chtet , die zwisc hen 1966 und 1983 eine n Tr ikuspidalklappener satz (TKE) erhic lten. Bei 57 Patient en wu rde ein prt rna rer TKE vorgen omm en im Zusammenha ng mit eine m a nde re n Klappen eingrtff meistens In "" 34) gleichzeitig mit eine m Mitralklap pen ersatz. Hei 17 Pat ienten handeh e es sich urn e inen se kundaren TKE. 52ma l wurde eine mechani sch e und 22mal eine biologische Klappe implantiert. Bis 1978 wu rden 33 Patient en ohne Kardioplegie. dana ch 41 Patien ten mit Kardioplegie operie rt. Die Fruhletalita t betrug nach pr ima rem TKE 36 .8 %. na ch sekundarem TKE 35.2 %. Die Fruhl etalit at war sig nilikant durch schlecht ere respi rat oris che Funktlonswerte (FEV,) und schlechte re Leberfu nktionswerte (Ser um· Bilirubin und alkalische Phosph atase) beet nflufn . was Pa tienten mit einem la nge Zeit bestchen den Mltr alvitlum betraf Nac h EinfU hru ng der Kard ioplegie kon nle die Fruhletalitat sign ifikan t gcsen kt werde n. Die Autorcn pladi er en au fgru nd ihrcr Ergeb nisse und untcr Bcriicksichtigun g der elnsc hlag igen Literatur ftlr an uloplastl sche Eing rifTe an de r Trikuspidalklapp e (Devega-Anulopl astik. Carpe ntier -Ring] wa nn imme r cs mogltch ist. Der Klappenersat z sollte nu r dan n vorge nomme n word en . wen n cin e a bso lute Indikation bcst eht. In diesen Fallen sollte man der Biopr cth ese den Vorz ug geb en .
repl acements or pro cedu res . the deta ils of ope ra tive procedures performed are summa rised in Tables 1 a nd 2. Mech ani cal prostheses were used in 52 pati ents (7 1.4 %) and bioprosth eses wer e
used in 22128.6%1 patients. Operati ons we re carried out using ca rdiopulmona ry bypass thr ough a median ste rno tomy with moderate hypothermia . Before 1978 myoca rdium was pr otected duri ng ischae mic arrest with continu ous coronary perfu sion in patients who und erw ent a concom lta nt aortic valve rep laceme nt. but in the rema ining pat ients mitral
Table 1 Primarytricuspid valve replacement: operative procedures, early & latedeaths n
Early deaths
l ate deaths
Simultaneous MVR + TVR Triplevalve replacement Open mitralvalvotomy + TVR Closure ofASD + TVR
34 19 3
10
9
4 2
1
2 nil
1 1
Total
57
21
8
Early mortality doublevalve vs triplevalve: no significant difference
Received for Publi cation : October 9 . t 989
Downloaded by: Universite Laval. Copyrighted material.
Summary
T. K. Kaul. 1. L. M ercer
Thom e. ear diol'as c. Surgeo1l38 (1 990) Table 2
valve surgical procedur es were performed with ischae mic arrest and moder ate hypothermi a (Phase ll. Since September 1978 cold crystalloid cardioplegia and surface cooling were used (Phase 11). Anterior and posterior leaflets of the tricuspid valve were excised leaving a 0,5 cm cufT. Prostheses were sutured with continuous 210 prolene or ethibond sutures and interrupted sutures were used in th e region of sep tal leaflet to avoid injury to the conduction system. Anticoagulant therap y was continued life-long in patients with a mecha nical prosthesis and was discontinued after 6 month s in pat ients who received a bioprosth esis. Primary TVH was performed in 57 patients and seconda ry TVR (TVH at a reoper ation) was per formed on 18 occasions in 17 patients at a mean interval of 42 ± 2 month s (SEM) following an open heart procedur e. One month after TVR there were 47 surv ivors (Group I) and 27 non survivors (early mortalities) (Group Ill. Tricuspid valve replacement was per formed either isolated or along with the other cardiac procedure s. All Starr-Edwards. Beall-Lent icular an d 13 of the Bjork-Shiley proth eses were implanted during the phas e I, and 19 biopro sth eses during the phase II. Bioprostheses were used for 10 secondar y TVH. The eflcct of vario us preoperat ive demographic , clinical, and haemodynam ic variabl es and respir atory. hepatic. and renal function on early mort ality was studied. Their values in Group I and Group (I patients, as well as in th ose who und erwent primary or secondary TVR were compared. The eITect of dichotomous variables (primary vs secondary: mechani cal vs bioprostheses) on early morta lity dur ing phase I an d phase II was exa mined, Multivari ate regressional analysis was used to demonst rate the influence of various preoperative variables on the early mort ality. The critical values of the factors which significantly influenced early mortal ity were determ ined , Long-term survival (more tha n one year) in relation to the replacement prostheses used and the inter val after Tv lt was examined, particularly in relation to the valve related complications egothrombosis. anticoagulation, endocarditi s, and primar y tissue failure.
Secondarytricuspid valvereplacement: operativeprocedures, early
& late deaths n
Early deaths
Late deaths
6
4
MVR+ TVR AVR+ MVR + TVR
10 1
2 nil
nil nil nil
Total
17
6
nil
IsolatedTVR
Early mortality isolatedTVR vs MVR + TVR: significant difference (p < 0.05)
Table 3
Preoperative clinicalfindings: primary and secondaryTVR
Age (years)
M/F Duration of valvular heart disease (years) Previous surgery Closed mitral valvotomy MVRor open mitral valvotomy NYHAclass II III- IV Diuretic therapy < 80 mg lasixlday > 80 mg lasix/day
Primary TVR(n- 57)
Secondary TVR(n - 17)
44 ± 1.l 2/ 55
53 ± 1.3 2/15
7.8 ± 0.9
12.1 2 ± l '
82.4%
100% 100%'
nil
17.5% 82.5%
nil
33.3% 66.7
nil
100%
100%
NYHA: New York Heart Association. • significant difference (p < 0.05)
Primary TVR n - 57
SecondaryTVR n - 17
Haemodynamic findings (mmHg)
RA RVEDP MPA LA LVEDP
13 ± 9± 45 ± 22 ± 11.2 ±
Tricuspid valve gradient in pureTS
TR (I + to 4 +)
~S]
17 ± 12 ± 52 ± 18 ± 9.8 ±
4.5 ± 0.5(n -ll ) 2.5 ± 0.3 (n - 14) [ 56 ± 08 ]
TR Malfunctioning tricuspid (mechanical) prostheses Respiratory Function FVC(L) FEVI( L) FEV/FVC% MBC(U min) Hepatic Function Serum Bilirubin (nmol/ L) SerumAlkaline phos.(U/L) Renal Function Blood urea (mmol/ L) Creatineclearance (mglmin)
RA RVEDP
0.8 0.4 2 1.2 1.2
0.97" 1.2 4.8 1.7 2
4.3(n - 2) 3.8 ± 0.4 (n - 8)
(n- 32)
nil
2.26 ± 0.2 n -6
nil
1.83 ± 1.27 ± 71 ± 50 ±
0.06 0.04 3% 38
1.52 ± 0.8' 1.1 1 ± 0.03' 58 ±4% 42 ± 7
25 ± 2 129 ± 8
21.8± 3 11O ±1O
10± 0.4 102 ± 6
9± 2 11 6 ± 2.8
'"
Rightatrial Right ventricular end TS · diastolic pressure MPA Main pulmonary artery TR LA ". Left atrial FVC LVEDP FEV) Left ventricular end diastolic pressure MBC · • significant difference (p < 0.05) primaryvs. secondaryTVR
Tricuspid stenosis Tricuspid regurgitation Forced vital capacity Forced expiratory volume Maximum breath ingcapacity
Table 4 Preoperative haemodynamic findings,respiratory, hepatic and renal function
Downloaded by: Universite Laval. Copyrighted material.
230
Thorac . cardioo"sc. Surgeoll 38 (19 90)
Tricuspid Valve Replacem ent: Factors Influencing Early and Late Mortality
Table 5 Preoperativeclinical findings: survivors andearlymortalities
Results ar e expressed as mean ± SEM, pair ed data ar e com pared by using students paire d ' t' test. Coxregression analysis. chi-squa re test, and actuarial analysis were used to show the influence of predictable variables on the post-operative surviva l.
Resu lts Early mortality was 36.8% (29.9 -43.8 %, 70% Cl) a fter prim ar y and 35.2% (24%-46 .8 %,70 % Cl) after secondary TVIl (non-significant differ ence). Early mortality was not influenced by the number of the valves replaced (Table 1), but was higher when TVR alon e was performed for severe right hear t decompensation (Table 2). The pati ents who underwent secondary TVIl wer e at higher risk due to carSurvivors
Survivors n = 47
Early mortalities
M/ F
48 ± 1.8 3/44
52 ± 1.2 1126
Durationof valvular heart disease (years)
8 ± 0.7
10 ± 1
Previous surgery Closed mitral valvotomy MVR or open mitralvalvotomy
63.8% 23.4%
100% 22.20%
NYHAciass II III- IV
21.3% 78.7%
nil
27.6%
nil
72.4%
100%
n ~ 27 Age (years)
Diuretic therapy < 80 mg lasix/day > 80 mg lasixlday
• significantdifference (p < 0.05) in NYHA-c1ass distribution
Table 6
Preoperative haemodynamic findings, respiratory, hepatic andrenal function: Survivors vs. earlymortalities after
Early mortalities n ~ 27
n ~ 47
100 %'
TVR Downloaded by: Universite Laval. Copyrighted material.
Statistical anatusis
Haemodynamic findings (mmHg)
RA RVEDP MPA LA LVEDP Tricuspid valve gradient in pureTS
TR (1+- 4+)
:S ] TR
Malfunctioning tricuspid (mechanical) prostheses
231
11 ± 11 ± 28 ± 17 ± 10 ±
13 ± 0.6 10 ± 2.1 38.5 ± 2 23 ± 3 12 ± 0.8 5±0 .5(n ~
I I)
2.8 ± 0,3 (n ~ 12) 5.8 ± 0.2] (n ~ 24) [ 2.2± 0.3
0.8 2.8 1.2 3.4
0.8
3.8 ± 0.4 In ~ 9) 2.9 ± 0.2 In ~ 10) 5.2 ± 0.3] [ 2,3 ± 0.1
(n ~
81
n ~3
Respiratory Function
FVC(L) FEV, (L) FEV,/FVC %
1.9 7 ± 0.11 1.33 ± 0.08
MBC (L/min)
52 ± 3
72 ± 2.8%
1.6 ± Ll 7 ± 68 ± 46 ±
0.12' 0.06'
2% 2
Hepatic Function Serum Bilirubin (nmol/ l) Serum Alkaline phos. (U/l)
20 ± 1.96 104 ± 64
27±2.1160 ± 31'
Renal Function Blood urea (mmoll l ) Creatine clearance (mglmin)
7.6 ± 0.4 114 ± 4
11.5 ± 1.2 92 ± 2
Abbreviationssame as in Table 4. • significantdifference (p < 0.05)primary vs. secondaryTVR
diac reoperations (Table 3) and a greater imp airment of their right heart and respiratory function (Tabl e 4). Preoper ative vari ables in Group I (survi vors) and Group II (early mort alities) have been compare d in Tabl es 5 and 6. All Group II pati ents wer e in NYHA Class Ill-IV, as compa red to 78% in Group I (p < 0.05, Tabl e 5). The differ ences between the haemod ynamic findin gs between th e two groups wer e not significant, but FVC an d FEV! we re significantl y lower , and the peak plasm a bilirubin and alkaline phosph ate highe r in Group II (Table 6). The effect of these vari abl es on early mort ality a nd their predicted critical values in this seri es are shown in Figs. 1-4 . Besides these variables. multivariate ana lysis pointed to sever e tricuspid regurgitation and lack of cardioplegic protection having a significant influen ce on the early mortality (Table 7). A significant redu ction in the early mortality during pha se II was du e to ca rdioplegic protection , despite a
Table 7 Factors influencingearly mortality (multivariate analysis) p Preoperative Variables
Age > 60 % Sex(female) NYHA class
TR FVC FEV, Bilirubin Alkaline phosphate
RA, RVED P, MPA LA, LVEDP, TS Intraoperative variables
Abbreviationssame as in Table 4
No cardioplegia Triple valve replacement Mechanical prostheses
< 0.05 < 0.05 < 0.001 < 0.001 < 0.001 < 0.001 0.05 > 0.05 < 0.0001 > 0.05 > 0.05
T. K. Kaul. J. L. Mercer
Thom e. eardiovase . Su rgeoll 38 (1990)
a: 100
>
I-
'" 100
...> .,.~
·
~ 80 ~
::.
80
~
-e 0
1:
0 M
:s
50
C
:s "
~
40
'"
no. of deaths
no. of patients
12
20
FVC 1.6
'E
•
60
'"c
u
20
< t.5
200
>
150
plasma alkaline phosphate
plasma bilirubin j,l mol/ L
Fig. 3
5 16
:.5
p < 0.01
11
90
e
20
20
no. of patients
60
M
-c
'"
no. of deaths
alk . pho s. U/ L
80
·•
::.•
'·"••
100
... ::•
...
60
2.5
Effect of pre-operative FEV 1 on early mortality afterTVR
>
>
e
22 p < 0 .05 35
1.5 2 FEV 1 in Li ters
3
Fig. 1 Effectof pre-operative FVC on early morta lityafter TVR
M
patients
5 16
>f'. 20
FV C in liters
.,.s
no. of
"
ec o.oi
2.5
no. of death s
Effect of pre-operative peak Bilirubinonearly mortality afterTVR
Fig. 4
> 350 Ull
Effect of pre-operativepeakAlkaHne Phosphateonearlymortalityafter
TYR
PrimaryTVR SecondaryTVR Mechanical prostheses Primary Secondary Bioprostheses Primary Secondary
Phase I Nocardioplegia(n - 33) Early %(95%CII deaths
Phase II Cardioplegic protection (n - 41) Early %(95%CI) deaths
14129 2/ 4
30%- 64% 1%- 99%
'"7 128 "4/13
9%-41% 5%-55%
14/29 011
30%-64% 0%
"""111 6 0/9
4.7%-8.5% 0%
nil 2/3
13%-90%
Primary (21/57, 24.3 %-49.3 %1 vs secondary (6/ 17, 12.4%- 58.1 %1N.S. Mechanical (17152, 20.7 %-45.4%) vsbioprostheses (10122, 25%- 65%1N.S. • p < 0.05;••• p < 0.001;CI - Confidence limits; rn/n ratio Number of deaths
6/ 12 21%-78 % 2/ 5 3%-82.3% (Replacementof amechanical prosthesis)
J %(95%cu 0
Number at risk
Table 8 Effect of dlchotomatous variables on early mortality
Downloaded by: Universite Laval. Copyrighted material.
23 2
Thorac . cardiollasc . Su rgeon 38 (199OJ
Tricuspid Valve Replacement: Factors Influencing Early and Late Mort ality
Table9 Tricuspidvalve replacement (replacement prosthesis, early &latedeaths)
Prosthesis
SE
as
B
H
CE
IS
Number used Primary Secondary
13
29 5
3 nil
10 81+1)
nil 2
2 nil
Total 57 Total 17
2
Earlydeaths Primary Secondary late deaths Primary Secondary
6
9 nil
2
4
2 nil
nil
233
nil nil
6 4
nil nil
nil nil
Total 21 Total 6
nil nil
2 nil
nil nil
nil nil
Total 8 Total nil
Replacement prosthesesforsecondary TVR: Replacement of Beall lenticular prosthesis (I) SE Failed annoluplasty(II BS Failedannuloplasty (41 + Epicardial PacingSystem Persistant TR following MVR (I)" CE Clotted It) ClottedBeall (I ) Hancock T. Valvotomy2" Clotted 12} + II)" Persistant TRafter MVR (3)" Replacement of BS prosthesis' SE: Starr Edward, BS: BjorkShirey, B: Beall, H; Hancock, CE: Carpentier Edwards, IS: lonescuShiley. • Early Deaths.
as
grea ter number of high -risk Isecondary TVR) a nd more complex procedu res (e.g. replacement of malfunctionin g mechanical prostheses) per formed duri ng this period ITable 8). Patient survival in relation to the replacement pr osth eses used is summar ised in Table 9. All Sta rrEdwa rds prosth eses wer e used during phase I and ea rly mortality was also influenced by inadequ ate myocardial protection. Ha ncock bioprostheses were mainly used during phase II and ea rly deat hs in these patie nts was due to a gross deran gement of their preoperative hepatic and
Table10 Causesof early &late deathsafterTVR PrimaryTVR n
Secondary TVR n
Causesof early deaths Congestive cardiac failure Myocardial infarction Cerebral infarction Arrhythmias & AV. Block Detached mitral prosthesis Haemorrhage Septicaemia
1 2 1 nil 1
nil
Total
21
6
2
nil
Causesof late deaths Earlycompletethromboticocclusionof BS prosthesis Earlypartialthromboticocclusionof BS prosthesiswith multiplepulmonary emboli l atethromboticocclusionof BS prosthesiswithmultiplepu lmonary emboli Overanticoagulationinpatientswith SEprosthesis Prosthetic valve endocard itisin patientswithHancock bioprosthesis
Total SE:Starr-Edwards, BS: Blerk-Shlley.
t5
3
1
nil nil nil nil
respiratory function. The mean preoperative bilirubin 1101 ± 8 nmol/L), alkaline phosph ate IU5 ± 4 Ll/ L), FVC (1.6 ± 0.1 L) a nd FEV, (1.5 ± 0.1 L) of the ea rly mortalities who received a Han cock bioprosthesis were well beyond their pred icted critical values in this ser ies. The mai n cause or mode of early death in this series was congestive cardiac failur e an d most of the late deaths 16/ 8) wer e due to the complications which developed following the implantation of a mechanical prosthesis ITab le 10). Patient long-ter m survival in relation to the replacement prostheses and the time interva l after TVR is shown in Figs. 5 and 6 respectively. The prob ability of death with in 12 months due to the thrombotic occlusion of a mechanical prosthesis was 1) % (3.5%-14.5 %,70 % Cl}, This occurred in the patients who remained in congestive cardiac failure des pite successful valve replacement. There was no ea rly or late failure of the bioproth eses used, but there were 2 valve-related deaths due to endocarditis (12. 1 and 60 months). Four patients who developed delayed conduction defect following the implantation ofa Bjork-Shiley prost hesis, received a permanent epica rdial pacing system.
3
nil nil
2
nil
2
nil
8
nil
Discussion In the ea rly yea rs ofthis series TVII was conside red idea lfor a complete restoration oftricuspid valve function, especially in patients with severe right hea rt failure. During this period, conservative procedu res (De Vega's annuloplasty, tricuspid valvotomy) were used only in more favourab le cas es owing to the possibility of imperfect results from over or und er correction 14, 14). However, in view of a high mortality associated with TVR a nd more consistan t and sa tisfactory long-term results with the conservative procedures, a gra dual cha nge in the tr eatment policy was persued. During the latter part of this series, in accord with othe r authors conservative procedur es IDe Vega's ann uloplasty and Carpetier' s flexible ring a nnulplas ty) were used more liberally; prim ary TVII was performed only for severe mixed organic tricuspid valve lesions, an d seconda ry TVR
Downloaded by: Universite Laval. Copyrighted material.
as
t: K. Kaul. J. L. Mercer
Thom e. eardiol'ase. Surgeofl38 (1990) 100 ; -
90
~
0.2
80
n "
.~
"-
70
l.I)
:1'-
~
6 3%
0.1
26
70%
55" '-;:;::;5""
50
---,
.""
*
no auve
3. _ 26 22· 12 l~· 6 6m
23 11 5 1
22
22
10
* 8S • BIO 4 "' SE
•5
10
monthsafter TV R
1 J
2
~..,%----~-------37" 35"
30
no. o f deaths
1
6
2
12
1
60
1 1
120 180
0.001 5
20
10
15
20
years after TVR
yean
Fig. 5 Actuarial survival after TVR inrelationtoreplacement prosthesis (including early mortality). 3 BEAl l : no mortahties
Fig. 6
was perfor med for (a ) th romb otic occlusion ofa mechani cal prosthesis in tricuspid position, (b) failed conse rvative procedures, and (c) persistant tricuspid regurgitation despite success ful mitral valve replacement (5, 6, 9, 10, 15). Despite cardioplegic protection, operative morta lity during phase II has remained high at 26.8 % (9,1%- 44,5% , 95 % CIl, due to a greater complexity of the operative pr ocedures (reoperat ions) perform ed in high-risk pati ent s. Long-term survival after TVRhas generally remain ed poor: repo rted act ua rial survival rate (including ea rly mortality) at 10 years has rang ed between 35%-45 %, irr espective of the nature of the replacemenl prostheses used (3, 5, 8). It has been possible to achieve similar survival rates after the conserva tive procedures De Vega's a nnulopasty, Carpentier's ring a nnuloplasty, and Kay' s annuloplasty (5, 8). Tricuspid a nnuloplas tic procedures have been generally used for the correction of modera te to severe functional tricuspid regurgitation, but they have also been successfully used in selected cases with mixed tricuspid valve lesions and also in patients with severe right heart failure (1, 5). Recent reports indicate that an excellent long-ter m pr eservation of tricuspid valve function is possible, even in patients with severe right failure, with De Vega's annuloplasty and Carpentier's ring a nnuloplasty (I , 15). Therefore it has been recommended that whenever possi ble conse rvative procedures should be used initially, an d TVR shou ld be reserved for its absolute indications (1), The choice of replacement prosthesis is a lso difficult for the tr icuspid position. Mechani cal prostheses, e.g. StarrEdwa rds (5, 12), Bjo rk-Shiley (3, 13) and St. Jud e prostheses (17), have functioned satisfactorily for over 10 years in the tricuspid position. However ba ll-and- cage prosth esis
is not ideal in the tricuspid position, as the cage of the pr osthesis conforms poorly to the wedge-sha ped cavity of the right ventricle an d the ball movement may be restricted by the subvalvular appa ratu s. Thrombotic occlusion of both ball-a nd-cage and disc prostheses is a major disadvant age in tricuspid position and may occur in up to 20 % of the mechan ical prostheses (2, 18). We have observed an ea rly thrombotic occlusion (within 1 yea r) of a Bjork-Shiley prosthesis in 13 % (6.1 %-20. 1%, 70 % CIl survivors in tricuspid position , despit e adequat e anticoagu lation. In this seri es this complication occurred in the patients who remained in ca rdiac failure, despite successful valve replacement. In view of the high risk of mechanical valve thrombosis and pro blems related with ant icoagu lation it is onlylogical to use a bioprosthesis in the tricuspid position. Some limitat ions of bioprostheses in patients with low cardiac output have been described (7), but in most of the series they have functioned satisfactorily duri ng their expected life time (8). Late morta lity may be redu ced or averted by an elective seconda ry TVR,
Probability of death after TVR in relationto timeintervalafter TVR
Acknowledgement
The authors gratefully acknowledge secretarial help of Mrs. Norma Sill.
Downloaded by: Universite Laval. Copyrighted material.
234
Tricusp id Val ve Replacement: Factors Influencing Early and Late Mort ality
• Ab e. T.. M. Tukamoto. M. Yanagiya. M. Mo rlkau-a. N. Wa tanabe. and S. Komatsu: De Vega' s annuloplasty for acqui red tr icuspid
l
3
4
5
1'1
7
8
q
10
disea se: Early and late results in 110 patients. Ann . Thora c. Surg . 48 (1989) 670-676 Hache . fl. J.• A H. L. From . A R. Castaneda. C. R. Jorqe rson. and Y. Wang : Late thrombotic obstruction with Star r-Edwa rds prosthesis. ChesI6 1{1972 )613-6 16 8j ,,,k. v. 0.. A Henz. a ndA Pet erffya : Cana mechan ical hear t valve be used in tricusp id position? Experience with Bj erk-Shiley tilting disc valve in 70 patien ts. Eur. Heart J. 1 (1980155 -61 Chidam baram. M.. S. A Abdulali, B. G. Ba ciga. and M. lones cu. Long-term results of De Vega tricuspid an nuloplasty. Ann. Thorac. Surg. 43 (1987) 185- 188 Cohanog lu. A . and A Starr: Tricuspid valve su rgery: Indications. methods and results. Cardiovasc. Clinic (valvular Ileart Disease) 16 (1986) 1', 2 375- 387 Grondin . P.. G. Lap age. Y. Costanguay. and C. Me ere: The tri cusp id valve: A surgical challenge. J. Thorac. Cardiovasc. Surg . 53 (1967) 7-20 ltorotoitz. M. S.: Porcine heterografts in tricus pid position . Am. J . Ca rdio\. 42 (1978) 691 Kay . G. L.. S. Morita. M . Mendez. A Zubiate, and J. II. Kay : Tricuspid regurgitation ass ociated with mitra l valve disease: Repair and replacement. Ann. Thorac. Surg. 48 (1989) 593-595 Klep etk oto, lV.. M . Kticpe ra. G. Kren ik: H. Magom etsch nig. J. M iczoc n. C. Muller. and E. Domanig: Functional tricusp id insufficiency: conservative or operative management . Thorac Ca rdlovasc . Surgeon 33 (1985) 167 - 172 King. fl. M.. H. V.Sc haff. G. K. Danielson. B. J. Gersh. 1: A. Ors zu tak; J. M. A chier. F. J. Puga. and J. fl. Plut h: Surge ry for tr icuspid regurgitation late after mitral valve replacement. Circulation 70 (1984) Suppl. L 193 -19 7
w: Step henson: Indications and resu lts of tricus pid valve replacement. Adv. Cardiel. 17 (19761 199 - 206 12 Ma cmanus. Q.. G. Grunkem eir. and A. Starr: Late results of tripl e valve replacem en t: a 14 year review. Ann. Thorac . Surg . 25(1 978) 402-406 13 Mestres. C. A. . A/gual. and M. Mur tr a: The Bjork-Shiley tilting disc valve in tricusp id position, 10 year experience. Scand . J. Thora c. Cardiovasc. Surg. 17 (1983) 197- 199 .4 Plu th. J. fl.. and F. ll. Ellis : Tricuspid ins ufficiency in patients und ergoing mitral valve replacement. J . Thorac. Cardiovasc. Surg. 58 (1969) 484-491 15 Riv era, R.. E. Dur an. andM. Aj uria: Carpentier's flexible ring vers us De Vega 's annulcplasty:A prospective randcmised study. J . Thorac. Ca rdiovasc. Surg. 89 (19851196- 203 11'1 Scnfeilppo. P. M .• E. R. Giuliani, G. K.Dunielson . fl./J. Walla ce. I': R. Pluth . and D. w: McGoon: Tricuspid valve prosthetic replacemen t. ear ly and late results with Starr -Edwards prosthesis. J. Thorac. Cardiovasc. Surg. 71 (1976) 441 -445 17 Singh. A. K.. I-: D. Christian. and D. O. Wi lliams: Follow up asse ssment ofSt. Jud e medical prosthetic valve in tricuspid position. Ann . Thora c. Surg. 37 (1984) 324-327 18 Tho rburn . P.. J . J . Morga n. M. X. S na nhan. and V. P. Chang : Longterm resu lts ofTVRand the prob lem of prostheti c valve thrombosis. Am. J. Cardio\. 51 (1983) 1128-11 32 Iq Yur cha k. P. M.. W M. Daqeu. and M . J. Buckley: Predictors of surviva l after tricuspid valve su rgery. Am. J . Cardiel. 54 09841 137- 141 11
235
Kouchoukos . N. T..and L.
Mr. T. K. Kaul
Royal Devon a nd Exeter Ilospital Iw onfordl Barr ack Road Exeter. EX2 SDW U. K.
Downloaded by: Universite Laval. Copyrighted material.
Referen ces
Thom e. eardi0l1ose. S urgeo1l38 ( 1990)
