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Eur J Cardiothorac Surg 2001;20:577-582
© 2001 Elsevier Science NL

Tricuspid valve surgery for functional tricuspid valve regurgitation associated with left-sided valvular disease

Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Chuo-ku, Sapporo 060-0061, Japan

Received 25 October 2000; received in revised form 8 March 2001; accepted 4 May 2001.

Corresponding author. Tel.: +81-11-611-2111, ext. 3312; fax: +81-11-613-7318
e-mail: kuwaki{at}sapmed.ac.jp

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Objectives: We have reviewed 260 patients who underwent initial tricuspid valve surgery for functional tricuspid valve regurgitation (TR) and analyzed independent predictors for early and late unfavorable results. Materials and methods: Between 1981 and 1998, 260 tricuspid valve operations were performed for functional TR. There were 94 males and 166 females with a mean age of 55 years. The tricuspid valve surgery procedures consisted of De Vega tricuspid annuloplasty in 240 patients, ring annuloplasty in four patients, and tricuspid valve replacement in 16 patients. The mean duration of follow-up was 7.8 years. Results: Hospital mortality was 8.9% (23 patients). Late deaths occurred in 34 patients including cardiac-related late deaths in 26 patients. The survival rates were 83±2% at 5 years and 78±3% at 10 years. Late tricuspid valve reoperation was performed on 13 patients due to residual or recurrent TR in 12 patients and thrombosed tricuspid bileaflet mechanical valve in one patient. The tricuspid valve reoperation-free survival rate was 90±2% at 5 years and 84±3% at 10 years. The only predictor of hospital mortality was preoperative highly elevated right atrial pressure (P=0.01). Variables predictive of cardiac-related late death were preoperative New York Heart Association (NYHA) class IV (P=0.01) and poor left ventricular ejection fraction (LVEF) (P=0.02). Residual TR of more than grade 2+ early after tricuspid annuloplasty was a significant risk factor for late tricuspid valve reoperation (P=0.01). Preoperative TR of grade 4+ was predictive of early residual TR (P=0.04). Conclusions: Tricuspid valve surgery for functional TR can be performed with acceptable levels of early mortality. Cardiac-related late mortality after tricuspid surgery may be improved by earlier surgical treatment before NYHA class IV or deterioration of LVEF occurs. To prevent late tricuspid reoperation, it is important not to leave residual TR of grade 2+ or more after tricuspid annuloplasty.

Key Words: Tricuspid valve regurgitation • Tricuspid valve surgery • Predictor of surgical results

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Surgical treatment of functional tricuspid valve regurgitation (TR) with left-sided valvular disease still remains a challenge for the cardiac surgeon. Uncorrected functional TR after repair of left-sided valvular lesion has been reported to have an adverse effect on early and late results [1–3]. Thus, surgical management of moderate to severe functional TR is now widely recommended to achieve better early and late clinical outcome [1–5]. However, evaluation of tricuspid valve surgery has been performed less frequently than that of left-sided valve surgery, and the influence of preoperative and intraoperative parameters on unfavorable results is still unclear.

We have reviewed our experience with 260 patients who underwent initial tricuspid valve surgery to define clearly the early and long-term clinical outcome and to analyze independent predictors of adverse results.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
From August 1981 to November 1998, 260 patients underwent primary tricuspid valve surgery for functional TR at Sapporo Medical University Hospital. Patients with tricuspid valve disease associated with congenital heart disease were excluded from this study. Preoperative patients' characteristics and hemodynamic data are shown in Tables 1 and 2, respectively.

The mean duration of follow-up excluding the 23 hospital deaths was 7.8 years (range 83 days to 18.2 years), and the cumulative follow-up was 1766.9 patient years. Ten patients were lost to follow-up, and the completeness of follow-up was 96%. Follow-up data were obtained from outpatient medical records in our hospital or through telephone contacts with either patients or referring physicians.

Statistical analysis was performed with StatView 5.0 software (Abacus Concept Inc., Berkeley, CA). We analyzed the influence of the following variables on hospital deaths, cardiac-related late deaths and late tricuspid reoperation: age, gender, NYHA class, LVEF, cardiac index (CI), TR grade, hepatomegaly, mean RA pressure, systolic PA pressure, mean PA pressure, mean PAW pressure, PAR, RVEDP, renal insufficiency, hepatic dysfunction, COPD, previous cardiac surgery, year of operation, aortic cross-clamp time, cardiopulmonary bypass time, myocardial protection, concomitant CABG, concomitant mitral valve repair for mitral regurgitation, concomitant OMC, concomitant MVR, and early residual grade 2+ or 3+ TR. We used three types of surgical technique to repair the functional TR: (1) De Vega procedure (240 patients; 92%); (2) TVR (16 patients; 6%); (3) ring annuloplasty (four patients; 2%). Because the latter two groups were too small to compare with the main group of the De Vega procedure, the types of tricuspid surgical procedures were not selected as variables examined in this study.

Time-dependent events including cardiac-related late deaths and late tricuspid valve reoperation were evaluated by univariate analysis of the log-rank test and the stepwise Cox proportional hazards multivariate model. Analysis of hospital deaths and residual TR early after tricuspid annuloplasty was carried out with the ²-test or Fisher's exact test and the multivariate logistic regression model. The variables with a P value of less than 0.1 on univariate analysis were entered into a multivariate analysis. A P value of less than 0.05 was considered significant. Survival and event-free curves were described by the Kaplan–Meier method. The probability estimates are expressed as the mean±standard error, and the continuous data are expressed as the mean±standard deviation.

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
3.1. Hospital mortality
Twenty-three patients died during hospitalization, giving a hospital mortality rate of 8.9%. The causes of hospital death were low cardiac output syndrome in 15 patients (66%), cerebrovascular event in two patients (9%), and multiple organ failure, bleeding, left ventricular rupture, mediastinitis, rupture of esophageal varices, and gastrointestinal bleeding each in one patient (26%).

Univariate analysis revealed age, gender, NYHA class, TR grade, mean RA pressure, liver dysfunction, COPD, aortic cross-clamp time, and cardiopulmonary bypass time as variables with a P value of less than 0.1. With the multivariate logistic regression analysis, a mean RA pressure of 15.0 mmHg (odds ratio, 5.6; 95% confidence interval, 1.7–78, P=0.01) was identified as an independent predictor of hospital deaths after tricuspid valve surgery (Table 4).

View larger version (19K): [in this window] [in a new window]   Fig. 1. Freedom from tricuspid reoperation, cardiac death, overall death, and all events after initial tricuspid valve operation. Freedom rates at 5 and 10 years are given.

3.3. Late cardiac reoperation
Forty-one late cardiac reoperations were performed in 40 patients during the follow-up period. The linearized rate of late cardiac reoperation was 2.3%/patient year. The procedures of reoperation consisted of valvular surgery in 36 patients, coronary artery surgery in one patient, aortic surgery in one patient, arrhythmic surgery in one patient, and others in two patients. Among these 40 patients, late tricuspid valve reoperations were required in 12 patients who had undergone a De Vega tricuspid annuloplasty at initial tricuspid operation and in one patient who had had a TVR with a bileaflet mechanical prosthesis. The indication for tricuspid reoperation was recurrent or residual TR in 12 patients (2+ TR, three patients; 3+ TR, six patients; 4+ TR, three patients) and thrombosed tricuspid bileaflet mechanical prosthesis in one patient. The procedures for tricuspid reoperations were as follows: TVR in nine patients (69%), ring annuloplasty in three patients (23%), and re-De Vega annuloplasty in one patient (8%). Five patients underwent isolated tricuspid reoperation, but eight patients had associated left-sided valvular procedures including mitral valve replacement in seven patients, aortic valve replacement in three patients, and re-OMC in one patient. The interval from initial tricuspid operation to tricuspid reoperation was from 1.7 to 13 years with a mean of 7.3 years. Three of 13 patients did not survive tricuspid reoperation (23%) due to postoperative cardiac failure. The tricuspid reoperation-free survival rate, including cases of hospital death, was 90±2% at 5 years and 84±3% at 10 years (Fig. 1). The linearized rate of late tricuspid reoperation was 0.7%/patient year.

Univariate analysis revealed LVEF, mean RA pressure, systolic PA pressure, year of operation, associated OMC, associated MVR, and residual TR early after tricuspid annuloplasty as variables with a P value of less than 0.1. By stepwise Cox proportional hazards multivariate analysis, residual TR early after tricuspid annuloplasty (P=0.01) was identified as an independent predictor for late tricuspid valve reoperation (Table 5). The tricuspid valve reoperation-free rate was 85±6% at 10 years for patients with residual TR (grade 2+ or 3+) early after tricuspid annuloplasty and 96±3% for those with no residual TR (non or grade 1+) (P=0.002, log-rank test).

3.4. Residual tricuspid regurgitation early after tricuspid annuloplasty
Residual TR early after reconstructive tricuspid annuloplasty is a major concern. We evaluated the effect of the previously described preoperative and intraoperative variables on the occurrence of residual TR (grade 2+ or more) early after tricuspid annuloplasty, which was evaluated by echocardiography between 7 days and 1 month after operation. One hundred ninety-four of 244 patients who underwent De Vega or ring tricuspid annuloplasty had echocardiographic evaluation between 7 days and 1 month after operation. Of them, 49 patients (25%) were found to have grade 2+ or 3+ TR. No patients had grade 4+ TR early after operation. Univariate analysis demonstrated gender, TR grade, hepatomegaly, mean RA pressure, year of operation, and mitral valve repair for mitral regurgitation as possible risk factors (P0.1) for grade 2+ or 3+ residual TR. By multivariate logistic regression analysis, preoperative TR grade 4+ (odds ratio, 2.4; 95% confidence interval, 1.0–5.8, P=0.04) was identified as an independent predictor of early postoperative residual TR after tricuspid annuloplasty (Table 4).

3.5. Late major complications
Twenty-three major late complications other than cardiac reoperations and cardiac-related late deaths were recognized during the follow-up period. They were as follows: cerebrovascular events in 13 patients (infarction in nine patients, bleeding in four patients), bleeding events in three patients, prosthetic valve endocarditis in three patients, thrombosed valve in three patients, and acute myocardial infarction in one patient. The incidence of major late complications was as follows: thromboembolism, 0.6%/patient year; bleeding, 0.4%/patient year; infective endocarditis, 0.4%/patient year; thrombosed valve 0.4%/patient year. When hospital deaths, cardiac-related late deaths, all late cardiac reoperations, late bleeding and thromboembolism, and infective endocarditis were taken into account as events, all event-free survival was 76±3% at 5 years and 62±4% at 10 years (Fig. 1).

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Treatment of functional TR with left-sided valvular disease still remains an important issue in cardiac surgery because there are several uncertainties regarding its accurate diagnosis, surgical indication, appropriate surgical procedure, and late results of surgical treatment. Previous literatures have reported that significant TR, if left uncorrected at the time of operation for left-sided valvular disease, would lead to a risk factor for unfavorable results [1–3]. Many investigators have recommended surgical treatment of moderate to severe TR to obtain a better prognosis [1–5], but a mild degree of functional TR could be expected to diminish after surgical relief of left-side valve pathology [6]. This retrospective report was performed to evaluate the early and long-term outcome of our initial tricuspid valve surgery in 260 patients with functional TR.

The hospital mortality in our series was 8.9%, which is comparable to that of 14.7–28% in other series of tricuspid surgery [7–9]. The most common cause of hospital death in our patients was congestive heart failure. Previous studies have shown that advanced preoperative NYHA class, previous cardiac operation, preoperative hepatomegaly, and advanced age at operation were significantly associated with increased hospital mortality after tricuspid surgery [4,8,10,11]. In this study, we found a mean RA pressure of 15 mmHg to be an independent predictor of hospital mortality. Hospital mortality was 28 and 5% for patients with a preoperative mean RA pressure of 15 mmHg and those with a mean RA pressure of 14.9 mmHg, respectively. Advanced elevation of RA pressure represents right heart failure, but no significant association was detected between various parameters of right heart dysfunction except for high RA pressure and hospital death in this study.

Of 34 patients who died in the late postoperative periods, 26 deaths were classified as cardiac-related late death. In this study, preoperative NYHA class IV and lower ejection fraction (EF) were identified as independent predictors of cardiac-related late death. Advanced cardiomyopathy due to multivalvular disease with functional TR might be the reason for these poor survival rates of patients with preoperative NYHA class IV or lower LVEF despite successful surgical management. Thus, earlier operation for patients with functional TR, before they reach such a deteriorated condition, should be performed to improve long-term survival. Severe deterioration of right ventricular function has been proposed to be an another important factor influencing late results of tricuspid valve surgery. However, in some previous literature on tricuspid valve surgery [11,12] as well as in this study, analysis of preoperative right ventricular function was not able to predict late outcome. This result might be explained by the difficulties of accurate assessment of right ventricular function.

Thirteen patients in this series required late tricuspid reoperation due to recurrent TR in 12 patients and thrombosis of bileaflet mechanical prosthesis in one patient. McGrath et al. [8] demonstrated that preoperative hepatomegaly, Kay's plication, and bicuspidization plication were the independent predictors of tricuspid reoperation. In this study, residual TR early after tricuspid annuloplasty was found to be predictive of late tricuspid reoperation.

Follow-up echocardiography in patients with early residual TR, which was performed from 1 to 16 years (mean 7.1 years) after the initial tricuspid surgery, showed that the severity of residual TR was unchanged in 29 patients, increased in 15, and decreased in only one. The majority of the residual TRs in the early postoperative period persisted in the same degree or deteriorated in the follow-up period. Czer et al. [13] also reported that there was no significant change in residual tricuspid regurgitation in late follow-up study up to 22 weeks postoperatively when compared with the immediate postoperative study in 18 patients with tricuspid annuloplasty. Previous literature has reported that recurrence of left-sided valvular disease, advanced right ventricular dysfunction, postoperative pulmonary artery pressure, postoperative pulmonary artery resistance, and severity of preoperative TR were important factors for residual or recurrent TR [3,4,12,14,15]. Therefore, multiple factors may be responsible for the development of residual or recurrent TR after tricuspid valve surgery. In this study, preoperative TR grade 4+ was identified as an independent predictor of residual TR early after tricuspid annuloplasty. Duran [16] and Chon [17] recommended De Vega tricuspid annuloplasty for patients with mild and moderate functional TR, and ring annuloplasty for those with severe functional TR to achieve a competent tricuspid valve. Duran [16] stated that any type of partial suture encircling annuloplasty might not stand the continuous and permanent stress on the annulus in severe functional TR.

In conclusion, the early and late outcomes (hospital mortality, 8.9%; overall survival including hospital death, 78±3% at 10 years) of our surgical treatment for functional TR were acceptable, but the early result in selected patients with preoperative highly elevated RA pressure was unsatisfactory (hospital mortality, 28%). Earlier surgical management for patients with functional TR before the development of NYHA class IV and/or poor LVEF would decrease the number of cardiac-related late deaths. To prevent late tricuspid reoperation, it is important not to leave residual TR of grade 2+ or more after tricuspid valve operation.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kiyofumi Morishita Tomio Abe Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kuwaki, K. Articles by Abe, T. Search for Related Content PubMed PubMed Citation Articles by Kuwaki, K. Articles by Abe, T. Related Collections Valve disease