Characteristic
Replacement
Repair
Number of patients
3,662
13,299
Follow up (years)
4.2 ± 4.3
4.7 ± 4.0
Age (years)
51.0 ± 13.8
58.9 ± 12.4
Male
34%
42%
Previous heart surgery
54%
31%
NYHA I–II
16%
32%
NYHA III–IV
84%
68%
Etiology
Functional (%)
15.4%
84.9%
Primary disease (%)
84.3%
14.3%
– Congenitala
31.3%
51.9%
– Endocarditisa
7.3%
4.4%
– Degenerationa
7.4%
3.3%
– Rheumatica
34.6%
29.7%
– Carcinoida
13.4%
0.0%
– Iatrogena
1.3%
1.3%
– Degenerated prosthesisa
3.9%
0.2%
Unknown (%)
0.3%
0.9%
Outcomes
Pooled early morality is 4.4% (95% CI [3.6—5.3%]). Late outcomes are shown in Table 16.2. Late mortality is substantial and nearly half of all deaths are cardiac.
Table 16.2
Late outcomes of tricuspid valve repair
Outcome | LOR | 95% CI |
|---|---|---|
Late mortality | 2.6%/year | 2.1–3.4 |
Late cardiac mortality | 1.1%/year | 0.8–1.7 |
Late valve-related mortality | 0.6%/year | 0.4–1.0 |
Reintervention | 0.6%/year | 0.2–0.4 |
Low cardiac output syndrome occurrs in 9.3% (95% CI[6.6%–13.2%]) of cases and the risk of early (<30 days) pacemaker implantation is 3.4% (95% CI[2.4–4.8%]). An early reintervention is necessary in 1 out of 100 patients.
Late pacemaker implantation rate is 0.8%/year (95% CI[0.5%/–1.2%/year]). Late reintervention rate is relatively low (0.6%/year). Pooled estimate shows that late endocarditis of the repaired tricuspid valve is rare (0.2%/year).
Tricuspid Valve Replacement
Tricuspid valve replacement is generally reserved for cases in which tricuspid valve repair is not technically feasible or when a tricuspid repair fails. The systematic review included 37 publications, 12 on mechanical and 15 on bioprosthetic valve replacement and 13 mixed. [9, 13, 16, 27, 30, 35, 40, 42, 48, 50, 55, 60–62, 67, 69, 79, 81, 88, 92, 94, 96–98, 100, 102, 103, 108, 111, 119, 128, 131, 132, 134, 135, 146–148].
Patient Presentation and Intraoperative Details
Patient characteristics and etiology are shown in Table 16.1. Notably, more than half of the patients has undergone previous heart surgery. Primary tricuspid valve disease is the most common etiology. Isolated tricuspid valve regurgitation is present in 85.7%, isolated stenosis in 4.5% of patients, and 9.8% of patients present with combined stenosis and regurgitation. Ascites prior surgery is present in almost a quarter of patients at the time of surgery. Atrial fibrillation is present in approximately half of the patients. Mean pooled systolic pulmonary artery pressure is 47.1 ± 14.4 mm Hg. Approximately half of patients undergo at least one concomitant procedure, mostly mitral valve (36%), aortic valve (23%) and/or pulmonary valve (13%) procedures.
A bioprosthesis is implanted in 72% of patients and a mechanical prosthesis in 28%. None of the patients received an allograft. Patients receiving a bioprosthesis are generally younger (41.6 ± 16.2 years) compared with patients receiving a mechanical prosthesis (49.6 ± 13.1 years). This can be explained by the fact that patients receiving a bioprosthesis are diagnosed with congenital tricuspid disease more frequently than those receiving a mechanical prosthesis (72.5% vs. 22.2%). In the bioprostheses group 59.3% were female versus 76.7% in the mechanical group. Patients receiving a mechanical prosthesis underwent prior heart surgery more frequently compared with patients receiving a bioprosthesis (72.9 vs. 35.3%).
Outcome
Pooled early mortality risk is 14.5% (95% CI [11.9–17.3%]). This risk is markedly higher than in mitral and aortic valve replacement [149, 150]. The high early mortality may be explained in part by the poor preoperative state of patients, characterized by a high prevalence of ascites and poor functional status (NYHA class III-IV). Early mortality has declined significantly in more recent years of surgery (odds ratio/10 years [0.73 (95% CI: 0.57–0.93]).
Low cardiac output syndrome occurred in 22.2% (95% CI [15.7–31.3%]) of patients. Early pacemaker implantation risk is 11.0% (95% CI [7.7–15.6%]) and late pacemaker implantation rate is 1.2%/year (95% CI [0.5–2.9%]). This can partly be explained by the close proximity of the atrioventricular conduction system to the tricuspid valve annulus. As a result, tricuspid valve replacement can cause a total atrioventricular block.
Late outcomes are presented in Table 16.3. Late mortality is substantial and the majority is cardiac. However, valve-related death is relatively low. Reintervention rate is 1.1%/year. Endocarditis of the tricuspid valve is also occurs rarely.
Table 16.3
Late outcomes after tricuspid valve replacement stratified by prosthesis type
Outcome | LOR Overall (95% CI) | LOR Bioprosthesis (95% CI) | LOR Mechanical prosthesis (95% CI) |
|---|---|---|---|
Number of publications | 37 | 15 | 13 |
Late mortality | 3.9%/year (3.1–4.8) | 2.8%/year (1.7–4.7) | 3.1%/year (1.9–5.1) |
Cardiac death | 1.7%/year (1.3–2.4) | 1.1%/year (0.5–2.3) | 1.0%/year (0.5–2.3) |
Valve-related mortality | 0.3%/year (0.2–0.6) | 0.3%/year (0.1–0.9) | 0.2%/year (0.0–0.9) |
Reintervention | 1.1%/year (0.8–1.5) | 1.2%/year (0.7–2.0) | 0.9%/year (0.5–1.6) |
Thromboembolism | 0.4%/year (0.2–0.7) | 0.3%/year (0.1–0.7) | 0.6%/year (0.2–1.6) |
Bleeding | 1.2%/year (0.8–1.7) | 0.6%/year (0.4–1.1) | 2.2%/year (1.2–4.2) |
SVD | 0.9%/year (0.6–1.3) | 1.1%/year (0.6–2.0) | 0.2%/year (0.1–0.6) |
NSVD | 0.2%/year (0.1–0.4) | 0.2%/year (0.1–0.4) | 0.3%/year (0.1–1.0) |
Valve thrombosis | 0.9%/year (0.6–1.3) | 0.2%/year (0.1–0.7) | 1.8%/year (1.1–3.0) |
Endocarditis | 0.2%/year (0.1–0.4) | 0.2%/year (0.1–0.5) | 0.4%/year (0.1–1.2) |
Outcomes of Bioprosthesis vs. Mechanical Prosthesis
Pooled early mortality for bioprosthesis is 14.0% (95% CI [9.2–21.4%]) and 14.1% (95% CI [9.0–21.0%]) for mechanical prosthesis. However, the substantial preoperative differences between patients receiving a bioprosthesis and those receiving a mechanical prosthesis preclude direct comparison of outcome between these prostheses.
Late outcomes are presented in Table 16.3. Bioprostheses are characterized by a high rate of SVD and subsequent reintervention and low, but not absent, rates of NSVD and valve thrombosis. On the contrary, mechanical prostheses are exceptionally durable in design, but require lifelong anticoagulation due to their thrombogenicity. This is reflected in the high rates of bleeding and valve thrombosis, but low rates of SVD. In conclusion, anticoagulation-related events remain an important limitation of mechanical valves. Most importantly, the lower risk of SVD compared to bioprostheses does not translate to a considerably lower risk of reintervention. This is due to the higher incidence of other indications for reintervention, in particular valve thrombosis. Thus, although valve thrombosis may often be successfully treated with thrombolytics, as evidenced by the low reintervention and valve-related mortality rates relative to the higher valve thrombosis rate, valve thrombosis still gives rise to a substantial reintervention risk in patients with a mechanical valve, which largely negates the advantage of the increased durability compared to bioprostheses.
Functional Tricuspid Regurgitation
Secondary tricuspid regurgitation , more commonly known as functional tricuspid regurgitation, is the most prevalent form of tricuspid valve disease [139]. Functional tricuspid regurgitation is defined as regurgitation with apparently normal leaflets and chords due to annular dilation of the tricuspid valve, mostly due to left sided valve disease [151]. Sometimes tethering is also present [152]. Functional tricuspid regurgitation (functional TR) has been found to be an independent risk factor for long term mortality [153]. Therefore, it has become common practice to repair the tricuspid valve during mitral valve surgery when deemed necessary. Among 46.500 mitral valve operations in the USA between 2011 and 2014, 4% of patients with no or mild TR underwent concomitant tricuspid valve repair, 35% of patients with moderate TR and 79% of patients with severe TR [154]. The systematic review for functional tricuspid disease encompassed 52 publications [7, 8, 10, 14, 18, 19, 22, 23, 28, 33, 34, 39, 45, 52, 54, 56, 63, 64, 66, 70–77, 80, 82, 84, 86, 90, 91, 93, 95, 105, 107, 112, 114, 115, 117, 121–123, 127, 129, 155–158].
Patient Presentation and Intraoperative Details
Characteristics are shown in Table 16.4. Notably, 6 out of 10 patients present with atrial fibrillation, probably due to the large proportion of patients with concomitant mitral valve disease. Only 79% of patients actually present with moderate or greater tricuspid regurgitation. This is due to the fact that current guidelines recommend tricuspid valve surgery if there is tricuspid annular dilatation of >40 mm, even when there is less than moderate tricuspid regurgitation, because this can help in prevent progressive regurgitation [159]. None of the patients presents with tricuspid stenosis. Intraoperative characteristics are presented in Table 16.5. The tricuspid valve is repaired in the vast majority of patients (99%), whereas replacement is performed rarely. Nearly all patients undergo concomitant surgery, usually a mitral valve operation. Some patients undergo multiple concomitant procedures, with a mean of 1.6 procedures per patient. Pulmonary valve procedures and tricuspid valve surgery for functional disease are rarely performed concomitantly.
Table 16.4
Pooled characteristics of functional TR, rheumatic tricuspid valve disease and congenital tricuspid valve disease
Characteristic | Functional | Rheumatic | Congential |
|---|---|---|---|
Number of patients | 10,558 | 1,808 | 1,555 |
Follow up (years) | 3.7 ± 2,4 | 10.4 ± 7.4 | 5.8 ± 5.0 |
Age (years) | 62.8 ± 11.8 | 45.3 ± 12.1 | 21.6 ± 15.8 |
Male | 46% | 23% | 51% |
Previous heart surgery | 29% | 23% | 25% |
NYHA I–II | 35% | 15% | 37% |
NYHA III-IV | 65% | 85% | 63% |
Table 16.5
Pooled intraoperative characteristics of functional TR, rheumatic tricuspid valve disease and congenital tricuspid valve disease
Intraoperative | Functional | Rheumatic | Congenital |
|---|---|---|---|
Repair (%) | 99% | 88% | 70% |
Replacement (%) | 1% | 12% | 30% |
Concomitant procedure (%)a | 98% | 98% | 88% |
–MV procedureb | 91.3% | 97.3% | 1.5% |
–AV proceduresb | 18.4% | 74.8% | 0.0% |
–PV proceduresb | 0.4% | 0.0% | 4.4% |
–Mazeb | 22.3% | 0.0% | 10.1% |
–CABGb | 19.3% | 0.5% | 0.8% |
–ASD/VSD closureb | 1.7% | 0.0% | 69.8% |
Outcome
Early mortality is 3.6% (95% CI [2.9– 4.5%]). The STS database describes a cohort of 21,056 double mitral and tricuspid valve procedures. For tricuspid valve repair concomitant with mitral valve replacement and repair, respectively, they report an operative mortality of 10.3% and 8.0%. The discrepancy between present meta-analysis and this study may be explained in part by the large proportion of non-elective surgeries in the STS cohort (31% and 29%), whereas only 5.8% of surgeries in this meta-analysis were non-elective [160]. Also, the STS database includes all etiologies. Late outcomes are presented in Table 16.6. Tricuspid valve surgery for functional disease is associated with high late mortality, with a vast majority being cardiac.
Table 16.6
Late outcome after surgery for functional tricuspid valve disease
Outcome | LOR | 95% CI |
|---|---|---|
Late mortality | 2.7%/year | 2.1–3.4 |
Late cardiac mortality | 1.1%/year | 0.8–1.7 |
Late valve-related mortality | 0.6%/year | 0.4–1.0 |
Reintervention | 0.3%/year | 0.2–0.4 |
Pacemaker implantation is a common complication after tricuspid valve surgery for functional tricuspid regurgitation, as evidenced by the pooled estimate of early pacemaker implantation risk in the systematic review of 3.6% (95% CI [2.5–5.3%]) and a late pacemaker implantation hazard rate of 0.7%/year (95% CI [0.3–1.3%]).
Reintervention rate is low, only 0.3%/year. The reintervention rate alone suggests that surgery for functional tricuspid disease is associated with exceptional durability. However, taking hemodynamic dysfunction into account besides reintervention, paints a different picture. Overall hazard of valve dysfunction, defined as recurrent tricuspid regurgitation graded as moderate or severe or the necessity for an reintervention is 2.2%/year, which indicates a suboptimal result after tricuspid valve surgery for functional disease.
Little is known about outcomes related to replacement of the tricuspid valve for functional TR, but Huang et al. described patients who received a tricuspid valve replacement for functional TR and reported a valve thrombosis rate of 0.2%/year and structural valve deterioration (SVD) and non-structural valve deterioration (NSVD) each occurred at a rate of 0.2%/year [19].
In summary, surgery for functional tricuspid regurgitation is associated with acceptable early mortality and late outcomes are characterized by a considerable occurence of valve dysfunction, with a low rate of subsequent reintervention.
Rheumatic Tricuspid Valve Disease
The prevalence of rheumatic heart disease has declined rapidly in industrialized and developed countries [161]. However, in third world countries the prevalence of rheumatic heart disease and subsequently the prevalence of rheumatic tricuspid valve disease remains high [162]. The systematic search of the literature resulted in seven publications [27, 31, 49, 99, 104, 144, 146], most of which originate from developing countries.
Patient Presentation and Intraoperative Details
Patient characteristics are presented in Table 16.4. In the included studies 77% is female. This is remarkable because no distinct gender difference in the incidence of rheumatic valve disease has been described in prior epidemiologic studies [162, 163]. Patients present in 84.6% of cases with isolated regurgitation, 8.6% with isolated stenosis and 6.8% with combined stenosis and regurgitation. Intraoperative details are presented in Table 16.5. When the valve is replaced, bioprostheses are used (60%) more frequently than mechanical prostheses (40%). Nearly all patients undergo concomitant surgery. Both mitral valve surgery and aortic valve surgery are performed frequently. Hence, most patients undergo triple valve surgery. The pulmonary valve is not operated on in this group of patients.
Outcomes
Pooled early mortality of rheumatic tricuspid valve disease is 7.4% (95% CI [5.5–10.1%]). Late outcomes are presented in Table 16.7. Late mortality is excessive, with most patients dying from cardiac causes. Almost a third of cardiac deaths are valve-related.
Table 16.7
Late outcomes after surgery for rheumatic tricuspid valve disease
Outcome | LOR | 95% CI |
|---|---|---|
Late mortality | 3.2%/year | 2.4–4.1 |
Late cardiac mortality | 2.5%/year | 2.0–3.4 |
Late valve-related mortality | 0.9%/year | 0.6–1.5 |
Reintervention | 0.8%/year | 0.6–1.2 |
Bleeding | 1.2%/year | 0.8–1.5 |
Replacement | ||
SVDa | 0.4%/year | 0.2–0.6 |
NSVDa | 0.2%/year | 0.1–0.5 |
Valve thrombosisa | 0.2%/year | 0.1–0.5 |
Of the patients that undergo valve replacement, 40% received a mechanical prosthesis, which requires lifelong anticoagulation. Additionally, a proportion of patients in which the tricuspid valve is repaired, may have undergone concomitant mechanical mitral and/or aortic valve replacement, which may explain the high rate of bleeding in these patients.
In summary, surgery for rheumatic tricuspid valve disease is associated with high early and late mortality and late complications is characterized by bleeding.
Congenital Tricuspid Valve Disease
Congenital defects of the tricuspid valve are rare when compared to other congenital heart disease [164]. Generally, three entities of congenital tricuspid valve disease are recognized: Ebstein’s anomaly , tricuspid valve dysplasia, hypoplasia or cleft and double orifice tricuspid valve [154]. The latter two are extremely rare and only a few cases have been reported to date [165, 166]. Ebstein’s anomaly is more prevalent with an incidence of 1 in 20,000 live births in the general population [167]. The systematic search of the literature resulted in 23 publications [12, 20, 21, 24, 29, 32, 41, 46, 50, 51, 83, 87, 101, 102, 110, 116, 118, 130, 133, 136, 137, 143, 168].
Patient Presentation and Intraoperative Details
Patient characteristics are presented in Table 16.4. Of all patients, 99.4% of patients is diagnosed with Ebstein’s anomaly. Patients are generally younger at the time of surgery than those with other etiologies of tricuspid valve disease. Approximately half of the patients is female, which is in line with the general belief that Ebstein’s anomaly has no predilection for either gender. 99.9% of patients present with isolated regurgitation and 0.1% of patients present with isolated stenosis. No patients present with combined stenosis and regurgitation. The intraoperative characteristics are presented in Table 16.5. The tricuspid valve is repaired in 7 out of 10 patients and replaced in 3 out of 10 patients. Of replacements in 85% a bioprosthesis is used and in 15% a mechanical prosthesis is used. Atrial and ventricular septal defect closure and other concomitant procedures are frequently performed in patients with Ebstein’s anomaly, with a mean of 2.2 procedures per patient.
Outcome
Pooled early mortality of congenital tricuspid disease is 4.0% (95% CI[2.6–6.2%]). Late mortality is low and deaths are mostly cardiac, a substantial proportion of which are valve-related. Late outcomes are presented in Table 16.8.
Table 16.8
Late outcomes of congenital tricuspid valve disease
Outcome | LOR | 95% CI |
|---|---|---|
Late mortality | 0.8%/year | 0.5–1.4 |
Late cardiac mortality | 0.6%/year | 0.4–1.1 |
Late valve-related mortality | 0.4%/year | 0.2–0.7 |
Reintervention | 1.4%/year | 0.9–2.2 |
Replacement | ||
SVDa | 1.0%/year | 0.4–3.0 |
NSVDa | 0.2%/year | 0.0–1.1 |
Valve thrombosisa | 0.4%/year | 0.1–1.9 |
Early reintervention (<30 days) is relatively frequent in these patients (2.8%), mostly due to early failure of the repair.
Late morbidity is characterized by high rates of SVD after valve replacement, which may be due in part to the frequent use of bioprostheses in this younger population and it has been previously described that younger age is associated with higher rates of SVD [169]. Furthermore, these younger patients with relatively favorable long-term survival are more likely to outlive the implanted prosthesis. Additionally, some repairs of tricuspid valve tend to fail over time. Subsequently, reintervention is frequent in these patients.
In summary, congenital tricuspid valve disease is associated with low late mortality, however some patients will eventually face a reoperation.
Carcinoid Disease of the Tricuspid Valve
Carcinoid heart disease may develop in patients with carcinoid syndrome, which is caused by the secretion of a range of vasoactive peptides by hepatic metastases of gastrointestinal carcinoid tumors. Symptoms of carcinoid heart syndrome are diarrhoea, flushing and bronchoconstriction [170].
Bhattachryya and colleagues reported on a series of 22 patients with carcinoid heart disease operated between 2006 and 2010. All tricuspid valves are replaced. In this series, 4 of 22 (18%) patients died within 30 days postoperative and actuarial 2-year survival is 44% ± 11.7%. During the follow up, one patient developed SVD (LOR 0.5 %/year) of the tricuspid valve but no patient required reintervention. NYHA class improvement with more than one grade is seen in 67% [111].
Another paper presented 195 patients operated between 1985 and 2012. All tricuspid valves are replaced. In this series overall 30-day mortality risk is 10%. After 2000 the 30-day mortality risk declines to 6% (8 deaths of 124 patients). Actuarial 10-year survival is 24%. During follow up, nine reinterventions on the tricuspid valve took place (during the initial intervention eight received a bioprosthesis and one received a mechanical prosthesis). NHYA class improvement is noted in 75% of patients that were in NYHA class III or IV preoperatively [132].
In conclusion, if patients undergo surgery for carcinoid tricuspid valve disease, a valve replacement is generally inevitable and long term prognosis is poor. However, with rapidly improving cancer treatment this may change in the near future.
Iatrogenic Damage of the Tricuspid Valve
The tricuspid valve may be damaged radiation or leads from a pacemaker or cardioverter-defibrillator (ICD) . Lin et al. reported on 41 patients with tricuspid valves damaged by pacemaker or ICD leads. In only 5 of 41 (12%) malfunction of the tricuspid valve is diagnosed pre-operatively by echocardiography. The tricuspid valve is replaced in 22 patients. One patient died in the early postoperative period (2.4%). During follow-up (mean 8.2 years) five patients died. Functional status according to the NYHA classification improved in all surviving patients [171].
Endocarditis of the Tricuspid Valve
The incidence of community acquired endocarditis ranges from 1.7 to 6.2 cases per 100,000 person years [172] and approximately 5–10% of overall endocarditis is right sided [173]. Endocarditis vegetations on the tricuspid valve often dislodge and cause pulmonary embolism. Therefore, in tricuspid valve endocarditis the presenting symptoms are more frequently pulmonary in nature rather than those of congestive heart failure. The majority of patients with right sided endocarditis are intravenous drug users, in whom Staphylococcus aureus is the most prevalent pathogen [174]. Among articles in our systematic literature review reporting on mixed etiology cohorts, endocarditis is diagnosed in 7.0% of patients. However, throughout literature only a few studies report on outcomes after tricuspid valve surgery for endocarditis specifically.
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