Asian Cardiovasc Thorac Ann 2004;12:369-371
© 2004 Asia Publishing EXchange Ltd
Triple Valve Replacement with Carpentier-Edwards Bioprostheses
Soma Guhathakurta, MCh,
Kotturathu M Cherian, FRACS
Unit of Frontier Life Line, International Centre for Cardiothoracic and Vascular Diseases, Chennai, India
For reprint information contact: Kotturathu M Cherian, FRACS Tel: 91 44 2656 7200 Fax: 91 44 2656 5150 Email: soma4828{at}yahoo.co.uk R 30C Ambattur Real Estate Road, Mogaippair, Chennai 600101, India.
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ABSTRACT
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We report a unique case of triple valve replacement with porcine bioprostheses in a young woman who remained asymptomatic 15 years later. Although in atrial fibrillation, she was taking only aspirin for anticoagulation until she delivered a normal child 2 years after surgery. Surprisingly, to date, her echocardiographic findings have remained the same as those after childbirth, and all the bioprostheses were functioning well, except for tricuspid annular calcification producing mild to moderate regurgitation.
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INTRODUCTION
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Triple valve replacement (TVR) surgery is an uncommon procedure, especially when bioprostheses are used. On the other hand, aortic and mitral valve replacement with tricuspid valve repair is commonly performed in India. We report a unique case of a woman who had TVR with bioprostheses 15 years ago and has remained asymptomatic since, despite the fact that there was no anticalcification treatment for bioprostheses in those days.
A 37-year-old female patient had been followed up regularly on an outpatient basis since undergoing TVR in 1988. At that time, as a 22-year-old, she began to experience New York Heart Association class III symptoms of breathlessness, fatigue, and palpitations. She gave a past history of rheumatic fever in her early childhood. Investigations revealed severe aortic stenosis with moderate regurgitation, mitral stenosis with moderate regurgitation, critical tricuspid stenosis with regurgitation, and atrial fibrillation (AF). Two-dimensional and M-mode echocardiograms showed severe subvalvular fusion of the mitral valve and of the tricuspid valve, which measured 1.25 cm in diameter when opened, with the papillary muscles fused to the ventricular wall, thus ruling out tricuspid valvotomy. Right heart catheterization revealed a significant provocable gradient across the tricuspid valve. Chest radiography showed a cardiothoracic ratio of 60%, signs of pulmonary hypertension, pulmonary venous engorgement, and left and right atrial enlargement.
The patient underwent TVR with Carpentier-Edwards bioprosthetic valves No. 21, 25, and 27 in the aortic, mitral, and tricuspid positions, respectively (Figure 1
). Surgery was performed under whole body hypothermia at 28°C, cold crystalloid cardioplegic arrest, and topical cooling with local ice slush. The patient was weaned from cardiopulmonary bypass without difficulty. The total cardiopulmonary bypass time was 102 minutes and aortic crossclamp time was 74 minutes. Postoperatively, infusions of 0.02 µg•kg–1•min–1 adrenaline and 5 µg•kg–1•min–1 dopamine with sodium nitroprusside were administered for 24 hours. The postoperative course was uneventful. Despite being in AF, she opted for the use of bioprostheses only and declined anticoagulation therapy, as she had just been married and intended to conceive. She delivered a healthy child without complications 2 years after the operation. Subsequently, in consideration of the presence of AF and the prosthetic valve in the tricuspid position, she was put on acitrome 2 mg and aspirin 75 mg daily. She was followed up every 6 months for the first 6 years and then annually, although she was asymptomatic.
During follow-up in October 2002, the patient complained of class I fatigue and revealed a swelling over the thyroid region. Investigations found hypothyroidism, and she was prescribed thyroxine. She did not have pedal or sacral edema and her jugular venous pressure was not raised, but she had a 4 cm palpable liver, which was firm yet not tender. Daily household chores and child-rearing did not appear to cause exertion, except when climbing stairs holding a heavy weight. On examination, she had AF, a controlled ventricular rate, systemic blood pressure of 110/70 mm Hg, as well as a grade 3/6 systolic murmur at the left sternal border and a mid-diastolic rumble at the left lower sternal border that were audible on auscultation. Her respiratory system appeared normal. The chest radiograph did not show any significant changes compared to films taken in recent years. The cardiothoracic ratio was 55%, and the lung fields appeared normal. Her liver function was within normal limits. Hemoglobin was 12.8 g•dL–1, and other basic blood parameters were within normal limits. Transesophageal echocardiography (TEE) showed normal functioning aortic, mitral, and tricuspid cusps, minimal calcific degeneration in the aortic and mitral annular areas but moderate calcification of the tricuspid annulus (Figure 2A), gradients across the tricuspid valve of 11 and 5 mm Hg, an effective valve area at the tricuspid position of 1.7 cm2, mild to moderate tricuspid regurgitation, good biventricular function, and an enlarged right atrium (Figure 2B). The TEE appeared similar to the postnatal TEE taken 12 years earlier, when the patient would have been expected to have a higher calcium turnover. She was prescribed spironolactone in addition to the existing medications of digoxin, acitrome, and furosemide.
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Figure 2. Echocardiograms showing (A) a calcified tricuspid annulus, the tricuspid valve opened in diastole, (B) the same valve closed in systole, and an enlarged right atrium. LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle, TV = tricuspid valve.
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DISCUSSION
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TVR is infrequently performed; instead, aortic and mitral valve replacement with tricuspid valve repair is preferred, as the outcome of TVR is not as satisfactory as single or double valve replacement.1 Tricuspid valve replacement remains the last resort in patients with tricuspid regurgitation and in the rare occurrence of tricuspid stenosis in which repair is not feasible or has failed.2 In our patient, the tricuspid valve presented with incompetence and severe stenosis with gross subvalvular fusion, ruling out valve repair. Few cases of TVR using a combination of different types of valves have been reported.1,3 It is well established that bioprosthetic valves in the aortic and mitral positions are associated with early degeneration and thus require early re-operation,3,4 although our patient had tricuspid annular calcification instead of aortic or mitral degeneration. On the other hand, experience with mechanical valves implanted in the tricuspid position has not been encouraging.5,6 Despite the drawbacks of mechanical prostheses; it would seem more advantageous to use all mechanical valves in order to minimize the risk of valve degeneration and therefore re-operation. Using a combination of mechanical and bioprosthetic valves in the same patient, especially if the patient has to be anticoagulated, imparts the disadvantages of both valve types and the advantages of neither.
Fifteen years ago, the Carpentier-Edwards bioprostheses available were of porcine origin only, and zero pressure fixation had not been developed. Despite these inadequacies, the bioprostheses in our patient were still functioning well after 15 years, and the tricuspid cusps were still pliable and opened well, although annular calcification had resulted in rigidity and thus regurgitation. Carpentier-Edwards pericardial bioprostheses have been found to offer good long-term outcomes;7 similar results have also been shown with Carpentier-Edwards and Hancock porcine bioprostheses.8 Our patient, in controlled AF, did not show any serious valve problems that warranted re-operation and was doing well with decongestive therapy. Her liver enlargement, in the absence of other signs of right heart failure, could be attributed to chronic tricuspid regurgitation and AF. Her recent lethargy may be related to hypothyroidism. If the lethargy subsides and the liver enlargement regresses with spironolactone therapy, she can probably retain a good quality of life with these valves for some time.
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ACKNOWLEDGMENTS
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We thank Dr. Renuka Naidu for her expert technical assistance on TEE, Mrs. GK Meera for her secretarial assistance, and Mr. Parry Uma for his photographic assistance.
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REFERENCES
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ABSTRACT
INTRODUCTION
