Asian Cardiovasc Thorac Ann 2006;14:47-50
© 2006 Asia Publishing EXchange Ltd
Long-Term Results of Triple-Valve Procedure
Yoshimasa Sakamoto, MD,
Kazuhiro Hashimoto, MD,
Hiroshi Okuyama, MD,
Shinichi Ishii, MD,
Takahiro Inoue, MD,
Katsushi Kinouchi, MD
Department of Cardiovascular Surgery, The Jikei University School of Medicine, Tokyo, Japan
For reprint information contact: Yoshimasa Sakamoto, MD Tel: 81 33 433 1111 Fax: 81 33 433 1175 Email: yysakamoto{at}aol.com, Department of Cardiovascular Surgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo 105-8461, Japan.
 |
ABSTRACT
|
|---|
Triple-valve procedures are associated with high early and late mortality. We reviewed our experience in 25 patients who underwent combined mitral and aortic valve replacement with tricuspid valve repair or replacement between 1979 and 2004. The mean follow-up was 7.8 years (range, 10 days to 24.5 years). The mean age at operation was 52 years (range, 31 to 72 years). Four patients underwent triple-valve replacement and 21 had double-valve replacement and tricuspid annuloplasty. Perioperative mortality was 20% and late mortality was 24%. Cumulative survival, calculated taking perioperative mortality into account, was 71% ± 10% at 10 years and 36% ± 15% at 15 years after surgery. Only 1 of 20 perioperative survivors required re-operation for prosthetic valve dysfunction. Double-valve replacement with tricuspid annuloplasty offers satisfactory long-term survival with freedom from thromboembolism and re-operation.
|
INTRODUCTION
|
|---|
Triple-valve procedures are uncommon and have been performed less frequently in recent years. However, whether to repair or replace the tricuspid valve remains controversial. Whenever possible, we have performed tricuspid valve repair instead of replacement due to a high mortality associated with tricuspid valve replacement in our early experience. The objective of this retrospective study was to review our experience of triple-valve procedures over 24 years.
|
PATIENTS AND METHODS
|
|---|
Between 1979 and 2004, 25 patients underwent a triple-valve procedure in our department. Patient characteristics are summarized in Table 1
. Most patients were in atrial fibrillation and one had a permanent pacemaker implanted because of sick sinus syndrome. Their valve lesions are listed in Table 2 and previous cardiac procedures are shown in Table 3. The triple-valve procedure defined in this series was a combination of aortic and mitral valve replacement with tricuspid valve replacement or repair at the same operation. Our overall experience with mechanical valves has been good. A standard St. Jude Medical mechanical prosthesis (St. Jude Medical, Inc., St. Paul, MN, USA) was used most often in the aortic position, and a Carbomedics mechanical prosthesis (Sulzer Carbomedics, Inc., Austin, TX, USA) was usually chosen for the mitral position because of our policy at that time. Ionescu-Shiley and Björk-Shiley (Shiley, Inc., Irvine, CA, USA), Edwards-Duromedics and Carpentier-Edwards (Baxter Healthcare Corp., Irvine, CA, USA) valves were also used (Table 4). All valves were placed in the intra-annular position. A porcine bioprosthesis was the choice for implantation in the aortic position in patients 
65 years and in the mitral position for those 70 years. We attempted to perform annuloplasty for tricuspid regurgitation when possible. Oral anticoagulation with sodium warfarin and a platelet inhibitor was given to all patients to maintain the prothrombin time at approximately twice normal.
The data are presented in terms of mean and standard deviation. Survival was calculated by the Kaplan-Meier method and compared by the long-rank test.
|
RESULTS
|
|---|
Of the 25 patients, 21 underwent double-valve replacement with tricuspid annuloplasty and 4 had triple-valve replacement. Tricuspid annuloplasty was performed in 19 patients using the DeVega technique, and with the Cosgrove flexible ring in one patient. Tricuspid commissurotomy was performed in 1 patient. The mean aortic crossclamp time was 158 ± 43 min.
There were 5 early deaths (20%) in patients who were in New York Heart Association (NYHA) class III or IV preoperatively. Perioperative mortality was 44% (4/9) in NYHA class III patients and 50% (1/2) in class IV patients. The causes of perioperative death were low cardiac output in 4 patients and pneumonia in one. Cumulative overall survival was 71% ± 10% at 10 years and 36% ± 15% at 20 years (Figure 1). The survival rates for primary and redo triple-valve procedures at 10 years were 69% ± 15% and 71% ± 12%, respectively. There was no significant difference between the two groups. There were 6 late deaths (24%). The causes of late death in the 20 operative survivors are listed in Table 5. Four patients died from thromboembolism or cerebral bleeding related to anticoagulant therapy. The survivors were all in NYHA functional classes I and II at the last follow-up.
Freedom from thromboembolism was 86% ± 13% at 20 years (Figure 2). The rate of thromboembolism was 0.5 per 100 patient-years. Freedom from anticoagulant-related hemorrhage was 80% ± 18% at 20 years (Figure 3). Freedom from re-operation was 93% ± 7% at 20 years (Figure 4). Only one case required re-operation because of valve dysfunction of an Ionescu-Shiley xenograft in the mitral position. Four patients required permanent pacemaker implantation postoperatively for sick sinus syndrome.
View larger version (10K):
[in this window]
[in a new window]
|
Figure 2. Actuarial freedom from thromboembolism in 20 operative survivors of a triple-valve procedure.
|
|
View larger version (11K):
[in this window]
[in a new window]
|
Figure 3. Actuarial freedom from anticoagulant-related hemorrhage in 20 operative survivors of a triple-valve procedure.
|
|
|
DISCUSSION
|
|---|
The number of cases of valve disease has decreased in our institute because of the decline in the incidence of rheumatic heart disease. Triple-valve procedures have rarely been performed in recent years. This procedure is associated with high operative mortality because of the poor clinical and hemodynamic status of patients before surgery.1–5 By the time of surgery, the liver, renal and respiratory, as well as cardiac functions have deteriorated severely because of chronic heart failure in most patients. Since 1988, we have had only one (1/22, 4.5%) operative death. Improvements in perioperative and intraoperative management may have contributed to the reduction in mortality.6 To reduce perioperative mortality, early surgical intervention should be considered before patients reach NYHA functional class IV.1,7 Reports suggest that the operative mortality rate tends to be high if patients have systolic pulmonary hypertension above 60 mm Hg.1 Sixteen of our 25 patients underwent a preoperative catheter examination; their mean pulmonary systolic pressure was 45 mm Hg. Four patients had high pulmonary systolic pressure in excess of 60 mm Hg, and one of them died of low cardiac output within 30 days after surgery. Pulmonary hypertension may be an important factor in early prognosis, although our cases were too few to endorse that comment.
The mean age at operation was relatively young in this series, and mechanical prostheses were used to replace the aortic and mitral valves in most cases. In recent reports on the long-term results of porcine bioprostheses, it was established that they are suitable for young patients.8,9 Our strategy is to implant a porcine bioprosthesis in the aortic position in patients 65 years, and in the mitral position in those 70 years. However, the optimal prosthesis in the tricuspid position is still controversial. It has been recommended that tricuspid annuloplasty be used as often as possible, and a bioprosthesis should be considered if tricuspid valve replacement is required.1,10 This is because mechanical prostheses in the tricuspid position have produced higher rates of dysfunction and thromboembolism than bioprostheses.2 This study demonstrated a very low rate of thromboembolism (1.02 events per 100 patient-years) and the benefit of tricuspid annuloplasty is well corroborated in terms of thromboembolic complications. On the other hand, bioprostheses feature a significantly higher rate of re-operation for valve degeneration, so a more durable mechanical valve may be recommended.11,12
Triple-valve replacement was associated with a high rate of hospital mortality in our experience, and we had only one patient who survived for 25 years without any complication after triple-valve replacement with St. Jude Medical prostheses. Subsequently, we attempted to avoid valve replacement in the tricuspid position and performed annuloplasty as often as possible. Ten-year survival rates have been reported to range from 37% to 55%.13,14 A 15-year survival rate of 23% was reported by Teply and colleagues.13 Our data show favorable long-term results with the triple-valve procedure. Double-valve replacement with DeVega tricuspid annuloplasty is promising. We have recently changed our strategy of tricuspid repair because of the recurrence of mild regurgitation after the DeVega procedure in some cases, and we have started using rings in patients with high pulmonary resistance.
The symptomatic improvement in the patients is encouraging. Patients undergoing primary and redo triple-valve procedures have similar long-term survival. Double-valve replacement with DeVega tricuspid annuloplasty offers satisfactory long-term survival and freedom from thromboembolism and re-operation. The use of tricuspid annuloplasty is recommended for patients without severe pulmonary hypertension.
|
REFERENCES
|
|---|
- Gersh BJ, Schaff HV, Vatterott PJ, Danielson GK, Orszulak TA, Piehler JM, et al. Results of triple valve replacement in 91 patients: perioperative mortality and long-term follow-up. Circulation 1985;72:130–7.[Abstract/Free Full Text]
- Kara M, Langlet MF, Blin D, Mouly A, Avierinos C, Goudard A, et al. Triple valve procedures: an analysis of early and late results. Thorac Cardiovasc Surg 1986;34:17–21.[Medline]
- Carrier M, Pellerin M, Bouchard D, Perrault LP, Cartier R, Hebert Y, et al. Long-term results with triple valve surgery. Ann Thorac Surg 2002;73:44–7.[Abstract/Free Full Text]
- Stephenson LW, Kouchoukos NT, Kirklin JW. Triple-valve replacement: an analysis of eight years’ experience. Ann Thorac Surg 1977;23:327–32.[Abstract]
- Tayama E, Kawano H, Takaseya T, Hiratsuka R, Oda T, Hayashida N, et al. Triple valve replacement with bileaflet mechanical valves: is the mechanical valve the proper choice for the tricuspid position? Jpn Circ J 2001;65:257–60.[Medline]
- Galloway AC, Grossi EA, Baumann FG, LaMendola CL, Crooke GA, Harris LJ, et al. Multiple valve operation for advanced valvular heart disease: results and risk factors in 513 patients. J Am Coll Cardiol 1992;19:725–32.[Abstract]
- Livi U, Bortolotti U, Rizzoli G, Valfre C, Mazzucco A, Gallucci V. Surgical treatment of patients with triple heart valve disease. Results and analysis of factors affecting the surgical outcome. Thorac Cardiovasc Surg 1982;30:288–91.[Medline]
- Munro AI, Jamieson WR, Tyers GF, Germann E. Tricuspid valve replacement: porcine bioprostheses and mechanical prostheses. Ann Thorac Surg 1995;60(2 Suppl):S470–4.[Medline]
- Jamieson WR, Miyagishima RT, Burr LH, Lichtenstein SV, Fradet GJ, Janusz MT. Carpentier-Edwards porcine bioprostheses: clinical performance assessed by actual analysis. J Heart Valve Dis 2000;9:530–5.[Medline]
- Coll-Mazzei JV, Jegaden O, Janody P, Rumolo A, Bonnefoy JY, Mikaeloff P. Results of triple-valve replacement: perioperative mortality and long term results. J Cardiovasc Surg (Torino) 1987;28:369–73.[Medline]
- Brown PS Jr, Roberts CS, McIntosh CL, Swain JA, Clark RE. Late results after triple-valve replacement with various substitute valves. Ann Thorac Surg 1993;55:502–8.[Abstract]
- Singh AK, Feng WC, Sanofsky SJ. Long-term results of St. Jude Medical valve in the tricuspid position. Ann Thorac Surg 1992;54:538–40.[Abstract]
- Teply JF, Grunkemeier GL, Sutherland HD, Lambert LE, Johnson VA, Starr A. The ultimate prognosis after valve replacement: an assessment at twenty years. Ann Thorac Surg 1981;32:111–9.[Abstract]
- Thorburn CW, Morgan JJ, Shanahan MX, Chang VP. Long-term results of tricuspid valve replacement and the problem of prosthetic valve thrombosis. Am J Cardiol 1983;51:1128–32.[Medline]
This article has been cited by other articles:
|
|
|
|
 
H. V. Schaff and R. M. Suri
Multiple Valve Disease
Card. Surg. Adult,
January 1, 2008;
3(2008):
1129 - 1158.
[Full Text]
|
|
|
TOP
ABSTRACT
INTRODUCTION
