Asian Cardiovasc Thorac Ann 2008;16:107-111
© 2008 Asia Publishing EXchange Ltd
Valvuloplasty in the Treatment of Rheumatic Tricuspid Disease
Shantanu Pande, MCh,
Surendra K Agarwal, MCh,
Gauranga Majumdar, MCh,
Aditya Kapoor, DM,
Niraj Kale, MS,
Anirban Kundu, MS
Depts of Cardiovascular and Thoracic Surgery and Cardiology Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, India
For reprint information contact: Shantanu Pande, MCh, Tel: 99 3521 9460, Fax: 91 522 266 8017, Email: spande{at}sgpgi.ac.in, Department of Cardiovascular and Thoracic Surgery, SGPGIMS, Lucknow, India.
 |
ABSTRACT
|
|---|
Organic involvement of the tricuspid valve is uncommon. Valve repair is preferred over replacement as it results in a low gradient across the valve and obviates the risk of prosthesis-related complications. From October 2002 to October 2004, 37 patients who required tricuspid valve repair for organic involvement were included in this study. They were divided into 2 groups depending on the surgical procedure for valve repair: 20 patients in group 1 had tricuspid commissurotomy and De Vega annuloplasty; 17 in group 2 had tricuspid commissurotomy only. There were significant reductions in peak and mean tricuspid gradients and right ventricular systolic pressure in both groups. Annular shortening was similar in both groups (median, 23% in group 1, 21% in group 2), but the ratio of the tricuspid regurgitation jet area to right atrial area was greater in group 2 (median, 0.40 in group 2, 0.19 in group 1). There was no postoperative death. We recommend supporting the tricuspid annulus with annuloplasty in patients with organic tricuspid valve disease and no dilatation of the annulus, if annular shortening is < 30%.
|
INTRODUCTION
|
|---|
Tricuspid regurgitation (TR) is seen in 10%–50% of cases of advanced mitral valve disease.1 Rheumatic involvement of the tricuspid valve is uncommon.2 Tricuspid regurgitation in mitral or combined mitral and aortic valve lesions is due to pulmonary arterial hypertension and right ventricular dilatation. It may sometimes decrease after repair or replacement of the left-sided valve. Tricuspid regurgitation is usually repaired by annuloplasty using a partially encircling suture or ring.3–5 This method alone is not useful in tricuspid stenosis with TR, and tricuspid valve replacement is often chosen.6 Repair of the valve is preferred over replacement as it produces a lower gradient across the valve. Furthermore, valve replacement is associated with the risks of reoperation, thromboembolism and structural valve deterioration (for bioprostheses). This study evaluated the results of repairs in patients with rheumatic involvement of the tricuspid valve.
|
PATIENTS AND METHODS
|
|---|
From October 2002 to October 2004, 206 patients underwent mitral valve replacement and 76 had both mitral and aortic valve replacement at our center. Of these 282 patients, 37 had mitral or combined mitral and aortic valve replacement with repair of the tricuspid valve for rheumatic valve disease. All patients were evaluated preoperatively by echocardiography for left ventricular size and function and tricuspid valve structure to evaluate commissural fusion and leaflet thickening. The tricuspid valve was assessed for the presence of organic involvement on the basis of gradient and regurgitation. Tricuspid regurgitation was graded on a scale of 1 to 4. Right ventricular size and function were not measured, and right ventricular systolic pressure was measured on TR velocity. The presence of commissural fusion at operation was considered an indication for tricuspid valve commissurotomy. Tricuspid annular dilatation was assessed at operation with a 3M Starr-Edward (Edwards Lifesciences, Irvine, CA, USA) valve sizer. If the annulus was > 30 mm, De Vega annuloplasty was performed. The patients were divided into 2 groups, depending on the anatomical findings at operation and the procedure performed for TV repair. The 20 patients in group 1 had tricuspid commissurotomy and De Vega annuloplasty, the other 17 in group 2 had tricuspid commissurotomy only.
With the patient under general anesthesia, the ascending aorta and both venae cavae were cannulated through a median sternotomy. Cardiopulmonary bypass was established. After moderate systemic hypothermia was attained, the ascending aorta was cross clamped, and cold blood cardioplegic solution was administered antegradely. Mitral valve replacement was performed using a mechanical valve through a posterior left atriotomy. If required, the aortic valve was replaced through an oblique aortotomy. The right atrium was opened after isolating it with vena caval snares, and the tricuspid valve was thoroughly examined after removal of the aortic cross clamp on a beating heart. Surgical procedures and operative data are summarized in Table 1
. Tricuspid commissurotomy was undertaken at the septal and anterior leaflet commissure in all 37 patients, and at the anterior and posterior leaflet commissure in 13. The papillary muscle was split in 17 cases as there was chordal shortening due to severe subvalvular pathology. De Vega annuloplasty was carried out to reduce the annular diameter to 30 mm.
All patients received nicoumalone as an anticoagulant postoperatively. They were followed up clinically and by Doppler echocardiography at 12 months after discharge. All patients were on diuretics for 3 months postoperatively, then only if hepatomegaly persisted. The following echocardiographic criteria were obtained to evaluate the tricuspid valve:7 maximum diastolic tricuspid annular diameter, from the point of insertion of the septal tricuspid leaflet to insertion of the anterior tricuspid leaflet; minimum systolic tricuspid annular diameter, using the same beat and plane in which the maximum diameter was noted; and percent tricuspid annular shortening: (maximum diameter – minimum diameter)/maximum diameter x 100%. The ratio of maximum TR area to right atrial area was also obtained. Tricuspid regurgitation was defined as mild when this ratio was 
0.25, moderate between 0.26 and 0.50, and severe if 
0.51.8
The results of tricuspid valve repair in the 2 groups were compared. Variables are expressed as median and range, and significance was calculated by nonparametric tests. Comparison of 2 variables in the same group was made by the Wilcoxon signed-rank test. Comparison of variables between groups was made by the Mann-Whitney U test. All analyses were performed with SPSS version 10 for Windows (SPSS, Inc., Chicago, IL, USA).
|
RESULTS
|
|---|
All patients were alive at the last follow-up. They were followed up for 12–24 months, and follow-up was complete in all cases. Patients in both groups showed improved New York Heart Association (NYHA) class, and liver enlargement regressed. In group 1, 17 patients were in NYHA class I and 3 were in class II, while 13 patients in group 2 improved to NYHA class I, with 4 in class III. Hepatomegaly disappeared in all patients in group 1, and none required diuretics after 1 year of follow-up. In group 2, 2 patients had hepatomegaly and required loop diuretics after 1 year of follow-up. Doppler studies pre and postoperatively showed a significant reduction in peak and mean tricuspid gradients and right ventricular systolic pressures after surgery in both groups, although the reduction was significantly greater in the peak and mean tricuspid gradients in group 1 (Table 2). There were no significant differences between groups with respect to pre and postoperative right ventricular systolic pressures. The median annular shortening was similar in both groups. The TR jet area/right atrial area ratio was less in group 1 (Table 2). There was a highly significant negative correlation (0.872) between annular shortening and TR jet area/right atrial area ratio in group 2 (Figure 1), but there was a weak correlation in group 1. Annular shortening < 30% was associated with more TR postoperatively.9 Annular shortening and TR jet area/right atrial area were compared in both groups on the basis of postoperative tricuspid end-diastolic diameter < or > 30 mm. There were no significant differences ( p = 0.65 and 0.13 in group 1; p = 0.8 and 0.35 in group 2). The 2 variables were evaluated on the basis of preoperative right ventricular systolic pressure < or > 60 mm Hg; in group 1, there was no difference in TR jet area/right atrial area ( p = 0.529), but there was a difference in annular shortening ( p = 0.009). There were no significant differences in these variables in group 2. There was a reduction in left ventricular end-diastolic diameter in group 1 from 53.7 ± 9.12 to 48.26 ± 3.65 mm ( p = 0.01); and in group 2 from 54.93 ± 7.95 to 49.15 ± 5.57 mm ( p = 0.03). The left ventricular end-systolic diameter and ejection fraction decreased in group 1 from 32.20 ± 6.77 to 28.53 ± 6.53 mm ( p = 0.05) and from 65.10% ± 6.66% to 54.78% ± 6.28% ( p = 0.002), respectively; and in group 2 from 32.21 ± 9.12 to 30.0 ± 7.11 mm ( p = 0.22) and 58.80% ± 20.30% to 54.86% ± 4.96% ( p = 0.02), respectively.
View larger version (7K):
[in this window]
[in a new window]
|
Figure 1. Relationship between tricuspid annular shortening (%TVA) and tricuspid regurgitation jet area/right atrial area ratio (TR/RAA) in group 2.
|
|
|
DISCUSSION
|
|---|
Tricuspid valve function depends on the pliability of the leaflets, state of the commissures and subvalvular apparatus and dimension of the annulus. This study found that the anteroseptal commissure was fused in all cases, but there was involvement of the anteroposterior commissure in 13 cases. Similar findings were reported by Shatapathy and colleagues.10 Commissurotomy was performed at both commissures because we found that opening one commissure only was insufficient to relieve the stenosis. Nakano and colleagues11 carried out single commissurotomy between the anterior and septal leaflets, and left the other commissure fused to achieve bicuspidization, with annuloplasty to reduce postoperative regurgitation. It may be ideal to assess and repair the tricuspid valve on an arrested heart, but we elected to do it on a beating heart to decrease aortic cross clamp time; this was effective. Since both groups underwent commissurotomy, it is possible that TR in group 1 was due to a combination of commissural fusion and annular dilatation, while in group 2, it was due solely to limited leaflet mobility. The anterior leaflet was unable to coapt with the posterior leaflet because of restricted mobility at the commissures, as described by Henein and colleagues,12 and also because of chordal-papillary shortening in 17 cases. The anterior leaflet was able to coapt with the posterior leaflet after repair (commissurotomy with or without papillary muscle splitting). Therefore, procedures such as autologous pericardial extension used in left-sided valve repairs were not performed. Shatapathy and colleagues10 reported similar findings when commissurotomy was carried out at both commissures, with papillary muscle splitting if required.
Tricuspid regurgitation during follow-up, which can be attributed to dilatation of the tricuspid annulus, was less in group 1 than group 2 after 6 months, although 12 months is not adequate to assess long-term results of repair. Six patients in group 2 had an end-diastolic diameter < 30 mm; the other 11 had dilatation of the annulus postoperatively. No change in the tricuspid annular diameter was observed postoperatively by Tager and colleagues8 in patients with a dilated annulus preoperatively, but in our study, an increase in tricuspid annular diameter was observed in patients with 30 mm end-diastolic annular diameter in group 2. Annular shortening was similar in both groups. Group 1 had De Vega annuloplasty to reduce the tricuspid diameter, preventing it from dilating during follow-up. Roguin and colleagues13 also suggested that annuloplasty prevents annular dilation after tricuspid repair. Patients who had annular dilatation later in the unsupported annulus (11/17) had annular shortening < 30%. This indicates weakened annular motion, and thus function, which might have contributed to annular dilatation at follow-up.
There was a significant correlation between annular shortening and TR jet area/right atrial area ratio in group 2, but not in group 1. Group 1 had annuloplasty, and thus the natural progression of dilatation and subsequent TR development was halted. There was a significant difference in postoperative annular shortening when group 1 was compared on the basis of preoperative right ventricular systolic pressure < or > 60 mm Hg. Patients in group 2 did not show this, although the numbers may be too small to reach statistical significance. Increased right ventricular load can affect systolic function and thus annular shortening. In both groups, the patients with TR were mostly in NYHA class II and tolerated TR well. In group 2, 2 patients were in NYHA class III with liver enlargement and required oral diuretics after 1 year, similar to a previous report.14 Gradients across the tricuspid valve decreased to a lesser extent in group 2, which may be explained by the fact that the pathology of the valve and subvalvular apparatus was more severe in this group, as evidenced by more bilateral commissurotomies and papillary muscle splitting. As there was no annular dilatation detected during the operation, suture annuloplasty was not performed in these patients. On retrospective analysis, we found that it might be preferable to support the annulus with an appropriately sized ring in these patients, so as not to decrease annular diameter which may result in stenosis, and prevent postoperative dilatation of the annulus.
We prefer tricuspid repair to valve replacement which is associated with higher mortality and morbidity in these patients with multivalvular disease. The long-term results of annuloplasty are more favorable than valve replacement, regardless of the technique used.15,16 Kratz and colleagues17 compared actuarial survival rates at 8 years for tricuspid replacement (41%) vs De Vega and Carpentier annuloplasties (62%) and concluded that valve replacement should be avoided except when the valve is destroyed or cannot be repaired. This study provides medium-term follow-up and confirms that commissurotomy significantly improves hemodynamics at 12 months in a sizable cohort of patients with organic tricuspid valve disease. It also clarifies the role of De Vega annuloplasty in these patients. Limitations of the study are its non-randomized and retrospective nature. Furthermore, the decision for annuloplasty was based on operative findings rather than preoperative indices from echocardiographic criteria.
Rheumatic involvement of the tricuspid valve is a combination of commissural fusion, leaflet thickening and chordal-papillary shortening, similar to the pathology seen in rheumatic mitral valve disease. Annular dilatation can also be present, requiring commissurotomy at 1–2 commissures, papillary muscle splitting and annuloplasty. In the absence of annular dilatation, a higher grade of TR and annular dilatation is observed during follow-up with annular shortening < 30% when the annulus is left unsupported. Supporting the annulus with an appropriately sized annuloplasty ring is advisable, and it will not lead to further reduction in the size of annulus. Annular shortening was also reduced when right ventricular systolic pressure was > 60 mm Hg. We recommend tricuspid annuloplasty in this group of patients.
|
ACKNOWLEDGMENTS
|
|---|
Authors would like to acknowledge the help provided by Dr. Uttam Singh, Assistant Professor, Department of Biostatistics, SGPGIMS, India, in statistical analysis.
|
REFERENCES
|
|---|
- Kirklin JW, Pacifico AD. Surgery for acquired valvular heart disease. 2 [Review]. N Engl J Med 1973;288:194–9.[Medline]
- Mueller XM, Tevaearai HT, Stumpe F, Fischer AP, Hurni M, Ruchat P, et al. Tricuspid valve involvement in combined mitral and aortic valve surgery. J Cardiovasc Surg (Torino) 2001;42:443–9.[Medline]
- De Vega NG. Selective, adjustable and permanent annuloplasty. An original technic for the treatment of tricuspid insufficiency. Rev Esp Cardiol 1972;25:555–6.[Medline]
- Carpentier A, Deloche A, Hanania G, Forman J, Sellier P, Piwnica A, et al. Surgical management of acquired tricuspid valve disease. J Thorac Cardiovasc Surg 1974;67:53–65.[Medline]
- Duran CG, Ubago JL. Clinical and hemodynamic performance of a totally flexible prosthetic ring for atrioventricular valve reconstruction. Ann Thorac Surg 1976;22:458–63.[Abstract]
- Jugdutt BI, Fraser RS, Lee SJ, Rossall RE, Callaghan JC. Long-term survival after triple valve replacement. Results with seven different prostheses. J Thorac Cardiovasc Surg 1977;74:20–7.[Abstract]
- Chopra HK, Nanda NC, Fan P, Kapur KK, Goyal R, Daruwalla D, et al. Can two-dimensional echocardiography and Doppler color flow mapping identify the need for tricuspid valve repair? J Am Coll Cardiol 1989;14:1266–74.[Abstract]
- Tager R, Skudicky D, Mueller U, Essop R, Hammond G, Sareli P. Long-term follow-up of rheumatic patients undergoing left-sided valve replacement with tricuspid annuloplasty-validity of preoperative echocardiographic criteria in the decision to perform tricuspid annuloplasty. Am J Cardiol 1998;81:1013–6.[Medline]
- Colombo T, Russo C, Ciliberto GR, Lanfranconi M, Bruschi G, Agati S, et al. Tricuspid regurgitation secondary to mitral valve disease: tricuspid annulus function as guide to tricuspid valve repair. Cardiovasc Surg 2001;9:369–77.[Medline]
- Shatapathy P, Aggarwal BK, Kamath SG. Tricuspid valve repair: a rational alternative. J Heart Valve Dis 2000;9:276–82.[Medline]
- Nakano S, Kawashima Y, Hirose H, Matsuda H, Shimazaki Y, Taniguchi K et al. Evaluation of long-term results of bicuspidalization annuloplasty for functional tricuspid regurgitation. J Thorac Cardiovasc Surg 1988;95:340–5.[Abstract]
- Henein MY, O’Sullivan CA, Li W, Sheppard M, Ho Y, Pepper J, et al. Evidence for rheumatic valve disease in patients with severe tricuspid regurgitation long after mitral valve surgery: the role of 3D echo reconstruction. J Heart Valve Dis 2003;12:566–72.[Medline]
- Roguin A, Rinkevich D, Milo S, Markiewicz W, Reisner SA. Long-term follow-up of patients with severe rheumatic tricuspid stenosis. Am Heart J 1998;136:103–8.[Medline]
- Fukuda N, Oki T, Iuchi A, Tabata T, Yamada H, Ito S, et al. Tricuspid inflow and regurgitant flow dynamics after mitral valve replacement: differences relating to surgical repair of the tricuspid valve. J Heart Valve Dis 1997;6:184–8.[Medline]
- Grondin P, Meere C, Limet R, Lopez-Bescos L, Delcan JL, Rivera R. Carpentier’s annulus and De Vegas annuloplasty. The end of the tricuspid challenge. J Thorac Cardiovasc Surg 1975;70:852–61.[Abstract]
- Péterffy A, Jonasson R, Szamosi A, Henze A. Comparison of Kay’s and De Vega’s annuloplasty in surgical treatment of tricuspid incompetence. Clinical and haemodynamic results in 62 patients. Scand J Thorac Cardiovasc Surg 1980;14:249–55.[Medline]
- Kratz JM, Crawford FA Jr, Stroud MR, Appleby DC Jr, Hanger KH. Trends and results in tricuspid valve surgery. Chest 1985;88:837–40.[Medline]
This article has been cited by other articles:
|
|
|
|
 
S. Pande, S. K. Agarwal, U. Dhir, A. Chaudhary, S. Kumar, and V. Agarwal
Pulmonary arterial hypertension in rheumatic mitral stenosis: does it affect right ventricular function and outcome after mitral valve replacement?
Interactive CardioVascular and Thoracic Surgery,
September 1, 2009;
9(3):
421 - 425.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
INTRODUCTION
