Asian Cardiovasc Thorac Ann 2008;16:157-158
© 2008 Asia Publishing EXchange Ltd
Hancock Valve Deterioration in Tricuspid Position for Ebstein’s Anomaly
Koichi Sughimoto, MD,
Kiyoharu Nakano, MD1,
Akihiko Gomi, MD1,
Hayao Nakatani, MD1,
Yoshitsugu Nakamura, MD1,
Atsuhiko Sato, MD1
Department of Cardiovascular Surgery, Chiba Cardiovascular Center, Ichihara City
1 Department of Cardiovascular Surgery, NTT Kanto MC, Tokyo, Japan
For reprint information contact: Koichi Sughimoto, MD, Tel: 81 43 688 3111, Fax: 81 43 688 3032, Email: ksughimoto{at}yahoo.co.jp, Chiba Cardiovascular Center, 575 Tsurumai, Ichihara, Chiba 290-0512, Japan.
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ABSTRACT
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A 65-year-old woman with a Hancock valve implanted 25 years earlier for Ebstein’s anomaly underwent a successful second tricuspid valve replacement with a Mosaic valve because of significant tricuspid regurgitation. At surgery, it was found that the Hancock valve had a cylinder-shaped hole and had lost its entire structure. Tricuspid valve dysfunction may be tolerated for a long time before surgery is contemplated.
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INTRODUCTION
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There is an apparent difference in bioprosthetic valve durability between the mitral and tricuspid positions. We describe a case of bioprosthesis failure in the tricuspid position after 25 years, due to severe deterioration.
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CASE REPORT
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A 65-year-old woman diagnosed with Ebstein’s anomaly was referred to our institution for tricuspid valve replacement due to regurgitation in a Hancock Standard mitral valve (Medtronic, Inc., Minneapolis, MN, USA) implanted 25 years earlier. Chest radiography revealed a cardiothoracic ratio of 78%. An electrocardiogram indicated bradycardia, atrial fibrillation and complete right bundle branch block. An enlarged right ventricle and mild tricuspid regurgitation were seen on echocardiography. Preoperative catheterization demonstrated elevated pulmonary arterial pressure of 46/25 mm Hg, with a mean pressure of 27 mm Hg. The pressure gradient in the diastolic phase between the right ventricle and the right atrium was 8 mm Hg. Coronary angiography showed total occlusion of the right coronary artery at the mid portion, due to the previous operation, and good collateral supply from the left anterior descending coronary artery to the right coronary artery. A repeat sternotomy was performed, followed by cardiopulmonary bypass with femoral arterial and bicaval cannulation. With the heart beating, the right atrium was opened, and the Hancock valve was identified. There was a cylinder-shaped hole in the center of the valve, and the leaflet structure had been entirely lost (Figure 1
). The atrialized right ventricle had been corrected at the previous surgery, and the Hancock valve was sutured upward on the coronary sinus so that the coronary vein returned to the right ventricle. The Hancock valve was excised and replaced with a 29-mm Mosaic bioprosthetic valve (Medtronic) in the previous position. A pacemaker lead was placed on the epicardium of the left ventricle. Weaning from bypass was uneventful. The explanted valve showed tissue deterioration associated with mineralization and pannus overgrowth on the right cusp. Heavy pannus overgrowth on the inflow and outflow of the valve extended over the left and noncoronary cusps, fixing them in a partially retracted position. There was extensive mineralization of all commissures (Figure 2). The patient was discharged from the hospital without any complication.
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Figure 2. Massive pannus formation and mineralization on the resected Hancock valve. One coronary cusp remained.
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DISCUSSION
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With a tissue valve in the mitral position (Hancock, Carpentier-Edwards porcine, or Carpentier-Edwards pericardial), Khan and colleagues1 reported an actuarial rate of freedom from reoperation at 15 years of 52% ± 5.7%, and freedom from structural valve deterioration at 20 years of 14% ± 3%. The long-term results of the Hancock valve in the mitral position seem to be satisfactory up to 15 years.2 With the Hancock bioprosthesis in the tricuspid position, Kawachi and colleagues3 found that freedom from structural valve deterioration at 10 years was 94% ± 6%, while freedom from prosthesis-related events at 10 years was 78% ± 10%. Nakano and colleagues4 noted that actuarial freedom from reoperation was 62.7% ± 10.7%, and freedom from structural valve deterioration was 96% ± 2.9% with a bioprosthesis in the tricuspid position. They concluded that structural valve deterioration occurred less in the tricuspid than the mitral position.
Our patient had maintained sinus rhythm for 18 years after the first operation, and did not require warfarin. As a result, reoperation on the tricuspid valve was inevitable after 25 years. However, this bioprosthesis in the tricuspid position had sufficed for more than 20 years. Although it had deteriorated and lost its valvular function entirely at the time of operation, the deterioration progressed gradually and it took time for the patient to manifest symptoms of cardiac failure. Patients can endure tricuspid valve dysfunction (stenosis or regurgitation) to some degree, so a bioprosthesis rather than a mechanical valve is preferred in the tricuspid position. Mechanical valve dysfunction is often related to a thrombotic event, leading to sudden death. Significant tricuspid regurgitation can be tolerated until symptoms of right heart failure manifest, as in this case.5 A bioprosthetic valve in the tricuspid position does not necessarily have a longer durability than in the mitral position, but tricuspid valve dysfunction may be or tolerated for longer, and it might be many years before a surgical option is chosen.
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REFERENCES
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- Khan SS, Trento A, DeRobertis M, Kass RM, Sandhu M, Czer LS, et al. Twenty-year comparison of tissue and mechanical valve replacement. J Thorac Cardiovasc Surg 2001;122:257–69.[Abstract/Free Full Text]
- Santini F, Luciani GB, Restivo S, Casali G, Pessotto R, Bertolini P, et al. Over twenty-year follow-up of the standard Hancock porcine bioprosthesis implanted in the mitral position. Ann Thorac Surg 2001;71:S232–5.[Medline]
- Kawachi Y, Tominaga R, Hisahara M, Nakashima A, Yasui H, Tokunaga K. Excellent durability of the Hancock porcine bioprosthesis in the tricuspid position. A sixteen-year follow-up study. J Thorac Cardiovasc Surg 1992;104:1561–6.[Abstract]
- Nakano K, Ishibashi-Ueda H, Kobayashi J, Sasako Y, Yagihara T. Tricuspid valve replacement with bioprostheses: long-term results and causes of valve dysfunction. Ann Thorac Surg 2001;71:105–9.[Abstract/Free Full Text]
- Chang BC, Lim SH, Yi G, Hong YS, Lee S, Yoo KJ, et al. Long-term clinical results of tricuspid valve replacement. Ann Thorac Surg 2006;81:1317–24.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
