HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Felix Unger W Gerald Rainer Dieter Horstkotte Probal Ghosh Christian L Olin Denton A Cooley Elek Bodor Bruno B Reichart Roland Schistek Wolfgang Ade Juro Wada Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Unger, F. Articles by Wada, J. Search for Related Content PubMed Articles by Unger, F. Articles by Wada, J.

Standards and Concepts in Valve Surgery

A Task Force report of the European Heart Institute (EHI) of the European Academy of Sciences and Arts and the International Society of Cardiothoracic Surgeons (ISCTS)

For reprint information contact: Felix Unger, MD Tel: 43 662 84 1445 Fax: 43 662 84 1343 email: office{at}european-heart-institute.org European Heart Institute, Waagplatz 3, Salzburg A-5020, Austria.

	Introduction

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 
With the advent of open heart surgery it has been possible to actively fight valvular diseases. Before World War II there were some reports of operations on the heart, but these operations were rare and anecdotal. Closed tech-niques were performed occasionally in mitral surgery after World War II. After 1952, a major breakthrough occurred with the introduction of artificial valves and coronary artery bypass graft (CABG) surgery for open heart surgery.

Standards are technical specifications that ensure all procedures are understood and widely accepted. Concepts are abstract ideas or new developments that may become standards if widely accepted. The first artificial valves were designed in the 1950s as ball valves, and later as monoleaflet and bileaflet valves in aortic and mitral positions. Biological valves were developed in the 1960s. Open valve-reconstruction and other techniques were introduced in the late 60s. These techniques were used first for mitral stenosis (MS) and later for mitral regurgitation (MR) and homografts.

The standard for valve replacement (VR) is to use extra-corporeal circulation (ECC) with myocardial protection. In most cases, reconstruction of the diseased valve will not result in good long-term results. Therefore, replace-ment with an artificial valve is preferred. Concomitant bypass surgery as indicated is performed. Device selection remains a challenge and must be tailored to the patient in conjunction with valve surgery. There are concepts in reconstructing the aortic valve as well as in designing new valves.

The management, including diagnostic and postoperative treatment, of patients with valvular diseases is complex. Valve selection can play an important role in the long-term outcome.

The following standards are set for surgeons:

1. Indication
   
2. Postoperative management
   

A previous task force of the American College of Cardiology and the American Heart Association¹ gave an excellent basis for classifying and fostering a useful terminology for cardiac surgeons and cardiologists. Demographics, life span, and epidemiologic characteristics of disease have changed globally in the last 30 years. The availability of cardiac surgery worldwide is highly variable and discrepant, with the USA and Europe offering more accessibility to open heart surgery facilities.²

	Types of Artificial Heart Valves in Current Use

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 

• Mechanical valves:
  • monoleaflet
    
  • bileaflet
    
  
  
• Biologic valves:
  • stented valves: porcine, bovine (cuspal, pericardial)
    
  • unstented valves
    
  • homografts
    
  • autografts
    
  • most biologic valve designs are also available in conduits
    
  
  

	Labeling of Valves

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 
The description of the devices must contain the internal and external diameters in millimeters, including cuff, and the geometrical and effective orifice areas in cm².

	Sizers

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 
Valve sizers should be exact replicas of the valves, including the sewing ring, to give the surgeon complete information on the exact fitting of the valve in the method the surgeon wants to employ for implantation of the valve. There is considerable sizer discrepancy between different manufacturers for the same nominal size. It is essential that the sizers be of consistent size.

	Sizing

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 
The size of a valve should be adapted to the body mass index. Adequacy criterion may refer to the size of the valve as effective orifice area indexed to body surface area or body mass index.

	Indications for Surgical Interventions on Valves

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 
The following three groups give an overview of the indications for surgical interventions on valves:

Group I
Surgery is useful and effective based on scientifically acceptable evidence from long-term studies.

Group II
Indications are tailored to the individual situation of the patient. Surgery may be based on conflicting evidence and/or on a divergence of opinion about the usefulness/efficacy.

1. Weight of evidence/opinion is in favor of usefulness/outcome
   
2. Usefulness/outcome is not well established by evidence/opinion
   

Group III
Surgery is not useful and in some cases may be harmful for patients with contraindications to ECC or otherwise.

To optimize the timing of valve replacement, the balance between natural history, prognosis, and quality of life are major factors. The prognosis depends on the myocardial adaptability to the chronic volume load and blood pressure. The quality of life depends on the symptoms and the possible complication in valve diseases and subjective need of the patient.

Echocardiography, including Doppler techniques, angio-cardiography, computed tomography (CT), and magnetic resonance imaging (MRI) may be sufficient tools to give the surgeon enough information for surgical intervention.

• Echocardiography—transthoracic (TTE) and transeso-phageal (TEE)—are indicated in:
  • diagnosis and assessment of severity of valve disease (VD)
    
  • assessment of left ventricle (LV) size, function, and/or hemodynamics
    
  • reevaluation of patients with known but changing symptoms or signs
    
  • assessment of valve structures
    
  • assessment of changes in hemodynamic severity and ventricular compensation in patients with known disease during pregnancy
    
  • assessment of growth in children and adolescents
    
  • reevaluation of asymptomatic patients
    
  • reevaluation of asymptomatic patients with mild to moderate VD and evidence of LV dysfunction or hypertrophy
    
  • evaluation of treatment outcome
    
  
  

Echocardiographic assessment may be further modified with stress/exercise or pharmaceuticals—when indicated.

• Cardiac catheterization and coronary angiography in valve diseases are indicated:
  • before VR in patients at risk for coronary artery disease (CAD)
    
  • when the assessment of the severity of VD in symptomatic patients or noninvasive tests are inconclusive, or when there is a discrepancy with clinical findings regarding the severity of VD
    
  • when the assessment of the severity of VD before VR and noninvasive tests are adequate and con-cordant with clinical findings; coronary angiography is not needed in patients older than 40 years of age without family history and/or without other risk factors
    
  
  
• Computer tomography is helpful in:
  • acute aortic regurgitation (AR)
    
  • acute and chronic aortic dissections
    
  
  
• Magnetic resonance may be useful for :
  • assessment of valve structures (not absolutely necessary)
    
  • information on the metabolic status of the heart with positron emission tomography/single photon emission CT (not absolutely necessary)
    
  
  

Ergometry or exercise/stress/pharmacological modifi-cations of catheterization or echocardiography may be needed when earlier tests are equivocal for selection of therapy.

	Selection of Valves for Replacement

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 
Recommendations for a Mechanical Prosthesis

• Group I. Mechanical prosthesis is recommended in:
  • patients with expected long lifespan
    
  • patients with a mechanical prosthetic valve already in place and in a position other than the valve to be replaced
    
  
  
• Group II. Mechanical prosthesis is recommended in patients:

  1. i)with renal failure, on hemodialysis, or with hypercalcemia
     

     ii)requiring anticoagulation therapy because of risk factors for thromboembolism and other indications
     

     iii)under 75 years for an aortic valve replacement (AVR) and 65 to 75 years for a mitral valve replacement (MVR)
     

     
     
  2. valve re-replacement for a thrombosed or degenerated biologic valve
     
  
  

Recommendations for Valve Replacement With a Bioprosthesis

• Group I. VR with a bioprosthesis is recommended in patients:
  • without compliance for anticoagulation therapy
    
  • over 75 years, who require an AVR, but do not have risk factors for thromboembolism or early structural dysfunction
    
  
  
• Group II. VR with a bioprosthesis is recommended in:
  1. patients considered to have possible compliance problems with anticoagulation therapy
     • young females who want to be or are pregnant
       
     • patients over 75 years who require a MVR or AVR but do not have risk factors for thrombo- embolism
       
     
     
  2. valve re-replacement for thrombosed mechanical valve
     • patients over 65 years, depending on the reasons for thrombosis
       
     
     
  
  

Thrombectomy of thrombosed mechanical valve and balloon dilatation of early bioprosthetic stenosis have been shown to be effective in selected cases in recent era.

Risk Stratification for Valve Replacement
In a recent publication of the STS National Cardiac Surgery Database, the mortality rate for surgery overall, based on 86,580 patients, is 7.5%.³

	Surgery in Aortic Valve Diseases

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 
Aortic Stenosis

1. The natural aortic orifice area in adults is up to 3 to 4 cm². The following characterizes the severity of aortic stenosis (AS):
   • mild: 1.5 cm²
     
   • moderate: 1.5 to 1 cm²
     
   • severe: less than 1 cm²
     
   
   

The absolute numbers need to be viewed according to body surface area, peak systolic gradient, and peak velocity against cardiac index.

Transvalvular pressure gradients are not a basis for classification. Valve resistance or pressure loss (mm Hg/mL stroke volume) is an indicator. One mm Hg/mL is a significant pressure loss.

Indications for valve replacement in aortic stenosis:

AVR is indicated in symptomatic patients with angina, dyspnea, syncope, dizziness, arrhythmia or ischemia, who will have symptomatic improvement and a better survival rate after AVR. The outcome with normal left ventricular function or moderate depression is excellent. The operative risk is 2% in elective cases. In elderly patients over 80 years, AVR often provides satisfactory outcome. Those patients usually have additional CAD. In patients with CAD, there are revascularization criteria to be met as well.

• AVR in AS is necessary if the following symptoms are present:
  • dizziness, syncope, angina, arrhythmia, manifes-tations of ST-T changes, or silent myocardial ischemia, as well as in patients who are asymptomatic and have an inadequate myocardial adaptability.
    
  
  

To identify the pathologic adaptation, different stress tests are necessary (i.e., radionuclide ventriculography and dobutamine/stress echocardiography). The progression of the valvular obstruction is indicated by a pressure loss of 1 mm Hg/mL of stroke volume. The progression of calcified aortic valve disease (AVD) is usually rapid, making early intervention necessary.

The following describes groups who require AVR with an artificial valve using ECC:

• Group I.
  • symptomatic with severe or moderate AS
    
  • symptomatic with severe or moderate AS undergoing CAB surgery
    
  • symptomatic with severe or moderate AS undergoing surgery on the aorta or other heart valves
    
  • symptomatic with severe AS and inappropriate myocardial adaptation (viz., EF under exercise)
    
  • symptomatic with severe AS and myocardial ischemia (silent or ST-T changes)
    
  • asymptomatic with severe AS and LV systolic or diastolic dysfunction
    
  
  
• Group II. Indications are tailored to patients with:
  1. moderate AS, undergoing CAB surgery or surgery on the aorta or other heart valves, who may expect rapid progression of AS.
     

  2. i)a valve area less than 0.60 cm²
     

     ii)ventricular tachycardia
     

     iii)marked or excessive LV hypertrophy (greater than 15 mm)
     

     
     
  
  

Valve reconstruction is a concept but rarely done, except in children/adolescents with a noncalcified aortic valve.

In asymptomatic patients the decision is controversial as surgery and prostheses may jeopardize the status of asymptomatic patients.

Concomitant coronary disease is very common. For CABG the criteria for revascularization should be met. Surgical valvotomy may be indicated in rare instances. Ultrasonic decalcification and valvotomy may be discussed in patients over 85 years and in patients with a small aortic root. It may provide acceptable early results but poor long-term outcome due to progressive cuspal retraction.

Aortic Regurgitation
The main feature for consideration in AR is the volume load of the LV. Acute aortic insufficiency mandates intervention in patients with acute endocarditis or acute failure of the valve with a massive regurgitant volume to the LV, which previously was of normal size. Acute chamber dilatation results in decreasing forward volume. AR may also be caused by aortic root dissection. Acute AR is a surgical emergency, which requires prompt identification, management, and surgery.

Echocardiography confirms the diagnosis. Cardiac catheterization needs to be performed when the diagnosis is uncertain and if assessing the coronary arteries is an important component. CT is indicated in acute dissections.

In chronic AR, the diagnosis is confirmed by echocardio-graphy and TEE, exercise testing angiography, and cardiac catheterization. The timing of operation depends on the degree of AR, volume load, and LV function.

VR is performed on ECC with artificial valves and in dissections with a conduit or reconstruction of the valvular apparatus. Cusp-sparing procedures and intravalvular implantation of prosthesis are used in suitable patients.

In AR, VR is used in patients who have a regurgitation fraction greater than 0.3 and symptoms of dyspnea, reduced exercise, arrhythmia, or with documented exhausted myocardial adaptability to the volume load (EF, 0.55; fractional shortening, 27%; end-systolic volume index (ESVI), 60 mL/m²; end-diastolic volume index (EDVI), 200 mL/m²; and left ventricular end-diastolic diameter (LVEDD), 70 mm). If there is no increase in the left ventricular EF under stress, then that is an indication of an exhausted load adaption.

Indications:

• Group I. VR in AR is indicated in patients who:
  • are classified as a Class III or IV by the New York Heart Association (NYHA), have a preserved LV systolic function, and have a normal EF at rest, which is defined as 0.55 to 0.60
    
  • are classified as a Class II by the NYHA and have a preserved LV systolic function (EF 0.55 to 0.60 at rest) but with progressive LV dilatation or declining EF at rest on serial studies or declining effort tolerance on exercise testing
    
  • have Class II or more angina by the Canadian Cardiovascular Society (CCS) Classification with or without CAD
    
  • are asymptomatic or symptomatic with mild to moderate LV dysfunction at rest (EF 0.25 to 0.49)
    
  • are undergoing CAB surgery or surgery on the aorta or other heart valves
    
  • suffer from acute severe AR in endocarditis and aortic root dissection
    
  
  
• Group II. Indications are to be considered in patients who:
  • are classified as a functional Class II by the NYHA and have a preserved LV
    
  • have stable LV size and systolic function (EF 0.50 at rest) on serial studies and stable exercise tolerance
    
  • are asymptomatic with a normal LV systolic function (EF > 0.50) but with severe LV dilatation (end-diastolic dimension 70 mm, or end-systolic dimension 50 mm)
    
  • have acute endocarditis and AR
    
  • have severe LV dysfunction (EF < 0.25)
    
  • are asymptomatic with normal systolic function at rest (EF > 0.50) and progressive LV dilatation when the degree of dilatation is moderately severe (end-diastolic dimension, 70 to 75 mm; end-systolic dimension, 50 to 55 mm)
    
  
  
• Group III. There is no indication in:
  • asymptomatic patients with a normal systolic function at rest (EF > 0.50) but with decline in EF during exercise radionuclide angiocardiography and/or stress echocardiography
    
  • asymptomatic patients with normal systolic function at rest (EF > 0.50) and LV dilatation when degree of dilatation is not severe (end-diastolic dimension < 70 mm, end-systolic dimension < 50 mm)
    
  
  

Combined Coronary Artery Bypass Surgery and Aortic Valve Replacement
Combined procedures, especially in elderly patients, are increasing. Thirty percent of all valve procedures in the western world are combined with CABG.

• Group I. Combined procedures are indicated in patients:
  • undergoing CABG who have severe AVD and who meet the criteria for VR in Indication Groups I, II(a), or II(b).
    
  • have massive atherosclerotic involvement of the coronary ostia
    
  
  
• Group II. The indication is to be considered in patients:
  1. undergoing CABG who have moderate AS (mean gradient, 30 to 50 mm Hg; or Doppler velocity, 3 to 4 m/s)
     
  2. undergoing AVR who have some anomalies of origin/proximal course of coronary arteries
     
  
  
• Group III. There is no indication in patients undergoing CABG who have mild AS (mean gradient, < 30 mm Hg; or Doppler velocity, < 3 m/s).
  

	Surgery in Mitral Diseases

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 
Mitral Stenosis
Surgery on the mitral valves has been performed for many years. Different closed techniques have been applied since the 1940s to 1950s but valvotomy, including closed valvotomy, still needs improvement. The outcome in mitral valve surgery is still challenged by prostheses.

The average mitral valve area is 4 to 5 cm² in an adult. A valve area under 2.5 cm² may cause symptoms. Indication for replacement depends on echocardiography (TTE, TEE) and cardiac catheterization. All significant stenosis should be defined as mitral valve orifice of area (MVOA) in cm²/m².

Anticoagulation is recommended in patients with atrial fibrillation, patients with a prior embolic event, and patients with severe mitral stenosis (MS) and left atrial enlargement ( 55 mm). MVR is recommended with preservation of the papillo-annular continuity. Balloon valvotomy is the recommended alternative, depending on the morphology of the valve structure.

Patients with MS:

VR is necessary if the morphology is not/cannot be amended with balloon valvotomy. If the right heart system is insufficient, the right ventricular (RV) end-diastolic diameter is 17 mm/m², or the result in spiroergometry is in Weber Class B and C, surgery is necessary. Pulmonary vascular resistance is not a parameter for the indication to surgery or for the prognosis in the postoperative follow-up.

Indications:

• Group I. VR in MS is indicated in patients when the structure is not suitable for repair in:
  • NYHA functional Class III or IV, moderate or severe MS (MVOA, 1.5 cm²), and impairment of RV function.
    
  • NYHA functional Class III or IV, moderate or severe MS (MVOA, 1.5 cm²), and if a left atrial thrombus is present despite anticoagulation.
    
  
  
• Group II. Patients with:
  1. severe MS (MVOA, 1.5 cm²) and severe pulmonary hypertension (pulmonary artery systolic pressure 60 to 80 mm Hg) and NYHA functional Class I or II symptoms
     
  2. severe MS (MVOA, 1.5 cm²) and who have had recurrent episodes of embolic events on adequate anticoagulation therapy
     
  
  
• Group III. No indication for surgery is found in patients:
  • with NYHA functional Class I or II symptoms and mild MS
    
  
  

Mitral Regurgitation
The indication for surgery is present when there is a significant volume of mitral regurgitation (MR). The indication is determined by the left ventricular systolic function, the diastolic pressure, the systolic volume, and pulmonary artery pressure at exercise.

Acute MR results from an overload of the LV. The preload of the LV and the afterload of the right ventricle are increased. Special attention is given in mitral valve regurgitation after acute myocardial infarction (MI) and myocardial ischemia (ischemic MR).

Mitral surgery in MR may be performed by reconstruction. If this is not possible, VR with an artificial valve is recommended. The diagnosis is established by TTE, TEE, 3-D echo. Coronary angiography is necessary prior to surgery in patients who are over 40 years of age and are at risk of CAD.

Reconstruction should be considered in patients with MR. The surgical intervention should be performed before permanent atrial fibrillation or left atrial dilatation 55 mm sets in. In VR the subvalvular structures should be conserved as standard.

Indications:

• Group I. When repair of the mitral valve is not feasible, MVR in MR is indicated in patients with:
  • acute symptomatic MR, where the first lung edema is not an indication
    
  • NYHA functional Class II, III, or IV symptoms with normal LV function defined as EF > 0.60 and end-systolic dimension < 40 mm
    
  • symptomatic or asymptomatic patients who have a mild LV dysfunction, EF 0.50 to 0.60 and end-systolic dimension 40 to 45 mm
    
  
  
• Group II. There are indications in patients who are:
  1. asymptomatic with a preserved LV function and pulmonary hypertension (pulmonary artery systolic pressure > 50 mm Hg at rest, or > 60 mm Hg at exercise)
     • asymptomatic with EF 0.50 to 0.60 and end-systolic dimension 45 to 55 mm
       
     
     
  2. with preserved LV function who have recurrent severe ventricular arrhythmia despite medical therapy
     • asymptomatic with preserved LV function and atrial fibrillation
       
     
     
  
  

Mitral Valve Repair

• Group I. Mitral valve repair should be considered in:
  • patients with NYHA Class III or IV symptoms, moderate or severe MS where valve morphology is favorable for repair and in patients with a left atrial thrombus despite anticoagulation
    
  • patients with NYHA II to IV, where valve mor-phology is favorable for repair
    
  • patients after failed balloon dilatation or early infective endocarditis with limited involvement in selected cases
    
  
  
• Group II. Mitral valve repair should be considered in:
  • patients with severe LV dysfunction (EF, < 0.3; and/or end-systolic dimension, > 50 mm) in whom chordal preservation is highly likely. An important subset comprises of patients with chronic heart failure (with dilated or ischemic cardiomyopathy) and with concomitant Batista partial left ventriculectomy
    
  
  

Mitral valve repair may be secured with a mitral ring. However, a ring reinforcement is not essential in all cases of mitral reconstruction.

Concomitant Coronary Bypass Surgery and Mitral Repair
The indication is composed by the indication for CABG, MS, MR, and mitral valve repair. Mitral repair is an option in MR after MI with chordal dysfunction.

Ablation Procedures During Surgery
Ablation procedures in patients with atrial fibrillation are concepts that might have a clinical significance.

Left Atrial Volume Reduction
Several left atrium (LA) volume reduction procedures have been used for giant LA ( 60 mm) which may not always have significant impact on outcome.

	Surgery in Multivalvular Disease

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 
Aortic and mitral valve replacements (DVR) are indicated in highly selective surgical groups. The combination of aortic replacement and mitral reconstruction is common as well as concomitant CABG. DVR and tricuspid annuloplasty are indicated under certain circumstances. TV reconstruction should be performed in all cases with preoperative significant tricuspid regurgitation (TR).

Group I. Patients with a NYHA functional Class II to IV symptoms: the patient's condition is determined by the most severe valvular disease, where one of the double valve replacements has a leading indication in group I or II.

	Tricuspid Disease

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 
Recommendations for Surgery in Tricuspid Regurgitation

• The ultimate goal of tricuspid valve (TV) surgery should be reconstruction. The main parameters for the basis of indications are:
  • TR > grade II/IV
    
  • TV regurgitant area/right atrium area > 34%
    
  • Right ventricular systolic pressure > 60 mm Hg
    
  • TV annular contraction < 25%
    
  • TV annular diameter max > 21 mm/m² BSA (body surface area)
    
  • TR vol/beat > 10 mL
    
  • End-diastolic TV annular diameter > 50 mm
    
  
  
• Group I. These are patients who need:
  • annuloplasty for severe TR and pulmonary hypertension in patients with mitral valve disease, requiring mitral valve surgery
    
  • annuloplasty for severe TR after trauma, infective endocarditis
    
  • annuloplasty for severe TR after atrial switch procedures, heart transplant, pericardectomy, etc.
    
  • annuloplasty for severe TR caused by congenital or acquired conditions of TV
    
  
  
• Group II. These are patients who need:
  1. VR for severe TR secondary to diseased abnormal TV leaflets not amenable to annuloplasty or repair
     • VR or annuloplasty for severe TR with mean pulmonary artery pressure < 60 mm Hg when symptomatic
       
     
     
  2. annuloplasty for mild TR in patients with pulmonary hypertension secondary to mitral valve disease requiring mitral valve surgery
     
  
  

The replacement of the TV by means of artificial valve should be a final consideration if TV repair fails.

	Valve Surgery in Pregnancy

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 
Valve surgery in pregnancy is a very difficult and complex undertaking. Surgery should be delayed as long as possible with the goal to have a viable fetus. Better fetal salvage rate and quality have been observed with closed mitral valvotomy or balloon mitral dilatation for critical MS in pregnant women.

Caesarean section may be performed concomitantly. Intervention needs to be considered only in low output syndrome. Volume overload related crises are usually ob-served around the 20th week of gestation and during labor.

Bypass technique should be with high flow and warm perfusion.

	Valve Surgery in Infective Endocarditis

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 
Acute endocarditis leads to deterioration of the valves and is complicated by emboli.

• Group I. Surgery is necessary in patients with:
  • deterioration of the circulation and reduced kidney function
    
  • embolic events
    
  • severe and mobile vegetations on the valves
    
  
  
• Group II. Surgery is necessary in patients with:
  • endocarditis when hemodynamics are stable
    
  • ongoing infection
    
  
  

Valve reconstruction has been shown to be feasible with encouraging results in selected cases in recent years.

	Management with Prosthetic Heart Valves

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

 
Recommendations for Anticoagulation Therapy in Patients With Prosthetic Heart Valves:

Recommendations for Follow-up of Patients With Prosthetic Heart Valves

• The following should be completed as a follow-up of patients with prosthetic heart valves:
  • history, physical examination, chest X-ray, echo-cardiogram, complete blood count, INR, ophthalmo-scopy, urine examination and serum chemistry, including lactate dehydrogenase (LDH), haptoglobin etc, electrogastrogram (EGG)—if indicated, at first postoperative outpatient evaluation.
    
  • radionuclide angiography or MRI to assess LV function if result of echocardiography is unsatis-factory.
    
  • routine follow-up visits at yearly intervals with earlier reevaluations for change in clinical status.
    
  • routine serial echocardiograms at time of annual follow-up visit in absence of change in clinical status.
    
  
  

Indications for Reoperation

• Group I. These are patients with:
  • evidence of moderate or severe paravalvular leak, annular or aortic abscess, sinus or aortic true or false aneurysm, fistula formation, new-onset conduction disturbances, or infection with gram-negative organisms or organisms with a poor response to antibiotics.
    1. persistent bacteremia after a prolonged course (7 to 10 days) of appropriate antibiotic therapy without noncardiac cause for therapy.
       
    2. vegetation of any size on/or near the prosthesis.
       
    
    
  • severe structural or nonstructural prosthetic valve dysfunction leading to hemodynamic or clinical status compromise.
    
  • progressive failure of valve reconstruction leading to hemodynamic or clinical status compromise.
    
  
  

Recommendations for Surgery in Prosthetic Endocarditis

• Group I. The reoperation is indicated in patients with:
  • early prosthetic valve endocarditis (first 2 months or less after surgery)
    
  • heart failure with prosthetic valve dysfunction
    
  • staphylococcal endocarditis not responding to antibiotic therapy
    
  • acute AR or MR with heart failure
    
  • acute AR with tachycardia and early closure of the mitral valve
    
  • evidence of annular or aortic abscess, and sinus or aortic true or false aneurysm
    
  • evidence of valve dysfunction and persistent infection after a prolonged period (7 to 10 days) of appropriate antibiotic therapy, as indicated by presence of fever, leukocytosis, and bacteremia, provided there are cardiac causes for infection
    
  
  
• Group II. These are patients with:
  1. recurrent emboli after appropriate antibiotic therapy
     • infection with gram-negative organisms or organisms with a poor response to antibiotics in patients with evidence of valve dysfunction
       
     
     
  2. mobile vegetations >10 mm
     
  
  

	Acknowledgment

 
Contributions by Drs. B. Gersak, N. Poirier, and H. Schulte are acknowledged.

	References

TOP Introduction Types of Artificial Heart... Labeling of Valves Sizers Sizing Indications for Surgical... Selection of Valves for... Surgery in Aortic Valve... Surgery in Mitral Diseases Surgery in Multivalvular Disease Tricuspid Disease Valve Surgery in Pregnancy Valve Surgery in Infective... Management with Prosthetic Heart... References

1. Bonnow RO, Carabello B, de Leon AC, Edmunds LH, Fedderly BJ, Freed MD, et al. Guidelines for the management of patients with valvular heart disease. ACC/AHA task force on practice guidelines. Circulation 1998;98:1949–84.[Free Full Text]

2. Unger F. Worldwide survey on cardiac interventions 1995. Cor Europaeum 1999;7:128–46.

3. Jamieson WRE, Edwards FH, Schwartz M, Bero JW, Clark RE, Grover FL. Risk stratification for cardiac valve replacement: National Cardiac Surgery database. Ann Thorac Surg 1999;67:943–51.[Abstract/Free Full Text]

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Felix Unger W Gerald Rainer Dieter Horstkotte Probal Ghosh Christian L Olin Denton A Cooley Elek Bodor Bruno B Reichart Roland Schistek Wolfgang Ade Juro Wada Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Unger, F. Articles by Wada, J. Search for Related Content PubMed Articles by Unger, F. Articles by Wada, J.