Elsevier

The Annals of Thoracic Surgery

Volume 82, Issue 5, November 2006, Pages 1735-1741
The Annals of Thoracic Surgery

Original article
Cardiovascular
Midterm Outcomes of Tricuspid Valve Repair Versus Replacement for Organic Tricuspid Disease

Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.
https://doi.org/10.1016/j.athoracsur.2006.06.016Get rights and content

Background

Organic tricuspid valve (TV) disease is uncommon. Few studies have compared TV repair with replacement in these patients. The current study compared midterm outcomes of TV repair versus replacement in a large group of patients with organic tricuspid disease.

Methods

Two-hundred and fifty patients underwent surgery for organic TV disease at our institution from 1979 to 2003. Clinical and echocardiographic follow-up were obtained, were 99% complete, and were 5.2 ± 4.1 years long (mean ± standard deviation).

Results

One hundred and seventy-eight patients (71%) underwent TV repair and 72 (29%) received TV replacement (54 bioprosthetic, 18 mechanical). Repair patients were more likely to have hypertension, rheumatic pathology, or elective surgery. Concomitant procedures included mitral (50% of patients), aortic (26%), and coronary bypass (6%) operations. Perioperative and midterm mortality were higher in the replacement group (both p < 0.001). Cox regression analysis revealed TV replacement as an independent predictor of midterm mortality (hazard ratio: 5.1, 95% confidence interval: 2.9 to 9.1, p < 0.001) and decreased event-free survival (hazard ratio: 2.0, 95% confidence interval: 1.1 to 3.6, p = 0.02). Follow-up echocardiography revealed more moderate to severe tricuspid regurgitation in repair patients (38% vs 5%, p < 0.001), but no difference in New York Heart Association functional class or reoperation rates.

Conclusions

Tricuspid valve repair is associated with better perioperative, midterm, and event-free survival than TV replacement in patients with organic tricuspid disease. Despite more tricuspid regurgitation in the repair group during follow-up, reoperation rates and functional class were similar. Repair should be performed whenever possible in patients with organic tricuspid disease.

Section snippets

Patients and Methods

Approval was attained from our institution’s research ethics board to review our prospective database and attain follow-up clinical notes and echocardiograms (waiving the need for individual consent of each patient or relative).

We performed a retrospective review of 250 patients who underwent surgery for organic TV disease between 1979 and 2003 at the Toronto General Hospital. Table 1 lists their pathologies, which included rheumatic, congenital (eg, Ebstein’s, atrioventricular septal defect),

Preoperative and Operative Characteristics

Table 1 shows the preoperative and intraoperative characteristics of the 250 patients who underwent either repair (n = 178) or replacement (n = 72) surgery for documented organic (nonsecondary) disease. The two groups were similar in most aspects, including era of operation. However, the repair group was more likely to have systemic hypertension, more likely to have rheumatic TV pathology, and less likely to undergo isolated TV surgery. The repair group was also less likely to be in

Comment

Organic TV disease is valvular dysfunction due to a primary structural pathology of the tricuspid valve, and not secondary to other valvular or cardiac disease. It is an uncommon clinical entity and therefore there is limited experience from any one center and a paucity of studies to elucidate the optimal surgical technique. To the best of our knowledge, there have not been any series comparing TV repair versus replacement for organic TV disease since the 1970s [6].

Tricuspid valve repair

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    In a small cohort study including 27 patients undergoing TVR, the authors identified significant decrease in RV volumes along with a decline in RV ejection fraction immediately after surgery.26 In their evaluation of mid-term outcomes of tricuspid valve surgery, Singh and colleagues27 speculated that TVR is associated with low cardiac output and increased RV dysfunction due to a rigid prosthesis in the TV position which may contribute to increased mortality. In contrast, a study evaluating hemodynamic effects of surgical correction for severe functional TR in 31 patients showed marked reduction in RV volumes with preservation of ejection fraction using cardiac magnetic resonance imaging over a median follow-up of 27 months.28

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