Propensity Score Matching Analysis of Mechanical Versus Bioprosthetic Tricuspid Valve Replacements

Long-term outcomes after bioprosthetic tricuspid valve replacement: a multicenter study

OBJECTIVES

Long-term evidence about bioprosthetic tricuspid valve replacement is scarce. This study aims to investigate the long-term clinical outcomes of patients who underwent tricuspid valve replacement with bioprostheses.

METHODS

This multicentre retrospective study included patients from 10 high-volume centres in 7 different countries, who underwent tricuspid valve replacement with bioprostheses. Echocardiographic and clinical data were reviewed. Long-term outcomes were investigated using Kaplan-Meier estimates, Cox regression, and competing risk analysis.

RESULTS

Of 675 patients, isolated tricuspid valve replacement was performed in 358 patients (53%), while 317 (47%) underwent concomitant procedures. Between these 2 groups, patients who underwent combined procedures reported a significantly higher incidence of infection, atrioventricular block, multi-organ failure, longer intensive care unit and hospital stay and higher 30-day mortality over patients who underwent isolated procedure. The overall 30-day mortality occurred in 70 patients (10.4%) [46 (14.6%) combined vs 24 (6.74%) isolated, P = 0.001]. During the follow-up, there was a continuous rate of attrition due to death, with cumulative incidences of death at 5, 10 and 15 years being 27.2%, 46.2% and 60.6%, respectively. In contrast, the risk of reintervention starts to significantly increase after 10 years of follow-up, with cumulative incidences of reintervention being 6.1%, 10.8% and 23.3%, respectively. Freedom from tricuspid valve reintervention, pacemaker implantation, tricuspid valve endocarditis and major thromboembolic events at 15 years were 56.5%, 77.3%, 84.0% and 86.4%, respectively.

CONCLUSIONS

Tricuspid valve replacement with bioprostheses is an effective treatment for valvular disease, despite being associated with relatively high early and long-term mortality. However, the risk of structural valve degeneration rises significantly after 10 years.

Results after Tricuspid Valve Surgery for Preserved and Dysfunctional Right Ventricle

BACKGROUND

 This study aimed to compare long-term outcomes after tricuspid valve (TV) repair (TVr) with those after TV replacement (TVR) by adjusting the right ventricular (RV) volume and function.

METHODS

 We enrolled 147 patients who underwent TVr (n = 78) and TVR (n = 69) for grade 3 or 4 tricuspid regurgitation and had preoperative cardiac magnetic resonance data. Long-term clinical outcomes were compared between the two groups using inverse probability treatment weighting (IPTW) to adjust for differences in preoperative characteristics between the two groups. Subgroup analyses were performed in patients with preserved and dysfunctional RV (ejection fraction < 50%).

RESULTS

 There were no significant differences in operative mortality or postoperative complications between the two groups before and after the IPTW adjustment. Five- and 10-year overall survival rates were 84.2 and 67.1%, respectively. Five- and 10-year cumulative incidences of TV-related events (TVREs) were 33.1 and 55.6%, respectively. There were no significant differences in overall survival and cumulative incidence of TVREs after IPTW adjustment (p = 0.236 and p = 0.989, respectively). The risk-adjusted overall survival was marginally higher in the TVr group of patients with preserved RV function (p = 0.054), while no such significant difference was found between the two groups of patients with dysfunctional RV (p = 0.513).

CONCLUSION

 Adjusted long-term clinical outcomes after TVr and TVR were comparable. TVr might be beneficial for patients with preserved RV function in terms of long-term survival; however, this benefit might disappear in patients with RV dysfunction.

Tricuspid valve replacement with mechanical versus biological prostheses: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Tricuspid valve replacement (TVR) is required when repair is not feasible, and it continues to be a relatively high-risk procedure owing to the complex medical and/or surgical profile of patients. The choice between mechanical and biological prostheses for TVR remains a subject of debate owing to their distinct advantages and disadvantages. This study aimed to analyse and compare the clinical outcomes of these two types of prostheses in the tricuspid position.

METHODS

PubMed, EMBASE, Web of Science, and the COCHRANE library were searched from 1995 to April 2023 for studies comparing clinical outcomes of mechanical versus biological valves in the tricuspid position. Data on 30-day mortality, reoperations, 5-year valve failure rates, thrombotic/thromboembolic events, and long-term survival were extracted, pooled, and analysed. Forest plots were generated using a random-effects model.

RESULTS

From an initial pool of 4716 citations, 37 studies meeting our inclusion criteria were assessed, collectively encompassing 8316 prostheses (3796 mechanical, 4520 bioprostheses). Our analysis revealed that mechanical valves exhibited a non-significant trend towards diminished 30-day mortality (RR = 0.85, 95% CI = 0.69-1.06). A distinct disparity emerged in valve durability, with mechanical valves demonstrating a significantly increased risk of 5-year valve failure (RR = 2.21, 95% CI = 1.38-3.56). Strikingly, mechanical valves displayed a substantial six-fold elevated risk of thrombotic events (RR = 6.29, 95% CI = 3.98-9.92). In contrast, the long-term survival and reoperation rates demonstrated no statistically significant differences between the two valve types.

CONCLUSIONS

This systematic review and meta-analysis provides insights into the selection of mechanical and bioprosthetic valves for TVR. These findings highlight the potential advantages and disadvantages of mechanical and bioprosthetic valves in terms of early mortality, valve durability, and thrombotic risk. Our analysis provides clinicians with evidence-based guidance for optimizing outcomes in TVR, offering a foundation for informed decision-making in this intricate surgical landscape. Despite these insights, clinicians must overcome the limitations of retrospective studies, evolving healthcare, and anticoagulant disparities to ensure careful consideration in tricuspid valve replacement decisions.

Prosthesis choice for tricuspid valve replacement: Comparison of clinical and echocardiographic outcomes

OBJECTIVES

There is limited evidence evaluating valve function and right heart remodeling after tricuspid valve replacement (TVR), as well as whether the choice of prosthesis has an impact on these outcomes.

METHODS

We reviewed 1043 consecutive adult patients who underwent first-time TVR; 33% had previous aortic and/or mitral valve operations. Severe tricuspid valve regurgitation (TR) was the indication for surgery in 94% patients. A mechanical valve was used in 149 (14%) patients and a bioprosthetic valve in 894 (86%). Concomitant major cardiac procedures were performed in 57% of patients.

RESULTS

The median age of the cohort was 68.8 (range, 25-94) years, and 57% were female. Overall survival at 5 and 10 years was 50% and 31%, respectively. Adjusted survival and cumulative incidence of reoperation after TVR were similar in patients with bioprosthetic and mechanical valves. Overall, right ventricular (RV) function and dilation improved postoperatively with the estimated proportion of patients with moderate or greater RV systolic dysfunction/dilatation decreasing by around 20% at 3 years follow-up. After adjusting for preoperative degree of dysfunction/dilatation, valve type had no effect on late improvement in RV function and dilation. Bioprosthetic TVR was associated with greater rates of recurrence of moderate or greater TR over late follow-up. Overall, a slight decline in tricuspid valve gradients was observed over time.

CONCLUSIONS

Mechanical and bioprosthetic valves provide comparable survival, incidence of reoperation, and recovery of RV systolic function and size after TVR. Bioprosthetic valves develop significant TR over time, and mechanical valves may have an advantage for younger patients and those needing anticoagulation.

Tricuspid valve replacement: The old and the new

Tricuspid regurgitation is a frequent and serious condition but tricuspid valve (TV) surgery, that may be a valve replacement when a repair is not feasible, is rarely performed. Recent development of transcatheter TV interventions offers new options for those high-surgical risk patients, especially TV replacement for patients who are not eligible for transcatheter TV repair. In this review, we describe indications and outcome after surgical TV replacement, and devices available or in development for transcatheter TV replacement.

Comparative analysis of structural valve deterioration after bioprosthetic tricuspid valve replacement: Bovine pericardial versus porcine valves

This study was conducted to compare the occurrence and the risk factors of structural valve deterioration (SVD) after bioprosthetic tricuspid valve replacement (TVR) between bovine pericardial valves and porcine valves. One-hundred and thirty-four TVR patients were enrolled; 108 patients underwent TVR with bovine pericardial bioprostheses (BTVR group) and 26 underwent TVR with porcine bioprostheses (PTVR group). The early results and long-term clinical outcomes were compared. The median follow-up duration was 90 (interquartile range: 33-135) months. Propensity score (PS) adjusted Cox regression and competing risk analyses were performed. The mean ages of the BTVR and PTVR groups were 62.2 ± 10.7 and 57.3 ± 13.9 years, respectively. The overall survival and cumulative incidence of cardiac death in the BTVR group were similar to those in the PTVR group (hazard ratio [95% confidence interval] = 1.399 [0.500-3.922] and 0.742 [0.249-2.212], respectively). SVD was significantly more frequent in the BTVR group (17.544 [1.070-243.902], P = .045). The tricuspid valve reoperation rate was significantly higher in the BTVR group (38.462 [2.591-476.190], P = .008). The cumulative incidence of SVD after bioprosthetic TVR was higher when using bovine pericardial valves than when using porcine valves.

Which is the best prosthesis in an isolated or combined tricuspid valve replacement?

OBJECTIVES

METHODS

From January 1999 to December 2018, 338 patients underwent tricuspid valve replacement. Patients were divided into an isolated group or a combined group according to whether their surgery was combined with a left heart valve surgery. Mechanical tricuspid valve replacement was performed in 142 patients (isolated group: 41 vs combined group: 101), and 196 patients underwent bioprosthetic tricuspid valve replacement (isolated group: 145 vs combined group: 51). Operative results, long-term survival and tricuspid valve-related events were compared.

RESULTS

Early mortality in the combined group was higher (n = 6, 4%) than that in the isolated group (n = 3, 2%), but no significant difference was observed between the mechanical and biological subgroups. In the isolated group, there was a higher event-free rate in the biological subgroup than in the mechanical subgroup (P = 0.042) and a similar result was also observed for patients without Ebstein’s anomaly (P = 0.039). In the combined group, no significant difference was observed (P = 0.98). Survival rates were similar between the mechanical and biological subgroups in both the isolated (P = 0.54) and combined (P = 0.81) groups. Mechanical valves in isolated tricuspid valve replacement were more prone to valve thrombosis and bleeding.

CONCLUSIONS

Every decision regarding tricuspid valve prostheses should be individualized, but biological prostheses may be an optimal choice for patients, especially for patients without Ebstein’s anomaly, in isolated tricuspid valve replacement.

Percutaneous tricuspid valve implantation in failing bioprosthesis

Severe tricuspid valve (TV) dysfunction in patients with congenital heart disease (CHD) is usually treated by open heart surgery in relatively young patients. If a valve plasty is not possible, a biological valve is implanted with a limited durability. Due to valve degeneration repeated valve exchanges are necessary in these patients. To expand the lifetime of a bioprosthesis in tricuspid position percutaneous TV implantation (PTVI) was introduced recently. PTVI is a promising new catheter interventional technology. The current review summarizes the indication for PTVI, describes the procedure itself and gives an outlook on medium to long-term results of this catheter intervention. PTVI in patients with severe TV dysfunction is less invasive, safe and effective, if performed by an experienced operator, and may help to reduce the total number of open-heart surgeries during a patient's life time. However, further studies with larger patient numbers and longer follow-up are needed.

Surgical Techniques for Tricuspid Valve Disease

Tricuspid valve disease affects millions of patients worldwide. It has always been considered less relevant than the left-side valves of the heart, but this “forgotten valve” still represents a great challenge for the cardiac surgeons, especially in the most difficult symptomatic scenarios. In this review we analyze the wide spectrum of surgical techniques for the treatment of a diseased tricuspid valve.

Risk factors associated with perioperative morbidity and mortality following isolated tricuspid valve replacement

BACKGROUND

Reports of isolated tricuspid valve replacement (iTVR) are relatively rare. The present study aimed to evaluate independent risk factors of perioperative morbidity and mortality after iTVR.

MATERIALS AND METHODS

We retrospectively reviewed 118 consecutive patients (42 males; mean age, 49.1 ± 12.9 y) who underwent iTVR from May 2003 to April 2016 in our center. The multivariate logistic regression model was used to analyze the independent risk factors associated with perioperative morbidity and mortality following iTVR.

RESULTS

One hundred one patients (85.6%) were classified as New York Heart Association functional class III or IV preoperatively. The overall perioperative mortality was 11.8% (14/118), and a significant difference was observed between the nonreoperative group and the reoperative group (6.7% versus 18.3%, P = 0.047). The multivariate logistic regression analyses identified that preoperative New York Heart Association functional class IV (OR [odds ratio] = 15.43, 95% CI [confidence interval] = 3.46-68.83, P = 0.000) and ascites (OR = 4.88, 95% CI = 1.24-19.27, P = 0.024) were independent risk factors of perioperative deaths. The previous cardiac surgery (OR = 3.28, 95% CI = 1.41-7.62, P = 0.006) was independently associated with perioperative major adverse events.

CONCLUSIONS

The present study revealed that iTVR has relatively high mortality and morbidity rates. Timely surgery may be recommended for this high-risk cohort of patients before the development of severe heart and end-organ failure.

Should a Mechanical or Biological Prosthesis Be Used for a Tricuspid Valve Replacement? A Meta-Analysis

BACKGROUND AND AIM OF THE STUDY

The prosthesis of choice for a tricuspid valve replacement is still unkown. This meta-analysis was undertaken to review the results of mechanical and bioprosthetic valves in the tricuspid position.

METHODS

We identified all relevant studies published in the past 20 years (from January 1, 1995 to December 31, 2014) through the Embase, Current Contents, and PubMed databases. The hazard ratio and its 95% confidence limits were utilized to evaluate time-to-event related effects of surgical procedures. The Q-statistic, Index of Inconsistency test, funnel plots, and Egger's test were used to assess the degree of heterogeneity and publication bias. Random effects models were used, and study quality was also assessed.

RESULTS

In our meta-analysis, 22 studies published from 1995 to 2014 were reviewed and 2630 patients and 14,694 follow-up years were analyzed. No statistically significant difference was identified between mechanical and biological valves in terms of survival, reoperation, and prosthetic valve failure. The respective pooled hazard ratio estimates were 0.95 (0.79 to 1.16, p = 0.62, I(2)  = 29%), 1.20 (0.84 to 1.71, p = 0.33, I(2)  = 0%), and 0.35 (0.06 to 2.01, p = 0.24, I(2)  = 0%). A higher risk of thrombosis was found in mechanical tricuspid valve prostheses (3.86, 1.38 to 10.82, p = 0.01, I(2)  = 0%).

CONCLUSIONS

No statistically significant difference was identified between mechanical and biological valves in terms of survival, reoperation, or prosthetic valve failure, but mechanical tricuspid valve prostheses had a higher risk of thrombosis. doi: 10.1111/jocs.12730 (J Card Surg 2016;31:294-302).

Surgical management of tricuspid valve endocarditis in the current era: A review

The incidence of isolated tricuspid valve infective endocarditis is increasing. Medical management is the mainstay of treatment but surgical intervention is required in a subset of patients. Surgical treatment options include valve excision and replacement or valve reconstruction. We searched PubMed and the Cochrane library to identify articles to be included in this review of surgical outcomes. References of selected articles were crosschecked for other relevant studies. Surgical management of tricuspid valve endocarditis can be achieved with satisfactory outcomes. However, the optimal indication and timing of surgery remain unclear, and the frequent association with intravenous drug use complicates management. Repair techniques are preferable though there is no clear evidence supporting one method over another.