Tricuspid valve replacement with the St. Jude Medical valve: 19 years of experience

Ten-year experience of tricuspid valve replacement with the St. Jude medical valve

Bioprosthetic valves for tricuspid valve replacement (TVR) have become increasingly popular in recent years, but mechanical valves remain valuable, particularly for the patients who want to avoid reoperation for bioprostheses malfunction. The aim of this study was to review our 10-year experience in adult patients who underwent TVR with the St. Jude Medical (SJM) valve. From 2005 to 2015, 265 TVRs with SJM valves were performed at our institution. The mean age at operation was 44.1 ± 9.7 years, and 207 cases (78.1%) were female. The mean follow-up was 4.9 ± 2.7 years. Preoperative atrial fibrillation was present in 199 cases (75.1%) and ascites in 26 (9.8%). Of all cases, 88.7% were characterized as New York Heart Association class III or IV. The hospital mortality was 6.4%. There were 9 deaths (3.8%) during late follow-up. The overall survival rates were 89.2% ± 2.2% at 5 years and 86.6% ± 2.9% at 10 years. The linearized rates of valve thrombosis and bleeding events were 0.8%/patient-year and 1.5%/patient-year, respectively. Three cases (1.3%) were reoperated due to prosthetic valve thrombosis. There was no reoperation for sperivalvular leakage and structural failure. The freedom from reoperation was 98.6% ± 0.8% at 5 years and 98.6% ± 0.8% at 10 years. The SJM valve in the tricuspid position is a reliable mechanical prosthesis with a low rate of valve thrombosis and reoperation. It is a reasonable choice for the patients who require mechanical valve replacement in the tricuspid position.

Antithrombotic Management of Patients With Prosthetic Heart Valves

Valvular heart disease is a major public health issue. The prevalence of valvular heart disease is expected to increase due to an aging population. Valve dysfunction manifests as valve stenosis, regurgitation, or both due to various etiologies. Valve repair and replacement are the main treatment options for severe valve dysfunction. Valve replacement is achieved by using either a mechanical or a bioprosthetic valve. Mechanical valves are more durable but require lifelong anticoagulation with associated complications. Bioprosthetic valves usually require anticoagulation only transiently after implantation but are less durable and degenerate more rapidly. In this article, we discuss antithrombotic regimens in persons after valve operations. We discuss general issues and antithrombotic recommendations for patients undergoing surgical bioprosthetic valve replacement, mechanical valve replacement (including different regimens for different positions and types of mechanical valves), mitral valve repair, and transcatheter aortic valve replacement. In addition, we discuss the antithrombotic management of patients in special circumstances, including patients with mechanical valves who have recurrent bleeding or thrombotic events, patients with mechanical valves undergoing surgery, and pregnant women with mechanical valves.

Doppler Echocardiographic Evaluation of Prosthetic Valves in Tricuspid Position

Doppler echocardiographic characteristics of 29 normally functioning prosthetic valves (23 mechanical, 6 biological) and 8 obstructed mechanical prostheses in the tricuspid position are reported. In normally functioning prostheses, peak velocity, mean pressure gradient, and pressure-half time were 1.25 ± 0.18 m·sec−1, 2.6 ± 1.1 mm Hg, and 122.6 ± 30.7 msec, respectively. Although no significant differences were seen in peak velocity and mean pressure gradient between mechanical and biological valves, the pressure half-time was significantly greater in biological valves. All normally functioning prostheses had a mean pressure gradient ⩽5.5 mm Hg and pressure half-time < 200 msec. In obstructed bileaflet valves, peak velocity was 1.66 ± 0.28 m·sec−1, mean pressure gradient was 6.1 ± 2.8 mm Hg, and pressure half-time was 265.8 ± 171.7 msec. These Doppler data were significantly greater than those in normally functioning valves where the mean pressure gradient was ⩽5.1 mm Hg and the pressure half-time was ⩽156 msec in all except one patient. Pathological obstruction of a tricuspid prosthesis can be strongly suspected in patients with a mean pressure gradient > 5.5 mm Hg and a pressure half-time > 200 msec on Doppler echocardiography.

Tricuspid Valve Replacement: Bioprosthetic or Mechanical Valve?

Significant morbidity and mortality is associated with tricuspid valve replacement, and controversy still exists as to the ideal prosthesis in this position. This study aimed to identify the risk factors for low cardiac output and mortality, and whether bioprosthetic or mechanical valves perform better in the tricuspid position. Results of 121 tricuspid valve replacements in 104 patients between January 1966 and December 2002 were reviewed. Most patients were in New York Heart Association functional class III or IV. Perioperative mortality was 19%. On multivariate analysis, age and preoperative jaundice were significant predictors of low cardiac output; age, jaundice, atrial fibrillation, and bypass time were significant predictors of mortality. Mechanical valves were significantly more prone to thromboembolism, whereas bioprostheses suffered structural valve deterioration. There were no significant differences in anticoagulation or bleeding episodes between the two groups, nor in valve-related events, deaths, and long term survival. There was no significant difference in performance so as to recommend one type over the other, but bioprosthetic valves may be more favorable as they fail predictably.

Transvenous transcatheter valve-in-valve implantation after bioprosthetic tricuspid valve failure

We describe the case of a 38-year-old man with a history of metastatic testicular cancer who had undergone multiple thoracic surgical procedures, including tricuspid valve replacement with a bioprosthetic valve as a result of tricuspid involvement of his malignancy. He presented at our outpatient cardiology clinic with worsening fatigue, shortness of breath, and peripheral edema, investigation of which revealed severe tricuspid bioprosthesis stenosis with central regurgitation. Because of the patient's medical history, he was considered to be a high-risk surgical candidate. Therefore, transcatheter tricuspid valve-in-valve implantation of a 26-mm Edwards Sapien(®) valve was attempted through a transjugular approach. The procedure restored tricuspid valvar competence and substantially improved the patient's symptoms. We discuss the technical aspects of this case and briefly review the usefulness of the valve-in-valve technique in the tricuspid position.

Long term results comparing mechanical and biological prostheses in the tricuspid valve position: which valve types are better--mechanical or biological prostheses?

OBJECTIVES

The aim of this study was to evaluate the clinical outcome of patients who underwent TVR focusing on long-term survival- and valve-related complications.

METHODS

Between January 1993 and June 2011, 132 patients underwent tricuspid valve replacement in our centre. Sixty-eight bioprosthetic valves (52%) and 64 mechanical valves (48%) were implanted for tricuspid position. For 51 patients (39%) this was a first-time tricuspid valve operation.

RESULTS

Nineteen patients died during hospitalisation, yielding a hospital mortality rate of 14%. The hospital mortality and morbidity were not statistically significantly different between the two groups. Sixteen patients (14,1%) died after discharge from the hospital. Twelve-year actuarial survival after mechanical and bioprosthetic TVR was 72,1±5,9 and 61.6±6,6%, respectively. No statistically significant difference was detected between mechanical and bioprosthetic valves in regard to event-free survival.

CONCLUSION

The choice between mechanical or biological prostheses in the tricuspid position should be individualised according to the clinical judgment, even though absence of any difference in the survival data supports the opinion that there is no "gold standard" for prosthetic tricuspid valve replacement.

Mechanical valve replacement versus bioprosthetic valve replacement in the tricuspid valve position

BACKGROUND

The purpose of this study was to evaluate the clinical outcomes and risk of tricuspid valve replacements and to compare bioprosthetic versus mechanical valves.

METHODS

Between 1991 and 2009, 104 consecutive patients (71 women; mean age, 57 ± 10.8 years) with tricuspid valvular disease underwent mechanical TVR (mechanical group; n = 59) or bioprosthetic TVR (bioprosthesis group; n = 45). Follow-up was complete in 97.1% (n = 101) with a median duration of 49.9 months (range 0-230 months).

RESULTS

Hospital mortality after mechanical TVR and bioprosthetic TVR was not different on adjusted analysis by propensity score. Ten-year actuarial survival after mechanical and bioprosthetic TVR was 83.9 ± 7.6% and 61.4 ± 9.1%, respectively (p = 0.004). However, there was also no significant difference in terms of adjusted analysis by propensity score (p = 0.084). No statistically significant difference was detected between mechanical and bioprosthetic valves in regard to event-free survival.

CONCLUSIONS

Mechanical TVR is not inferior to bioprosthetic TVR in terms of occurrence of valve-related events, especially anticoagulation-related complications.

Management of recurrent mechanical prosthetic tricuspid valve thrombosis in the perioperative period of noncardiac surgery: a case report

Introduction

Mechanical valves in the tricuspid position may be prone to thrombosis with even brief lapses in anticoagulation. The management of patients with a history of recurrent mechanical tricuspid valve thrombosis who require noncardiac surgery is complex.

Case presentation

A 43-year-old Pakistani woman with a mechanical tricuspid valve and a history of multiple episodes of mechanical valve thrombosis presented for noncardiac surgery. After her surgery she was found to have another episode of valve thrombosis and underwent a redo tricuspid valve replacement.

Conclusion

This case brings up the important dilemma that exists when patients with a mechanical tricuspid valve and a history of recurrent valve thrombosis require noncardiac surgery.

Mechanical tricuspid valve replacement is not superior in patients younger than 65 years who need long-term anticoagulation

BACKGROUND

We evaluated long-term results of tricuspid valve replacement (TVR) with mechanical valves and bioprostheses in patients less than 65 years old who needed anticoagulation therapy irrespective of TVR.

METHODS

Among 156 patients who underwent TVR from January 1996 to April 2010, 119 patients younger than 65 years who needed anticoagulation therapy independent of the TVR were studied. Anticoagulation therapy was needed owing to left-sided mechanical valves (n = 11), atrial fibrillation (n = 13), or both (n = 95). Seventy patients underwent mechanical TVR, and 49 underwent bioprosthetic TVR. The follow-up duration was 68 ± 38 months. Propensity score-adjusted analyses were performed.

RESULTS

Early postoperative outcomes were similar between groups, with an operative morality rate of 6.7% (8 of 119). Overall survival rates at 5 and 10 years were 86.4% and 80.3%, respectively. There were no differences in propensity score-adjusted overall survival rates between the two groups (p = 0.291). Freedom from the composite endpoint of thrombosis, embolism, and bleeding was lower in the mechanical TVR group than in the bioprosthetic TVR group (76.3% and 70.0% at 5 and 10 years, respectively, versus 97.6% and 97.6%, p = 0.020). Five- and 10-year valve-related event-free survivals were also lower in the mechanical TVR group than in the bioprosthetic TVR group, although not statistically significant (75.0% and 61.7% versus 89.2% and 80.3%, p = 0.129).

CONCLUSIONS

Even in younger patients who need anticoagulation therapy irrespective of TVR, mechanical TVR is not superior because of increased occurrence of valve-related events, especially the composite of thrombosis, embolism, and bleeding.

Long-Term Results of Isolated Tricuspid Valve Replacement

The long-term outcome of isolated tricuspid valve replacement is unclear because this procedure is rare and usually performed in combination with replacement of other valves. The results of all 31 isolated tricuspid valve replacements carried out in 23 patients in Kyushu University Hospital between 1975 and 2004 were retrospectively reviewed. A bioprosthesis was used in 27 cases and a mechanical valve in 4. There were 2 operative deaths and 4 late deaths. One patient with a mechanical prosthesis needed redo tricuspid valve replacement due to valve thrombosis 6 months after surgery. The mean cardiothoracic ratio and functional class improved significantly postoperatively. At 15 years after tricuspid valve replacement, actuarial survival was 75.6% and freedom from valve-related events was 84.9%. For bioprostheses, freedom from structural valve deterioration at 5, 10 and 15 years was 95.2%, 95.2% and 85.7%, respectively. The long-term results of tricuspid valve replacement are considered satisfactory, and a bioprosthesis can be recommended due to its good outcome and no need for anticoagulation. We should not wait until the development of endstage cardiac impairment before carrying out tricuspid valve surgery.

Tricuspid valve replacement with a bioprosthetic valve

Significant tricuspid regurgitation (TR) is present in many patients with heart failure. Valve replacement is necessary in patients in whom the valve is irreparable or in whom there is a high risk of late failure. The following manuscript and videos describe our approach to tricuspid valve replacement with a bioprosthetic valve.

What to expect after tricuspid valve replacement? Long-term results

OBJECTIVE

Current knowledge in long-term results of tricuspid valve replacement is limited. Present study reviews our experience from a consecutive series.

METHODS

Forty-two patients (16 male, 26 female; mean age: 33+/-15) underwent tricuspid valve replacement between March 1987 and December 2004. The etiology was rheumatic in 64%, Ebstein's anomaly in 31%, and endocarditis in 5%. Nineteen patients were in New York Heart Association (NYHA) Class III functional capacity (45%), and 13 in class IV (31%). Twenty patients (48%) underwent isolated tricuspid valve replacement. The remaining underwent combined (mitral and/or aortic) valve replacements. Tricuspid replacement device was mechanical in 31% and bioimplant in 69%.

RESULTS

Hospital mortality was 26%. Rheumatic etiology, reoperation and elevated pulmonary artery pressure were associated with higher early mortality. The patients with decreased functional capacity (NYHA Class III/IV), congestive symptoms and rheumatic origin were more prone to low cardiac output development. The Kaplan-Meier survivals were 37% at 10 years and 30% at 15 years. The 10-year event-free survival was 31%. Elevated pulmonary artery pressure and rheumatic etiology unfavorably affected the long-term results. The average functional capacity in survivors improved significantly after operation.

CONCLUSIONS

Any tricuspid disease not amenable to repair thus necessitating replacement is an unfortunate situation since both the short and long-term results of valve replacement are suboptimal in regard to those of left-sided valve replacements, probably due to different structural and geometrical characteristics of right ventricle and the low-pressure venous system hemodynamics. Etiology, clinical presentation and pulmonary vascular hemodynamics are major determinants of the outcome.

Long-Term Clinical Results of Tricuspid Valve Replacement

BACKGROUND

Tricuspid valve replacement (TVR) has been performed with mechanical or bioprosthetic valves. However, the relative advantages of the two types are incompletely known.

METHODS

Between 1978 and 2003, we performed 138 TVR (35 bioprosthetic, 103 mechanical) in 125 patients (50 men, 75 women), with a mean age of 43.7 +/- 16.6 years. The diseases that required TVR were rheumatic (94), prosthetic valve failure (14), congenital (14), infective endocarditis(5), isolated tricuspid regurgitation (4), and miscellaneous conditions (7). The operations included the following: isolated TVR (41), double valve replacement (58), and triple valve replacement (39). The follow-up rate was 98.3%, and cumulative follow-up was 828.5 patient-years.

RESULTS

There were 22 in-hospital deaths (17.6%) and 13 (10.4%) late deaths. Fourteen patients required additional operations. There were 33 postoperative valve-related events including 11 thromboembolisms and 3 bleeding episodes. Kaplan-Meier survival for the entire group at 15 years was 73.8 +/- 8.5% (bioprosthetic: 70.2 +/- 10.4%, mechanical: 66.0 +/- 19.4%). At 15 years, freedom from reoperation was 66.3 +/- 9.4% (bioprosthetic: 55.1 +/- 13.8%, mechanical: 86.0 +/- 6.2%) and freedom from valve-related events was 49.9 +/- 8.0%. The linearized incidence of valve thrombosis was 1.28%/patient-year (bioprosthetic: 0, mechanical: 1.92), anticoagulation-related bleeding was 0.37%/patient-year (mechanical: 0.54), reoperation was 1.71%/patient-year (bioprosthetic: 2.68, mechanical: 1.25), and valve-related events were 4.33%/patient-year (bioprosthetic: 3.83, mechanical: 4.6).

CONCLUSIONS

Both bioprosthetic and mechanical valves revealed similar long-term outcomes. However, findings suggest that greater care is needed to prevent valve thrombosis in mechanical valves in the early postoperative period, and there is a greater chance for reoperation in bioprosthetic valves.

Tricuspid valve replacement: an analysis of 25 years of experience at a single center

BACKGROUND

Tricuspid valve replacement is seldom used in clinical practice, but the choice between mechanical and biologic prostheses remains controversial.

METHODS

Between 1977 and 2002, 97 patients underwent tricuspid valve replacement and were followed at the Montreal Heart Institute Valve Clinic. Patients underwent replacement with bioprostheses (n = 82) and mechanical valves (n = 15).

RESULTS

Patients with bioprosthetic tricuspid replacements averaged 53 +/- 13 years of age compared with 48 +/- 11 years in those with tricuspid mechanical valve replacements (p = 0.2). Isolated tricuspid valve replacement was performed in 11 patients (73%) in the mechanical valve group compared with 31 patients (38%. p = 0.01) in the bioprosthetic replacement group. In patients undergoing bioprosthetic tricuspid replacement, 51 (62%) underwent multiple associated valve replacements. The 5-year survival after tricuspid replacement averaged 60% +/- 13% in the mechanical valve group and 56% +/- 6% in the biologic replacement group (p = 0.8). The 5-year freedom rate from tricuspid valve reoperation averaged 91% +/- 9% in patients with mechanical valves and 97% +/- 3% in those with biologic valves (p = 0.2). CONCLUSIONS; Patient survival after tricuspid valve replacement is suboptimal but related to the clinical condition at operation. The use of biologic prostheses for tricuspid valve replacement remains a good option in young patients because of limited life expectancy unrelated to the type of tricuspid prostheses at long-term follow-up.

Prosthetic replacement of tricuspid valve: bioprosthetic or mechanical

BACKGROUND

Tricuspid valve replacement is one of the most challenging operations in cardiac surgery. Selection of the suitable prosthesis is still debatable.

METHODS

In our institution, between January 1980 and December 2000, 129 tricuspid valve replacements were performed in 122 patients (14.7%). Bioprosthetic valves were used in 32 patients, whereas 97 patients had mechanical valve implantation. Twenty-two percent of replacements were done on men. Mean age was 35.27+/-11.56 years. In all patients, initially an annuloplasty technique was tried. Tricuspid valve replacement was performed when annuloplasty was not sufficient. In most of the cases, tricuspid valve interventions were done under cardiopulmonary bypass and on a beating heart.

RESULTS

Early mortality was 24.5%. Patients were followed for 2 to 228 months. Seven patients underwent reoperation because of tricuspid valve dysfunction (7.6%). Nine patients died during the follow-up period. Late mortality was 9.7%. Actuarial estimates of survival in 20 years of follow-up for all tricuspid prosthetic valves, mechanical valves, and bioprosthetic valves were 65.1%+/-9.3%, 68.3%+/-10.6%, and 54.8%+/-12.1%, respectively. For the bioprosthetic valve group, freedom from structural valve degeneration was 90%+/-5.5%; for the mechanical valve group, freedom from deterioration, endocarditis, and leakage was 97.8%+/-4.2%, and freedom from thromboembolism was 92.6%+/-6.9%.

CONCLUSIONS

We found that there was no statistically significant difference between the two groups in terms of early mortality, re-replacement, and midterm mortality (p > 0.05). Nevertheless, we recommend low profile modern bileaflet mechanical valves for prosthetic replacement of the tricuspid valve, due to their favorable hemodynamic characteristics and durability.

Triple valve replacement with bileaflet mechanical valves: is the mechanical valve the proper choice for the tricuspid position?

A more durable mechanical valve may be a better choice for the tricuspid position than a bioprosthesis when the patient already has mechanical prosthesis in the left side of the heart. Eleven cases of triple valve replacement (total follow-up period, 49.5 patient years), all with mechanical valves, are reviewed to assess optimal valve selection. Nine patients had undergone a total of 12 previous cardiac surgeries. Three patients died in hospital (27.3%), but there were no late deaths among the survivors. Two cases of valve thrombosis in the tricuspid position occurred (linearized incidence: 4.04%/patient years) and 1 of these required reoperation. Because of this high incidence of valve thrombosis, the bileaflet mechanical valve is not considered to be the best choice. Even if mechanical valves are implanted in the left side of the heart, a bioprosthesis may be a better choice at the tricuspid position.