Reoperations after tricuspid valve repair: re-repair versus replacement

Outcomes of minimally invasive isolated tricuspid valve reoperation after left-side valve surgery: A single-center experience

BACKGROUND

Late severe tricuspid regurgitation (TR) after left-side valve surgery (LSVS) is not uncommon. However, the tricuspid valve has been deemed the forgotten valve because the isolated TR is well tolerated with medication, and reoperation has a higher rate of adverse events. With the advancement of minimally invasive techniques, isolated tricuspid valve reoperation (ITVR) via totally endoscopy or transcatheter approach brings the tricuspid valve into spotlight. Our aim is to report the safety and efficacy of minimally invasive ITVR using endoscopic and transcatheter approaches.

METHODS

From October 2020 to October 2021, 21 patients with LSVS history and secondary massive TR underwent minimally invasive ITVR in our institution. Baseline characteristics, surgical outcomes and follow-up results were analyzed, and data between the totally endoscopy approach and the transcatheter approach were compared.

RESULTS

Of the 21 cases, totally endoscopic isolated tricuspid valve surgery (EITVS) accounts for 16 (76.2%) cases, with 14 tricuspid valvuloplasty cases, and 2 tricuspid valve replacement cases; the remaining 5 (23.8%) cases underwent transcatheter tricuspid valve replacement (TTVR). The mean age was (60.0 ± 8.4) years, with 15 (71.4%) being female. Minimally invasive ITVR procedures were 100% successfully performed in all patients without any perioperative mortality, sternotomy conversion, or reoperation. During the median follow-up of 16.8 months (IQR, 13.0-20.6 months), New York Heart Association Class improved significantly from baseline (P = 0.004). TR severity was significantly improved during postoperative and follow-up period (both P < 0.001). Compared with the EITVS group, the TTVR group had a higher clinical risk score [8.00 (8.00, 9.00) vs. 5.00 (3.25, 5.00), P = 0.001], but a higher success rate in reducing TR to less than grade 1+ (100 vs. 43.8%, P = 0.045) at follow-up.

CONCLUSION

In our series, minimally invasive ITVR, including EITVS and TTVR, is a safe and feasible option for severe TR after LSVS, and presents excellent early outcomes in selected patients. TTVR is a reliable alternative for patients with high surgical risk. To improve the results of ITVR, it is necessary to improve patient's preoperative status or perform reoperation before the onset of significant right heart failure. Further studies with a larger sample size and a longer follow-up period are awaited.

Case report: Transcatheter edge-to-edge repair after prior surgical tricuspid annuloplasty

Residual and recurrent tricuspid regurgitation may occur frequently after surgical tricuspid valve repair. However, reoperation for tricuspid regurgitation is rare, although many patients are again highly symptomatic. Tricuspid transcatheter edge-to-edge repair (TEER) is a promising therapy for severe tricuspid regurgitation. Herein, we report a 77-year-old woman with recurrent symptomatic massive tricuspid regurgitation 2 years after sutured annuloplasty of the tricuspid valve. TEER was successfully performed using the TriClip® device and tricuspid regurgitation was reduced to a mild degree. In conclusion, tricuspid TEER is feasible following surgical suture annuloplasty. TEER is an alternative option for patients with a failed previous annuloplasty repair for tricuspid regurgitation to undergo a less invasive treatment rather than a potentially higher-risk reoperation.

Isolated tricuspid valve surgery; long-term outcomes based on Tehran Heart Center data bank report

Background

Given that isolated tricuspid valve (TV) repair or replacement is performed relatively rarely, we sought to evaluate the rate of long-term mortality and readmission following this surgery.

Methods

The current study was conducted in Tehran Heart Center on patients who underwent isolated TV repair or replacement between 2010 and 2018. Totally, 197 patients (repair = 150 vs replacement = 47) were included in our study and were then followed right after surgery for a median of 8 years to assess the incidence of postoperative events, readmission, and all-cause mortality.

Results

The final analysis was conducted on 197 patients at a mean age of 44.4 ± 13.8 years. Most of the patients were female (56.9%). Ejection fraction, TAPSE, and right ventricular function improved in both groups after TV surgery. Length of stay in the intensive care unit per hour and hospitalization per day were higher in the replacement group and compared to the repair group (158.34 vs. 55.11 and 18.21 vs. 9.34, respectively). In-hospital mortality occurred in 20 patients, of whom 15 had TV replacement. Readmission occurred in five (2.5%) patients,all were in the repair group.

Conclusions

The result of this single-center study showed that TV replacement is associated with a higher rate of postoperative events and all-cause mortality compared to TV repair. Whereas, repair group had a higher rate of readmission. Therefore, the overwhelming tendency is toward repair; nonetheless, no hesitation is permissible if a replacement is adjudged to confer a better outcome for the patient.

Early and Late Outcomes of Isolated Tricuspid Valve Surgery Following Valvular Surgery

PURPOSE

Isolated tricuspid valve surgery (TVS) following valvular surgery has been still challenging. We reviewed our experience to determine early and late outcomes.

METHODS

We retrospectively analyzed 14 patients (mean age, 57.0 ± 17.8 years old) who underwent isolated TVS after valvular surgery between January 1990 and December 2010. The causes of isolated TVS were structural valve deterioration (SVD) (n = 5) and symptomatic severe tricuspid regurgitation (n = 9). The mean follow-up period was 6.4 ± 5.9 years.

RESULTS

At redo, seven patients underwent tricuspid valve replacement (TVR) using a bioprosthesis and the remaining underwent tricuspid valve repair (TVP). Early mortality rate was 7.1% (1/14). Survival rates at 5 and 10 years were 68.8% ± 13.1% and 68.8% ± 13.1%, respectively. Three deaths (two for heart failure and one for cerebral hemorrhage) were observed. Freedom from valve-related events was 58.3% ± 14.2% at 2 and 48.6% ± 14.8% at 5 years. Six events were observed (five for heart failure and one for cerebral hemorrhage). There was no statistically significant difference between TVP and TVR as to freedom from valve-related events (log-rank p = 0.3655).

CONCLUSIONS

Early and late outcomes of isolated TVS after valvular surgery seem to be satisfactory. Special attention should be paid to heart failure following TVP.

Isolated tricuspid regurgitation: outcomes and therapeutic interventions

Isolated tricuspid regurgitation (TR) can be caused by primary valvular abnormalities such as flail leaflet or secondary annular dilation as is seen in atrial fibrillation, pulmonary hypertension and left heart disease. There is an increasing recognition of a subgroup of patients with isolated TR in the absence of other associated cardiac abnormalities. Left untreated isolated TR significantly worsens survival. Stand-alone surgery for isolated TR is rarely performed due to an average operative mortality of 8%–10% and a paucity of data demonstrating improved survival. When surgery is performed, valve repair may be preferred over replacement; however, there is a risk of significant recurrent regurgitation after repair. Existing society guidelines do not fully address the management of isolated TR. We propose that patients at low operative risk with symptomatic severe isolated TR and no reversible cause undergo surgery prior to the onset of right ventricular dysfunction and end-organ damage. For patients at increased surgical risk novel percutaneous interventions may offer an alternative treatment but further research is needed. Significant knowledge gaps remain and future research is needed to define operative outcomes and provide comparative data for medical and surgical therapy.

Repair or Replacement for Isolated Tricuspid Valve Pathology? Insights from a Surgical Analysis on Long-Term Survival

Background

Long-term follow-up data concerning isolated tricuspid valve pathology after replacement or reconstruction is limited. Current American Heart Association guidelines equally recommend repair and replacement when surgical intervention is indicated. Our aim was to investigate and compare operative mortality and long-term survival in patients undergoing isolated tricuspid valve repair surgery versus replacement.

Material/Methods

Between 1995 and 2011, 109 consecutive patients underwent surgical correction of tricuspid valve pathology at our institution for varying structural pathologies. A total of 41 (37.6%) patients underwent tricuspid annuloplasty/repair (TAP) with or without ring implantation, while 68 (62.3%) patients received tricuspid valve replacement (TVR) of whom 36 (53%) were mechanical and 32 (47%) were biological prostheses.

Results

Early survival at 30 days after surgery was 97.6% in the TAP group and 91.1% in the TVR group. After 6 months, 89.1% in the TAP group and 87.8% in the TVR group were alive. In terms of long-term survival, there was no further mortality observed after one year post surgery in both groups (Log Rank p=0.919, Breslow p=0.834, Tarone-Ware p=0.880) in the Kaplan-Meier Survival analysis. The 1-, 5-, and 8-year survival rates were 85.8% for TAP and 87.8% for TVR group.

Conclusions

Surgical repair of the tricuspid valve does not show survival benefit when compared to replacement. Hence valve replacement should be considered generously in patients with reasonable suspicion that regurgitation after repair will reoccur.