- Email: [email protected]
Postoperative Outcome of Isolated Tricuspid Valve Operation Using Arrested-Heart or Beating-Heart Technique
ADULT CARDIAC
Postoperative Outcome of Isolated Tricuspid Valve Operation Using Arrested-Heart or Beating-Heart Technique Bettina Pfannmüller, MD, Piroze Davierwala, MD, Martin Misfeld, MD, PhD, Michael A. Borger, MD, PhD, Jens Garbade, MD, PhD, and Friedrich W. Mohr, MD, PhD Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
Background. Tricuspid valve (TV) operations can be done with either a beating-heart or arrested-heart technique. We herein report the postoperative outcome of patients with isolated TV operations performed with a beating heart or arrested heart, having a closer look at echocardiographic results after TV repair, postoperative incidence of pacemaker implantations, neurologic complications, survival, and freedom from TV-related reoperation. Methods. We present a retrospective analysis of 105 patients who underwent isolated TV operations with a beating-heart (n ⴝ 63) or arrested-heart technique (n ⴝ 42). Mean patient age was 61.2 ⴞ 15.1 years. Male patients were 41.9% of the total, and the average log EuroSCORE was 12.4% ⴞ 11.4%. Redo operations made up 51.4% of the total. Follow-up was 95% complete, with a mean duration of 32.0 ⴞ 32.6 months. Results. Overall operative mortality was 8.6%. Fiveyear survival was 68.8% ⴞ 7.1% versus 66.3% ⴞ 9.1% for
patients with beating-heart versus arrested-heart operations (p ⴝ 0.9). During follow-up, 7 patients underwent TV reoperations, resulting in a 5-year event-free survival rate of 90.1% ⴞ 5.9% for patients with beating-heart and 84.0% ⴞ 6.7% for patients with arrested-heart operations. There was no significant difference regarding postoperative echocardiographic results after TV repair, postoperative pacemaker implantations, or neurologic outcome. Conclusions. Although both cohorts were very heterogeneous and difficult to compare, our results show that both surgical strategies for TV repair have good results regarding postoperative survival, neurologic complications, and postoperative indications for a pacemaker. TV repair with the beating-heart technique has excellent results and can be safely accomplished in a minimally invasive manner.
T
exposition of the anteroseptal part of the annulus near the aorta. It remains unclear whether there are differences in postoperative outcomes in patients operated on by 1 technique or the other. It needs to be clarified if the incidence of AV block and neurologic complications is comparable and whether specific indications exist for the preference of 1 of the 2 techniques. In an attempt to answer these questions, we analyzed our experience with isolated TV operations performed with cardiopulmonary bypass with and without cardiac arrest.
ricuspid valve (TV) operations are routinely performed with cardiopulmonary bypass with or without clamping of the ascending aorta. Both methods have been described in the literature [1–5]; however there are no reports comparing their postoperative outcomes. The advantages of performing an isolated TV procedure on a beating heart without clamping the aorta (BH-TV) over performing the operation with an aortic cross-clamp on an arrested heart (AH-TV) include no myocardial ischemic time and reduced risk of systemic embolization because of the aortic clamp [6, 7]. In addition, damage to the atrioventricular (AV) node from sutures passed through the septal part of the tricuspid annulus can be recognized from development of an AV block and can be immediately rectified. Advantages of TV operations with an arrested heart are less blood flow through the coronary sinus, no movement of the leaflets (in the case of vegetations, thrombus, or tumor), no posterior movement of the septal part of the annulus, and a better
Accepted for publication May 3, 2012. Address correspondence to Dr Pfannmüller, Department of Cardiac Surgery, University of Leipzig Heart Center, Strümpellstrasse 39, 04289 Leipzig, Germany; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2012;94:1218 –22) © 2012 by The Society of Thoracic Surgeons
Patients and Methods One hundred five patients underwent isolated TV repair or replacement between May 1997 and August 2010 at our institution— 42 patients (40%) with AH-TV and 63 patients (60%) with BH-TV. Indications for TV repair were symptomatic severe tricuspid regurgitation (TR) or TV endocarditis (or both), atrial myxoma involving the TV in 1 patient, and TV stenosis in another patient. Preoperative, intraoperative, and postoperative data from all patients were prospectively entered into a pa0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.05.020
¨ LLER ET AL PFANNMU ISOLATED TRICUSPID VALVE OPERATION
Ann Thorac Surg 2012;94:1218 –22
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Variable Age (y) Male sex Mean preoperative NYHA Log EuroSCORE LVEF Previous cardiac operation Atrial fibrillation Hypertension Diabetes mellitus Permanent pacemaker Functional TR Acute tricuspid endocarditis
All Patients (N ⫽ 105)
Arrested Heart (n ⫽ 42)
Beating Heart (n ⫽ 63)
p
61.2 ⫾ 15.1 44 (41.9%) 2.5 ⫾ 0.8 12.4% ⫾ 11.4% 58.4% ⫾ 10.9% 54 (51.4%) 33 (31.4%) 58 (55.2%) 19 (18.1%) 44 (41.9%) 71 (72.4%) 34 (32.3%)
55.2 ⫾ 17.3 23 (54.8%) 2.4 ⫾ 1.0 10.0% ⫾ 9.7% 61.2% ⫾ 11.8% 11 (26.2%) 6 (14.3%) 22 (52.4%) 6 (14.3%) 17 (39.5%) 18 (48.6%) 24 (57.1%)
65.2 ⫾ 11.9 21 (33.3%) 2.5 ⫾ 0.8 14.11% ⫾ 12.3% 56.6% ⫾ 10.3% 43 (68.3%) 27 (42.9%) 36 (57.1%) 13 (20.6%) 27 (42.9%) 53 (86.9%) 10 (15.9%)
⬍ 0.001 0.03 0.1 0.2 0.8 ⬍ 0.001 ⬍ 0.001 0.9 0.07 0.8 ⬍ 0.001 ⬍ 0.001
log EuroSCORE ⫽ logistic EuroSCORE predicted risk of operative mortality; Association; TR ⫽ tricuspid regurgitation.
tient data management system and then retrospectively analyzed. Patients were contacted and interviewed by telephone. If no further information was available, family physicians were contacted. Follow-up was 95% complete, with a mean follow-up time of 32.0 ⫾ 32.6 months (range, 1 day to 12.3 years). Further chart review and information from preoperative and predischarge echocardiographic reports was collected and analyzed. TR was calculated by measurement of vena contracta in a 4-chamber view [8]. With patient agreement, we contacted the patients’ cardiologists to obtain the last postoperative echocardiograms taken, which were available in 49% of the surviving patients with a mean follow-up time of 3.3 ⫾ 2.7 years (range 23 days to 10.4 years). Ethics approval was granted from the local ethics committee for this investigation. Demographic data from all patients who underwent isolated TV operations are shown in Table 1. Average age for the entire patient cohort was 61.2 ⫾ 15.0 years, and more than half of the patients were women. Mean New York Heart Association (NYHA) classification was 2.5 ⫾ 0.8. Left ventricular function was within normal limits in the majority of patients. A third of the patients presented with atrial fibrillation and the majority had arterial hypertension. There were significant differences between the BH-TV and AH-TV patient groups. Patients who underwent AH-TV operations were significantly younger and had a significantly lower number of reoperations and a lower incidence of atrial fibrillation. However the incidence of acute TV endocarditis as an indication for TV operations was significantly higher in patients who underwent AH-TV operations (Fig 1). Functional TR was present in 53 patients (86.9%) in the BH-TV group and in 18 patients (48.6%) in the AH-TV group (p ⬍ 0.001). Overall, 33 patients (31.4%) required TV operations for acute TV endocarditis; of these cases, drug abuse was the likely cause of TV endocarditis in 9 patients (27.3%). In 8 patients (24.2%), vegetations had developed on permanent pacemaker leads, and the remaining 16 patients had TV endocarditis of unknown origin.
LVEF ⫽ left ventricular ejection fraction;
NYHA ⫽ New York Heart
TV operations were performed using standard techniques, including bicaval cannulation and mild hypothermic total cardiopulmonary bypass through a median sternotomy in 38 patients (36.2%). Minimally invasive operations were performed in 67 patients (63.8%) through a right lateral minithoracotomy with arterial and venous femorofemoral and venous jugular cannulation for cardiopulmonary bypass; 38% (16/42) of the patients underwent AH-TV and 81% (51/63) of the patients underwent BH-TV operations (p ⬍ 0.001). Indications for TV repair or replacement and the decision whether to use the AH-TV or BH-TV technique was determined by the operating surgeon.
Statistical Evaluation Results are displayed in the standard format with continuous variables expressed as mean ⫾ standard deviation and categorical data as proportions. Cumulative survival was calculated by the Kaplan-Meier method and differences in follow-up were calculated with 95% confidence limits and compared by the log rank (Mantel) test. All statistical analyses were performed using SPSS sta-
Fig 1. Surgical procedures performed in previous operations. (AVR ⫽ aortic valve reconstruction/replacement; CABG ⫽ coronary artery bypass grafting; MVR ⫽ mitral valve reconstruction/replacement; S.p. ⫽ status post; TVR ⫽ tricuspid valve repair.)
ADULT CARDIAC
Table 1. Demographic Data
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Ann Thorac Surg 2012;94:1218 –22
Table 2. Perioperative Patient Characteristics Variable
ADULT CARDIAC
Operation time (min) Cross-clamp time (min) CPB time (min) Minimally invasive access Postoperative LVEF Procedure type Replacement Ring annuloplasty Suture annuloplasty No annuloplasty
All Patients (N ⫽ 105)
Arrested Heart (n ⫽ 42)
Beating Heart (n ⫽ 63)
p
160.0 ⫾ 58.9 ... 93.9 ⫾ 46.0 67 (63.8%) 58.1 ⫾ 9.5
170.0 ⫾ 71.8 44.0 ⫾ 21.8 90.9 ⫾ 52.4 16 (38.1%) 60.0 ⫾ 8.4
153.4 ⫾ 48.0 0 95.8 ⫾ 41.6 51 (81.0%) 57.0 ⫾ 10.0
0.03
29 (27.6%) 58 (55.2%) 6 (5.7%) 12 (11.4)
17 (40.5%) 13 (31.0%) 4 (9.5%) 8 (19.0%)
12 (19.0%) 45 (71.4%) 2 (3.2%) 4 (6.3%)
0.3 ⬍ 0.001 0.1 0.001
Data are mean ⫾ standard deviation. CPB ⫽ cardiopulmonary bypass;
LVEF ⫽ left ventricular ejection fraction.
tistical package, version 17.0 (SPSS Inc, Chicago, IL). A p value less than 0.05 was considered statistically significant.
Results Intraoperative data and perioperative echocardiographic findings are shown in Table 2. Operation time was significantly longer in patients who underwent AH-TV operations; however cardiopulmonary bypass time was comparable in both groups. There was a significantly larger number of patients in the BH-TV group (79.4%) than in the AH-TV group (49.5%). The majority of patients had preoperative TR grade 3⫹ to 4⫹. Eight patients had TR grade 0⫹ to 1⫹. Of these, 6 patients had TV endocarditis or vegetation on a permanent pacemaker lead (or both), 1 patient had a myxoma of the right ventricle with involvement of the TV, and another patient had TV stenosis after previous TV replacement (Table 3).
Postoperative Outcomes Predischarge TR grade 3⫹ to 4⫹ was documented in 7 patients (7.1%) (BH-TV, 5 patients; AH-TV, 2 patients) (Table 3). Reasons for recurrent TR 3⫹ to 4⫹ in the BH-TV group were dehiscence of a rigid annuloplasty ring in 2 patients and central regurgitation in 3 patients. The 2 patients who received AH-TV operations underwent excision of vegetations without any ring annuloplasty. Residual TR was accepted in these patients to avoid further implantation of foreign material into the tricuspid annulus because of the potential risk of recurrent endocarditis. Five patients (BH-TV, 4.7%; AH-TV, 4.7%; p ⫽ 1.0) required reexploration for bleeding. Four patients (6.4%) in the BH-TV group and 3 patients (7.1%) in the AH-TV group required postoperative permanent pacemaker implantation. Nine patients (14.1%) in the BH-TV group and 4 patients (10.0%) in the AH-TV group (p ⫽ 0.54) had transient perioperative neurologic complications. Transient neurologic events included epilepsy (BH-TV, 6.4%;
AH-TV, 2.4%), transient postoperative psychotic syndrome (BH-TV, 6.4%; AH-TV, 7.1%), and reversible ischemic neurologic deficit (BH-TV, 1.6%; AH-TV, 0%). There was 1 postoperative stroke (1.0%) in a patient in the AH-TV-group. It was a fatal intracerebral bleeding episode in the only patient receiving postoperative extracorporeal membrane oxygenation. The overall operative mortality was 8.6% (n ⫽ 9). Operative mortality in patients in the BH-TV group was 6.3% (3⫻ low-cardiac-output syndrome, 1⫻ sepsis after TV endocarditis–related operations) and 11.9% in the AH-TV group (4⫻ low cardiac output syndrome, 1⫻ fatal intracerebral hemorrhage). There was no significant difference between the groups (p ⫽ 0.1).
Table 3. Preoperative, Predischarge, and Follow-Up Echocardiographic Results Variable Preoperative TR TR0⫹ TR1⫹ TR2⫹ TR3⫹ TR4⫹ Predischarge TR TR0⫹ TR1⫹ TR2⫹ TR3⫹ TR4⫹ Follow-up TR TR0⫹ TR1⫹ TR2⫹ TR3⫹ TR4⫹
All Patients
Arrested Heart
Beating Heart
n ⫽ 105 4 (3.8%) 3 (2.9%) 6 (5.7%) 65 (61.9%) 27 (25.7%) n ⫽ 99 39 (39.4%) 31 (31.3%) 22 (22.2%) 6 (6.1%) 1 (1.0%) n ⫽ 38 10 (26.3%) 16 (42.1%) 8 (21.1%) 4 (10.5%) 0 (0.0%)
n ⫽ 42 2 (4.8%) 3 (7.1%) 3 (7.1%) 23 (54.8%) 11 (26.2%) n ⫽ 40 21 (52.5%) 9 (22.5%) 8 (20.0%) 1 (2.5%) 1 (2.5%) n ⫽ 11 4 (36.4%) 3 (27.3%) 2 (18.2%) 2 (18.2%) 0 (0.0%)
n ⫽ 63 2 (3.2%) 0 (0.0%) 3 (4.8%) 42 (66.7%) 16 (25.4%) n ⫽ 59 18 (30.5%) 22 (37.3%) 14 (23.7%) 5 (8.5%) 0 (0.0%) n ⫽ 27 6 (22.2%) 13 (48.1%) 6 (22.2%) 2 (7.4%) 0 (0.0%)
TR ⫽ tricuspid regurgitation.
p 0.2
0.2
0.5
¨ LLER ET AL PFANNMU ISOLATED TRICUSPID VALVE OPERATION
Ann Thorac Surg 2012;94:1218 –22
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Fig 2. Postoperative survival.
Follow-Up Figure 2 shows overall long-term survival. Five-year survival was 68.8 ⫾ 7.1 years in the BH-TV group and 66.3 ⫾ 9.1 years in the AH-TV group (log rank p ⫽ 0.9). Freedom from TV reoperation during follow-up is seen in Fig 3. At 5 years, freedom from TV reoperation was 90.1% ⫾ 5.9% in the BH-TV group and 84.0% ⫾ 6.7% in the AH-TV group (p ⫽ 0.3). A total of 7 patients underwent reoperation between 20 days and 3 years postoperatively; 3 patients had severe recurrent TR (BH-TV, 2 patients; AH-TV, 1 patient) and 4 developed recurrent endocarditis (BH-TV, 1 patient; AH-TV, 3 patients). Cause for reoperation in the 2 patients without endocarditis was ring dehiscence in the BH-TV group and central insufficiency after TV repair with a Carpentier-Edwards Classic Annuloplasty Ring (Edwards Lifesciences, Irvine, CA). In the AH-TV group, the cause for reoperation in the patient without endocarditis was central recurrent TR after a De Vega annuloplasty. Postoperative echocardiographic data with a mean follow-up time of 3.3 ⫾ 2.7 years was available in 38 of the surviving patients (Table 3). This cohort did not include any of the patients who underwent repeated TV-related operations. Follow-up predischarge echocardiography showed an increase of TR in 4 patients. Severe TR was seen in follow-up echocardiograms in 2 patients who underwent BH-TV operations for tricuspid repair; predischarge echocardiograms in these patients showed mild to moderate TR and moderate TR in these patients, respectively. In another 2 patients who underwent AH-TV operations and had no predischarge TR after tricuspid repair and replacement, moderate and severe TR, respectively, was seen in follow-up echocardiograms.
To the best of our knowledge, this is the first study that compares the operative technique of BH-TV with AH-TV operations in patients undergoing TV operations. We saw comparable intraoperative and postoperative results with both surgical techniques, but both patient cohorts were very heterogeneous and difficult to compare, which must be kept in mind when we evaluate our results. Survival rates and rates of freedom from TV reoperations were comparable in both groups. Operation time was significantly longer in patients operated on with an arrested heart, but the difference of 10 minutes should not have any clinical relevance. Additionally, comparable cardiopulmonary bypass times in both groups imply that the BH-TV technique is not more demanding than the AH technique. This is supported by the fact that there were 68% reoperations in the BH-TV group compared with only 26% reoperations in the AH-TV group. TV operations performed with either technique showed comparable rates of postoperative AV block, with no significant difference in the incidence of implantation of pacemakers (7.1% versus 6.4%). Jokinen and colleagues [9] described a rate of 11.1% AV block necessitating pacemaker implantation after tricuspid repair and replacement. None of the patients in this study had a pacemaker preoperatively. Nearly half of the patients in our study had pacemakers preoperatively, so we have to take into account that the rate of new-onset of AV block in our series may be higher and also undetected. In the predischarge echocardiograms, we saw 3 patients with dehiscence of a Carpentier-Edwards Classic Annuloplasty Ring in the septal part of the annulus in the BH-TV group compared with no dehiscence in the AH-TV group, although there was no statistical signifi-
Fig 3. Postoperative freedom from tricuspid valve (TV)-related reoperation.
ADULT CARDIAC
Comment
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ADULT CARDIAC
cant difference between the groups and there was a limited number of patients with the rigid ring (BH-TV, 21 patients; AH-TV, 6 patients). The BH technique may be a reason for dehiscence of the rigid ring. A possible explanation could be that increased shearing forces occur at the septal portion of the annulus during BH operations. These shearing forces would be even higher if a rigid ring was used. This line of argumentation is supported by the studies addressing the dynamics of the native tricuspid annulus [10 –12]. There are significant changes in the tricuspid annular dimensions from systole to diastole, with a 19% change of annular circumference and a 30% change in the annular area [11]. Neurologic deficits were comparable and mostly transient in both groups. To avoid mediastinal dissection, Lee and coworkers [13] abandon snaring or occlusion of the venae cavae, working only with vacuum assistance in minimally invasive tricuspid procedures. They, too, did not observe neurologic complications with this technique. We prefer occluding the cannulated upper and lower venae cavae with bands in patients undergoing median sternotomy and with small bulldog clamps in minimally invasive operations. In the latter case, during reoperation we alternatively use Fogarty catheters, blocking both venae cavae after insertion from the cervical and femoral sides to avoid dissection and potential injury of the venae cavae. We prefer this technique instead of the strategy described by Lee and associates [13] to avoid microemboli in the arterial line caused by air trapping in the venous line, which has been described in previous studies [14].
Study Limitations The main limitation of the current study is its retrospective nature. Although retrospective studies can be associated with significant bias, the majority of evidence for surgical valvular therapy is based on such studies because of the relatively small number of patients who present with these pathologic processes. In addition, the patient cohort in this study is somewhat inhomogeneous: The BH-TV group included patients who underwent reoperation, patients with atrial fibrillation, and patients who underwent minimally invasive operations; the AH-TV group included younger patients, patients with endocarditis, and patients with predominantly sinus rhythm who underwent procedures with conventional sternotomy. We have to take this into account when analyzing the postoperative outcomes of both patient groups. Another limitation is the lack of complete echocardiographic follow-up data, which is partially related to the fact that many patients were referred from other regions and we had to rely on echocardiograms from the referring cardiologists. However, to our knowledge, the current study represents 1 of the largest series of patients who have undergone isolated tricuspid operations.
Ann Thorac Surg 2012;94:1218 –22
Conclusions Although both cohorts are very heterogeneous and difficult to compare, our results show that both surgical strategies of TV repair have good results regarding postoperative survival, neurologic complications, and postoperative indications for pacemaker implantation. TV repair with BH technique has excellent results and can also be safely accomplished in a minimally invasive manner.
References 1. Iscan ZH, Vural KM, Bahar I, Mavioglu L, Saritas A. What to expect after tricuspid valve replacement? Long-term results. Eur J Cardiothorac Surg 2007;32:296 –300. 2. Kaplan M, Kut MS, Demirtas MM, Cimen S, Ozler A. Prosthetic replacement of tricuspid valve: bioprosthetic or mechanical. Ann Thorac Surg 2002;73:467–73. 3. Park CK, Park PW, Sung K, Lee YT, Kim WS, Jun TG. Early and midterm outcomes for tricuspid valve surgery after left-sided valve surgery. Ann Thorac Surg 2009;88:1216 –23. 4. Sung K, Park PW, Park KH, et al. Is tricuspid valve replacement a catastrophic operation? Eur J Cardiothorac Surg 2009;36:825–9. 5. Vigano G, Guidotti A, Taramasso M, Giacomini A, Alfieri O. Clinical mid-term results after tricuspid valve replacement. Interact Cardiovasc Thorac Surg 2010;10:709 –13. 6. Bucerius J, Gummert JF, Borger MA, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg 2003;75:472– 8. 7. Calafiore AM, Di Mauro M, Teodori G, et al. Impact of aortic manipulation on incidence of cerebrovascular accidents after surgical myocardial revascularization. Ann Thorac Surg 2002;73:1387–93. 8. Fehske W, Omran H, Manz M, Kohler J, Hagendorff A, Luderitz B. Color-coded Doppler imaging of the vena contracta as a basis for quantification of pure mitral regurgitation. Am J Cardiol 1994;73:268 –74. 9. Jokinen JJ, Turpeinen AK, Pitkanen O, Hippelainen MJ, Hartikainen JE. Pacemaker therapy after tricuspid valve operations: implications on mortality, morbidity, and quality of life. Ann Thorac Surg 2009;87:1806 –14. 10. Fukuda S, Saracino G, Matsumura Y, et al. Threedimensional geometry of the tricuspid annulus in healthy subjects and in patients with functional tricuspid regurgitation: a real-time, 3-dimensional echocardiographic study. Circulation 2006;114:I492– 8. 11. Tei C, Pilgrim JP, Shah PM, Ormiston JA, Wong M. The tricuspid valve annulus: study of size and motion in normal subjects and in patients with tricuspid regurgitation. Circulation 1982;66:665–71. 12. Ton-Nu TT, Levine RA, Handschumacher MD, et al. Geometric determinants of functional tricuspid regurgitation: insights from 3-dimensional echocardiography. Circulation 2006;114:143–9. 13. Lee TC, Desai B, Glower DD. Results of 141 consecutive minimally invasive tricuspid valve operations: an 11-year experience. Ann Thorac Surg 2009;88:1845–50. 14. Taylor RL, Borger MA, Weisel RD, Fedorko L, Feindel CM. Cerebral microemboli during cardiopulmonary bypass: increased emboli during perfusionist interventions. Ann Thorac Surg 1999;68:89 –93.
Postoperative Outcome of Isolated Tricuspid Valve Operation Using Arrested-Heart or Beating-Heart Technique Bettina Pfannmüller, MD, Piroze Davierwala, MD, Martin Misfeld, MD, PhD, Michael A. Borger, MD, PhD, Jens Garbade, MD, PhD, and Friedrich W. Mohr, MD, PhD Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
Background. Tricuspid valve (TV) operations can be done with either a beating-heart or arrested-heart technique. We herein report the postoperative outcome of patients with isolated TV operations performed with a beating heart or arrested heart, having a closer look at echocardiographic results after TV repair, postoperative incidence of pacemaker implantations, neurologic complications, survival, and freedom from TV-related reoperation. Methods. We present a retrospective analysis of 105 patients who underwent isolated TV operations with a beating-heart (n ⴝ 63) or arrested-heart technique (n ⴝ 42). Mean patient age was 61.2 ⴞ 15.1 years. Male patients were 41.9% of the total, and the average log EuroSCORE was 12.4% ⴞ 11.4%. Redo operations made up 51.4% of the total. Follow-up was 95% complete, with a mean duration of 32.0 ⴞ 32.6 months. Results. Overall operative mortality was 8.6%. Fiveyear survival was 68.8% ⴞ 7.1% versus 66.3% ⴞ 9.1% for
patients with beating-heart versus arrested-heart operations (p ⴝ 0.9). During follow-up, 7 patients underwent TV reoperations, resulting in a 5-year event-free survival rate of 90.1% ⴞ 5.9% for patients with beating-heart and 84.0% ⴞ 6.7% for patients with arrested-heart operations. There was no significant difference regarding postoperative echocardiographic results after TV repair, postoperative pacemaker implantations, or neurologic outcome. Conclusions. Although both cohorts were very heterogeneous and difficult to compare, our results show that both surgical strategies for TV repair have good results regarding postoperative survival, neurologic complications, and postoperative indications for a pacemaker. TV repair with the beating-heart technique has excellent results and can be safely accomplished in a minimally invasive manner.
T
exposition of the anteroseptal part of the annulus near the aorta. It remains unclear whether there are differences in postoperative outcomes in patients operated on by 1 technique or the other. It needs to be clarified if the incidence of AV block and neurologic complications is comparable and whether specific indications exist for the preference of 1 of the 2 techniques. In an attempt to answer these questions, we analyzed our experience with isolated TV operations performed with cardiopulmonary bypass with and without cardiac arrest.
ricuspid valve (TV) operations are routinely performed with cardiopulmonary bypass with or without clamping of the ascending aorta. Both methods have been described in the literature [1–5]; however there are no reports comparing their postoperative outcomes. The advantages of performing an isolated TV procedure on a beating heart without clamping the aorta (BH-TV) over performing the operation with an aortic cross-clamp on an arrested heart (AH-TV) include no myocardial ischemic time and reduced risk of systemic embolization because of the aortic clamp [6, 7]. In addition, damage to the atrioventricular (AV) node from sutures passed through the septal part of the tricuspid annulus can be recognized from development of an AV block and can be immediately rectified. Advantages of TV operations with an arrested heart are less blood flow through the coronary sinus, no movement of the leaflets (in the case of vegetations, thrombus, or tumor), no posterior movement of the septal part of the annulus, and a better
Accepted for publication May 3, 2012. Address correspondence to Dr Pfannmüller, Department of Cardiac Surgery, University of Leipzig Heart Center, Strümpellstrasse 39, 04289 Leipzig, Germany; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2012;94:1218 –22) © 2012 by The Society of Thoracic Surgeons
Patients and Methods One hundred five patients underwent isolated TV repair or replacement between May 1997 and August 2010 at our institution— 42 patients (40%) with AH-TV and 63 patients (60%) with BH-TV. Indications for TV repair were symptomatic severe tricuspid regurgitation (TR) or TV endocarditis (or both), atrial myxoma involving the TV in 1 patient, and TV stenosis in another patient. Preoperative, intraoperative, and postoperative data from all patients were prospectively entered into a pa0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.05.020
¨ LLER ET AL PFANNMU ISOLATED TRICUSPID VALVE OPERATION
Ann Thorac Surg 2012;94:1218 –22
1219
Variable Age (y) Male sex Mean preoperative NYHA Log EuroSCORE LVEF Previous cardiac operation Atrial fibrillation Hypertension Diabetes mellitus Permanent pacemaker Functional TR Acute tricuspid endocarditis
All Patients (N ⫽ 105)
Arrested Heart (n ⫽ 42)
Beating Heart (n ⫽ 63)
p
61.2 ⫾ 15.1 44 (41.9%) 2.5 ⫾ 0.8 12.4% ⫾ 11.4% 58.4% ⫾ 10.9% 54 (51.4%) 33 (31.4%) 58 (55.2%) 19 (18.1%) 44 (41.9%) 71 (72.4%) 34 (32.3%)
55.2 ⫾ 17.3 23 (54.8%) 2.4 ⫾ 1.0 10.0% ⫾ 9.7% 61.2% ⫾ 11.8% 11 (26.2%) 6 (14.3%) 22 (52.4%) 6 (14.3%) 17 (39.5%) 18 (48.6%) 24 (57.1%)
65.2 ⫾ 11.9 21 (33.3%) 2.5 ⫾ 0.8 14.11% ⫾ 12.3% 56.6% ⫾ 10.3% 43 (68.3%) 27 (42.9%) 36 (57.1%) 13 (20.6%) 27 (42.9%) 53 (86.9%) 10 (15.9%)
⬍ 0.001 0.03 0.1 0.2 0.8 ⬍ 0.001 ⬍ 0.001 0.9 0.07 0.8 ⬍ 0.001 ⬍ 0.001
log EuroSCORE ⫽ logistic EuroSCORE predicted risk of operative mortality; Association; TR ⫽ tricuspid regurgitation.
tient data management system and then retrospectively analyzed. Patients were contacted and interviewed by telephone. If no further information was available, family physicians were contacted. Follow-up was 95% complete, with a mean follow-up time of 32.0 ⫾ 32.6 months (range, 1 day to 12.3 years). Further chart review and information from preoperative and predischarge echocardiographic reports was collected and analyzed. TR was calculated by measurement of vena contracta in a 4-chamber view [8]. With patient agreement, we contacted the patients’ cardiologists to obtain the last postoperative echocardiograms taken, which were available in 49% of the surviving patients with a mean follow-up time of 3.3 ⫾ 2.7 years (range 23 days to 10.4 years). Ethics approval was granted from the local ethics committee for this investigation. Demographic data from all patients who underwent isolated TV operations are shown in Table 1. Average age for the entire patient cohort was 61.2 ⫾ 15.0 years, and more than half of the patients were women. Mean New York Heart Association (NYHA) classification was 2.5 ⫾ 0.8. Left ventricular function was within normal limits in the majority of patients. A third of the patients presented with atrial fibrillation and the majority had arterial hypertension. There were significant differences between the BH-TV and AH-TV patient groups. Patients who underwent AH-TV operations were significantly younger and had a significantly lower number of reoperations and a lower incidence of atrial fibrillation. However the incidence of acute TV endocarditis as an indication for TV operations was significantly higher in patients who underwent AH-TV operations (Fig 1). Functional TR was present in 53 patients (86.9%) in the BH-TV group and in 18 patients (48.6%) in the AH-TV group (p ⬍ 0.001). Overall, 33 patients (31.4%) required TV operations for acute TV endocarditis; of these cases, drug abuse was the likely cause of TV endocarditis in 9 patients (27.3%). In 8 patients (24.2%), vegetations had developed on permanent pacemaker leads, and the remaining 16 patients had TV endocarditis of unknown origin.
LVEF ⫽ left ventricular ejection fraction;
NYHA ⫽ New York Heart
TV operations were performed using standard techniques, including bicaval cannulation and mild hypothermic total cardiopulmonary bypass through a median sternotomy in 38 patients (36.2%). Minimally invasive operations were performed in 67 patients (63.8%) through a right lateral minithoracotomy with arterial and venous femorofemoral and venous jugular cannulation for cardiopulmonary bypass; 38% (16/42) of the patients underwent AH-TV and 81% (51/63) of the patients underwent BH-TV operations (p ⬍ 0.001). Indications for TV repair or replacement and the decision whether to use the AH-TV or BH-TV technique was determined by the operating surgeon.
Statistical Evaluation Results are displayed in the standard format with continuous variables expressed as mean ⫾ standard deviation and categorical data as proportions. Cumulative survival was calculated by the Kaplan-Meier method and differences in follow-up were calculated with 95% confidence limits and compared by the log rank (Mantel) test. All statistical analyses were performed using SPSS sta-
Fig 1. Surgical procedures performed in previous operations. (AVR ⫽ aortic valve reconstruction/replacement; CABG ⫽ coronary artery bypass grafting; MVR ⫽ mitral valve reconstruction/replacement; S.p. ⫽ status post; TVR ⫽ tricuspid valve repair.)
ADULT CARDIAC
Table 1. Demographic Data
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Table 2. Perioperative Patient Characteristics Variable
ADULT CARDIAC
Operation time (min) Cross-clamp time (min) CPB time (min) Minimally invasive access Postoperative LVEF Procedure type Replacement Ring annuloplasty Suture annuloplasty No annuloplasty
All Patients (N ⫽ 105)
Arrested Heart (n ⫽ 42)
Beating Heart (n ⫽ 63)
p
160.0 ⫾ 58.9 ... 93.9 ⫾ 46.0 67 (63.8%) 58.1 ⫾ 9.5
170.0 ⫾ 71.8 44.0 ⫾ 21.8 90.9 ⫾ 52.4 16 (38.1%) 60.0 ⫾ 8.4
153.4 ⫾ 48.0 0 95.8 ⫾ 41.6 51 (81.0%) 57.0 ⫾ 10.0
0.03
29 (27.6%) 58 (55.2%) 6 (5.7%) 12 (11.4)
17 (40.5%) 13 (31.0%) 4 (9.5%) 8 (19.0%)
12 (19.0%) 45 (71.4%) 2 (3.2%) 4 (6.3%)
0.3 ⬍ 0.001 0.1 0.001
Data are mean ⫾ standard deviation. CPB ⫽ cardiopulmonary bypass;
LVEF ⫽ left ventricular ejection fraction.
tistical package, version 17.0 (SPSS Inc, Chicago, IL). A p value less than 0.05 was considered statistically significant.
Results Intraoperative data and perioperative echocardiographic findings are shown in Table 2. Operation time was significantly longer in patients who underwent AH-TV operations; however cardiopulmonary bypass time was comparable in both groups. There was a significantly larger number of patients in the BH-TV group (79.4%) than in the AH-TV group (49.5%). The majority of patients had preoperative TR grade 3⫹ to 4⫹. Eight patients had TR grade 0⫹ to 1⫹. Of these, 6 patients had TV endocarditis or vegetation on a permanent pacemaker lead (or both), 1 patient had a myxoma of the right ventricle with involvement of the TV, and another patient had TV stenosis after previous TV replacement (Table 3).
Postoperative Outcomes Predischarge TR grade 3⫹ to 4⫹ was documented in 7 patients (7.1%) (BH-TV, 5 patients; AH-TV, 2 patients) (Table 3). Reasons for recurrent TR 3⫹ to 4⫹ in the BH-TV group were dehiscence of a rigid annuloplasty ring in 2 patients and central regurgitation in 3 patients. The 2 patients who received AH-TV operations underwent excision of vegetations without any ring annuloplasty. Residual TR was accepted in these patients to avoid further implantation of foreign material into the tricuspid annulus because of the potential risk of recurrent endocarditis. Five patients (BH-TV, 4.7%; AH-TV, 4.7%; p ⫽ 1.0) required reexploration for bleeding. Four patients (6.4%) in the BH-TV group and 3 patients (7.1%) in the AH-TV group required postoperative permanent pacemaker implantation. Nine patients (14.1%) in the BH-TV group and 4 patients (10.0%) in the AH-TV group (p ⫽ 0.54) had transient perioperative neurologic complications. Transient neurologic events included epilepsy (BH-TV, 6.4%;
AH-TV, 2.4%), transient postoperative psychotic syndrome (BH-TV, 6.4%; AH-TV, 7.1%), and reversible ischemic neurologic deficit (BH-TV, 1.6%; AH-TV, 0%). There was 1 postoperative stroke (1.0%) in a patient in the AH-TV-group. It was a fatal intracerebral bleeding episode in the only patient receiving postoperative extracorporeal membrane oxygenation. The overall operative mortality was 8.6% (n ⫽ 9). Operative mortality in patients in the BH-TV group was 6.3% (3⫻ low-cardiac-output syndrome, 1⫻ sepsis after TV endocarditis–related operations) and 11.9% in the AH-TV group (4⫻ low cardiac output syndrome, 1⫻ fatal intracerebral hemorrhage). There was no significant difference between the groups (p ⫽ 0.1).
Table 3. Preoperative, Predischarge, and Follow-Up Echocardiographic Results Variable Preoperative TR TR0⫹ TR1⫹ TR2⫹ TR3⫹ TR4⫹ Predischarge TR TR0⫹ TR1⫹ TR2⫹ TR3⫹ TR4⫹ Follow-up TR TR0⫹ TR1⫹ TR2⫹ TR3⫹ TR4⫹
All Patients
Arrested Heart
Beating Heart
n ⫽ 105 4 (3.8%) 3 (2.9%) 6 (5.7%) 65 (61.9%) 27 (25.7%) n ⫽ 99 39 (39.4%) 31 (31.3%) 22 (22.2%) 6 (6.1%) 1 (1.0%) n ⫽ 38 10 (26.3%) 16 (42.1%) 8 (21.1%) 4 (10.5%) 0 (0.0%)
n ⫽ 42 2 (4.8%) 3 (7.1%) 3 (7.1%) 23 (54.8%) 11 (26.2%) n ⫽ 40 21 (52.5%) 9 (22.5%) 8 (20.0%) 1 (2.5%) 1 (2.5%) n ⫽ 11 4 (36.4%) 3 (27.3%) 2 (18.2%) 2 (18.2%) 0 (0.0%)
n ⫽ 63 2 (3.2%) 0 (0.0%) 3 (4.8%) 42 (66.7%) 16 (25.4%) n ⫽ 59 18 (30.5%) 22 (37.3%) 14 (23.7%) 5 (8.5%) 0 (0.0%) n ⫽ 27 6 (22.2%) 13 (48.1%) 6 (22.2%) 2 (7.4%) 0 (0.0%)
TR ⫽ tricuspid regurgitation.
p 0.2
0.2
0.5
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Fig 2. Postoperative survival.
Follow-Up Figure 2 shows overall long-term survival. Five-year survival was 68.8 ⫾ 7.1 years in the BH-TV group and 66.3 ⫾ 9.1 years in the AH-TV group (log rank p ⫽ 0.9). Freedom from TV reoperation during follow-up is seen in Fig 3. At 5 years, freedom from TV reoperation was 90.1% ⫾ 5.9% in the BH-TV group and 84.0% ⫾ 6.7% in the AH-TV group (p ⫽ 0.3). A total of 7 patients underwent reoperation between 20 days and 3 years postoperatively; 3 patients had severe recurrent TR (BH-TV, 2 patients; AH-TV, 1 patient) and 4 developed recurrent endocarditis (BH-TV, 1 patient; AH-TV, 3 patients). Cause for reoperation in the 2 patients without endocarditis was ring dehiscence in the BH-TV group and central insufficiency after TV repair with a Carpentier-Edwards Classic Annuloplasty Ring (Edwards Lifesciences, Irvine, CA). In the AH-TV group, the cause for reoperation in the patient without endocarditis was central recurrent TR after a De Vega annuloplasty. Postoperative echocardiographic data with a mean follow-up time of 3.3 ⫾ 2.7 years was available in 38 of the surviving patients (Table 3). This cohort did not include any of the patients who underwent repeated TV-related operations. Follow-up predischarge echocardiography showed an increase of TR in 4 patients. Severe TR was seen in follow-up echocardiograms in 2 patients who underwent BH-TV operations for tricuspid repair; predischarge echocardiograms in these patients showed mild to moderate TR and moderate TR in these patients, respectively. In another 2 patients who underwent AH-TV operations and had no predischarge TR after tricuspid repair and replacement, moderate and severe TR, respectively, was seen in follow-up echocardiograms.
To the best of our knowledge, this is the first study that compares the operative technique of BH-TV with AH-TV operations in patients undergoing TV operations. We saw comparable intraoperative and postoperative results with both surgical techniques, but both patient cohorts were very heterogeneous and difficult to compare, which must be kept in mind when we evaluate our results. Survival rates and rates of freedom from TV reoperations were comparable in both groups. Operation time was significantly longer in patients operated on with an arrested heart, but the difference of 10 minutes should not have any clinical relevance. Additionally, comparable cardiopulmonary bypass times in both groups imply that the BH-TV technique is not more demanding than the AH technique. This is supported by the fact that there were 68% reoperations in the BH-TV group compared with only 26% reoperations in the AH-TV group. TV operations performed with either technique showed comparable rates of postoperative AV block, with no significant difference in the incidence of implantation of pacemakers (7.1% versus 6.4%). Jokinen and colleagues [9] described a rate of 11.1% AV block necessitating pacemaker implantation after tricuspid repair and replacement. None of the patients in this study had a pacemaker preoperatively. Nearly half of the patients in our study had pacemakers preoperatively, so we have to take into account that the rate of new-onset of AV block in our series may be higher and also undetected. In the predischarge echocardiograms, we saw 3 patients with dehiscence of a Carpentier-Edwards Classic Annuloplasty Ring in the septal part of the annulus in the BH-TV group compared with no dehiscence in the AH-TV group, although there was no statistical signifi-
Fig 3. Postoperative freedom from tricuspid valve (TV)-related reoperation.
ADULT CARDIAC
Comment
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ADULT CARDIAC
cant difference between the groups and there was a limited number of patients with the rigid ring (BH-TV, 21 patients; AH-TV, 6 patients). The BH technique may be a reason for dehiscence of the rigid ring. A possible explanation could be that increased shearing forces occur at the septal portion of the annulus during BH operations. These shearing forces would be even higher if a rigid ring was used. This line of argumentation is supported by the studies addressing the dynamics of the native tricuspid annulus [10 –12]. There are significant changes in the tricuspid annular dimensions from systole to diastole, with a 19% change of annular circumference and a 30% change in the annular area [11]. Neurologic deficits were comparable and mostly transient in both groups. To avoid mediastinal dissection, Lee and coworkers [13] abandon snaring or occlusion of the venae cavae, working only with vacuum assistance in minimally invasive tricuspid procedures. They, too, did not observe neurologic complications with this technique. We prefer occluding the cannulated upper and lower venae cavae with bands in patients undergoing median sternotomy and with small bulldog clamps in minimally invasive operations. In the latter case, during reoperation we alternatively use Fogarty catheters, blocking both venae cavae after insertion from the cervical and femoral sides to avoid dissection and potential injury of the venae cavae. We prefer this technique instead of the strategy described by Lee and associates [13] to avoid microemboli in the arterial line caused by air trapping in the venous line, which has been described in previous studies [14].
Study Limitations The main limitation of the current study is its retrospective nature. Although retrospective studies can be associated with significant bias, the majority of evidence for surgical valvular therapy is based on such studies because of the relatively small number of patients who present with these pathologic processes. In addition, the patient cohort in this study is somewhat inhomogeneous: The BH-TV group included patients who underwent reoperation, patients with atrial fibrillation, and patients who underwent minimally invasive operations; the AH-TV group included younger patients, patients with endocarditis, and patients with predominantly sinus rhythm who underwent procedures with conventional sternotomy. We have to take this into account when analyzing the postoperative outcomes of both patient groups. Another limitation is the lack of complete echocardiographic follow-up data, which is partially related to the fact that many patients were referred from other regions and we had to rely on echocardiograms from the referring cardiologists. However, to our knowledge, the current study represents 1 of the largest series of patients who have undergone isolated tricuspid operations.
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Conclusions Although both cohorts are very heterogeneous and difficult to compare, our results show that both surgical strategies of TV repair have good results regarding postoperative survival, neurologic complications, and postoperative indications for pacemaker implantation. TV repair with BH technique has excellent results and can also be safely accomplished in a minimally invasive manner.
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