- Email: [email protected]
Surgical Algorithm for Rheumatic Tricuspid Disease
Surgical Algorithm for Rheumatic Tricuspid Disease Alok Mathur, MC, Neeraj Sharma, MCh, Pradeep Goyal, MD, and Piyush Mittal, MD Department of Cardio-thoracic and Vascular Surgery and Department of Cardiac Anesthesia, CK Birla Hospital/RBH, Jaipur; Department of Cardiac Anesthesia, NH Hospital, Jaipur; and Department of Cardiac Anesthesia, SDM Hospital, Jaipur, India
Rheumatic involvement of the tricuspid valve frequently occurs in patients with mitral and aortic valve disease. Inadequate attention to tricuspid valve function can lead to increased morbidity and may necessitate reoperation. A surgical algorithm is developed and presented for treatment of rheumatic heart disease. Seventy-four
R
heumatic involvement of the tricuspid valve frequently occurs in patients with mitral and aortic valve disease. Although numerous publications have stressed the importance of treating the rheumatic tricuspid valve, clear guidelines do not exist. Echocardiography is observer dependent in assessment of rheumatic tricuspid valve disease. The standard evaluation involving the degree of tricuspid regurgitation (TR) and gradients across the valve is not appropriate for dictating intervention. We present a surgical algorithm for evaluation and surgical treatment of rheumatic tricuspid valve disease.
Technique Seventy-two of 305 patients who were undergoing mitral or double valve replacement from January 2014 to July 2018 (at CK Birla Hospital/RBH, NH Hospital, and SDM Hospital, Jaipur, India) had concomitant tricuspid valve repair. Two patients had undergone an earlier mitral valve replacement and needed a tricuspid valve repair. The mean age of these patients was 38 9 years. Twentytwo patients had tricuspid stenosis. The degree of TR was not an overtly important factor in deciding on the surgical strategy. Mild TR without annular dilatation can be a feature of advanced tricuspid rheumatic disease involvement. Indications for visual inspection and intervention for tricuspid valve were as follows:
patients underwent tricuspid valve repair. Competent tricuspid valve (not more than mild tricuspid regurgitation) could be achieved in all of these patients. (Ann Thorac Surg 2019;108:e129–32) Ó 2019 by The Society of Thoracic Surgeons
and tricuspid stenosis, as assessed on echocardiography or visual inspection. The surgical technique involved standard aortobicaval cardiopulmonary bypass. Femorofemoral bypass was used for the two redo operations. The mitral and aortic valves were replaced with prostheses first. The rheumatic tricuspid valve often manifests with total obliteration of the commissures (Fig 1). Commissurotomy was performed on the septal anterior and the septal posterior commissures. The commissures were split up to the annulus, and the subvalvular tissue was also incised, including the papillary muscles to ensure adequate mobility of the leaflets (Fig 2A). The septal leaflet mobility was addressed by cutting any restricting basal chords. The technique of patch augmentation of the anterior tricuspid leaflet (ATL) has already been described [1]. The
1. Moderate or more severe TR in the presence of annular dilatation. 2. Mild or more severe TR in the absence of annular dilatation irrespective of valve disease. This mandated at least inspection of the valve. 3. Features of rheumatic tricuspid valve involvement, including commissural fusion, subvalvular disease, Accepted for publication Feb 4, 2019. Address correspondence to Dr Mathur, 37, Girnar Colony, Gautam Marg, Jaipur 302021, India; email: [email protected].
Ó 2019 by The Society of Thoracic Surgeons Published by Elsevier Inc.
Fig 1. Totally fused commissures in rheumatic tricuspid valve involvement. 0003-4975/$36.00 https://doi.org/10.1016/j.athoracsur.2019.02.009
e130
HOW TO DO IT MATHUR ET AL SURGERY FOR RHEUMATIC TRICUSPID DISEASE
Ann Thorac Surg 2019;108:e129–32
Fig 2. Surgical steps. (A) Adequate commissurotomy. (B) Detachment of the anterior tricuspid leaflet from the annulus. (C) Anterior tricuspid leaflet augmentation using a fresh autologous pericardial patch. (D) Competent tricuspid valve before annuloplasty.
ATL was detached from the annulus, and the incision for detachment stopped just short of the commissurotomy (Fig 2B). A fresh pericardial patch approximately 2.5 cm wide was sutured to the annulus and the ATL cut edge with 6-0 running Prolene (Ethicon, Somerville, NJ) (Fig 2C). The valve was tested with saline and was usually competent before annuloplasty (Fig 2D). For tricuspid annuloplasty, a De Vega annuloplasty was performed to target an annular diameter of about 31 mm, or a 30-mm prosthetic ring (Carpentier-Edwards Physio Tricuspid annuloplasty ring, Edwards Lifesciences, Irvine, CA) was used. Thirty-five of the patients in our group had isolated annuloplasty. Twelve patients had commissurotomy and annuloplasty. Two patients in this group required an ATL augmentation for moderate TR. Twenty-seven patients had ATL augmentation with commissurotomy and annuloplasty. There was no surgical mortality in the group. No patient required tricuspid valve replacement. The follow-up is 98.6% complete (73 of 74 patients). Mean follow-up has been 27.1 17.0 months; 37% (27 of 73) of patients have been followed up for more than 3 years. All patients are asymptomatic without diuretic therapy. At present, all
patients in follow-up are in New York Heart Association functional class I or II. Follow-up includes echocardiography every 3 months for the first 2 years after surgery and then annually. The mean gradients across the tricuspid valve are less than 4 mm Hg in all patients. On follow-up, 28 patients have no TR, another 28 have trace TR, 15 have mild TR, and 2 have moderate TR.
Comment Rheumatic disease involvement of the tricuspid valve manifests as commissural fusion, leaflet thickening and retraction, subvalvular fibrosis, and annular dilatation. The mechanism of TR in these patients is failure of coaptation secondary to inadequate or tethered leaflets [2]. Rheumatic disease involvement of the tricuspid valve has been reported in approximately 10% of patients with rheumatic heart valve disease in India [3]. It is also reported as an independent risk factor for mortality in patients undergoing surgery for combined valve disease [4, 5]. Even after adequate commissurotomy and annuloplasty, the ATL tissue is often not sufficient to provide
Ann Thorac Surg 2019;108:e129–32
HOW TO DO IT MATHUR ET AL SURGERY FOR RHEUMATIC TRICUSPID DISEASE
e131
Fig 3. Surgical algorithm for rheumatic tricuspid valve disease. (ATL ¼ anterior tricuspid leaflet; ECHO ¼ echocardiography.)
competence. Historically, ATL augmentation was not very popular because it is a major add-on procedure that requires at least 30 minutes of additional clamp time. Although it is not technically demanding, most surgeons preferred to accept some TR rather than waste clamp time in achieving perfect tricuspid competence. Unfortunately, this approach has led to increased morbidity and prolonged use of diuretic agents that often limit physical activity in this young, productive population. Redo surgery for tricuspid valve disease carries a higher risk and financial burden for the patient [6]. In our experience, the extra time and effort spent on the tricuspid valve at the time of the initial operation is worthwhile for achieving excellent long-term results. A favorable surgical outcome must include withdrawal of diuretic agents and improvement in functional capacity. If the ATL is deemed adequate, a generous commissurotomy and an annuloplasty is added to address annular dilatation and to protect the repair. The effectiveness of this approach with some variations has been documented by other investigators [1].
ATL augmentation with a pericardial patch is not a new technique [1, 7] Its inclusion in the surgical algorithm as a first choice for rheumatic tricuspid valve disease without annular dilatation is a new concept, however [8]. The most challenging group in our study consisted of patients with mild or little more than mild TR and a normal-sized tricuspid annulus. Most of these patients had nearly normal gradients across the tricuspid valve. According to our algorithm, these patients mandated at least visual inspection, and we found a surprisingly advanced degree of rheumatic disease involvement in these patients. Of the 74 patients, 14 (19%) were not recommended for tricuspid valve repair on the basis of echocardiographic findings. All 14 of them needed ATL augmentation. We believe that aggressive use of this technique has led to the desired result of competent tricuspid valves and has practically eliminated the use of diuretic agents in the long-term care of these patients. A surgical algorithm has been devised on the basis of these experiences (Fig 3). A De Vega annuloplasty was used in our initial experience (39 of 74 patients). Since June 2016, we have used a
e132
HOW TO DO IT MATHUR ET AL SURGERY FOR RHEUMATIC TRICUSPID DISEASE
prosthetic ring for all patients (35 of 74). The change is based on some publications highlighting long-term issues with the De Vega repair. We have observed no difference in our short follow-up. Although the follow-up duration is short, and concerns about the fate of untreated pericardium for ATL augmentation have been raised, we believe that the proposed surgical algorithm will yield good long-term results for this difficult to address valve [1, 7].
References 1. Tang H, Xu Z, Zou L, et al. Valve repair with autologous pericardium for organic lesions in rheumatic tricuspid valve disease. Ann Thorac Surg 2009;87:726–30. 2. Dreyfus GD, Martin RP, Chan KM, Dulguerov F, Alexandrescu C. Functional tricuspid regurgitation: a need to revise our understanding. J Am Coll Cardiol 2015;65: 2331–6.
Ann Thorac Surg 2019;108:e129–32
3. Manjunath CN, Srinivas P, Ravindranath KS, Dhanalakshmi C. Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: a single center experience. Indian Heart J 2014;66:320–6. 4. Bernal JM, Pont on A, Diaz B, et al. Surgery for rheumatic tricuspid valve disease: a 30-year experience. J Thorac Cardiovasc Surg 2008;136:476–81. 5. Navia JL, Brozzi NA, Klein AL, et al. Moderate tricuspid regurgitation with left-sided degenerative heart valve disease: to repair or not to repair? Ann Thorac Surg 2012;93:59–67; discussion 68–9. 6. Bernal JM, Morales D, Revuelta C, Llorca J, GutierrezMorlote J, Revuelta JM. Reoperations after tricuspid valve repair. J Thorac Cardiovasc Surg 2005;130:498–503. 7. Dreyfus GD, Raja SG, John Chan KM. Tricuspid leaflet augmentation to address severe tethering in functional tricuspid regurgitation. Eur J Cardiothorac Surg 2008;34: 908–10. 8. Nishimura R, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. Circulation 2014;129:e521–643.
Rheumatic involvement of the tricuspid valve frequently occurs in patients with mitral and aortic valve disease. Inadequate attention to tricuspid valve function can lead to increased morbidity and may necessitate reoperation. A surgical algorithm is developed and presented for treatment of rheumatic heart disease. Seventy-four
R
heumatic involvement of the tricuspid valve frequently occurs in patients with mitral and aortic valve disease. Although numerous publications have stressed the importance of treating the rheumatic tricuspid valve, clear guidelines do not exist. Echocardiography is observer dependent in assessment of rheumatic tricuspid valve disease. The standard evaluation involving the degree of tricuspid regurgitation (TR) and gradients across the valve is not appropriate for dictating intervention. We present a surgical algorithm for evaluation and surgical treatment of rheumatic tricuspid valve disease.
Technique Seventy-two of 305 patients who were undergoing mitral or double valve replacement from January 2014 to July 2018 (at CK Birla Hospital/RBH, NH Hospital, and SDM Hospital, Jaipur, India) had concomitant tricuspid valve repair. Two patients had undergone an earlier mitral valve replacement and needed a tricuspid valve repair. The mean age of these patients was 38 9 years. Twentytwo patients had tricuspid stenosis. The degree of TR was not an overtly important factor in deciding on the surgical strategy. Mild TR without annular dilatation can be a feature of advanced tricuspid rheumatic disease involvement. Indications for visual inspection and intervention for tricuspid valve were as follows:
patients underwent tricuspid valve repair. Competent tricuspid valve (not more than mild tricuspid regurgitation) could be achieved in all of these patients. (Ann Thorac Surg 2019;108:e129–32) Ó 2019 by The Society of Thoracic Surgeons
and tricuspid stenosis, as assessed on echocardiography or visual inspection. The surgical technique involved standard aortobicaval cardiopulmonary bypass. Femorofemoral bypass was used for the two redo operations. The mitral and aortic valves were replaced with prostheses first. The rheumatic tricuspid valve often manifests with total obliteration of the commissures (Fig 1). Commissurotomy was performed on the septal anterior and the septal posterior commissures. The commissures were split up to the annulus, and the subvalvular tissue was also incised, including the papillary muscles to ensure adequate mobility of the leaflets (Fig 2A). The septal leaflet mobility was addressed by cutting any restricting basal chords. The technique of patch augmentation of the anterior tricuspid leaflet (ATL) has already been described [1]. The
1. Moderate or more severe TR in the presence of annular dilatation. 2. Mild or more severe TR in the absence of annular dilatation irrespective of valve disease. This mandated at least inspection of the valve. 3. Features of rheumatic tricuspid valve involvement, including commissural fusion, subvalvular disease, Accepted for publication Feb 4, 2019. Address correspondence to Dr Mathur, 37, Girnar Colony, Gautam Marg, Jaipur 302021, India; email: [email protected].
Ó 2019 by The Society of Thoracic Surgeons Published by Elsevier Inc.
Fig 1. Totally fused commissures in rheumatic tricuspid valve involvement. 0003-4975/$36.00 https://doi.org/10.1016/j.athoracsur.2019.02.009
e130
HOW TO DO IT MATHUR ET AL SURGERY FOR RHEUMATIC TRICUSPID DISEASE
Ann Thorac Surg 2019;108:e129–32
Fig 2. Surgical steps. (A) Adequate commissurotomy. (B) Detachment of the anterior tricuspid leaflet from the annulus. (C) Anterior tricuspid leaflet augmentation using a fresh autologous pericardial patch. (D) Competent tricuspid valve before annuloplasty.
ATL was detached from the annulus, and the incision for detachment stopped just short of the commissurotomy (Fig 2B). A fresh pericardial patch approximately 2.5 cm wide was sutured to the annulus and the ATL cut edge with 6-0 running Prolene (Ethicon, Somerville, NJ) (Fig 2C). The valve was tested with saline and was usually competent before annuloplasty (Fig 2D). For tricuspid annuloplasty, a De Vega annuloplasty was performed to target an annular diameter of about 31 mm, or a 30-mm prosthetic ring (Carpentier-Edwards Physio Tricuspid annuloplasty ring, Edwards Lifesciences, Irvine, CA) was used. Thirty-five of the patients in our group had isolated annuloplasty. Twelve patients had commissurotomy and annuloplasty. Two patients in this group required an ATL augmentation for moderate TR. Twenty-seven patients had ATL augmentation with commissurotomy and annuloplasty. There was no surgical mortality in the group. No patient required tricuspid valve replacement. The follow-up is 98.6% complete (73 of 74 patients). Mean follow-up has been 27.1 17.0 months; 37% (27 of 73) of patients have been followed up for more than 3 years. All patients are asymptomatic without diuretic therapy. At present, all
patients in follow-up are in New York Heart Association functional class I or II. Follow-up includes echocardiography every 3 months for the first 2 years after surgery and then annually. The mean gradients across the tricuspid valve are less than 4 mm Hg in all patients. On follow-up, 28 patients have no TR, another 28 have trace TR, 15 have mild TR, and 2 have moderate TR.
Comment Rheumatic disease involvement of the tricuspid valve manifests as commissural fusion, leaflet thickening and retraction, subvalvular fibrosis, and annular dilatation. The mechanism of TR in these patients is failure of coaptation secondary to inadequate or tethered leaflets [2]. Rheumatic disease involvement of the tricuspid valve has been reported in approximately 10% of patients with rheumatic heart valve disease in India [3]. It is also reported as an independent risk factor for mortality in patients undergoing surgery for combined valve disease [4, 5]. Even after adequate commissurotomy and annuloplasty, the ATL tissue is often not sufficient to provide
Ann Thorac Surg 2019;108:e129–32
HOW TO DO IT MATHUR ET AL SURGERY FOR RHEUMATIC TRICUSPID DISEASE
e131
Fig 3. Surgical algorithm for rheumatic tricuspid valve disease. (ATL ¼ anterior tricuspid leaflet; ECHO ¼ echocardiography.)
competence. Historically, ATL augmentation was not very popular because it is a major add-on procedure that requires at least 30 minutes of additional clamp time. Although it is not technically demanding, most surgeons preferred to accept some TR rather than waste clamp time in achieving perfect tricuspid competence. Unfortunately, this approach has led to increased morbidity and prolonged use of diuretic agents that often limit physical activity in this young, productive population. Redo surgery for tricuspid valve disease carries a higher risk and financial burden for the patient [6]. In our experience, the extra time and effort spent on the tricuspid valve at the time of the initial operation is worthwhile for achieving excellent long-term results. A favorable surgical outcome must include withdrawal of diuretic agents and improvement in functional capacity. If the ATL is deemed adequate, a generous commissurotomy and an annuloplasty is added to address annular dilatation and to protect the repair. The effectiveness of this approach with some variations has been documented by other investigators [1].
ATL augmentation with a pericardial patch is not a new technique [1, 7] Its inclusion in the surgical algorithm as a first choice for rheumatic tricuspid valve disease without annular dilatation is a new concept, however [8]. The most challenging group in our study consisted of patients with mild or little more than mild TR and a normal-sized tricuspid annulus. Most of these patients had nearly normal gradients across the tricuspid valve. According to our algorithm, these patients mandated at least visual inspection, and we found a surprisingly advanced degree of rheumatic disease involvement in these patients. Of the 74 patients, 14 (19%) were not recommended for tricuspid valve repair on the basis of echocardiographic findings. All 14 of them needed ATL augmentation. We believe that aggressive use of this technique has led to the desired result of competent tricuspid valves and has practically eliminated the use of diuretic agents in the long-term care of these patients. A surgical algorithm has been devised on the basis of these experiences (Fig 3). A De Vega annuloplasty was used in our initial experience (39 of 74 patients). Since June 2016, we have used a
e132
HOW TO DO IT MATHUR ET AL SURGERY FOR RHEUMATIC TRICUSPID DISEASE
prosthetic ring for all patients (35 of 74). The change is based on some publications highlighting long-term issues with the De Vega repair. We have observed no difference in our short follow-up. Although the follow-up duration is short, and concerns about the fate of untreated pericardium for ATL augmentation have been raised, we believe that the proposed surgical algorithm will yield good long-term results for this difficult to address valve [1, 7].
References 1. Tang H, Xu Z, Zou L, et al. Valve repair with autologous pericardium for organic lesions in rheumatic tricuspid valve disease. Ann Thorac Surg 2009;87:726–30. 2. Dreyfus GD, Martin RP, Chan KM, Dulguerov F, Alexandrescu C. Functional tricuspid regurgitation: a need to revise our understanding. J Am Coll Cardiol 2015;65: 2331–6.
Ann Thorac Surg 2019;108:e129–32
3. Manjunath CN, Srinivas P, Ravindranath KS, Dhanalakshmi C. Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: a single center experience. Indian Heart J 2014;66:320–6. 4. Bernal JM, Pont on A, Diaz B, et al. Surgery for rheumatic tricuspid valve disease: a 30-year experience. J Thorac Cardiovasc Surg 2008;136:476–81. 5. Navia JL, Brozzi NA, Klein AL, et al. Moderate tricuspid regurgitation with left-sided degenerative heart valve disease: to repair or not to repair? Ann Thorac Surg 2012;93:59–67; discussion 68–9. 6. Bernal JM, Morales D, Revuelta C, Llorca J, GutierrezMorlote J, Revuelta JM. Reoperations after tricuspid valve repair. J Thorac Cardiovasc Surg 2005;130:498–503. 7. Dreyfus GD, Raja SG, John Chan KM. Tricuspid leaflet augmentation to address severe tethering in functional tricuspid regurgitation. Eur J Cardiothorac Surg 2008;34: 908–10. 8. Nishimura R, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. Circulation 2014;129:e521–643.