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Tricuspid annuloplasty
Tricuspid annuloplasty Five and one-half years' experience with 78 patients From January, 1968, through June, 1973, 78 tricuspid annuloplasties and 90 tricuspid valve replacements were performed in association with mitraL or mitral-aortic valve procedures. Tricuspid insufficiency was not recognized preoperativeLy (either clinically or by cardiac catheterization) in 35 per cent of these patients, a fact which emphasizes the importance of routine digital palpation of the tricuspid vaLve. The severity of tricuspid disease was roughly comparabLe in the two groups. The hospital mortality rate was 14 per cent in the annuloplasty group and 34 per cent in the replacement group. Late deaths occurred in 17 and 19 per cent of the two groups, respectiveLy. Sixty-nine per cent of the patients having tricuspid annuloplasty are currently alive, as compared to 45 per cent of the patients having tricuspid vaLve replacement. Tricuspid insufficiency recurred in 5 patients after annuloplasty and resuLted from an inadequate mitral vaLve procedure or left ventricular failure. The present study suggests that tricuspid annuloplasty is a rapid and reliable means of correcting tricuspid insufficiency and is superior to tricuspid vaLvereplacement.
Arthur D. Boyd, M.D., Richard M. Engelman, M.D. (by invitation), O. Wayne Isom, M.D. (by invitation), George E. Reed, M.D., and Frank C. Spencer, M.D., New York, N. Y.
Acquired tricuspid regurgitation is frequently encountered in patients having mitral or combined mitral and aortic valve operations. One hundred sixty-eight (22 per cent) of 755 patients having mitral valve procedures at the New York University Medical Center from January, 1968, through June, 1973, had associated tricuspid regurgitation which required correction. This incidence coresponds closely to that reported by others." " The correct management of acquired tricuspid insufficiency remains controversial. Whereas some advocate replacementv " or repair" ,-. of the valve, others feel that nothing need be done"; they maintain that, after correction of the mitral valve disease, the tricuspid insufficiency will improve or From the New York University Medical Center, 566 First Avenue, New York, N. Y. 10016. Read at the Fifty-fourth Annual Meeting of The American Association for Thoracic Surgery, Las Vegas, Nevada, April 22, 23, and 24, 1974.
344
disappear as the right-sided pressures and chamber dilatation return toward normal. In our experience tricuspid regurgitation was not significantly lessened after correction of mitral valve disease. This experience is similar to that reported by Pluth' and Starr." Prior to 1972, tricuspid valve replacement was used in the majority of our patients. Since 1972, however, we have performed annuloplasty with greater frequency because of our dissatisfaction with the high operative mortality rate of tricuspid valve replacement and because of our impression that the hemodynamic results of annuloplasty were equal or superior to those of valve replacement. To evaluate tricuspid annuloplasty more objectively, we have compared the results of this procedure with the results of tricuspid valve replacement for the period January, 1968, through June, 1973, during which time approximately equal numbers of each procedure were performed.
Volume 68 Number 3 September, 1974
345
Tricuspid annuloplasty
Table I. Operative procedures and comparative mortality rates in 168 patients with tricuspid valve disease Patients Procedure
No.
MVR, TA OMC, TA MA, TA MVR, CBG,TA AVR, MVR, TA AVR, MA, TA AVR, OMC, TA Totals
44 10 2 2 15 3 78
MVR, TVR OMC, TVR MA, TVR MVR, CBG, TVR AVR, MVR, TVR AVR, MA, TVR AVR, OMC, TVR Totals
60 4 0 2 24 0 0 90
I Per cent
Per cent
Tricuspid annuloplasty
2
56 12 3 3 19 4 3 100
6 1 0 0 4 0 0 11
13
10 27 14
10 0 0 1 2 0 0 13
23 50 14 17
Tricuspid valve replacement
67 4
20 0
33
11 0
2 27
1 11
50 46
0 6
25
100
32
36
17
19
18
Legend: MVR, Mitral valve
replacement. TA, Tricuspid annuloplasty, OMC, Open mitral commissurotomy. MA, Mitral annuloplasty. CBG, Coronary bypass graft. AYR, Aortic valve replacement. TYR, Tricuspid valve replacement.
Materials and methods
Seventy-eight patients (52 women and 26 men) who ranged in age from 19 to 68 years had tricuspid annuloplasty performed at the time of mitral or aortic and mitral valve operations at the New York University Medical Center from January, 1968, through June, 1973. During this same period 90 patients (62 women and 28 men) ranging in age from 18 to 72 years had tricuspid valve replacement primarily with Starr-Edwards prostheses (6310 and 6320 series) (Fig. 1). The use of annuloplasty progressively increased during this period (Fig. 2). The operative procedures performed are shown in Table I. Of the patients having annuloplasty, 48 (62 per cent) were in the Functional Class III and 26 (33 per cent) in Functional Class IV of the New York Heart Association. Of those having valve replacement, 63 (69 per cent) were in Class III and 25 (28 per cent) in Class IV. Sixty patients (77 per cent) of the annuloplasty group and 71 (79 per cent) of the valve replacePatients.
ment group had elevated right-sided pressures at preoperative catheterization. Significant tricuspid insufficiency was not diagnosed preoperatively in 32 (41 per cent) of the patients having annuloplasty and 27 (30 per cent) of those having valve replacement. Technique of annuloplasty. At operation in patients who required mitral valve procedures, the right side of the heart was carefully inspected, right atrial thickness evaluated, and the right atrial pressure measured. Prior to insertion of the venous cannulas, a finger was inserted into the right atrium, the tricuspid valve palpated, and its competency evaluated. If more than a trace of tricuspid insufficiency was found on digital examination, after the mitral or combined mitral-aortic procedure had been completed, the right atrium was opened parallel to and 1 em. from the atrioventricular groove and the tricuspid valve was carefully examined. Annuloplasty was usually performed at the commissure between the anterior and posterior leaflets or, rarely, at the
The Journal of
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Boyd et al.
Thoracic and Cardiovascular Surgery
Table II. Causes of hospital death in patients having tricuspid procedures
755 Mitral and Mitral-Aortic Valve Procedures
No. of deaths Causes of hospital death Arrhythmias Hemorrhage Infection Low output Neurologic Renal failure Totals
168 (22'%) wi th Tricuspid I nsuff ic iency
/ / /
/
/
/
/
,
\
\
, -, ,
(62 WOmen. 28 men) 18 to 72 years
No. of deaths
Dtricuspid annuloplasty mtricuspid valve replacement
30
1969
1 1 11 (14%)
Table III. Causes of late death in patients having tricuspid procedures
Fig. 1. Breakdown of the patient population that required tricuspid valve procedures from January, 1968, through June, 1973.
1968
4
3 2 4 18 3 2 32 (36%)
90 Tricuspid Valve Replacement
(52 women. 26 men) 19 to 68 years
No. of
1 2 2
Valve replacement
\
78
Tricuspid Annuloplasty
patients
Annuloplasty
1970 1971 YEAR
1972
1973
16m•• 1
Fig. 2. Tricuspid annuloplasty and valve replacement performed yearly from January, 1968, through June, 1973.
commissure between the anterior and septal leaflets (Fig. 3). The repair was performed with simple sutures passed around the annulus if the tissues were thickened and with mattress sutures passed beneath the annulus if the tissues were of normal consistency. In each instance the needle entered 2 mm, on the atrial side of the annulus, passed around the annulus, and exited 2 mm. on the valvular side of the annulus. When mattress sutures were used, 6 mm. was left between the limbs of the sutures, and pledgets of Teflon felt were used as buttresses. The
Causes of late death Arrhythmias Congestive heart failure Hepatitis Neurologic Obstructed prosthesis Unrelated Totals
Annuloplasty
I Valve
replacement
3
3
5 0 3
5 1 3
0 2 13 (17%)
2 3 17 (19%)
repair usually required one or two mattress sutures. The resulting orifice was acceptible only if it easily admitted two fingers (a diameter of 5 em. or more). If tricuspid stenosis was found, commissurotomy was performed followed by annuloplasty. The atrium was then closed, care being taken to remove all air from the right side of the heart prior to completion of the closure. After cardiopulmonary bypass was discontinued and an adequate cardiac output and systemic pressure were present, the venous cannulas were removed from the right atrium, the tricuspid valve was again digitally examined, and pressures were measured. More than a trace of tricuspid insufficiency or a gradient of more than 3 to 4 mm. across the valve was unacceptable and necessitated either adjustment of the annuloplasty or use of a prosthesis. Operative findings. At the operating
Volume 68
Tricuspid annuloplasty
Number 3 September, 1974
347
Fig. 3. Technique of annuloplasty performed at commissure between anterior and posterior leaflets. a, Anterior leaflet. p, Posterior leaflet. s, Septal leaflet.
table, tricuspid insufficiency was judged to be severe in 25 (32 per cent), moderate in 38 (49 per cent), and mild in 15 (19 per cent) of the patients having annuloplasty. In those patients having valve replacement, the insufficiency was severe in 32 (36 per cent), moderate in 51 (57 per cent), and mild in 7 (8 per cent). Diseased tricuspid leaflets were noted in 9 (12 per cent) of the patients who had annuloplasty and in 23 (26 per cent) of those having valve replacement. Some tricuspid stenosis was present in 6 (8 per cent) of the patients having annuloplasty and in 11 ( 12 per cent) of those having valve replacement. The annulus was found to be dilated in all 78 patients (100 per cent) of the annuloplasty group and in 86 (97 per cent) of the valve replacement group. Tricuspid
commissurotomy was combined with annuloplasty in the 6 patients who had some degree of tricuspid stenosis. Among the patients who had an annuloplasty, a trace of tricuspid insufficiency was present after cardiopulmonary bypass in 14 ( 18 per cent), whereas in 64 (82 per cent) no insufficiency could be palpated. Tricuspid annuloplasty added 35 minutes and tricuspid valve replacement added 75 minutes to the average bypass time. Results Eleven patients (14 per cent) died in the hospital after tricuspid annuloplasty; 32 (34 per cent) died after tricuspid valve replacement. There were thirteen (17 per cent) and seventeen late deaths (19 per cent) in the annuloplasty and valve replace-
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Table IV. Late failure of tricuspid annuloplasty Patient 1 2 3
4 5
I
Treatment
Current status
Operative procedure
Cause of failure
MA, TA OMC, TA MVR, resection of VA, TA OMC, TA OMC, TA
Breakdown of MA Resulting MI LVF
TVR TVR Medical
Alive and well Dead Dead
Resulting MI Resulting MI
TVR Medical
Alive and well Severely debilitated
Legend: MA, Mitral annuloplasty. TA, Tricuspid annuloplasty. OMC, Open mitral commissurotomy. MVR, Mitral valve replacement. VA, Ventricular aneurysm. MI, Mitral insufficiency. LVF, Left ventricular failure. TVR, Tricuspid valve replacement.
ment groups, respectively. The causes of death are shown in Tables II and III. Fortyfive (58 per cent) of the patients in whom an annuloplasty was performed are alive and well, whereas 9 (12 per cent) are alive but limited. Of the patients having tricuspid replacement, 30 (33 per cent) are alive and well and 11 (12 per cent) are alive but limited. Tricuspid annuloplasty failed in 5 patients (Table IV). In all 5 patients, elevated right-sided pressures were not relieved by the first operative procedure on the mitral valve. In 3, mitral insufficiency resulted after open mitral commissurotomy. In 1 patient a mitral annuloplasty broke down, and in another left ventricular failure resulted from coronary disease. In none of the 78 patients having tricuspid annuloplasty was heart block noted, either in the immediate postoperative period or as a late complication. Discussion Tricuspid insufficiency occurred in 22 per cent of our patients who had mitral or combined aortic and mitral valve disease. The diagnosis was made preoperatively in 65 per cent of these patients. In the other 35 per cent, tricuspid insufficiency was recognized only when the tricuspid valve was palpated at the operating table. Because of this experience we examine the tricuspid valve digitally before initiating cardiopulmonary bypass in all patients having mitral valve procedures. Our results with prosthetic replacement of the tricuspid valve have been disappoint-
ing, as have the results reported by others.': 5 The hospital mortality rate of 36 per cent following tricuspid valve replacement was excessively high. Low cardiac output was the most frequent cause of death in these patients. In patients who underwent annuloplasty, not only was the total mortality rate considerably less, but low cardiac output was the principal cause of death far less frequently. This suggests that the hemodynamic characteristics of the prosthetic valve in the tricuspid position contributed to the high incidence of low cardiac output and a consequent high hospital mortality rate after tricuspid valve replacement. The late mortality rates of patients with annuloplasty and those with valve replacement were comparable. Particularly disturbing, however, was the fact that 2 of our patients died from late obstruction of the tricuspid prostheses. This complication has been reported by others':" and should be considered in all patients with prosthetic tricuspid valves who have signs of right heart failure. Tricuspid insufficiency recurred secondary to persistent right-sided hypertension in 5 of our patients treated by annuloplasty. In 4 this was due to inadequate repair of the mitral valve, and in 1 patient the cause was left ventricular failure from coronary artery disease. We have seen no recurrent tricuspid insufficiency following annuloplasty in cases in which the mitral procedure and the left ventricular function have been satisfactory. With the use of buttressed, heavy mattress sutures, annuloplasty has proved to
Volume 68
Tricuspid annuloplasty
Number 3 September, 1974
be a reliable technique for permanently correcting tricuspid insufficiency. Also, bypass time is shorter and the combined mortality rate is lower for annuloplasty than for valve replacement. Consequently, in the past 2 years annuloplasty has been our preferred method of treating patients with tricuspid regurgitation. When stenosis accompanies insufficiency, annuloplasty with commissurotomy has been effective. If significant tricuspid insufficiency should persist, a prosthetic ring as described by Carpentier- might be tried. Valvular replacement should be resorted to only if this technique is unsuccessful. REFERENCES 1 Pluth, J. R., and Ellis, F. H., Jr.: Tricuspid Insufficiency in Patients Undergoing Mitral Valve Replacement, J. THORAC. CARDIOVASC. SURG. 58: 484, 1969. 2 Starr, A.: Acquired Disease of the Tricuspid Valve, in Gibbon, J., editor: Surgery of the Chest, Philadelphia, 1969, W. B. Saunders Company. 3 Lillehei, C. W., Gannon, P. G., Levy, M. J., Varco, R. L., and Wang, Y.: Valve Replacement for Tricuspid Stenosis or Insufficiency Associated With Mitral Valvular Disease, Circulation 33: 34, 1966. 4 Kay, 1. H., Maselli-Campagna, C., and Tsuji, H. K.: Surgical Treatment of Tricuspid Insufficiency, Ann. Surg, 53: 162, 1965. 5 Carpentier, A., Deloche, A., Hanania, G., Forman, J., Sellier, Ph., Piwnica, A. and Dubost, Ch.: Surgical Management of Acquired Tricuspid Valve Disease, J. THORAC. CARDIOVASC. SURG. 67: 53, 1974. 6 Braunwald, N. S., Ross, J., and Morrow, A. G.: Conservative Management of Tricuspid Regurgitation in Patients Undergoing Mitral Valve Replacement, Circulation 35: 63, 1967 (Suppl. 1). 7 Bache, R. J., From, A. H. L., Castaneda, A. R., Jorgensen, C. R., and Wang, Y.: Late Thrombotic Obstruction of Starr-Edwards Tricuspid Valve Prosthesis, Chest 61: 613, 1972. 8 Samaan, H. A., and Murali, R.: Acute Tricuspid Valve Obstruction Following the Use of Tricuspid Ball Valve Prosthesis, Thorax, 25: 334, 1970. 9 Vander Veer, J. B., Jr., Rhyneer, G. S., Hodam, R. P., and Kloster, F. E.: Obstruction of Tricuspid Ball Valve Prosthesis, Circulation, 43: 62, 1971 (Suppl. 1).
349
Discussion DR. FERN ANDO ALONSO-LEJ Oviedo, Spain
I want to congratulate Dr. Boyd for his fine presentation. I agree with his conservative attitude toward tricuspid insufficiency. However, we approach this problem in a different manner, trying to reconstruct the deformed valve so that its anatomy is more normal. [Slide] Tricuspid insufficiency develops when the annulus supporting the anterior and posterior leaflets is affected by dilatation of the external wall of the right ventricle. The logical operation is to shorten this portion of the annulus. We accomplish this with a modification of the operation developed in Madrid by Dr. de Vega-incorporation of external control. We place a long suture around the annulus from the junction of the septal and posterior leaflets to the right fibrous trigone and there we buttress the suture in a Teflon pledget. Next, we suture in the opposite direction to the beginning of the first suture. Both needles are passed through another Teflon felt pledget, then through the wall of the atrium, and again buttressed in Teflon felt. Both ends of the sutures are attached to a Rummel tourniquet. We then close the atrium. The heart supports the circulation entirely. We close the Rummel clamp gradually and gently, tighten the suture, and, of course, reduce and narrow the annulus of the tricuspid valve. With a finger inserted through the appendage of the left atrium, we can feel when the reflux disappears. At this moment we put a clamp between the Rummel clamp and the Teflon felt, remove the Rummel clamp, and knot the suture on top of the Teflon felt. Of course, during the gradual closure of the Rummel clamp, we distribute the tension along the entire suture. In this way a totally competent valve can be produced without unnecessary narrowing. We are very pleased with this technique because it is rapid, simple, and does not require use of any foreign material. In due time we will publish our results with this new alternative in the treatment of tricuspid insufficiency. DR.GEORGEE.GREEN New York, N. Y.
There are two categories of tricuspid insufficiency that can be distinguished by the external appearance of the right atrial wall. Category 1 is episodic, transient tricuspid insufficiency. It is often due to acute left atrial distention, with bulging of the left atrial wall separating the tricuspid septal leaflet from the other tricuspid leaflets. Because it is episodic, this type of insufficiency can be relieved by decompression of the
350
The Journol of Thoracic and Cardiovascular Surgery
Boyd et at.
left atrium, either medical or surgical, and does not cause thickening of the right atrial wall. Established tricuspid insufficiency (category 2) results in the right atrium, becoming markedly thickened, and it rarely responds to anything other than annuloplasty or valve replacement. I would be eager to know whether Dr. Boyd has correlated the thickness of the right atrial wall with the severity of tricuspid insufficiency in his cases and with the success of his annuloplasty method. DR. JEROME HAROLD KAY La" Angeles, Calif.
Since 1960, we have operated upon 103 patients with pure tricuspid insufficiency secondary to mitral valve disease. All 103 patients had mitral valve disease, and 17 had aortic valve disease as well. Our method of tricuspid annuloplasty has not changed during these 14 years. The valve is decreased from a four or five fingerbreadth size to a loose two fingerbreadth size by doing away with the posterior leaflet. Two or three interrupted figure-of-eight sutures of NO.2 silk are placed in the annulus to accomplish this. We were able to perform a tricuspid annuloplasty in 87 of the 103 patients. There were fourteen hospital deaths (16 per cent) and eight late deaths (9 per cent). There were twelve failures, in all 12 cases due to failure of the mitral valve repair or replacement. Fifty-three patients, however, are living and well I year to 14 years after operation. In other words, 61 per cent have not had another operation and have done well with tricuspid annuloplasty. DR. PIERRE GRONDIN Montreal. Quebec, Canada
We have been interested in the problem of tricuspid insufficiency for many years. At first we used the technique described by Drs. Kay and Boyd. However, over the past year we have been impressed by the simplicity and the effectiveness of a method of tricuspid annuloplasty described 3 years ago by a Spanish surgeon from Madrid, Dr. Norberto Gonzales de Vega. This technique, which Dr. Alonso-Lej has already described, consists in the use of two parallel purse-string sutures of 0-0 Mersilene placed in a horseshoe fashion at the base of the anterior and posterior leaflets; the septal portion of the tricuspid annulus is left free. After inserting these sutures, we tie them together at one end over a Teflon pladget. Then we introduce two fingers into the annulus and tighten the sutures at the other end, tying them again over a piece of Teflon in order to plicate the annulus at the two fingerbreadths size.
We have used this method over the past year in more than 30 cases at the Montreal Heart Institute. The operation has restored perfect competence of the valve, as can be evaluated by palpation through the atrial appendage before closure of the thorax. This technique of plicating the posterior and anterior attachments of the tricuspid valve produces the same effect as the Carpentier annulus. In contrast, however, the de Vega technique leaves a supple and pliable annulus. Also, if there is coexistence of stenosis and insufficiency of the tricuspid valve, a commissurotomy can be combined with this type of annuloplasty. We are pleased to report that since we started using this technique, no tricuspid valve has needed prosthetic replacement at our Institution in the last 12 months. DR. ALAIN CARPENTIER Paris, France
My first point concerns the value of digital examination in the detection of tricuspid insufficiency. The degree of tricuspid insufficiency depends upon many factors: blood volume, atrial fibrillation, pulmonary hypertension, and cardiac insufficiency. Those factors are themselves subject to important variations during operation, so that it is easy to overestimate or underestimate the degree of insufficiency and fail to explore a valve which should be treated. We therefore place greater emphasis on the evolution of tricuspid insufficiency under optimal medical treatment, permitting us to discriminate between reversible tricuspid insufficiency, which need not be corrected, and irreversible-c-or partially reversible-tricuspid insufficiency, which requires correction. My second point is technical. One must keep in mind that the three goals of a valvuloplasty are; to give a predictable result, to preserve normal valve function, and to provide a definitive repair. Current techniques fail to achieve these goals and oscillate between the risks of overcorrection of the insufficiency, leading to stenosis, and undercorrection, leading to residual regurgitation. Prosthetic rings give rise to a different result because the concept is different. The aim is to correct the tricuspid insufficiency by providing the valve orifice with a normal morphology. The use of prosthetic rings graded according to size and adapted to each individual valve preserves the orificial square area. The precisely measured valvuloplasty gives rise to normal valve function and achieves a predictable result. Moreover, since this technique does not result in any appreciable narrowing of the orifice, contrary to current techniques, the correction of combined tricuspid insufficiency and stenosis can be achieved.
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Tricuspid annuloplasty
351
September, 1974
Between October, 1968, and January, 1974, 269 patients with acquired tricuspid valve disease associated with mitral valve disease were treated at the Broussais Hospital in Paris. Fifty had organic lesions of the tricuspid valve, which were corrected by commissurotomy and an annuloplasty incorporating a ring; the remaining 219 had severe or moderate tricuspid insufficiency resistant to medical treatment and were treated by simple placement of the prosthetic ring. The hospital mortality rate was 7.5 per cent. There was no significant residual insufficiency, The incidence of recurrent insufficiency was 0.6 per cent, occurring mainly in patients who had a complication of the mitral valve. Finally, I would like to point out that 96 per cent of the tricuspid valve diseases requiring surgical intervention were treated by this technique of valvuloplasty and only 4 per cent needed valve replacement. I noted that in Dr. Boyd's series the proportion of valve replacement was 54 per cent. Does Dr. Boyd think that this difference can be explained by the difference between valvuloplasty techniques? DR. BOYD (Closing) I would like to thank all of the discussers for their comments. I was surprised and pleased that
our figures so closely approximate those of Dr. Kay, who was the originator of the technique described in this presentation. The new technique described by Dr. Alonso-Lej and Dr. Grondin is intriguing, and I look forward to hearing some long-term results on their patients, We would certainly agree with Dr. Green that the vast majority of the patients in whom we performed annuloplasty had marked thickening of the right atrial wall, This is very good evidence that significant tricuspid insufficiency is present. Dr. Carpentier, in the last 1Y2 years, we have tended to perform many more annuloplasties than we had previously because of our concern about prosthetic valves in the tricuspid position. We have not done annuloplasties in 90 per cent of our patients, as you have utilizing the Carpentier ring. However, I suspect that in the years to come we will approach that figure. I am intrigued by the ring, but we have not used it. I suspect that in some of our patients in whom annuloplasty proved unsuccessful, a Carpentier ring might have satisfactorily corrected the insufficiency. I believe that, in the future, prosthetic valves will be utilized far less often in the tricuspid position than at the present time.
Arthur D. Boyd, M.D., Richard M. Engelman, M.D. (by invitation), O. Wayne Isom, M.D. (by invitation), George E. Reed, M.D., and Frank C. Spencer, M.D., New York, N. Y.
Acquired tricuspid regurgitation is frequently encountered in patients having mitral or combined mitral and aortic valve operations. One hundred sixty-eight (22 per cent) of 755 patients having mitral valve procedures at the New York University Medical Center from January, 1968, through June, 1973, had associated tricuspid regurgitation which required correction. This incidence coresponds closely to that reported by others." " The correct management of acquired tricuspid insufficiency remains controversial. Whereas some advocate replacementv " or repair" ,-. of the valve, others feel that nothing need be done"; they maintain that, after correction of the mitral valve disease, the tricuspid insufficiency will improve or From the New York University Medical Center, 566 First Avenue, New York, N. Y. 10016. Read at the Fifty-fourth Annual Meeting of The American Association for Thoracic Surgery, Las Vegas, Nevada, April 22, 23, and 24, 1974.
344
disappear as the right-sided pressures and chamber dilatation return toward normal. In our experience tricuspid regurgitation was not significantly lessened after correction of mitral valve disease. This experience is similar to that reported by Pluth' and Starr." Prior to 1972, tricuspid valve replacement was used in the majority of our patients. Since 1972, however, we have performed annuloplasty with greater frequency because of our dissatisfaction with the high operative mortality rate of tricuspid valve replacement and because of our impression that the hemodynamic results of annuloplasty were equal or superior to those of valve replacement. To evaluate tricuspid annuloplasty more objectively, we have compared the results of this procedure with the results of tricuspid valve replacement for the period January, 1968, through June, 1973, during which time approximately equal numbers of each procedure were performed.
Volume 68 Number 3 September, 1974
345
Tricuspid annuloplasty
Table I. Operative procedures and comparative mortality rates in 168 patients with tricuspid valve disease Patients Procedure
No.
MVR, TA OMC, TA MA, TA MVR, CBG,TA AVR, MVR, TA AVR, MA, TA AVR, OMC, TA Totals
44 10 2 2 15 3 78
MVR, TVR OMC, TVR MA, TVR MVR, CBG, TVR AVR, MVR, TVR AVR, MA, TVR AVR, OMC, TVR Totals
60 4 0 2 24 0 0 90
I Per cent
Per cent
Tricuspid annuloplasty
2
56 12 3 3 19 4 3 100
6 1 0 0 4 0 0 11
13
10 27 14
10 0 0 1 2 0 0 13
23 50 14 17
Tricuspid valve replacement
67 4
20 0
33
11 0
2 27
1 11
50 46
0 6
25
100
32
36
17
19
18
Legend: MVR, Mitral valve
replacement. TA, Tricuspid annuloplasty, OMC, Open mitral commissurotomy. MA, Mitral annuloplasty. CBG, Coronary bypass graft. AYR, Aortic valve replacement. TYR, Tricuspid valve replacement.
Materials and methods
Seventy-eight patients (52 women and 26 men) who ranged in age from 19 to 68 years had tricuspid annuloplasty performed at the time of mitral or aortic and mitral valve operations at the New York University Medical Center from January, 1968, through June, 1973. During this same period 90 patients (62 women and 28 men) ranging in age from 18 to 72 years had tricuspid valve replacement primarily with Starr-Edwards prostheses (6310 and 6320 series) (Fig. 1). The use of annuloplasty progressively increased during this period (Fig. 2). The operative procedures performed are shown in Table I. Of the patients having annuloplasty, 48 (62 per cent) were in the Functional Class III and 26 (33 per cent) in Functional Class IV of the New York Heart Association. Of those having valve replacement, 63 (69 per cent) were in Class III and 25 (28 per cent) in Class IV. Sixty patients (77 per cent) of the annuloplasty group and 71 (79 per cent) of the valve replacePatients.
ment group had elevated right-sided pressures at preoperative catheterization. Significant tricuspid insufficiency was not diagnosed preoperatively in 32 (41 per cent) of the patients having annuloplasty and 27 (30 per cent) of those having valve replacement. Technique of annuloplasty. At operation in patients who required mitral valve procedures, the right side of the heart was carefully inspected, right atrial thickness evaluated, and the right atrial pressure measured. Prior to insertion of the venous cannulas, a finger was inserted into the right atrium, the tricuspid valve palpated, and its competency evaluated. If more than a trace of tricuspid insufficiency was found on digital examination, after the mitral or combined mitral-aortic procedure had been completed, the right atrium was opened parallel to and 1 em. from the atrioventricular groove and the tricuspid valve was carefully examined. Annuloplasty was usually performed at the commissure between the anterior and posterior leaflets or, rarely, at the
The Journal of
346
Boyd et al.
Thoracic and Cardiovascular Surgery
Table II. Causes of hospital death in patients having tricuspid procedures
755 Mitral and Mitral-Aortic Valve Procedures
No. of deaths Causes of hospital death Arrhythmias Hemorrhage Infection Low output Neurologic Renal failure Totals
168 (22'%) wi th Tricuspid I nsuff ic iency
/ / /
/
/
/
/
,
\
\
, -, ,
(62 WOmen. 28 men) 18 to 72 years
No. of deaths
Dtricuspid annuloplasty mtricuspid valve replacement
30
1969
1 1 11 (14%)
Table III. Causes of late death in patients having tricuspid procedures
Fig. 1. Breakdown of the patient population that required tricuspid valve procedures from January, 1968, through June, 1973.
1968
4
3 2 4 18 3 2 32 (36%)
90 Tricuspid Valve Replacement
(52 women. 26 men) 19 to 68 years
No. of
1 2 2
Valve replacement
\
78
Tricuspid Annuloplasty
patients
Annuloplasty
1970 1971 YEAR
1972
1973
16m•• 1
Fig. 2. Tricuspid annuloplasty and valve replacement performed yearly from January, 1968, through June, 1973.
commissure between the anterior and septal leaflets (Fig. 3). The repair was performed with simple sutures passed around the annulus if the tissues were thickened and with mattress sutures passed beneath the annulus if the tissues were of normal consistency. In each instance the needle entered 2 mm, on the atrial side of the annulus, passed around the annulus, and exited 2 mm. on the valvular side of the annulus. When mattress sutures were used, 6 mm. was left between the limbs of the sutures, and pledgets of Teflon felt were used as buttresses. The
Causes of late death Arrhythmias Congestive heart failure Hepatitis Neurologic Obstructed prosthesis Unrelated Totals
Annuloplasty
I Valve
replacement
3
3
5 0 3
5 1 3
0 2 13 (17%)
2 3 17 (19%)
repair usually required one or two mattress sutures. The resulting orifice was acceptible only if it easily admitted two fingers (a diameter of 5 em. or more). If tricuspid stenosis was found, commissurotomy was performed followed by annuloplasty. The atrium was then closed, care being taken to remove all air from the right side of the heart prior to completion of the closure. After cardiopulmonary bypass was discontinued and an adequate cardiac output and systemic pressure were present, the venous cannulas were removed from the right atrium, the tricuspid valve was again digitally examined, and pressures were measured. More than a trace of tricuspid insufficiency or a gradient of more than 3 to 4 mm. across the valve was unacceptable and necessitated either adjustment of the annuloplasty or use of a prosthesis. Operative findings. At the operating
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Fig. 3. Technique of annuloplasty performed at commissure between anterior and posterior leaflets. a, Anterior leaflet. p, Posterior leaflet. s, Septal leaflet.
table, tricuspid insufficiency was judged to be severe in 25 (32 per cent), moderate in 38 (49 per cent), and mild in 15 (19 per cent) of the patients having annuloplasty. In those patients having valve replacement, the insufficiency was severe in 32 (36 per cent), moderate in 51 (57 per cent), and mild in 7 (8 per cent). Diseased tricuspid leaflets were noted in 9 (12 per cent) of the patients who had annuloplasty and in 23 (26 per cent) of those having valve replacement. Some tricuspid stenosis was present in 6 (8 per cent) of the patients having annuloplasty and in 11 ( 12 per cent) of those having valve replacement. The annulus was found to be dilated in all 78 patients (100 per cent) of the annuloplasty group and in 86 (97 per cent) of the valve replacement group. Tricuspid
commissurotomy was combined with annuloplasty in the 6 patients who had some degree of tricuspid stenosis. Among the patients who had an annuloplasty, a trace of tricuspid insufficiency was present after cardiopulmonary bypass in 14 ( 18 per cent), whereas in 64 (82 per cent) no insufficiency could be palpated. Tricuspid annuloplasty added 35 minutes and tricuspid valve replacement added 75 minutes to the average bypass time. Results Eleven patients (14 per cent) died in the hospital after tricuspid annuloplasty; 32 (34 per cent) died after tricuspid valve replacement. There were thirteen (17 per cent) and seventeen late deaths (19 per cent) in the annuloplasty and valve replace-
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Table IV. Late failure of tricuspid annuloplasty Patient 1 2 3
4 5
I
Treatment
Current status
Operative procedure
Cause of failure
MA, TA OMC, TA MVR, resection of VA, TA OMC, TA OMC, TA
Breakdown of MA Resulting MI LVF
TVR TVR Medical
Alive and well Dead Dead
Resulting MI Resulting MI
TVR Medical
Alive and well Severely debilitated
Legend: MA, Mitral annuloplasty. TA, Tricuspid annuloplasty. OMC, Open mitral commissurotomy. MVR, Mitral valve replacement. VA, Ventricular aneurysm. MI, Mitral insufficiency. LVF, Left ventricular failure. TVR, Tricuspid valve replacement.
ment groups, respectively. The causes of death are shown in Tables II and III. Fortyfive (58 per cent) of the patients in whom an annuloplasty was performed are alive and well, whereas 9 (12 per cent) are alive but limited. Of the patients having tricuspid replacement, 30 (33 per cent) are alive and well and 11 (12 per cent) are alive but limited. Tricuspid annuloplasty failed in 5 patients (Table IV). In all 5 patients, elevated right-sided pressures were not relieved by the first operative procedure on the mitral valve. In 3, mitral insufficiency resulted after open mitral commissurotomy. In 1 patient a mitral annuloplasty broke down, and in another left ventricular failure resulted from coronary disease. In none of the 78 patients having tricuspid annuloplasty was heart block noted, either in the immediate postoperative period or as a late complication. Discussion Tricuspid insufficiency occurred in 22 per cent of our patients who had mitral or combined aortic and mitral valve disease. The diagnosis was made preoperatively in 65 per cent of these patients. In the other 35 per cent, tricuspid insufficiency was recognized only when the tricuspid valve was palpated at the operating table. Because of this experience we examine the tricuspid valve digitally before initiating cardiopulmonary bypass in all patients having mitral valve procedures. Our results with prosthetic replacement of the tricuspid valve have been disappoint-
ing, as have the results reported by others.': 5 The hospital mortality rate of 36 per cent following tricuspid valve replacement was excessively high. Low cardiac output was the most frequent cause of death in these patients. In patients who underwent annuloplasty, not only was the total mortality rate considerably less, but low cardiac output was the principal cause of death far less frequently. This suggests that the hemodynamic characteristics of the prosthetic valve in the tricuspid position contributed to the high incidence of low cardiac output and a consequent high hospital mortality rate after tricuspid valve replacement. The late mortality rates of patients with annuloplasty and those with valve replacement were comparable. Particularly disturbing, however, was the fact that 2 of our patients died from late obstruction of the tricuspid prostheses. This complication has been reported by others':" and should be considered in all patients with prosthetic tricuspid valves who have signs of right heart failure. Tricuspid insufficiency recurred secondary to persistent right-sided hypertension in 5 of our patients treated by annuloplasty. In 4 this was due to inadequate repair of the mitral valve, and in 1 patient the cause was left ventricular failure from coronary artery disease. We have seen no recurrent tricuspid insufficiency following annuloplasty in cases in which the mitral procedure and the left ventricular function have been satisfactory. With the use of buttressed, heavy mattress sutures, annuloplasty has proved to
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be a reliable technique for permanently correcting tricuspid insufficiency. Also, bypass time is shorter and the combined mortality rate is lower for annuloplasty than for valve replacement. Consequently, in the past 2 years annuloplasty has been our preferred method of treating patients with tricuspid regurgitation. When stenosis accompanies insufficiency, annuloplasty with commissurotomy has been effective. If significant tricuspid insufficiency should persist, a prosthetic ring as described by Carpentier- might be tried. Valvular replacement should be resorted to only if this technique is unsuccessful. REFERENCES 1 Pluth, J. R., and Ellis, F. H., Jr.: Tricuspid Insufficiency in Patients Undergoing Mitral Valve Replacement, J. THORAC. CARDIOVASC. SURG. 58: 484, 1969. 2 Starr, A.: Acquired Disease of the Tricuspid Valve, in Gibbon, J., editor: Surgery of the Chest, Philadelphia, 1969, W. B. Saunders Company. 3 Lillehei, C. W., Gannon, P. G., Levy, M. J., Varco, R. L., and Wang, Y.: Valve Replacement for Tricuspid Stenosis or Insufficiency Associated With Mitral Valvular Disease, Circulation 33: 34, 1966. 4 Kay, 1. H., Maselli-Campagna, C., and Tsuji, H. K.: Surgical Treatment of Tricuspid Insufficiency, Ann. Surg, 53: 162, 1965. 5 Carpentier, A., Deloche, A., Hanania, G., Forman, J., Sellier, Ph., Piwnica, A. and Dubost, Ch.: Surgical Management of Acquired Tricuspid Valve Disease, J. THORAC. CARDIOVASC. SURG. 67: 53, 1974. 6 Braunwald, N. S., Ross, J., and Morrow, A. G.: Conservative Management of Tricuspid Regurgitation in Patients Undergoing Mitral Valve Replacement, Circulation 35: 63, 1967 (Suppl. 1). 7 Bache, R. J., From, A. H. L., Castaneda, A. R., Jorgensen, C. R., and Wang, Y.: Late Thrombotic Obstruction of Starr-Edwards Tricuspid Valve Prosthesis, Chest 61: 613, 1972. 8 Samaan, H. A., and Murali, R.: Acute Tricuspid Valve Obstruction Following the Use of Tricuspid Ball Valve Prosthesis, Thorax, 25: 334, 1970. 9 Vander Veer, J. B., Jr., Rhyneer, G. S., Hodam, R. P., and Kloster, F. E.: Obstruction of Tricuspid Ball Valve Prosthesis, Circulation, 43: 62, 1971 (Suppl. 1).
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Discussion DR. FERN ANDO ALONSO-LEJ Oviedo, Spain
I want to congratulate Dr. Boyd for his fine presentation. I agree with his conservative attitude toward tricuspid insufficiency. However, we approach this problem in a different manner, trying to reconstruct the deformed valve so that its anatomy is more normal. [Slide] Tricuspid insufficiency develops when the annulus supporting the anterior and posterior leaflets is affected by dilatation of the external wall of the right ventricle. The logical operation is to shorten this portion of the annulus. We accomplish this with a modification of the operation developed in Madrid by Dr. de Vega-incorporation of external control. We place a long suture around the annulus from the junction of the septal and posterior leaflets to the right fibrous trigone and there we buttress the suture in a Teflon pledget. Next, we suture in the opposite direction to the beginning of the first suture. Both needles are passed through another Teflon felt pledget, then through the wall of the atrium, and again buttressed in Teflon felt. Both ends of the sutures are attached to a Rummel tourniquet. We then close the atrium. The heart supports the circulation entirely. We close the Rummel clamp gradually and gently, tighten the suture, and, of course, reduce and narrow the annulus of the tricuspid valve. With a finger inserted through the appendage of the left atrium, we can feel when the reflux disappears. At this moment we put a clamp between the Rummel clamp and the Teflon felt, remove the Rummel clamp, and knot the suture on top of the Teflon felt. Of course, during the gradual closure of the Rummel clamp, we distribute the tension along the entire suture. In this way a totally competent valve can be produced without unnecessary narrowing. We are very pleased with this technique because it is rapid, simple, and does not require use of any foreign material. In due time we will publish our results with this new alternative in the treatment of tricuspid insufficiency. DR.GEORGEE.GREEN New York, N. Y.
There are two categories of tricuspid insufficiency that can be distinguished by the external appearance of the right atrial wall. Category 1 is episodic, transient tricuspid insufficiency. It is often due to acute left atrial distention, with bulging of the left atrial wall separating the tricuspid septal leaflet from the other tricuspid leaflets. Because it is episodic, this type of insufficiency can be relieved by decompression of the
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left atrium, either medical or surgical, and does not cause thickening of the right atrial wall. Established tricuspid insufficiency (category 2) results in the right atrium, becoming markedly thickened, and it rarely responds to anything other than annuloplasty or valve replacement. I would be eager to know whether Dr. Boyd has correlated the thickness of the right atrial wall with the severity of tricuspid insufficiency in his cases and with the success of his annuloplasty method. DR. JEROME HAROLD KAY La" Angeles, Calif.
Since 1960, we have operated upon 103 patients with pure tricuspid insufficiency secondary to mitral valve disease. All 103 patients had mitral valve disease, and 17 had aortic valve disease as well. Our method of tricuspid annuloplasty has not changed during these 14 years. The valve is decreased from a four or five fingerbreadth size to a loose two fingerbreadth size by doing away with the posterior leaflet. Two or three interrupted figure-of-eight sutures of NO.2 silk are placed in the annulus to accomplish this. We were able to perform a tricuspid annuloplasty in 87 of the 103 patients. There were fourteen hospital deaths (16 per cent) and eight late deaths (9 per cent). There were twelve failures, in all 12 cases due to failure of the mitral valve repair or replacement. Fifty-three patients, however, are living and well I year to 14 years after operation. In other words, 61 per cent have not had another operation and have done well with tricuspid annuloplasty. DR. PIERRE GRONDIN Montreal. Quebec, Canada
We have been interested in the problem of tricuspid insufficiency for many years. At first we used the technique described by Drs. Kay and Boyd. However, over the past year we have been impressed by the simplicity and the effectiveness of a method of tricuspid annuloplasty described 3 years ago by a Spanish surgeon from Madrid, Dr. Norberto Gonzales de Vega. This technique, which Dr. Alonso-Lej has already described, consists in the use of two parallel purse-string sutures of 0-0 Mersilene placed in a horseshoe fashion at the base of the anterior and posterior leaflets; the septal portion of the tricuspid annulus is left free. After inserting these sutures, we tie them together at one end over a Teflon pladget. Then we introduce two fingers into the annulus and tighten the sutures at the other end, tying them again over a piece of Teflon in order to plicate the annulus at the two fingerbreadths size.
We have used this method over the past year in more than 30 cases at the Montreal Heart Institute. The operation has restored perfect competence of the valve, as can be evaluated by palpation through the atrial appendage before closure of the thorax. This technique of plicating the posterior and anterior attachments of the tricuspid valve produces the same effect as the Carpentier annulus. In contrast, however, the de Vega technique leaves a supple and pliable annulus. Also, if there is coexistence of stenosis and insufficiency of the tricuspid valve, a commissurotomy can be combined with this type of annuloplasty. We are pleased to report that since we started using this technique, no tricuspid valve has needed prosthetic replacement at our Institution in the last 12 months. DR. ALAIN CARPENTIER Paris, France
My first point concerns the value of digital examination in the detection of tricuspid insufficiency. The degree of tricuspid insufficiency depends upon many factors: blood volume, atrial fibrillation, pulmonary hypertension, and cardiac insufficiency. Those factors are themselves subject to important variations during operation, so that it is easy to overestimate or underestimate the degree of insufficiency and fail to explore a valve which should be treated. We therefore place greater emphasis on the evolution of tricuspid insufficiency under optimal medical treatment, permitting us to discriminate between reversible tricuspid insufficiency, which need not be corrected, and irreversible-c-or partially reversible-tricuspid insufficiency, which requires correction. My second point is technical. One must keep in mind that the three goals of a valvuloplasty are; to give a predictable result, to preserve normal valve function, and to provide a definitive repair. Current techniques fail to achieve these goals and oscillate between the risks of overcorrection of the insufficiency, leading to stenosis, and undercorrection, leading to residual regurgitation. Prosthetic rings give rise to a different result because the concept is different. The aim is to correct the tricuspid insufficiency by providing the valve orifice with a normal morphology. The use of prosthetic rings graded according to size and adapted to each individual valve preserves the orificial square area. The precisely measured valvuloplasty gives rise to normal valve function and achieves a predictable result. Moreover, since this technique does not result in any appreciable narrowing of the orifice, contrary to current techniques, the correction of combined tricuspid insufficiency and stenosis can be achieved.
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Between October, 1968, and January, 1974, 269 patients with acquired tricuspid valve disease associated with mitral valve disease were treated at the Broussais Hospital in Paris. Fifty had organic lesions of the tricuspid valve, which were corrected by commissurotomy and an annuloplasty incorporating a ring; the remaining 219 had severe or moderate tricuspid insufficiency resistant to medical treatment and were treated by simple placement of the prosthetic ring. The hospital mortality rate was 7.5 per cent. There was no significant residual insufficiency, The incidence of recurrent insufficiency was 0.6 per cent, occurring mainly in patients who had a complication of the mitral valve. Finally, I would like to point out that 96 per cent of the tricuspid valve diseases requiring surgical intervention were treated by this technique of valvuloplasty and only 4 per cent needed valve replacement. I noted that in Dr. Boyd's series the proportion of valve replacement was 54 per cent. Does Dr. Boyd think that this difference can be explained by the difference between valvuloplasty techniques? DR. BOYD (Closing) I would like to thank all of the discussers for their comments. I was surprised and pleased that
our figures so closely approximate those of Dr. Kay, who was the originator of the technique described in this presentation. The new technique described by Dr. Alonso-Lej and Dr. Grondin is intriguing, and I look forward to hearing some long-term results on their patients, We would certainly agree with Dr. Green that the vast majority of the patients in whom we performed annuloplasty had marked thickening of the right atrial wall, This is very good evidence that significant tricuspid insufficiency is present. Dr. Carpentier, in the last 1Y2 years, we have tended to perform many more annuloplasties than we had previously because of our concern about prosthetic valves in the tricuspid position. We have not done annuloplasties in 90 per cent of our patients, as you have utilizing the Carpentier ring. However, I suspect that in the years to come we will approach that figure. I am intrigued by the ring, but we have not used it. I suspect that in some of our patients in whom annuloplasty proved unsuccessful, a Carpentier ring might have satisfactorily corrected the insufficiency. I believe that, in the future, prosthetic valves will be utilized far less often in the tricuspid position than at the present time.