- Email: [email protected]
Tricuspid Regurgitation Secondary to Severe Pulmonary Regurgitation: When to Operate on Which Valves?
Ann Thorac Surg 2015;100:2411–20
Simultaneous Carotid Artery Stenting and Heart Surgery: The Risk of Bleeding To the Editor:
2417
Viale Oxford 81 00133 Rome, Italy e-mail: [email protected]
References 1. Svensson LG, Kapadia S, Tuzcu M. Invited commentary. Ann Thorac Surg 2015;99:1297. 2. Chiariello L, Nardi P, Pellegrino A, et al. Simultaneous carotid artery stenting and heart surgery: expanded experience of hybrid surgical procedures. Ann Thorac Surg 2015;99:1291–7. 3. Velissaris I, Kiskinis D, Anastasiadis K. One stage carotid artery stenting and open heart surgery: a novel approach. J Cardiovasc Surg(Torino) 2011;52:539–43. 4. Barrera JG, Rojas KE, Balestrini C, et al. Early results after synchronous carotid stent placement and coronary artery bypass graft in patients with asymptomatic carotid stenosis. J Vasc Surg 2013;57(2 Suppl):58S–63S.
Tricuspid Regurgitation Secondary to Severe Pulmonary Regurgitation: When to Operate on Which Valves? To the Editor: We read with interest the study by Kogon and colleagues [1] on the outcome after pulmonary valve replacement (PVR) with or without concomitant tricuspid valve (TV) repair in 35 patients with at least moderate tricuspid regurgitation (TR) [1]. Their conclusions are somewhat surprising, ie, no beneficial early effects of TV repair and more recurrence of TR in the TV repair group. The rationale of TV repair is to prevent recurrence of TR during follow-up and improve clinical outcome. Concomitant TV repair is effective and recommended in patients with severe noncongenital TR undergoing left-sided valve repair. The study by Kogon and colleagues [1] is warmly welcomed, because only limited data are available on the efficacy of concomitant TV repair in patients with congenital heart disease and secondary TR caused by annulus dilatation. Earlier this year, Cramer and colleagues [2] also reported comparable postoperative TR grade, irrespective of TV repair, in a report published in this journal. Both Kogon and Cramer and their colleagues question the necessity of performing concomitant TV repair in patients with congenital heart disease with at least moderate TR undergoing PVR. These findings are in contrast to our analysis of 129 patients with tetralogy of Fallot undergoing PVR in which we demonstrated a larger reduction of TR grade in patients with concomitant TV repair, after correcting for the preoperative TR severity [3]. The unfavorable outcomes after TV repair in the reports of Kogon and Cramer and their colleagues may therefore be explained by preoperative differences in the degree of TR between both groups and anatomic factors that were not accounted for. The studies by both Kogon and Cramer and their colleagues lack data on clinical outcomes after PVR. Our study revealed that severe preoperative TR is associated with late adverse events (arrhythmias, heart failure, and mortality), whereas patients with tetralogy of Fallot and moderate TR preoperatively did not have an increased risk. In light of these studies, we advocate for performing PVR in patients with severe PR and secondary TR before it progresses to severe TR. Jouke P. Bokma, MD
Paolo Nardi, MD, PhD Pellegrino Antonio, MD Cardiac Surgery Unit Tor Vergata University Policlinic of Rome Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Department of Cardiology Academic Medical Center Meibergdreef 9 Amsterdam, 1105 AZ, the Netherlands 0003-4975/$36.00
MISCELLANEOUS
We read with great interest the Invited Commentary by Svensson and colleagues [1], which centered on the risk of bleeding after treatment of carotid artery stenosis by stenting (CAS) followed by coronary and noncoronary cardiac surgical intervention as proposed by our institution [2]. In our protocol, aspirin was started at least 2 days before CAS, and clopidogrel was added just 6 hours after the surgical procedure [2] in order to reduce the risk of early formation of platelet aggregates immediately after CAS, without increasing the risk of bleeding during the cardiac operation. The incidence of stroke during weaning from general anesthesia was 0.75%: 0% in group 1 and 2.86% in group 2. In order to reduce the risk of bleeding, other authors have proposed starting antiplatelet therapy immediately after the operation or after the first postoperative day, without preoperative use of acetylsalicylic acid. Velissaris and colleagues [3], in 90 patients undergoing 1-stage CAS and cardiac operations, avoided preoperative use of antiaggregation therapy completely. Indeed, they did not report bleeding complications but reported a 2.2% incidence of stroke and ischemic transient attack after weaning from general anesthesia after cardiac operations. Barrera and colleagues [4], in a selected population of 15 patients undergoing synchronous CAS and isolated coronary artery bypass grafting (CABG), interrupted aspirin administration the day of the CAS and CABG procedure and restarted aspirin 2.2 days after CABG as well as clopidogrel after the second postoperative day. There was no episode of postoperative bleeding requiring reexploration, and the median number of red blood cell transfusions was 3. However, 1 patient (6.6%) experienced a transient ischemic episode 24 hours after CABG [4]. In our experience, surgical reexploration for bleeding was needed in 8 patients (6%), and the mean number of blood units transfused per patient was 4.6 2.4. In detail, in group 1 (CAS, isolated CABG) the incidence of surgical reexploration for bleeding was 4.1% (4 of 97 cases), in group 2 (CAS, isolated noncoronary or complex surgical procedures—ie, aortic or mitral valve surgical procedures plus CABG or ascending aorta replacement), it was 11.4% (4 of 35 cases). Because approximately 25% of the surgical procedures were complex, the overall incidence of bleeding with our protocol seemed acceptable compared with The Society of Thoracic Surgeons data, which report in the period 2007 to 2009 an incidence of reexploration for bleeding or any reoperation of 2.5% in isolated CABG, 5.4% to 7.9% in combined aortic valve replacement or mitral valve operations plus CABG, 15.7% in double mitral and aortic valve replacement, and 14.7% in ascending aorta replacement. In conclusion, the risk of bleeding from single or double perioperative antiplatelet therapy is acceptable for straightforward procedures, but it certainly should be taken into consideration when complex and more extensive surgical procedures are required (eg, aortotomy, atriotomy, aneurysmal resection), but it seems that double antiplatelet therapy reduces the risk of embolic stroke related to carotid stenting during the hours after the implantation.
CORRESPONDENCE
2418
CORRESPONDENCE
and Interuniversity Cardiology Institute of the Netherlands Moreelsepark 1 Utrecht, 3511 EP, the Netherlands Michiel M. Winter, MD, PhD Department of Cardiology Academic Medical Center Amsterdam, the Netherlands Barbara J. M. Mulder, MD, PhD Berto J. Bouma, MD, PhD Department of Cardiology Academic Medical Center Amsterdam, the Netherlands and Interuniversity Cardiology Institute of the Netherlands Utrecht, the Netherlands e-mail: [email protected]
References 1. Kogon B, Mori M, Alsoufi B, Kanter K, Oster M. Leaving moderate tricuspid valve regurgitation alone at the time of pulmonary valve replacement: a worthwhile approach. Ann Thorac Surg 2015;99:2117–23. 2. Cramer JW, Ginde S, Hill GD, et al. Tricuspid repair at pulmonary valve replacement does not alter outcomes in tetralogy of Fallot. Ann Thorac Surg 2015;99:899–904. 3. Bokma JP, Winter MM, Oosterhof T, et al. Severe tricuspid regurgitation is predictive for adverse events in tetralogy of Fallot. Heart 2015;101:794–9.
MISCELLANEOUS
Reply To the Editor: We have now presented/published two abstracts and corresponding articles looking at tricuspid valve function after pulmonary valve replacement in 35 adult congenital cardiac surgical patients. The history of this project may shed some light on our thought process. Before the project, the decision to perform concomitant tricuspid valve operations likely was based on numerous factors: degree of tricuspid valve regurgitation, proposed mechanism of tricuspid valve regurgitation, right ventricular function, patient comorbidities, whether a double-valve operation would be tolerated, and surgeon’s bias. From echocardiograms early after operation we gained a sense that the degree of tricuspid valve regurgitation was similar after pulmonary valve replacement with or without tricuspid valve repair. Our first retrospective study, “Management of moderate functional tricuspid valve regurgitation at the time of pulmonary valve replacement: is concomitant tricuspid valve repair necessary?” [1] confirmed this suspicion and was presented at the 56th annual Southern Thoracic Surgical Association meeting. The presentation was met with a lot of criticism. In an audience poll, almost unanimously, surgeons would address moderate tricuspid valve regurgitation surgically at the time of pulmonary valve replacement. One major concern was that as the new pulmonary valve started to fail and the right ventricular dilated again, the tricuspid valve regurgitation would return if an annuloplasty had not been performed. Thus, our second retrospective study, “Leaving moderate tricuspid valve regurgitation alone at the time of pulmonary valve replacement: a worthwhile approach” [2], looked at the same patients, at a median follow-up time of 7 years. Interestingly, we found that tricuspid valve function was worse in those patients who had undergone concomitant annuloplasty at the Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2015;100:2411–20
original pulmonary valve replacement operation. We presented these findings at the 61st annual Southern Thoracic Surgical Association meeting, at which time they were met with less skepticism and criticism. We have also been encouraged by the report by Cramer and colleagues [3] supporting our concept. Nonetheless, the letter to the editor by Bokma and colleagues [4] has numerous points well taken, and we certainly appreciate their contribution [5]. We agree that tricuspid valve regurgitation is associated with adverse events and should be minimized. We also agree that progressive tricuspid valve regurgitation should trigger pulmonary valve replacement before it becomes severe. However, we may have to continue to disagree on the best way to achieve this desired tricuspid valve competence, annuloplasty or not. Brian Kogon, MD Department of Cardiothoracic Surgery Emory University 1405 Clifton Rd Atlanta, GA 30322 e-mail: [email protected]
References 1. Kogon B, Patel M, Leong T, McConnell M, Book W. Management of moderate functional tricuspid valve regurgitation at the time of pulmonary valve replacement: is concomitant tricuspid valve repair necessary? Pediatr Cardiol 2010;31:843–8. 2. Kogon B, Mori M, Alsoufi B, Kanter K, Oster M. Leaving moderate tricuspid valve regurgitation alone at the time of pulmonary valve replacement: a worthwhile approach. Ann Thorac Surg 2015;99:2117–23. 3. Cramer JW, Ginde S, Hill GD, et al. Tricuspid repair at pulmonary valve replacement does not alter outcomes in tetralogy of Fallot. Ann Thorac Surg 2015;99:899–904. 4. Bokma JP, Winter MM, Mulder BJM, Bouma BJ. Tricuspid regurgitation secondary to severe pulmonary regurgitation: when to operate on which valves? (letter). Ann Thorac Surg 2015;100:2417–8. 5. Bokma JP, Winter MM, Oosterhof T, et al. Severe tricuspid regurgitation is predictive for adverse events in tetralogy of Fallot. Heart 2015;101:794–9.
Pulmonary Valve Replacement: What Did We Learn? To the Editor: The authors of “Right Ventricular Remodeling After Pulmonary Valve Replacement: Early Gains, Late Losses” highlighted the importance of careful surveillance after pulmonary valve replacement (PVR) [1]. These obvious suggestions did not increase the knowledge on this matter because of several flaws. Inclusion criteria considered patients with a diagnosis of tetralogy of Fallot or pulmonary stenosis, truncus arteriosus, and pulmonary atresia with intact ventricular septum, with the initial operation at mean age 8 months (range, 1 month to 41 years) for tetralogy of Fallot repair with or without transannular patch, pulmonary valvotomy, or valved conduit, and PVR at a median age of 19 years (range, 5–60 years). Including the large spectrum of ages, malformations, and previous operations, the huge variability of right ventricular (RV) morphologic characteristics and function does not allow meaningful comparisons among a heterogeneous study population [2]. Patients younger than 5 years at PVR were excluded. This is difficult to justify considering the superior results reported with percutaneous PVR in younger patients, with incremental improvements in RV size and function. 0003-4975/$36.00
Simultaneous Carotid Artery Stenting and Heart Surgery: The Risk of Bleeding To the Editor:
2417
Viale Oxford 81 00133 Rome, Italy e-mail: [email protected]
References 1. Svensson LG, Kapadia S, Tuzcu M. Invited commentary. Ann Thorac Surg 2015;99:1297. 2. Chiariello L, Nardi P, Pellegrino A, et al. Simultaneous carotid artery stenting and heart surgery: expanded experience of hybrid surgical procedures. Ann Thorac Surg 2015;99:1291–7. 3. Velissaris I, Kiskinis D, Anastasiadis K. One stage carotid artery stenting and open heart surgery: a novel approach. J Cardiovasc Surg(Torino) 2011;52:539–43. 4. Barrera JG, Rojas KE, Balestrini C, et al. Early results after synchronous carotid stent placement and coronary artery bypass graft in patients with asymptomatic carotid stenosis. J Vasc Surg 2013;57(2 Suppl):58S–63S.
Tricuspid Regurgitation Secondary to Severe Pulmonary Regurgitation: When to Operate on Which Valves? To the Editor: We read with interest the study by Kogon and colleagues [1] on the outcome after pulmonary valve replacement (PVR) with or without concomitant tricuspid valve (TV) repair in 35 patients with at least moderate tricuspid regurgitation (TR) [1]. Their conclusions are somewhat surprising, ie, no beneficial early effects of TV repair and more recurrence of TR in the TV repair group. The rationale of TV repair is to prevent recurrence of TR during follow-up and improve clinical outcome. Concomitant TV repair is effective and recommended in patients with severe noncongenital TR undergoing left-sided valve repair. The study by Kogon and colleagues [1] is warmly welcomed, because only limited data are available on the efficacy of concomitant TV repair in patients with congenital heart disease and secondary TR caused by annulus dilatation. Earlier this year, Cramer and colleagues [2] also reported comparable postoperative TR grade, irrespective of TV repair, in a report published in this journal. Both Kogon and Cramer and their colleagues question the necessity of performing concomitant TV repair in patients with congenital heart disease with at least moderate TR undergoing PVR. These findings are in contrast to our analysis of 129 patients with tetralogy of Fallot undergoing PVR in which we demonstrated a larger reduction of TR grade in patients with concomitant TV repair, after correcting for the preoperative TR severity [3]. The unfavorable outcomes after TV repair in the reports of Kogon and Cramer and their colleagues may therefore be explained by preoperative differences in the degree of TR between both groups and anatomic factors that were not accounted for. The studies by both Kogon and Cramer and their colleagues lack data on clinical outcomes after PVR. Our study revealed that severe preoperative TR is associated with late adverse events (arrhythmias, heart failure, and mortality), whereas patients with tetralogy of Fallot and moderate TR preoperatively did not have an increased risk. In light of these studies, we advocate for performing PVR in patients with severe PR and secondary TR before it progresses to severe TR. Jouke P. Bokma, MD
Paolo Nardi, MD, PhD Pellegrino Antonio, MD Cardiac Surgery Unit Tor Vergata University Policlinic of Rome Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Department of Cardiology Academic Medical Center Meibergdreef 9 Amsterdam, 1105 AZ, the Netherlands 0003-4975/$36.00
MISCELLANEOUS
We read with great interest the Invited Commentary by Svensson and colleagues [1], which centered on the risk of bleeding after treatment of carotid artery stenosis by stenting (CAS) followed by coronary and noncoronary cardiac surgical intervention as proposed by our institution [2]. In our protocol, aspirin was started at least 2 days before CAS, and clopidogrel was added just 6 hours after the surgical procedure [2] in order to reduce the risk of early formation of platelet aggregates immediately after CAS, without increasing the risk of bleeding during the cardiac operation. The incidence of stroke during weaning from general anesthesia was 0.75%: 0% in group 1 and 2.86% in group 2. In order to reduce the risk of bleeding, other authors have proposed starting antiplatelet therapy immediately after the operation or after the first postoperative day, without preoperative use of acetylsalicylic acid. Velissaris and colleagues [3], in 90 patients undergoing 1-stage CAS and cardiac operations, avoided preoperative use of antiaggregation therapy completely. Indeed, they did not report bleeding complications but reported a 2.2% incidence of stroke and ischemic transient attack after weaning from general anesthesia after cardiac operations. Barrera and colleagues [4], in a selected population of 15 patients undergoing synchronous CAS and isolated coronary artery bypass grafting (CABG), interrupted aspirin administration the day of the CAS and CABG procedure and restarted aspirin 2.2 days after CABG as well as clopidogrel after the second postoperative day. There was no episode of postoperative bleeding requiring reexploration, and the median number of red blood cell transfusions was 3. However, 1 patient (6.6%) experienced a transient ischemic episode 24 hours after CABG [4]. In our experience, surgical reexploration for bleeding was needed in 8 patients (6%), and the mean number of blood units transfused per patient was 4.6 2.4. In detail, in group 1 (CAS, isolated CABG) the incidence of surgical reexploration for bleeding was 4.1% (4 of 97 cases), in group 2 (CAS, isolated noncoronary or complex surgical procedures—ie, aortic or mitral valve surgical procedures plus CABG or ascending aorta replacement), it was 11.4% (4 of 35 cases). Because approximately 25% of the surgical procedures were complex, the overall incidence of bleeding with our protocol seemed acceptable compared with The Society of Thoracic Surgeons data, which report in the period 2007 to 2009 an incidence of reexploration for bleeding or any reoperation of 2.5% in isolated CABG, 5.4% to 7.9% in combined aortic valve replacement or mitral valve operations plus CABG, 15.7% in double mitral and aortic valve replacement, and 14.7% in ascending aorta replacement. In conclusion, the risk of bleeding from single or double perioperative antiplatelet therapy is acceptable for straightforward procedures, but it certainly should be taken into consideration when complex and more extensive surgical procedures are required (eg, aortotomy, atriotomy, aneurysmal resection), but it seems that double antiplatelet therapy reduces the risk of embolic stroke related to carotid stenting during the hours after the implantation.
CORRESPONDENCE
2418
CORRESPONDENCE
and Interuniversity Cardiology Institute of the Netherlands Moreelsepark 1 Utrecht, 3511 EP, the Netherlands Michiel M. Winter, MD, PhD Department of Cardiology Academic Medical Center Amsterdam, the Netherlands Barbara J. M. Mulder, MD, PhD Berto J. Bouma, MD, PhD Department of Cardiology Academic Medical Center Amsterdam, the Netherlands and Interuniversity Cardiology Institute of the Netherlands Utrecht, the Netherlands e-mail: [email protected]
References 1. Kogon B, Mori M, Alsoufi B, Kanter K, Oster M. Leaving moderate tricuspid valve regurgitation alone at the time of pulmonary valve replacement: a worthwhile approach. Ann Thorac Surg 2015;99:2117–23. 2. Cramer JW, Ginde S, Hill GD, et al. Tricuspid repair at pulmonary valve replacement does not alter outcomes in tetralogy of Fallot. Ann Thorac Surg 2015;99:899–904. 3. Bokma JP, Winter MM, Oosterhof T, et al. Severe tricuspid regurgitation is predictive for adverse events in tetralogy of Fallot. Heart 2015;101:794–9.
MISCELLANEOUS
Reply To the Editor: We have now presented/published two abstracts and corresponding articles looking at tricuspid valve function after pulmonary valve replacement in 35 adult congenital cardiac surgical patients. The history of this project may shed some light on our thought process. Before the project, the decision to perform concomitant tricuspid valve operations likely was based on numerous factors: degree of tricuspid valve regurgitation, proposed mechanism of tricuspid valve regurgitation, right ventricular function, patient comorbidities, whether a double-valve operation would be tolerated, and surgeon’s bias. From echocardiograms early after operation we gained a sense that the degree of tricuspid valve regurgitation was similar after pulmonary valve replacement with or without tricuspid valve repair. Our first retrospective study, “Management of moderate functional tricuspid valve regurgitation at the time of pulmonary valve replacement: is concomitant tricuspid valve repair necessary?” [1] confirmed this suspicion and was presented at the 56th annual Southern Thoracic Surgical Association meeting. The presentation was met with a lot of criticism. In an audience poll, almost unanimously, surgeons would address moderate tricuspid valve regurgitation surgically at the time of pulmonary valve replacement. One major concern was that as the new pulmonary valve started to fail and the right ventricular dilated again, the tricuspid valve regurgitation would return if an annuloplasty had not been performed. Thus, our second retrospective study, “Leaving moderate tricuspid valve regurgitation alone at the time of pulmonary valve replacement: a worthwhile approach” [2], looked at the same patients, at a median follow-up time of 7 years. Interestingly, we found that tricuspid valve function was worse in those patients who had undergone concomitant annuloplasty at the Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2015;100:2411–20
original pulmonary valve replacement operation. We presented these findings at the 61st annual Southern Thoracic Surgical Association meeting, at which time they were met with less skepticism and criticism. We have also been encouraged by the report by Cramer and colleagues [3] supporting our concept. Nonetheless, the letter to the editor by Bokma and colleagues [4] has numerous points well taken, and we certainly appreciate their contribution [5]. We agree that tricuspid valve regurgitation is associated with adverse events and should be minimized. We also agree that progressive tricuspid valve regurgitation should trigger pulmonary valve replacement before it becomes severe. However, we may have to continue to disagree on the best way to achieve this desired tricuspid valve competence, annuloplasty or not. Brian Kogon, MD Department of Cardiothoracic Surgery Emory University 1405 Clifton Rd Atlanta, GA 30322 e-mail: [email protected]
References 1. Kogon B, Patel M, Leong T, McConnell M, Book W. Management of moderate functional tricuspid valve regurgitation at the time of pulmonary valve replacement: is concomitant tricuspid valve repair necessary? Pediatr Cardiol 2010;31:843–8. 2. Kogon B, Mori M, Alsoufi B, Kanter K, Oster M. Leaving moderate tricuspid valve regurgitation alone at the time of pulmonary valve replacement: a worthwhile approach. Ann Thorac Surg 2015;99:2117–23. 3. Cramer JW, Ginde S, Hill GD, et al. Tricuspid repair at pulmonary valve replacement does not alter outcomes in tetralogy of Fallot. Ann Thorac Surg 2015;99:899–904. 4. Bokma JP, Winter MM, Mulder BJM, Bouma BJ. Tricuspid regurgitation secondary to severe pulmonary regurgitation: when to operate on which valves? (letter). Ann Thorac Surg 2015;100:2417–8. 5. Bokma JP, Winter MM, Oosterhof T, et al. Severe tricuspid regurgitation is predictive for adverse events in tetralogy of Fallot. Heart 2015;101:794–9.
Pulmonary Valve Replacement: What Did We Learn? To the Editor: The authors of “Right Ventricular Remodeling After Pulmonary Valve Replacement: Early Gains, Late Losses” highlighted the importance of careful surveillance after pulmonary valve replacement (PVR) [1]. These obvious suggestions did not increase the knowledge on this matter because of several flaws. Inclusion criteria considered patients with a diagnosis of tetralogy of Fallot or pulmonary stenosis, truncus arteriosus, and pulmonary atresia with intact ventricular septum, with the initial operation at mean age 8 months (range, 1 month to 41 years) for tetralogy of Fallot repair with or without transannular patch, pulmonary valvotomy, or valved conduit, and PVR at a median age of 19 years (range, 5–60 years). Including the large spectrum of ages, malformations, and previous operations, the huge variability of right ventricular (RV) morphologic characteristics and function does not allow meaningful comparisons among a heterogeneous study population [2]. Patients younger than 5 years at PVR were excluded. This is difficult to justify considering the superior results reported with percutaneous PVR in younger patients, with incremental improvements in RV size and function. 0003-4975/$36.00