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J Thorac Cardiovasc Surg 2004;127:674-685
© 2004 The American Association for Thoracic Surgery
Surgery for acquired cardiovascular disease |
a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Read at the Eighty-third Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 4-7, 2003.
Received for publication May 5, 2003; revisions received November 3, 2003; accepted for publication November 10, 2003.
* Address for reprints: Patrick M. McCarthy, MD, Department of Thoracic and Cardiovascular Surgery, 9500 Euclid Ave, Desk F24, Cleveland, OH 44195, USA
mccartp{at}ccf.org
OBJECTIVES: To compare durability of tricuspid valve annuloplasty techniques, identify risk factors for repair failure, and characterize survival, reoperation, and functional class of surviving patients.
METHODS: From 1990 to 1999, 790 patients (mean age 65 ± 12 years, 51% New York Heart Association functional class III or IV, and mean right ventricular systolic pressure 56 ± 18 mm Hg) underwent tricuspid valve annuloplasty for functional regurgitation using 4 techniques: Carpentier-Edwards semi-rigid ring, Cosgrove-Edwards flexible band, De Vega procedure, and customized semicircular Peri-Guard annuloplasty. Of these patients, 89% had concomitant mitral valve surgery. A total of 2245 follow-up transthoracic echocardiograms were retrieved. Tricuspid regurgitation was analyzed, and risk factors for worsening regurgitation were identified, by multivariable ordinal longitudinal methods.
RESULTS: Tricuspid regurgitation 1 week after annuloplasty was 3+ or 4+ in 14% of patients. Regurgitation severity was stable across time with the Carpentier-Edwards ring (P = .7), increased slowly with the Cosgrove-Edwards band (P = .05), and rose more rapidly with the De Vega (P = .002) and Peri-Guard (P = .0009) procedures. Risk factors for worsening regurgitation included higher preoperative regurgitation grade, poor left ventricular function, permanent pacemaker, and repair type other than ring annuloplasty. Right ventricular systolic pressure, ring size, preoperative New York Heart Association functional class, and concomitant surgery were not risk factors. Tricuspid reoperation was rare (3% at 8 years), and hospital mortality after reoperation was 37%.
CONCLUSIONS: Tricuspid valve annuloplasty did not consistently eliminate functional regurgitation, and across time regurgitation increased importantly after Peri-Guard and De Vega annuloplasties. Therefore, these repair techniques should be abandoned, and transtricuspid pacing leads should be replaced with epicardial leads.
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