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J Thorac Cardiovasc Surg 2001;122:611-614
© 2001 The American Association for Thoracic Surgery
Brief Communications |
From the Department of Cardiac Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province,a and the Department of Cardiac Surgery, An Zhen Hospital, Beijing,b People's Republic of China.
Received for publication May 18, 2000. Accepted for publication Nov 27, 2000. Address for reprints: Liang Yiwu, MD, Department of Cardiac Surgery, Second Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, P. R. China.
See related editorial on page 427.
Experience in recent years has indicated that no technique of tricuspid annuloplasty is perfect. The present study was undertaken to explore a better way of treating secondary tricuspid regurgitation (TR).
Methods
Patient data
Between March 1997 and January 1998, 20 patients (8 male, 12 female) who had rheumatic heart disease with moderate to severe secondary TR underwent multiple valve operations. The average age of the patients was 42.11 ± 13.96 years. The cardiothoracic ratio was 0.58 ± 0.05. Average cardiac functional class was 3.25 (New York Heart Association). No organic rheumatic involvement of the tricuspid leaflets was detected. The patients were divided into two groups: group A underwent our new annuloplasty procedure, and group B, the exact quantitative technique of De Vega.
Surgical technique and operative data
Obturators that we developed are illustrated in Figure 1. Concomitant procedures carried out at the time of tricuspid valve repair were mitral valve replacement in 11 patients (5 in group A, 6 in group B) and mitral plus aortic valve replacement in 9 patients (5 in group A, 4 in group B). Figure 2 illustrates the details of the tricuspid valve repair technique for group A andFigure 3 shows the technique used for group B.
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Hemodynamic measurements
Two catheters (including a thermodilution catheter) were inserted into the right side of the heart and were used to measure the hemodynamic data.
Results
All patients recovered and were discharged from the hospital an average of 21.7 ± 3.2 days postoperatively. The average time required for tricuspid annuloplasty was 15.6 ± 2.5 minutes in group A and 10.1 ± 1.3 minutes in group B. An average of 28.5 ± 17.1 mm (14-47 mm) of isolated anulus was excluded within the annulorrhaphy in all patients.
Echocardiographic results
The proximal isovelocity area and length of TR flow were significantly reduced after the operation in all patients. The proximal isovelocity area was reduced from 14.35 ± 1.10 cm2 to 1.51 ± 0.19 cm2 in group A and from 13.97 ± 0.91 cm2 to 2.28 ± 0.33 cm2 in group B. The length of TR flow was reduced from 4.48 ± 0.25 cm to 1.41 ± 0.15 cm in group A and from 4.88 ± 0.23 cm to 2.38 ± 0.13 cm in group B. According to color Doppler grading, 15 patients (7 in group A, 8 in group B) had grade 3+ TR before the operation and 5 patients (3 in group A, 2 in group B) had grade 4+ TR. The corresponding data after the operation were grade 1+ in 18 patients (8 in group A, 10 in group B) and grade 0 in 2 patients (group A).
Hemodynamic results
The right atrial V-wave amplitude in group A was reduced from 14.0 ± 1.10 mm Hg to 8.3 ± 0.47 mm Hg in group A and from 13.6 ± 0.97 mm Hg to 7.5 ± 0.41 mm Hg in group B. The diastolic right ventricular pressure was reduced from 14.3 ± 0.83 mm Hg to 2.1 ± 0.59 mm Hg in group A and from 12.0 ± 1.14 mm Hg to 8.6 ± 0.75 mm Hg in group B. The pulmonary artery pressure was reduced from 36.2 ± 3.39 mm Hg to 27.1 ± 2.68 mm Hg in group A and from 35.4 ± 3.06 mm Hg to 25.8 ± 1.87 mm Hg in group B.
Follow-up results
All patients have been followed up by a series of letters. The interval of sending follow-up letters to each patient is 3 to 6 months (every 3 months up to the first year after the operation and every 6 months thereafter). The maximum follow-up duration is 30 months and the minimum, 21 months. All patients are still alive (except for one who died in a traffic accident 20 months after the operation) an average of 25.5 ± 2.9 months after the operation. No patients had valve-related complications. All patients had improved to class I or class II (New York Heart Association) by 6 months after the operation. Because most patients are not living in our city, follow-up TR indices are available for only 7 patients. According to the most recent data (up to January 2000), for group B the maximum proximal isovelocity area is 2.37 cm2 and the length of TR flow is 2.1 cm; for group A the minimum proximal isovelocity area is 1.32 cm2 and the length of TR flow is 1.2 cm. For both groups the corresponding TR grade is 1+.
Discussion
Although Braunwald, Ross, and Morrow
1 reported that secondary TR usually resolved after successful left-sided heart valve replacement, subsequent experience does not support their findings. Nowadays, we know that secondary TR is caused by tricuspid annular dilatation. The anatomic problem is that the anterior and posterior anuli dilate without the septal anulus dilating, while tricuspid leaflets are normal, so that the leaflets are relatively smaller, as was reported by Deloche, 2 Mitsuhiro, 3 and their associates.
In terms of this concept, the anterior and posterior anuli should be shortened by tricuspid annuloplasty without affecting the septal anulus and the shrinking tricuspid leaflet. Annuloplasty should also restore the natural relationship of the tricuspid valve orifice and provide a stable repair. In shortening the dilated anulus, it is also important to take into account the anatomic character of each individual anulus to restore the physiologic status.
Beginning with the method described by Kay, Maselli, and Tsuji, 4 several techniques avoiding artificial material have been used in treating secondary TR, but no technique has taken into account the physiologic and anatomic character of each individual patient's tricuspid anulus. As a consequence, annular stenosis and residual TR often occur after the operation.
In 1990, Minale and colleagues 5 reported selective annuloplasty of the tricuspid valve. Their technique is more stable than that of surgeons who do not use an artificial ring: The dilated anulus is reduced selectively on the anterior and posterior portions without excluding the active surface of the valve leaflets. It also maintains the natural relationship of the tricuspid valve orifice. However, theirs is not an exact quantitative repair, because the change in the anulus is not individualized to the physiologic and anatomic character of each patient's tricuspid anulus.
In 1986, Mitsuhiro and coworkers, 3 in autopsy studies, found that the length ratio of the different parts of the normal tricuspid anulus is as follows: anterior length/septal length/posterior length = 1:1:0.75; by contrast, that of the rheumatic heart is as follows: anterior/septal/posterior = 1.22:1:0.9. The septal parts of healthy hearts and rheumatic hearts were compared, and no significant difference was observed. In tricuspid annuloplasty, the extent to which the dilated tricuspid anulus should be shortened is still uncertain, because different surgeons use different criteria according to their own experiences. An ideal criterion needs to be established. Minale's and Mitsuhiro's findings are the foundation of our work. We developed a set of obturators that are practical, easy to use, and simplified the operative procedure. The new technique we developed not only has all the advantages of Minale's, but also shortens the dilated anulus according to the characteristics of each individual anulus. Therefore, this technique offers an exact quantitative and individual tricuspid annuloplasty. In our study, the scope of the excluded anulus is very large (from 14 to 37 mm). We therefore think the quantitative and individual concept is very important. Not only should surgeons not shorten the anulus to the same size in different patients, but different surgeons should not be using different criteria. With our new concept, some blind actions were overcome during the operation, and the operative technique became more reasonable.
To observe the new technique's short-term and long-term results, we designed group B as a contrast, in which patients underwent the exact quantitative technique of De Vega. Either technique yields similar acceptable results.
In conclusion, we think the exact selective quantitative concept is useful for clinical work.
References
This article has been cited by other articles:
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  J. Wang, Y.-w. Liang, and J.-i. Hayashi Selective Annuloplasty for Tricuspid Regurgitation in Children Ann. Thorac. Surg., March 1, 2005; 79(3): 937 - 941. [Abstract] [Full Text] [PDF]
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