Objective To analyze and explore the risk factors of secondary tricuspid regurgitation (TR) after left-sided valve surgery (left cardiac valve replacement or valvuloplasty) using meta-analysis, so as to provide evidence for clinical diagnosis and treatment of secondary TR. Methods We electronically searched databases including PubMed, MEDLINE, CBM, CNKI, VIP, for literature on the risk factors of secondary TR after left-sided valve surgery from 1995 to 2012. According to the inclusion and exclusion criteria, we screened literature, extracted data, and assessed methodological quality. Then, meta-analysis was performed using RevMan 5.0 software. Results A total of 6 case-control studies were included, involving 437 patients and 2 102 controls. The results of meta-analysis showed that, the risk factors of progressive exacerbation of secondary TR after left-sided valve surgery included preoperative atrial fibrillation (OR=3.90, 95%CI 3.00 to 5.07; adjusted OR=3.04, 95%CI 2.21 to 4.16), age (MD=5.36, 95%CI 3.49 to 7.23), huge left atrium (OR=5.17, 95%CI 3.12 to 8.57; adjusted OR=1.91, 95%CI 1.49 to 2.44) or left atrium diameter (MD=4.85, 95%CI 3.18 to 6.53), degradation of left heart function (OR=2.97, 95%CI 1.73 to 5.08), rheumatic pathological change (OR=3.06, 95%CI 1.66 to 4.68), preoperative TR no less than 2+ (OR=3.52, 95%CI 1.26 to 9.89), and mitral valve replacement (MVR) (OR=2.35, 95%CI 1.68 to 3.30). Sex (OR=1.54, 95%CI 0.94 to 2.52) and preoperative pulmonary arterial hypertension (OR=1.28, 95%CI 0.77 to 2.12) were not associated with secondary TR after left-sided valve surgery. Conclusion The risk factors of progressive exacerbation of secondary TR after left-sided valve surgery include preoperative atrial fibrillation, age, huge left atrium or left atrium diameter, degradation of left heart function, rheumatic pathological change, preoperative TR no less than 2+, and MVR. Understanding these risk factors helps us to improve the long-time effectiveness of preventing and treating TR after left-sided valve surgery.
Objective To observe early and intermediate-term clinical outcomes of tricuspid valvuloplasty withannuloplasty ring for the treatment of secondary tricuspid regurgitation （TR） of patients with rheumatic heart disease. MethodsFrom December 2009 to September 2011, 41 patients with rheumatic heart disease underwent left-side heart valve replacementand concomitant tricuspid valvuloplasty with annuloplasty ring in Sichuan Jianyang People’s Hospital. There were 12 males and 29 females with their mean age of 49 （21-67） years. Preoperatively, there were 38 patients with atrial fibrillation, 13 patients with left atrial thrombus; 2 patients with trivial TR, 5 patients with mild TR, 11 patients with moderate TR, and 23 patients with severe TR. Twenty-eight patients received mitral valve replacement and 13 patients received mitral and aortic valve replacement. All the patients were followed up every 3 months at the outpatient department, and received color Doppler echocardiography examination to observe TR degree at the 6th postoperative month. Results Postoperative heart function improved by 2-3 class in all the patients. There were 39 patients with New York Heart Association (NYHA) classⅠorⅡ postoperatively, and postoperative heart function was significantly better than preoperative heart function（P＜0.05）. All the patients were followed up for 6-27 months, and there was no death during follow-up. Color Doppler echocardiography at the 6th postoperative month showed that TR degrees were significantly decreased than preoperative TR degrees. There were 39 patients with trivial or mild TR during follow-up, which was significantly different with preoperativeTR degree （P＜0.05）. Right ventricle dimension decreased from preoperative 20 mm to 17 mm during follow-up, which were statistically different （P＜0.05）. Conclusion Early and intermediate-term clinical outcomes of tricuspid valvuloplasty with annuloplasty ring for the treatment of TR are satisfactory, while further evaluation for its long-term outcome is needed.
Abstract： Objective To evaluate the surgical effect of ring annuloplasty using prosthetic vascular graft for the treatment of tricuspid regurgitation. Methods From July 2000 to July 2010, ring annuloplasty using prosthetic vascular graft was performed to a total of 56 patients with tricuspid regurgitation in Changhai Hospital of Second Military Medical University. There were 24 male patients and 32 female patients. Their mean age was（45.7±21.8）years (ranging from 14 to 73 years). All the patients were diagnosed as moderate to severe tricuspid regurgitation by color Doppler echocardiography examination, including 47 patients with rheumatic heart valve diseases, and 9 patients with congenital heart disease (Ebstein’s anomaly). All the 56 patients underwent ring annuloplasty using prosthetic vascular graft instead of Carpentier annuloplasty ring for the treatment of tricuspid regurgitation. Results There was no in-hospital death. Postoperatively, one patient had acute respiratory failure, one patient had acute kidney failure, and one patient had re-exploration for bleeding. All patients had none or mild tricuspid regurgitation by echocardiography examination one month after surgery. Forty eight patients were followed up from 1.0 to 9.5 years with a median follow-up time of 3.8 years. During follow-up, there was no late death, but one patient had brain embolism as an anticoagulation complication. Sixteen patients were in New York Heart Association (NYHA) functional classⅠ, 26 patients in NYHA classⅡ, and 6 patients in NYHA class Ⅲ. Thirty six patients had no tricuspid regurgitation, 10 patients had mild tricuspid regurgitation, and 2 patients had moderate tricuspid regurgitation by echocardiography examination during follow-up. Conclusion The early and mid-term follow-up results of ring annuloplasty using prosthetic vascular graft instead of Carpentier annuloplasty ring for the treatment of tricuspid regurgitation are satisfactory. It is a good choice for the surgical treatment of tricuspid regurgitation.
Abstract： Objective To evaluate clinical outcomes of tricuspid annuloplasty using a C-type ring made of autologous pericardium for the treatment of functional tricuspid regurgitation （TR）. Methods Eleven patients underwent tricuspid annuloplasty in Guizhou Provincial People’s Hospital between March 2009 and January 2011， including 5 male patients and 6 female patients with their age of 32-57 （43.80±12.20） years. There were 3 patients with mild TR， 7 patients with moderate TR， and 1 patient with severe TR. Concomitant procedures included mitral valve replacement and/or aortic valve replacement and/or left atrial thrombectomy. The C-type ring was created using a strip of pericardium after 0.8% glutaraldehyde fixation for 15 minutes. Interrupted horizontal mattress suture was used to secure the C-type ring to the tricuspid annulus. Hear function and echocardiography were examined during follow-up. Results There was no in-hospital death， and the hospital stay was 15-28 （21.10±3.80） days. All the patients were followed up for 8-28 （18.50±7.00）months. There was no death or reoperation because of TR or tricuspid stenosis during follow-up. Ten patients had TR during follow-up， including 9 patients with mild TR and 1 patient with mild to moderate TR， but there was no patient with severe TR. The degree of TR during follow-up was significantly reduced than preoperative degree （Z =-2.81，P＜0.05）. Preoperative and postoperative right ventricular dimension （19.95±5.11 mm vs. 21.57±12.81 mm，P=0.705） and right atrial dimension（37.55±6.79 mm vs. 35.55±5.22 mm，P=0.317）were not statistically different. Conclusion Tricuspid annuloplasty using a C-type ring made of autologous pericardium has satisfactory clinical outcomes for patients with functional TR.
Objective To observe whether the adoptation of tricuspid annulus diameter as surgical indication for tricuspid annuloplasty will reduce the occurrence of moderate-severe tricuspid regurgitation(TR) in patients after mitral valve replacement (MVR). Methods Between April 2005 and June 2006, MVR was performed in 56 patients with no or mild TR in our Department. The patients were divided into two groups according to tricuspid annulus diameter(TAD)/body surface area (BSA)≥21mm/m2. Tricuspid annuloplasty group(TA group): 22 cases, male 8, female 14, age 45.0±7.7 years, TAD 36.8±3.8mm, BSA 1.57±0.15m2, New York Heart Association(NYHA) functional class Ⅲ/Ⅲ-Ⅳ 18/4, sinus rhythm(SR)/atrial fibrillation (AF) 2/20. Notricuspid annuloplasty group (NTA group): 34 cases, male 9, female 25, age 42.9±11.0 years, TAD 28.5±4.4mm, BSA 1.58±0.13m2, NYHA Ⅲ/Ⅲ-Ⅳ 28/6, SR/AF 9/25. Kay annuloplasty was performed for TA group patients. The patients were followed in outpatient clinical regularly and evaluated by echocardiography at 6 months after operation. Results All patients recovered and were discharged from hospital. The duration of follow-up was 11.0±2.4 months. Except 2 cases, all patients received echocardiography evaluation at 6 months after operation. There were no significantly differences between two groups patients in general clinical characteristics (Pgt;0.05). Compared with NTA group before operation, right atrial diameter (RAD, 49.3±7.0mm) and TAD(36.8±3.8mm) were bigger and more mild TR in TA group (Plt;0.05). RAD(44.1±8.9mm) and TAD(28.9±6.1mm) reduced and the proportion of TR degree improved (Plt;0.05) in TA group but did not occur in NTA group after surgery (Pgt;0.05). There were three cases of moderate TR in NTA group. Conclusion Tricuspid annuloplasty adopting TAD as surgical indication may reduce the occurrences of postoperative moderate-severe TR for patients of MVR with no or mild preoperative TR.
Objective To examine the regression, residue, or progression of tricuspid regurgitation （TR） after mitral valve replacement so as to improve the clinical evaluation and management of TR. Methods From January 1998 to December 2003, a total of 287 consecutive patients of mitral valve replacement were followed and reviewed for this study. There were 86 male patients and 201 female patients whose ages ranged from 15 to 66 years （41.0±11.0 years）. The predominant mitral vane lesion was stenosis in 199 patients （69%）, regurgitation in 66 patients （23%） and mixed in 22 patients （8%）. A total of 201 patients （70%） had atrial fibrillation and 86 patients （30%） were in sinus rhythm. According to ratio of maximal regurgitation area to right atrial area TR was graded as mild （＋）, mild-moderate （＋/＋＋） moderate （＋＋） moderate-severe （＋＋/＋＋＋） and severe （＋＋＋）. There were 101 mild TR （36.7%）, 5 mild-moderate（1.8%）, 27 moderate （9.8%）, 2 moderate-severe （0.7%） and 21 severe （7.6%）. Depending on the surgical findings tricuspid annuloplasty was performed. The patients were followed in outpatient clinical and had echocardiography evaluation regularly. Results The follow-up ranged from 2 to 7 years （4.0±1.6 years）. Twelve patients were lost during the follow-up periods. Compared with preoperation, clinical condition of the majority of patients was improved after surgery. The diameter of left atrium, right atrium, left ventricle and right ventricle decreased significantly after operation （P〈0.01）. The ejection fraction and fraction of shorting increased significantly after surgery （P〈0.05）. However there were no significantly changes between pre- TR and post- TR in these patients （P〉0.05）. Tricuspid annuloplasty was not performed for 129 patients who had TR because TR was judged intraoperatively not to be severe. Of those patients, TR regressed in 54 patients, improved in 12 patients, did not change in 46 patients and progressed in 17 patients respectively after surgery. There were 27 patients who received De Vega tricuspid annuloplasty. Among them, TR regressed in 10 patients, improved in 12 patients and did not change in 5 patients respectively after surgery. Conclusion It is not adequate to evaluate the degree of TR in mitral valve diseases with rate of maximal regurgitation area to right atrial area. It should be improved to adopt intraoperative findings for tricuspid annuloplasty. TR may occur in patients who do not have TR before operation.
ObjectiveTo analyze risk factors and long-term outcomes of surgical treatment for isolated tricuspid regurgitation (TR) after left-sided valve replacement. MethodsWe retrospectively analyzed clinical data of 65 patients who underwent surgical treatment for severe isolated TR after left-sided valve replacement in Guangdong Cardiovascular Institute from January 2000 to June 2013. There were 12 male and 53 female patients with their age of 37-72 (52.3±8.0) years. Fifty-nine patients had atrial fibrillation (AF). There were 61 patients with functional TR and 4 patients with rheumatic TR. Six patients were in New York Heart Association (NYHA) functional class Ⅱ,40 patients were in NYHA class Ⅲ,and 19 patients were in NYHA class Ⅳ.The duration between the first and second cardiac operation was 1-26 (11.2±4.7) years. Fifty-five patients received tricuspid valve replacement (TVR) and 10 patients received tricuspid valvuloplasty (TVP). ResultsEleven patients (16.9%) died postoperatively. Univariate analysis showed that male gender,right ventricular internal dimension,preoperative serum albumin level (ALB) direct bilirubin (DBil) level,cardiopulmonary bypass (CPB) time and preoperative NYHA functional class Ⅳ were significantly correlated with postoperative death. Preoperative cardiothoracic ratio(C/T) TR area,left ventricular ejection fraction (LVEF) pulmonary arterial systolic pressure (PAs) preoperative hemoglobin(HGB) level,creatinine (Cr) level,total bilirubin (TBil) level,alanine aminotransferase (ALT) level and the duration between the first and second cardiac operation were not significantly related with surgical mortality. Multivariate logistic regression analysis showed that preoperative NYHA functional class Ⅳ was an independent risk factor of in-hospital death (OR=7.23,95% CI:1.57-33.25,P=0.01). Among the 54 survivors,50 patients (92.6%) were followed up for 1-160(47.2±43.3) months. Five patients died during follow-up including 3 TVR patients with heart failure,1 TVR patient with aortic valve obstruction and 1 TVP patient with sudden cardiac arrest. One-year and 5-year survival rates of TVR patients were 95%±3% and 89%±7% respectively,and 1-year and 5-year survival rates of TVP patients were 100% and 80%±18% respectively(P=0.92). Cox regression analysis showed that preoperative Cr level was an independent risk factor of long-term mortality (HR=1.10,95% CI:1.03-1.17,P<0.01). ConclusionIn-hospital mortality of patients with isolated TR after left-sided valve replacement who undergo surgical treatment is significantly related with preoperative overall condition and heart function. Surgical therapy should be performed before severe heart failure occurs. Postoperative 5-year survival rate is good,and long-term mortality is related with preoperative Cr level.
ObjectiveTo summarize clinical outcomes of atrial septal defect (ASD)occlusion for patients with ASD and tricuspid regurgitation (TR). MethodsBetween July 2006 and January 2012, 98 patients with ASD and TR under-went ASD occlusion in Xinhua Hospital, Shanghai Jiaotong University School of Medicine. There were 36 male and 62 female patients with their age aging from 2 months to 80 years. All ASD were secundum ASD with their diameter of 3-23 mm. There were 60 patients with mild TR, 28 patients with moderate TR, and 10 patients with severe TR. All the patients received ASD closure without specific management for TR, including 51 patients under digital subtraction angiography (DSA), 46 patients via a minithoracotomy approach, and 1 patient guided by transthoracic echocardiography. All the patients were followed up with echocardiography to evaluate changes of TR after ASD closure. ResultsThere was no in-hospital death. ASD occlusion was not successful in 1 patient who was found to have residual ASD shunt on the third postoperative day. Another patient underwent reexploration for abnormal bleeding on the third postoperative day. All the other patients had uneventful postoperative recovery. Eighty-four patients were followed up for 1-64 (26.56±21.35)months. During follow-up, the patient who have residual ASD shunt on the third postoperative day received open chest repair 6 months after discharge. TR of 73 patients (86.90%)improved in different degrees. Preoperative severe TR in 10 patients changed into mild TR in 8 patients, moderate TR in 1 patients and still severe TR in 1 patient. Preoperative moderate TR in 26 patients changed into none TR in 6 patients, mild TR in 18 patients and still moderate TR in 2 patients. Preoperative mild TR in 48 patients changed into none TR in 40 patients and still mild TR in 8 patients. ConclusionFor patients with ASD and TR, conservative treatment strategy is recommended. Simple ASD closure can provide satisfactory clinical outcomes, and also avoid adverse complications of cardiopulmonary bypass including myocardial injury and lung injury.
ObjectiveTo investigate the therapeutic effect of modified tricuspid valvuloplasty using anterior leaflet in patients with partial antrioventricular septal defect and tricuspid septal leaflet dysplasia. MethodsNinety-five patients with partial antrioventricular septal defect and tricuspid septal leaflet dysplasia underwent surgical treatment in our hospital from June 2002 to March 2014. There were 39 males and 56 females with an average age of 3.2±6.6 years (range 3 months to 46 years). Preoperative echocardiography prompted all patients had varying degrees of tricuspid valve dysplasia and tricuspid regurgitation (mild in 14 cases, moderate in 49 cases, and severe in 32 cases). According to the different development of anterior and septal leaflet, we used different techniques to repair the tricuspid problems. If the residual septal leaflet was larger than one third of the normal septal leaflet, we continuously stitched the half of the septal side of anterior leaflet to the two third of the left side of residual septal leaflet. If the residual septal leaflet was less than one third of the normal septal leaflet, we reserved part of pericardial patch at right side of septal crest at repairing the atrial septal defect, and continuously stitched the left two third of the patch edge to the half of septal side of anterior leaflet. All patients received transesophageal echocardiography (TEE) to evaluate the intraoperative effect of valvuloplasty. The patients were followed up with echocardiography after 3 to 6 months to evaluate the condition of tricuspid. ResultsThere was no perioperative death or Ⅲ degree atrioventricular block. Intraoperative TEE showed that the effect of tricuspid valvuloplasty was good with 3 cases of mild regurgitation and 2 cases of moderate regurgitation. Other 90 cases had no significant regurgitation. The aortic cross-clamping time was 35.2±11.2 min and cardiopulmonary bypass time was 64.9±16.6 min. In the followed-up between 3 to 6 months, tricuspid regurgitation situation improved significantly than that in preoperative period with mild regurgitation or no reflux in 89 cases and moderate regurgitation in 6 cases. There was no severe regurgitation occurred. ConclusionThe therapeutic effect is satisfactory by using anterior leaflet to repair the regurgitation of tricuspid in patients with partial antrioventricular septal defect and tricuspid septal leaflet dysplasia.
ObjectiveTo compare the outcomes of repeated tricuspid valve surgery for patients with late severe tricuspid regurgitation (TR) after cardiac surgery through right anterior minithoracotomy and conventional median sternotomy approaches. MethodsBetween June 2002 and June 2013, 89 patients with late severe tricuspid regurgitation after cardiac surgery underwent repeated tricuspid valve surgery through right anterior minithoracotomy in our hospital. The patients were divided into two groups. Fifty one patients were in a minimally invasive group with 28 males and 23 females at age of 46.59±11.53 years. Thirty eight patients were in a conventional median sternotomy (conventional group) with 15 males and 23 females at age of 50.42±9.30 years. The outcomes of the two groups were compared. ResultsThere was no statisitcal difference in preoperative clinical data between two groups. All patients successfully underwent repeated tricuspid valve surgery. Tricuspid valve replacement (TVR) was performed in 68 patients (38 patients vs. 30 patients), and tricuspid valvuloplasty (TVP) was performed in 21 patients (13 patients vs. 8 patients). Compared with the conventional group, operation time, time of establishing cardiopulmonary bypass and postoperative in-hospital time were significantly shorter in the minimally invasive group (P<0.001). The postoperative drainage was significantly reduced in the minimally invasive group compared with the value of the conventional group (P<0.001). Three patients died in the early postoperative period (1 patient vs. 2 patients). In the conventional group, one patient needed re-exploration for bleeding and 2 patients had wound infection. At discharge, transthoracic echocardiography showed that all patients had no or mild TR and no paravalvular leakage occurred. During the follow-up (12-144 months), 4 patients died (2 patients vs. 2 patients). In the minimally invasive group, one patient underwent repeated TVR due to severe TR associated with infective endocarditis, and another patient had moderate TR. In the conventional group, one patient underwent repeated TVR due to mechanical valve thrombosis. ConclusionRight anterior minithoracotomy is safe, effective and reliable for patients with late severe TR after cardiac surgery. It has the similar effect of the correction of valvular lesions with conventional median sternotomy, but right anterior minithoracotomy has more benefits, including more, minimally invasive, less blood loss, shorter operation time and faster recover.