Appraisal of Long-Term Outcomes of Tricuspid Valve Replacement in the Current Perspective

Tricuspid valve replacement with mechanical versus biological prostheses: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Tricuspid valve replacement (TVR) is required when repair is not feasible, and it continues to be a relatively high-risk procedure owing to the complex medical and/or surgical profile of patients. The choice between mechanical and biological prostheses for TVR remains a subject of debate owing to their distinct advantages and disadvantages. This study aimed to analyse and compare the clinical outcomes of these two types of prostheses in the tricuspid position.

METHODS

PubMed, EMBASE, Web of Science, and the COCHRANE library were searched from 1995 to April 2023 for studies comparing clinical outcomes of mechanical versus biological valves in the tricuspid position. Data on 30-day mortality, reoperations, 5-year valve failure rates, thrombotic/thromboembolic events, and long-term survival were extracted, pooled, and analysed. Forest plots were generated using a random-effects model.

RESULTS

From an initial pool of 4716 citations, 37 studies meeting our inclusion criteria were assessed, collectively encompassing 8316 prostheses (3796 mechanical, 4520 bioprostheses). Our analysis revealed that mechanical valves exhibited a non-significant trend towards diminished 30-day mortality (RR = 0.85, 95% CI = 0.69-1.06). A distinct disparity emerged in valve durability, with mechanical valves demonstrating a significantly increased risk of 5-year valve failure (RR = 2.21, 95% CI = 1.38-3.56). Strikingly, mechanical valves displayed a substantial six-fold elevated risk of thrombotic events (RR = 6.29, 95% CI = 3.98-9.92). In contrast, the long-term survival and reoperation rates demonstrated no statistically significant differences between the two valve types.

CONCLUSIONS

This systematic review and meta-analysis provides insights into the selection of mechanical and bioprosthetic valves for TVR. These findings highlight the potential advantages and disadvantages of mechanical and bioprosthetic valves in terms of early mortality, valve durability, and thrombotic risk. Our analysis provides clinicians with evidence-based guidance for optimizing outcomes in TVR, offering a foundation for informed decision-making in this intricate surgical landscape. Despite these insights, clinicians must overcome the limitations of retrospective studies, evolving healthcare, and anticoagulant disparities to ensure careful consideration in tricuspid valve replacement decisions.

Efficacy and Safety of Cardioband in Patients with Tricuspid Regurgitation: Systematic Review and Meta-Analysis of Single-Arm Trials and Observational Studies

Background/Objectives: The incidence and prevalence of tricuspid regurgitation (TR) are increasing worldwide. "Traditional" drug therapy with diuretics is often ineffective and the identification of new strategies, including non-pharmacological ones, is an urgent need. The aim of this study was to summarize the results on the efficacy and safety of Cardioband, one of the few approved transcatheter tricuspid valve repair systems, in patients with TR. Methods: Three databases (Medline, Scopus, and CENTRAL) were searched to identify clinical trials and observational studies on the efficacy (primary outcome) and safety (secondary outcome) of Cardioband. A random-effects meta-analysis was performed with R software (version 4.3.3). Survival and freedom from heart failure (HF) hospitalization were estimated with the method of reconstructing individual patient data from Kaplan-Meier curves (IPDfromKM). Results: Eleven studies were included in this systematic review and meta-analysis. Cardioband significantly reduced annulus diameter (-9.31 mm [95% Confidence Interval, CI: -11.47; -7.15]), vena contracta (-6.41 mm [95% CI: -8.34; -4.49]), and effective regurgitant orifice area (EROA) (-0.50 cm2 [95% CI: -0.72; -0.28]) in patients with TR. Cardioband reduced the severity of TR and the extent of heart failure in 91% [95% CI: 85; 97] and 63% [95% CI: 52-75] of patients, respectively. Finally, Cardioband implantation was associated with prolonged survival and freedom from HF hospitalization (80.1% and 57.8% at 24 months, respectively). Conclusions: This study demonstrates that Cardioband implantation leads to cardiac remodeling and mechanical improvements, reduces the severity of TR, and improves quality of life. Therefore, Cardioband is an effective option for the non-pharmacological treatment of TR.

The Tricuspid Valve: A Review of Pathology, Imaging, and Current Treatment Options: A Scientific Statement From the American Heart Association

Tricuspid valve disease is an often underrecognized clinical problem that is associated with significant morbidity and mortality. Unfortunately, patients will often present late in their disease course with severe right-sided heart failure, pulmonary hypertension, and life-limiting symptoms that have few durable treatment options. Traditionally, the only treatment for tricuspid valve disease has been medical therapy or surgery; however, there have been increasing interest and success with the use of transcatheter tricuspid valve therapies over the past several years to treat patients with previously limited therapeutic options. The tricuspid valve is complex anatomically, lying adjacent to important anatomic structures such as the right coronary artery and the atrioventricular node, and is the passageway for permanent pacemaker leads into the right ventricle. In addition, the mechanism of tricuspid pathology varies widely between patients, which can be due to primary, secondary, or a combination of causes, meaning that it is not possible for 1 type of device to be suitable for treatment of all cases of tricuspid valve disease. To best visualize the pathology, several modalities of advanced cardiac imaging are often required, including transthoracic echocardiography, transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, to best visualize the pathology. This detailed imaging provides important information for choosing the ideal transcatheter treatment options for patients with tricuspid valve disease, taking into account the need for the lifetime management of the patient. This review highlights the important background, anatomic considerations, therapeutic options, and future directions with regard to treatment of tricuspid valve disease.

Melody Valve Implantation in the Tricuspid Position After Pediatric Heart Transplantation-A Case Report

Tricuspid regurgitation (TR) is common after a heart transplant and is associated with worse clinical outcomes. The incidence ranges from 34% immediately after transplant to 20% by 10 years. Most patients can be managed medically; however, severe TR and symptomatic right heart failure warrant tricuspid valve replacement. The use of Melody transcatheter pulmonary valve in the tricuspid position is previously described. We report a unique case of posttransplant severe TR treated with surgical bioprosthetic tricuspid valve replacement who subsequently underwent successful transcatheter Melody valve placement in tricuspid position for progressive bioprosthetic valve stenosis with 11 years of follow-up.

The Application of Precision Medicine in Structural Heart Diseases: A Step towards the Future

The personalized applications of 3D printing in interventional cardiology and cardiac surgery represent a transformative paradigm in the management of structural heart diseases. This review underscores the pivotal role of 3D printing in enhancing procedural precision, from preoperative planning to procedural simulation, particularly in valvular heart diseases, such as aortic stenosis and mitral regurgitation. The ability to create patient-specific models contributes significantly to predicting and preventing complications like paravalvular leakage, ensuring optimal device selection, and improving outcomes. Additionally, 3D printing extends its impact beyond valvular diseases to tricuspid regurgitation and non-valvular structural heart conditions. The comprehensive synthesis of the existing literature presented here emphasizes the promising trajectory of individualized approaches facilitated by 3D printing, promising a future where tailored interventions based on precise anatomical considerations become standard practice in cardiovascular care.

Prosthesis choice for tricuspid valve replacement: Comparison of clinical and echocardiographic outcomes

OBJECTIVES

There is limited evidence evaluating valve function and right heart remodeling after tricuspid valve replacement (TVR), as well as whether the choice of prosthesis has an impact on these outcomes.

METHODS

We reviewed 1043 consecutive adult patients who underwent first-time TVR; 33% had previous aortic and/or mitral valve operations. Severe tricuspid valve regurgitation (TR) was the indication for surgery in 94% patients. A mechanical valve was used in 149 (14%) patients and a bioprosthetic valve in 894 (86%). Concomitant major cardiac procedures were performed in 57% of patients.

RESULTS

The median age of the cohort was 68.8 (range, 25-94) years, and 57% were female. Overall survival at 5 and 10 years was 50% and 31%, respectively. Adjusted survival and cumulative incidence of reoperation after TVR were similar in patients with bioprosthetic and mechanical valves. Overall, right ventricular (RV) function and dilation improved postoperatively with the estimated proportion of patients with moderate or greater RV systolic dysfunction/dilatation decreasing by around 20% at 3 years follow-up. After adjusting for preoperative degree of dysfunction/dilatation, valve type had no effect on late improvement in RV function and dilation. Bioprosthetic TVR was associated with greater rates of recurrence of moderate or greater TR over late follow-up. Overall, a slight decline in tricuspid valve gradients was observed over time.

CONCLUSIONS

Mechanical and bioprosthetic valves provide comparable survival, incidence of reoperation, and recovery of RV systolic function and size after TVR. Bioprosthetic valves develop significant TR over time, and mechanical valves may have an advantage for younger patients and those needing anticoagulation.

The Current Landscape of Transcatheter Tricuspid Valve Intervention

Tricuspid regurgitation (TR) is common, and its prevalence increases with age. It was previously estimated that there are 1.6 million patients in the United States with moderate or worse TR, and more contemporary data suggest the age-adjusted prevalence of TR is 0.55%. Increasing TR severity is associated with an adverse prognosis independent of the pulmonary artery pressure and the degree of right heart failure. In heart failure with reduced ejection fraction, survival is significantly worsened when moderate or severe TR is present. The mainstay of therapy has traditionally been surgery, but outcomes are poor. There has been increasing attention on the potential role of transcatheter interventions for TR. Numerous platforms are in developmental evolution, which broadly fall into 3 categories: valve replacement, valve repair (subdivided into annular, leaflet, and chordal platforms), and caval valve implantation. In this review, we examine all these strategies and devices, including guidance on how to appropriately select patients who can benefit from intervention.

Transcatheter Tricuspid Valve Interventions: A Triumph for Transcatheter Procedures?

Tricuspid regurgitation (TR) is a common valvular pathology, estimated to affect 1.6 million people in the United States alone. Even though guidelines recommend either medical therapy or surgical treatment for TR, the misconception of TR as a benign disease along with the high mortality rates of surgical intervention led to undertreating this disease and commonly describing it as a "forgotten" valve. Recently, the development of transcatheter interventions for TR show promising potential for use in the clinical setting. There are currently few approved and numerous tested percutaneously delivered devices, which can be categorized, based on their mechanism of action, to either valve repair or valve replacement procedures. Both procedures were tested in clinical trials and show an echocardiographic reduction in TR sustained for at least 1 year after the procedure, as well as symptom relief and functional improvement of the patients. Device selection should be personalized, taking into consideration the anatomy of each valve and the available options at each heart center. Moreover, appropriate patient selection and timing of the procedure are also crucial for the success of the procedure. In this review, we analyze the clinical trials available for all devices currently approved or tested, aiming to provide a comprehensive summary of the most recent evidence in the field of transcatheter TR interventions.

Transcatheter Tricuspid Valve-in-Valve Replacement Using a J-Valve System for a Failed Tricuspid Bioprosthesis

Background

Redo operation for failed tricuspid bioprosthetic valves is associated with high morbidity and mortality. Transcatheter tricuspid valve-in-valve implantation has become an acceptable option for high-risk patients with a failed tricuspid bioprosthesis. We present a case of successful tricuspid valve-in-valve implantation using a J-valve in a failed tricuspid bioprosthesis position. Case Summary. A 48-year-old male, who had a failed tricuspid bioprosthesis, presented with right-side heart failure, right-to-left shunting at the atrial level, severe dyspnea, cyanosis, peripheral edema, hepatauxe, and ascites. After the interdisciplinary assessment, we successfully performed transcatheter tricuspid valve-in-valve implantation with the J-valve system. At 34-month postoperative follow-up, the patient had no symptoms of heart failure and the echocardiogram showed good valve position and well hemodynamic status.

Conclusions

This case demonstrated that the J-valve system may be a new option for high-risk patients with a failed tricuspid bioprosthetic valve.

Tricuspid valve replacement: The old and the new

Tricuspid regurgitation is a frequent and serious condition but tricuspid valve (TV) surgery, that may be a valve replacement when a repair is not feasible, is rarely performed. Recent development of transcatheter TV interventions offers new options for those high-surgical risk patients, especially TV replacement for patients who are not eligible for transcatheter TV repair. In this review, we describe indications and outcome after surgical TV replacement, and devices available or in development for transcatheter TV replacement.

[Redo tricuspid valve replacement with mechanical prosthesis for repeated early bioprosthetic valve failure]

Tricuspid leaflet lesion following infective endocarditis is a severe condition requiring surgical treatment in most cases. Currently, tricuspid valve replacement with mechanical prosthesis is still essential in the treatment of patients ineligible for reconstructive surgery or bioprosthesis implantation. The authors describe redo tricuspid valve replacement with mechanical prosthesis for repeated early bioprosthetic valve failure.

Isolated reoperation for tricuspid regurgitation after left-sided valve surgery: technique evolution

OBJECTIVES

This study aimed to compare the isolated replacement and repair of severe tricuspid regurgitation after left-sided valve surgery (LSVS) and to report the evolution of this surgical technique.

METHODS

From January 2005 to August 2018, 118 patients underwent isolated tricuspid valve replacement (iTVR, n = 93) or repair (iTVr, n = 25) for severe tricuspid regurgitation after LSVS. The surgical protocol at our institution has significantly changed since 2015, implementing the right thoracotomy approach (95.5%) and peripheral cannulation strategy with the vacuum-assist single venous drainage technique (93.2%) with a concomitant enhancement in preoperative right heart function optimization. Patients were followed up for 32.5 ± 34.6 (1.6-158.7) months.

RESULTS

The operative mortality rate was 8.5% (8.6% in iTVR and 8.0% in iTVr, P = 0.924) with a significant decrease from 23.3% (2005-2014) to 3.4% (2015-2018) (P < 0.001), which was associated with preoperative New York Heart Association functional class IV [odds ratio (OR) 14.73, 95% confidence interval (CI) 2.68-80.90; P = 0.002] and anaemia (OR 6.60, 95% CI 1.03-42.22; P = 0.046). After adjusting the logistic regression model, the vacuum-assist single venous drainage technique was also associated with lower operative mortality and composite adverse outcomes. The overall 1- and 5-year survival rates were 91.5% (95% CI 84.8-95.3%) and 77.9% (95% CI 60.0-88.3%), respectively, and no difference was found between the iTVR and iTVr groups (P = 0.813).

CONCLUSIONS

Isolated tricuspid valve reoperation for severe tricuspid regurgitation after LSVS is historically a high-risk procedure, but satisfactory results are achievable with advanced surgical techniques and improved perioperative management. Bioprosthetic iTVR is a reliable alternative for severe tricuspid regurgitation after LSVS.

Endoscopic repeat isolated tricuspid valve surgery after left-sided valve replacement: valvuloplasty or replacement

BACKGROUND

The strategy of isolated tricuspid valve surgery has undergone innovations in recent years. This study aimed to summarize our experience using an endoscopic approach to repeat isolated tricuspid valve surgery (RITS) after left-sided valve replacement (LSVR).

METHODS

From June 2013 to May 2019, 79 patients underwent endoscopic RITS after LSVR at our institution. Patients were divided into the tricuspid valvuloplasty (TVP) group (n = 49) and the tricuspid valve replacement (TVR) group (n = 30); perioperative outcomes and followup results were compared.

RESULTS

There were seven postoperative deaths (8.9%). In-hospital mortality was higher in the TVR group than in the TVP group, although this difference was not statistically significant (13.3% vs. 6.1%, P = 0.417). More patients experienced residual moderate-tosevere tricuspid regurgitation (TR) at discharge in the TVP group than in the TVR group (26.7% vs. 0%, P = 0.003). Five patients died from heart, and multiorgan failure during follow-up; the overall 3- and 5-year survival rates were 93.8% [95% confidence interval (CI): (87.1-99.9%)] and 85.3% (95% CI: 73.3-9.2%), respectively, and no significant differences were found between the two groups (P = 0.103). The overall rates of the 3- and 5-year freedom from severe recurrent TR were 93.2% (95% CI: 85.9-99.9%) and 89.0% (78.7-99.9%), respectively, and no significant difference was found between groups (P = 0.176).

CONCLUSIONS

Repeat isolated tricuspid valve surgery after left-sided valve replacement is associated with adverse perioperative outcomes. Endoscopic access offers an alternative approach for RITS after LSVR with acceptable results. TVP results in lower surgical mortality than TVR while carrying a higher risk of residual moderate-to-severe TR.

Reappraisal of mechanical tricuspid valve replacement in the current era: a single center retrospective study

Background

This study aimed to investigate the early and late outcomes of mechanical tricuspid valve replacement (mTVR).

Methods

We evaluated 113 patients (82 women; median age, 53 years) who underwent mTVR between 1995 and 2017. Based on a history of cardiac surgery, patients were divided into primary (n=42) and reoperative mTVR (n=71) groups. The median follow-up duration was 12.7 years in primary and 9.3 years in reoperative mTVR, respectively (P=0.045).

Results

Patients in the reoperative group were older (54 vs. 46 years; P=0.007) and showed higher central venous pressure (16±6 vs. 13±6 mmHg; P=0.002) than the primary group. Early mortality occurred in 2 patients in the reoperative group (2 vs. 0; P=0.529). There was no significant difference in overall survival between the primary and reoperation groups (15-year survival rate: 86% vs. 78%; P=0.215). The independent risk factors of overall survival were age [P<0.001; hazard ratio (HR), 1.11; 95% confidential interval (CI), 1.05–1.18], left ventricular ejection fraction of less than 40% (P=0.001; HR, 5.1; 95% CI, 2.21–28.2), and central venous pressure over 20 mmHg (P=0.016; HR, 3.7; 95% CI, 1.28–10.7). Overall survival did not differ between the age groups (<60 vs. 60–70 years) in the reoperative group (P=0.772). Tricuspid valve thrombosis occurred in 8 patients (7 primary, 1 reoperative; P=0.004).

Conclusions

The incidence of tricuspid valve thrombosis was significantly higher in the primary mTVR group compared with the reoperative mTVR group. The patients who underwent mTVR at a relatively young age showed good early and late outcomes in both groups.

Comparative analysis of structural valve deterioration after bioprosthetic tricuspid valve replacement: Bovine pericardial versus porcine valves

This study was conducted to compare the occurrence and the risk factors of structural valve deterioration (SVD) after bioprosthetic tricuspid valve replacement (TVR) between bovine pericardial valves and porcine valves. One-hundred and thirty-four TVR patients were enrolled; 108 patients underwent TVR with bovine pericardial bioprostheses (BTVR group) and 26 underwent TVR with porcine bioprostheses (PTVR group). The early results and long-term clinical outcomes were compared. The median follow-up duration was 90 (interquartile range: 33-135) months. Propensity score (PS) adjusted Cox regression and competing risk analyses were performed. The mean ages of the BTVR and PTVR groups were 62.2 ± 10.7 and 57.3 ± 13.9 years, respectively. The overall survival and cumulative incidence of cardiac death in the BTVR group were similar to those in the PTVR group (hazard ratio [95% confidence interval] = 1.399 [0.500-3.922] and 0.742 [0.249-2.212], respectively). SVD was significantly more frequent in the BTVR group (17.544 [1.070-243.902], P = .045). The tricuspid valve reoperation rate was significantly higher in the BTVR group (38.462 [2.591-476.190], P = .008). The cumulative incidence of SVD after bioprosthetic TVR was higher when using bovine pericardial valves than when using porcine valves.

Bioprosthetic tricuspid valve stenosis: a case series

Background

Bioprosthetic tricuspid valve stenosis is a late sequela of tricuspid valve replacement (TVR); however, detailed information regarding its clinical picture is lacking.

Case summary

Thirty-one patients with bioprosthetic TVR (mean age: 60.5 ± 16.6 years, male/female: 11/20) were followed-up for 79.5 ± 49.1 months (14–188 months). Eleven patients developed bioprosthetic tricuspid valve stenosis (mean tricuspid gradient >5 mmHg) at a median interval of 96 months (interquartile range: 61–114 months). The mean tricuspid gradient at the time of tricuspid valve stenosis diagnosis was 10.9 ± 3.9 mmHg. Although the mid-term tricuspid valve stenosis-free survival was favourable (92.4% at 60 and 78.7% at 84 months), it had declined steeply to 31.5% by 120 months. Ten out of 11 tricuspid valve stenosis patients showed signs of right heart failure (RHF) as manifested by oedema and elevated jugular venous pressure, requiring moderate-to-high doses of diuretics. Diastolic rumble was audible in 10 patients. Five of the 11 tricuspid valve stenosis patients required redo TVR as a result of refractory RHF. Examination of the five excised bioprostheses showed pannus in four, fusion of the commissure in three, native valve attachment in two, and sclerosis in one. Detailed clinical pictures and pathology of the explanted valves in three cases that underwent surgery are presented in this case series.

Discussion

Bioprosthetic tricuspid valve stenosis is not uncommon after 8 years. Tricuspid valve replacement performed at the second surgery was associated with a higher incidence of bioprosthetic tricuspid valve stenosis.

Ten-year experience of tricuspid valve replacement with the St. Jude medical valve

Bioprosthetic valves for tricuspid valve replacement (TVR) have become increasingly popular in recent years, but mechanical valves remain valuable, particularly for the patients who want to avoid reoperation for bioprostheses malfunction. The aim of this study was to review our 10-year experience in adult patients who underwent TVR with the St. Jude Medical (SJM) valve. From 2005 to 2015, 265 TVRs with SJM valves were performed at our institution. The mean age at operation was 44.1 ± 9.7 years, and 207 cases (78.1%) were female. The mean follow-up was 4.9 ± 2.7 years. Preoperative atrial fibrillation was present in 199 cases (75.1%) and ascites in 26 (9.8%). Of all cases, 88.7% were characterized as New York Heart Association class III or IV. The hospital mortality was 6.4%. There were 9 deaths (3.8%) during late follow-up. The overall survival rates were 89.2% ± 2.2% at 5 years and 86.6% ± 2.9% at 10 years. The linearized rates of valve thrombosis and bleeding events were 0.8%/patient-year and 1.5%/patient-year, respectively. Three cases (1.3%) were reoperated due to prosthetic valve thrombosis. There was no reoperation for sperivalvular leakage and structural failure. The freedom from reoperation was 98.6% ± 0.8% at 5 years and 98.6% ± 0.8% at 10 years. The SJM valve in the tricuspid position is a reliable mechanical prosthesis with a low rate of valve thrombosis and reoperation. It is a reasonable choice for the patients who require mechanical valve replacement in the tricuspid position.

Cardiac surgery 2016 reviewed

For the year 2016, more than 20,000 published references can be found in Pubmed when entering the search term "cardiac surgery". Publications last year have helped to more clearly delineate the fields where classic surgery and modern interventional techniques overlap. The field of coronary bypass surgery (partially compared to percutaneous coronary intervention) was enriched by five large prospective randomized trials. The value of CABG for complex coronary disease was reconfirmed and for less complex main stem lesions, PCI was found potentially equal. For aortic valve treatment, more evidence was presented for the superiority of transcatheter aortic valve implantation for patients with intermediate risk. However, the 2016 evidence argued against the liberal expansion to the low-risk field, where conventional aortic valve replacement still appears superior. For the mitral valve, many publications emphasized the significant impact of mitral valve reconstruction on survival in structural mitral regurgitation. In addition, there were many relevant and other interesting contributions from the purely operative arena in the fields of coronary revascularization, surgical treatment of valve disease, terminal heart failure (i.e., transplantation and ventricular assist devices), and aortic surgery. While this article attempts to summarize the most pertinent publications it does not have the expectation of being complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.

A case of an explanted 26-year-old Carpentier-Edwards supra-annular valve in the tricuspid position

Whether a mechanic or bioprosthetic valve is better for tricuspid valve replacement is still controversial. One problem of bioprostheses is structure valve deterioration. However, a bioprosthesis in the tricuspid position is more durable than that in the aortic and mitral positions. We report a case of an explanting Carpentier-Edwards supra-annular valve (CE-SAV) (Baxter Healthcare Corp., Irvine, CA, USA) in tricuspid position 26 years after tricuspid valve replacement. A 36-year-old female underwent total correction of tetralogy of Fallot at the age of five, and three years later she underwent tricuspid valve replacement for severe tricuspid regurgitation using a Björk-Shiley valve. Two years later, the mechanical valve was explanted due to thrombus formation, and a 29-mm CE-SAV was implanted in tricuspid position. Twenty-six years after implantation, we explanted the valve due to structural valve deterioration. The leaflets of the valve were hard and stiff, and calcifications were present on all the leaflets. A small tear existed in the part of most calcified leaflet. To the best of our knowledge, this is the longest durability of CE-SAV in tricuspid position. <Learning objective: Whether bioprosthetic or mechanical valve should be chosen for tricuspid valve replacement is still controversial. A bioprosthesis in the tricuspid position is more durable than that in the aortic or mitral position. We explanted the valve due to structural valve deterioration 26 years after implantation. The leaflets were hard and stiff, and calcifications were present on all the leaflets. A small tear existed in the part of most calcified leaflet.>.

Fate of Hancock valve in tricuspid position 36 years after implantation

Mid- to long-term durability of bioprosthesis in tricuspid position is acceptable. However, little is known about more extended long-term structural valve changes of Hancock valve. In present report, we describe Hancock valve images 36 years after implantation.