Tricuspid Valve Replacement: An Analysis of Risk Factors and Outcomes

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.

Long-Term Outcomes of Tricuspid Valve Replacement With Mechanical Versus Tissue Valves: Meta-Analysis of Reconstructed Time-to-Event Data

Tricuspid valve replacement (TVR) with mechanical versus tissue valves remains a controversial subject. To evaluate the long-term effects of types of valves on patient-relevant outcomes, we performed a systematic review with meta-analysis of reconstructed time-to-event data of studies published by March 15, 2024 (according to referred the Reporting Items for Systematic Reviews and Meta-analyses guidelines). A total of 21 studies met our eligibility criteria and included 7,166 patients (mechanical: 2,495 patients, 34.8%). Patients who underwent mechanical TVR had a lower risk of death than those who received a tissue valve (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.70 to 0.84, p <0.001). Mechanical TVR was associated with lifetime gain, as evidenced by the restricted mean survival time, which was 2.2 years longer in patients who underwent TVR with mechanical valves (12.4 vs 10.2 years, p <0.001). Our landmark analysis for reoperations revealed the following: from the time point 0 to 7 years, we found no difference in the risk of reoperation between mechanical and tissues valves (HR 0.98, 95% CI 0.60 to 1.61, p = 0.946); however, from the time point 7 years onward, we found that mechanical TVR had a lower risk of reoperation in the follow-up (HR 0.24, 95% CI 0.08 to 0.72, p = 0.001). The meta-regression analysis demonstrated a modulating effect of atrial fibrillation on the association between mechanical valves and mortality; the HRs for all-cause death tended to decrease in the presence of populations with a larger proportion of atrial fibrillation (p = 0.018). In conclusion, our results suggest that TVR with mechanical valves, whenever considered clinically reasonable and accepted by patients as an option, can offer a better long-term survival and lower risk of reoperation in the long run.

Outcomes of minimally invasive isolated tricuspid valve repair and replacement through right mini-thoracotomy

Objective

Isolated tricuspid valve surgery is uncommon and associated with high perioperative morbidity and mortality. We aimed to study the overall outcomes of patients who underwent minimally invasive right thoracotomy tricuspid valve surgery (Mini-TVS), consisting of either tricuspid valve repair (TVre) or replacement (TVR).

Methods

We performed a retrospective analysis of all Mini-TVS procedures (2017-2022), through which we identified isolated tricuspid valve surgeries. We examined in-hospital outcomes, survival analysis over a 4-year period, and competing risk analysis for reoperative surgery.

Results

Among a total of 51 patients, the average age was 60 ± 16 years, and 67% (n = 34) were female. Severe tricuspid regurgitation was present in all cases. Infective endocarditis was noted in 7.8% (n = 4), and 24% (n = 12) had preexisting pacemakers. Mini-TVS included TVre in 18 patients (35%) and TVR in 33 patients (65%). The in-hospital and 30-day mortality rates were 4% (n = 2) and 6% (n = 3), respectively. At 4 years, the overall TVS survival was 76% (confidence interval, 62-93%), with no significant difference between TVre and TVR (91% vs 69%, P = .16). At follow-up, 3 patients required repeat surgery for recurrent regurgitation after 2.6, 3.3, and 11 months, with a reoperation rate of 7.3% (confidence interval, 2.4-22%) at 2 years. Factors associated with worse overall survival included nonelective surgery, right ventricular dysfunction, serum creatinine >2 g/dL, and concomitant left-sided valve disease.

Conclusions

A nonsternotomy minimally invasive approach is a feasible option for high-risk patients. Midterm outcomes were similar in repair or replacement. Patients with right ventricular dysfunction and left-sided disease had worse outcomes.

Transcatheter Tricuspid Valve Replacement: Case Selection, Technical Considerations, and Procedural Planning

Tricuspid regurgitation (TR) is a highly prevalent valve disorder in the US, with prevalence increasing with age. Without treatment, severe TR carries a poor prognosis. Tricuspid valve (TV) surgery is recommended for patients with severe TR undergoing left-sided valve surgery. Transcatheter TV repair or transcatheter TV replacement are potential options for patients who are not surgical candidates. A few small studies have demonstrated the feasibility and efficacy of transcatheter TV repair in patients with severe symptomatic TR. Careful patient selection by assessing tricuspid valve anatomy, right ventricular and pulmonary hemodynamics, candidacy for anticoagulation, comorbid conditions, and frailty is key to procedural success. Transcatheter TV repair can be performed via the transjugular or transfemoral access, and requires a large-caliber sheath (up to 45 Fr) and delivery system, particularly with dilated tricuspid annulus due to right ventricular enlargement. Multimodality imaging is essential for diagnosing TR severity, defining valve anatomy, and comprehensive functional assessment of the tricuspid valve, right atrium, and right ventricle. Several prosthetic valves, including the EVOQUE system, NaviGate system, Intrepid valve, and Cardiovalve, are currently being investigated in clinical trials.

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.

Isolated Tricuspid Valve Replacement for Infective Endocarditis

BACKGROUND

Existing data regarding isolated tricuspid valve replacement for primary tricuspid valve disease such as infective endocarditis (IE) are limited. The aim of this study was to review our experience of isolated tricuspid valve replacement for IE.

METHODS

A retrospective review was performed to evaluate the perioperative and long-term outcomes of patients undergoing isolated tricuspid valve replacement for IE at our tertiary referral center between January 2000 and December 2014. Surgical outcomes were reviewed to include survival and postoperative complications.

RESULTS

Seven patients underwent isolated tricuspid valve replacement for IE during the study period. Mean age was 41 ± 14 years with six (86%) males. Six patients (86%) were intravenous drug users. Five patients (71%) presented with septic emboli to the lungs. Five patients (71%) had active endocarditis at the time of surgery. The indications for surgery were heart failure in three patients (43%), persistent sepsis in three patients (43%) and both in one patient (14%). Methicillin-sensitive Staphylococcus aureus was the most common infective organism, isolated in five patients (71%). There were no in-hospital mortalities or permanent pacemaker implantations. Follow-up was completed in 86% of the cases. The median follow-up period was 13 months (range 2 to 129 months). Three patients (43%) died during the follow-up period, at 7 months, 8 months and 13 months, respectively. All deaths were associated with prosthetic valve IE and recurrent intravenous drug use.

CONCLUSIONS

This study supplements the paucity of data pertaining to tricuspid valve replacement for IE in the local population. Survival outcomes can be improved with prompt surgical intervention, optimal medical optimization, and a holistic, psychosocial approach targeting intravenous drug abuse.

Hemodynamic Characteristics and Outcomes of Pulmonary Hypertension in Patients Undergoing Tricuspid Valve Repair or Replacement

BACKGROUND

The impact of pulmonary hypertension (PH) on outcomes after surgical tricuspid valve replacement (TVR) and repair (TVr) is unclear. We sought to characterize PH in patients undergoing TVR/TVr, based on invasive hemodynamics and evaluate the effect of PH on mortality.

METHODS

We identified 86 consecutive patients who underwent TVR/TVr with invasive hemodynamic measurements within 3 months before surgery. We used Kaplan-Meier survival and restricted mean survival time (RMST) analyses to quantify the effects of PH on survival.

RESULTS

The mean age was 63 ± 13 years, 59% were female, 45% had TVR, 55% had TVr, 39.5% had isolated TVR/TVr, and 60.5% had TVR/TVr concomitant with other cardiac surgeries). Eighty-six percent of these patients had PH with a mean pulmonary artery pressure of 30 ± 10 mm Hg, pulmonary vascular resistance (PVR) of 2.5 (interquartile range: 1.5-3.9) Wood units (WU), pulmonary arterial compliance of 2.3 (1.6-3.6) mL/mm Hg, and pulmonary arterial elastance of 0.8 (0.6-1.2) mm Hg/mL. Cardiac output was mildly reduced at 4.0 ± 1.4 L/min, with elevated right-atrial pressure (14 ± 12 mm Hg) and pulmonary capillary wedge pressure (19 ± 7 mm Hg). Over a median follow-up of 6.3 years, 22% of patients died. Patients with PVR ≥ 2.5 WU had lower RMST over 5 years compared with patients with PVR < 2.5 WU.

CONCLUSION

PH is common in patients undergoing TVR/TVr, with combined pre- and postcapillary being the most common type. PVR ≥ 2.5 WU is associated with lower survival at 5-year follow-up.

Bilateral Pneumothoraces: A Rare Complication of Septic Pulmonary Emboli in Intravenous Drug Abusers

Patient: Male, 39

Final Diagnosis: Infective endocarditis

Symptoms: Cough

Medication: —

Clinical Procedure: None

Specialty: Critical Care Medicine

Clinical results of tricuspid valve replacement - a 21-case report

Objective

To summarize the clinical experiences of 21 patients treated with tricuspid valve replacement (TVR) and investigate the surgical indications and methods.

Methods

Data from 21 patients who underwent TVR from December 2002 to March 2009 were retrospectively collected and analyzed. The mean age was 48.86±15.37 years (range: 20-72 years). The underlying disease of the patients was classified as rheumatic (n = 10), congenital (n = 8), endocarditis (n = 2) or chest trauma (n = 1). Previous cardiac surgery had been performed in 12 patients (57.14%).

Results

In-hospital death occurred in two patients (9.52%). Postoperative morbidities included cardiac failure (n = 2), bleeding related re-operation (n = 1), and plural effusion (n = 2).

Conclusion

The early outcomes of TVR were acceptable. At the present time TVR can be performed through optimal perioperative management.

The Role of Tricuspid Valve Surgery in the Late Management of Tetralogy of Fallot

While surgical repair of tetralogy of Fallot (TOF) is generally associated with good early outcomes, late complications affect long-term survival and may require reoperation. Pulmonary regurgitation (PR) and tricuspid regurgitation (TR) may increase the risk of arrhythmias, reduced cardiac function, and sudden death. Tricuspid valve function can be compromised secondarily in the setting of PR or directly as a result of injury or alteration of the valve related to the original TOF repair. This article reviews the etiologic mechanisms, pathophysiological implications, and surgical interventions for TR. Effective management following TOF repair requires consideration of TR to optimize late outcomes.