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Abdelaal SA, Hefnawy MT, Ewais E, Mostafa N, Abozaid AM, Mouffokes A, Moustapha A, Mohamed M, Ghaith HS, Ramadan A, Kengo NE, Negida A. Rigid ring vs. flexible band for tricuspid valve repair in patients with tricuspid valve regurgitation: A systematic review and meta-analysis. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 22:200296. [PMID: 39026609 PMCID: PMC11255101 DOI: 10.1016/j.ijcrp.2024.200296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 05/11/2024] [Accepted: 06/04/2024] [Indexed: 07/20/2024]
Abstract
Background & objectives Rigid ring and Flexible band are techniques used to repair tricuspid valve regurgitation. The comparison between both techniques' effectiveness is controversial in the literature. We conducted this systematic review and meta-analysis to compare the safety and efficacy of rigid ring versus flexible band for tricuspid valve repair in patients with tricuspid valve regurgitation. Methods We conducted a PRISMA-compliant systematic review and meta-analysis. A systematic search was performed in major databases, including PubMed, Scopus, Web of Science, and Cochrane CENTRAL to identify relevant published studies. Data were extracted and analyzed using Stata (version 17 for Mac) and Revman (version 5.4 for Windows). Results Twelve studies were included in this meta-analysis. Total number of patients was 4259. The rigid ring wasn't superior to the flexible band in terms of postoperative tricuspid regurgitation RR 0.74, 95 % CI (0.43-1.27) (P = 0.29). However, the results were not homogeneous. After employing sensitivity analysis, the significance of the pooled effect estimate didn't change, showing no significant difference between the two annuloplasty RR 0.72, 95%CI (0.45-1.15). On the other hand, the rigid ring was associated with a higher bypass time than the flexible band (RR 4.85, P = 0.00). There were no differences between the two groups in terms of hospital stay, ICU stays, prolonged ventilation, mechanical ventilation time, annuloplasty size, stroke, concomitant mitral valve surgery, concomitant aortic valve surgery, atrial fibrillation, pacemaker implantation, low cardiac output, in-hospital death, or late death (all P > 0.05). Conclusion Our study findings suggested no difference between rigid ring compared to flexible band regarding the rates of postoperative tricuspid regurgitation; however, rigid ring may encompass a higher bypass time. Therefore, further research is required to ensure our findings.
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Affiliation(s)
| | - Mahmoud Tarek Hefnawy
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
- Medical Affairs Department, Volaris LLC, Dubai, UAE
| | - Enas Ewais
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
- Faculty of Nursing, Ain Shams University, Cairo, Egypt
| | | | | | - Adel Mouffokes
- Faculty of Medicine, University of Oran 1 Ahmed Ben Bella, Oran, Algeria
| | | | | | | | - Alaa Ramadan
- Faculty of Medicine, South Valley University, Qena, Egypt
| | - Nathan Ezie Kengo
- Faculty of Medicine and Biomedical Sciences, University of Garoua, Garoua, Cameroon
| | - Ahmed Negida
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Lee H, Kim J, Jung JH, Yoo JS. Mid-term outcomes of tricuspid annuloplasty using the Tri-Ad Adams tricuspid annuloplasty ring. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 39:ivae131. [PMID: 38995834 PMCID: PMC11334059 DOI: 10.1093/icvts/ivae131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 06/19/2024] [Accepted: 07/10/2024] [Indexed: 07/14/2024]
Abstract
OBJECTIVES The Tri-Ad Adams tricuspid annuloplasty ring is a recent innovative prosthesis characterized by a semi-rigid central component and fully flexible extremities. The goal of this study was to assess the short-term and mid-term results following implantation of the Tri-Ad Adams ring. METHODS A retrospective analysis was conducted on patients who underwent tricuspid annuloplasty using the Tri-Ad Adams ring between August 2016 and October 2021. RESULTS Our study enrolled a total of 248 participants. The median age was 64.0 (interquartile range: 56.0-71.5) years. The median EuroSCORE II was 4.3% (2.7-7.5%), with 37 patients (14.9%) having a history of cardiac operations. Tricuspid regurgitation of grade 2-3 was observed in 63.7% of cases, and the median tricuspid annular diameter was 3.3 (2.8-3.6) cm. Concurrent procedures included mitral valve replacement (n = 160, 64.5%), mitral valve repair (n = 75, 30.2%), aortic valve replacement (n = 72, 29.0%) and the maze procedure (n = 170, 68.5%). Immediate postoperative tricuspid regurgitation≥moderate was present in 1 patient (0.4%). Early death occurred in 14 patients (5.6%). Major complications included low cardiac output syndrome (n = 18, 0.3%), acute kidney injury (n = 14, 5.6%) and permanent pacemaker placement (n = 15, 6.0%). According to the Kaplan-Meier analysis, the 4-year rates of freedom from overall mortality and moderate-to-severe tricuspid regurgitation were 96.9% and 91.6%, respectively. There were no incidents of tricuspid valve reoperations, ring detachment or significant tricuspid stenosis (trans-tricuspid valve gradient ≥ 5 mmHg). CONCLUSIONS Tricuspid annuloplasty utilizing the Tri-Ad Adams ring demonstrated favourable outcomes in both the early and midterm periods. Further studies are warranted to confirm the long-term results.
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Affiliation(s)
- Heemoon Lee
- Department of Thoracic and Cardiovascular Surgery, Bucheon Sejong Hospital, Bucheon, Gyeonggi-do, Republic of Korea
| | - Jihoon Kim
- Department of Thoracic and Cardiovascular Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hyun Jung
- Division of Cardiology, Department of Internal Medicine, Bucheon Sejong Hospital, Bucheon, Gyeonggi-do, Republic of Korea
| | - Jae Suk Yoo
- Department of Thoracic and Cardiovascular Surgery, Bucheon Sejong Hospital, Bucheon, Gyeonggi-do, Republic of Korea
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Ailawadi G, Voisine P, Raymond S, Gelijns AC, Moskowitz AJ, Falk V, Overbey JR, Chu MWA, Mack MJ, Bowdish ME, Krane M, Yerokun B, Conradi L, Bolling SF, Miller MA, Taddei-Peters WC, Fenton KN, Jeffries NO, Kramer RS, Geirsson A, Moquete EG, O'Sullivan K, Hupf J, Hung J, Beyersdorf F, Bagiella E, Gammie JS, O'Gara PT, Iribarne A, Borger MA, Gillinov M. Pacemaker implantation associated with tricuspid repair in the setting of mitral valve surgery: Insights from a Cardiothoracic Surgical Trials Network randomized trial. J Thorac Cardiovasc Surg 2024; 167:2104-2116.e5. [PMID: 36669972 PMCID: PMC10247904 DOI: 10.1016/j.jtcvs.2022.11.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 11/04/2022] [Accepted: 11/20/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES In a recent trial, tricuspid annuloplasty (TA) during mitral valve surgery (MVS) for degenerative mitral regurgitation and moderate or less tricuspid regurgitation (TR) reduced the composite rate of death, reoperation for TR, or TR progression at 2 years. However, this benefit was counterbalanced by an increase in implantation of permanent pacemakers (PPMs). In this study, we analyzed the timing, indications, and risk factors for these implantations. METHODS We randomized 401 patients (MVS alone = 203; MVS + TA = 198). Potential risk factors for PPMs were assessed using multivariable time-to-event models with death and PPM implantation for heart failure indications as competing risks. RESULTS A PPM was implanted in 36 patients (9.6; 95% CI, 6.8-13.0) within 2 years of randomization, with 30/187 (16.0%) in the MVS + TA and 6/188 (3.2%) in the MVS groups (rate ratio, 5.08; 95% CI, 2.16-11.94; P < .001). Most (29/36; 80.6%) implantations occurred within 30 days postoperatively. Independent risk factors for PPM implantation within 2 years were TA (hazard ratio [HR], 5.94; 95% CI, 2.27-15.53; P < .001), increasing age (5 years, HR, 1.23; 95% CI, 1.01-1.52; P = .04), and left ventricular ejection fraction (LVEF; HR, 0.96; 95% CI, 0.92-0.99; P = .02). In the subset of TA recipients (n = 197), age (5 years, HR, 1.05; 95% CI, 1.00-1.10; P = .04) and LVEF (HR, 0.95; 95% CI, 0.91-0.99; P = .01) were associated with PPM within 2 years. CONCLUSIONS Concomitant TA, age, and baseline LVEF were risk factors for PPM implantation in patients who underwent MVS for degenerative mitral regurgitation. Although TA was effective in preventing progression of TR, innovation is needed to identify ways to decrease PPM implantation rates.
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Affiliation(s)
- Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Pierre Voisine
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Québec, Canada
| | - Samantha Raymond
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Alan J Moskowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsche Herzzentrum Berlin, Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, and German Centre for Cardiovascular Research, DZHK, Partner Site Berlin, Berlin, Germany
| | - Jessica R Overbey
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael W A Chu
- Division of Cardiac Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Michael J Mack
- Cardiac and Thoracic Surgery, Baylor Scott & White Health, Plano, Tex
| | - Michael E Bowdish
- Department of Surgery and Population and Public Health Sciences, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Markus Krane
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Babatunde Yerokun
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, NC
| | - Lenard Conradi
- University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Marissa A Miller
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Wendy C Taddei-Peters
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Kathleen N Fenton
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Neal O Jeffries
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Robert S Kramer
- Thoracic Surgery (Cardiothoracic Vascular Surgery), Internal Medicine, Maine Medical Center, Portland, Maine
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Ellen G Moquete
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karen O'Sullivan
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jonathan Hupf
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Boston, Mass
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James S Gammie
- Cardiac Surgery, Johns Hopkins Heart and Vascular Institute, Baltimore, Md
| | - Patrick T O'Gara
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Alexander Iribarne
- Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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You T, Ma YH, Yi K, Gao J, Xu JG, Xu XM, He SE, Wang W, Ji M. Impact of 3D Rigid Ring Annuloplasty for Tricuspid Regurgitation: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:725968. [PMID: 35345483 PMCID: PMC8957110 DOI: 10.3389/fcvm.2022.725968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 01/19/2022] [Indexed: 01/10/2023] Open
Abstract
BackgroundTricuspid annuloplasty (TAP) is accepted as the standard technique for correcting tricuspid regurgitation (TR). We conducted the present study to provide an overview of the contemporary results of 3D rigid ring annuloplasty for TR.MethodsA systematic literature search was carried out in eight databases to collect all relevant studies on the three-dimensional (3D) rigid ring annuloplasty treatment of TR published before October 1, 2020. The main outcomes of interest were postoperative TR grade, perioperative mortality, and recurrent TR.ResultsA total of eight studies were included, all of which were retrospective observational studies. Rigid 3D rings were compared with flexible bands, and there was no difference in perioperative mortality [odds ratio (OR) = 1.02; 95% CI (0.52, 2.02); p = 0.95], late mortality [OR = 0.99; 95% CI (0.28, 3.50); p = 0.98], or recurrent TR [OR = 0.59; 95% CI (0.29, 1.21); p = 0.15]. The postoperative TR grade associated with 3D rigid rings was 0.12 lower [mean difference (MD) = −0.12; 95% CI (−0.22, −0.01); p = 0.03], which indicated that 3D rigid rings result in better postoperative outcomes than flexible bands. Compared with suture annuloplasty, the postoperative TR grade of the 3D rigid ring group was 0.51 lower [MD = −0.51; 95% CI (−0.59, −0.43); p < 0.05]. Within the 5 years of follow-up, patients who underwent 3D rigid ring annuloplasty had lower TR recurrence [OR = 0.26; 95% CI (0.13, 0.50); p < 0.05].ConclusionsCompared with suture annuloplasty, 3D rigid rings present early advantages. The 3D rigid rings provide an acceptable short-term effect similar to that of the flexible bands, and a significant difference between these approaches was not discovered. However, the conclusion was based on the limited, short-term data available at the time of the study. Further research on the long-term effects of 3D rigid ring annuloplasty for TR is clearly needed.Systematic Review Registrationhttps://inplasy.com/inplasy-2021-3-0105/, identifier: 202130105.
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Affiliation(s)
- Tao You
- Department of Cardiovascular Surgery, Gansu Provincial Hospital, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- *Correspondence: Tao You
| | - Yu-Hu Ma
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Kang Yi
- Department of Cardiovascular Surgery, Gansu Provincial Hospital, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
| | - Jie Gao
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Jian-Guo Xu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Xiao-Min Xu
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Shao-E He
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The Second Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Wei Wang
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Meng Ji
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6540687. [DOI: 10.1093/ejcts/ezac147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/04/2022] [Accepted: 02/19/2022] [Indexed: 11/12/2022] Open
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Algarni KD, Alfonso J, Pragliola C, Kheirallah H, Adam AI, Arafat AA. Long-term Outcomes of Tricuspid Valve Repair: The Influence of the Annuloplasty Prosthesis. Ann Thorac Surg 2021; 112:1493-1500. [DOI: 10.1016/j.athoracsur.2020.09.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 09/18/2020] [Accepted: 09/18/2020] [Indexed: 11/29/2022]
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Rigid Ring Versus Flexible Band for Tricuspid Valve Repair in Patients Scheduled for Mitral Valve Surgery: A Prospective Randomised Study. Heart Lung Circ 2021; 30:1949-1957. [PMID: 34629244 DOI: 10.1016/j.hlc.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 08/04/2021] [Accepted: 08/12/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Tricuspid valve repair for functional regurgitation is effectively performed with different annuloplasty devices. However, it remains unclear whether there are advantages associated with rigid rings compared to flexible bands. This prospective randomised study aimed to compare results of using a flexible band ring versus a rigid ring for functional tricuspid regurgitation in patients undergoing mitral valve surgery. METHODS A single-centre randomised study was designed to allocate patients with functional tricuspid regurgitation undergoing mitral valve surgery to be treated with a flexible band or rigid ring. These patients were analysed by echocardiographic follow-up. The primary outcome was freedom from recurrent tricuspid regurgitation at 12-months follow-up. Secondary outcomes were 30-day mortality, survival, freedom from tricuspid valve reoperation, right ventricular reverse remodelling, and rate of major adverse events. RESULTS A total of 308 patients were allocated to receive concomitant tricuspid valve annuloplasty with the flexible band or rigid ring. There was no between-group difference in freedom from recurrent tricuspid regurgitation: 97.3% in Rigid group (95% CI, 93.0-98.8) and 96.2% in the Flexible group (95% CI, 92.0-98.5) at 12-months follow-up (log-rank, p=0.261). Early mortality, survival, freedom from tricuspid valve reoperation, and global right ventricle systolic function were also comparable in both groups of patients. However, the flexible band had advantage in restoring regional right ventricle function (Doppler-derived systolic velocities of the annulus [S], tricuspid annular plane systolic excursion) at 12-months follow-up. CONCLUSION Both the rigid ring and flexible band offered acceptable outcomes for functional tricuspid regurgitation correction without significant differences, as assessed at 12-months follow-up.
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Sarraj-Asil A, Diez-Villanueva P. Insight into functional tricuspid valve regurgitation pathogenesis, pathological stages, and surgical management. Int J Cardiol 2021; 338:161-167. [PMID: 34087338 DOI: 10.1016/j.ijcard.2021.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/28/2021] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
Abstract
The tricuspid valve has generally been ignored, and considered as a "second class structure" in cardiac valve surgery. Tricuspid valve regurgitation is considered "functional" in over 70% of cases, generally produced by pulmonary hypertension secondary to left heart diseases in the context of an anatomically normal tricuspid valve apparatus. Many questions and doubts persist regarding to the pathogenesis of so-called functional tricuspid valve regurgitation. This article reviews the interfering factors in the function of the tricuspid valve to better identify the entity of the term "functional" and clarify its different pathological stages including the surgical procedures recommended in each stage.
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Affiliation(s)
- Anas Sarraj-Asil
- Department of cardiovascular surgery, Hospital Universitario de La Princesa. Madrid, Spain.
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9
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The influence of tricuspid annuloplasty prostheses on ovine annular geometry and kinematics. J Thorac Cardiovasc Surg 2021; 161:e191-e207. [DOI: 10.1016/j.jtcvs.2019.09.060] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 11/19/2022]
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Impact of Different Annuloplasty Methods for Tricuspid Regurgitation: A Network Meta-Analysis. Ann Thorac Surg 2020; 111:2004-2010. [PMID: 33011167 DOI: 10.1016/j.athoracsur.2020.07.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although moderate to severe tricuspid valve regurgitation (TR) is an independent risk factor for progressive heart failure and increased mortality, the best method for tricuspid valve repair remains controversial. Therefore, this study conducted a network meta-analysis to compare early and late outcomes for suture, flexible band, and rigid ring as tricuspid annuloplasty (TAP) in patients with TR. METHODS Medline and EMBASE were searched through February 15, 2020 to identify randomized controlled trials and observational trials that investigated early and late outcomes after TAP for TR. The outcomes of interest were perioperative mortality, all-cause mortality, and TR recurrence with more than 1-year follow-up. TR recurrence was defined as at least moderate (TR grade 2) on serial echocardiograms. RESULTS Two randomized controlled trials and 15 observational trials were identified, including 6138 patients who underwent TAP. The median follow-up period was 1 to 7.4 years. There were no significant differences of perioperative and all-cause mortality among 3 TAP methods. Rigid ring TAP was associated with a significant reduction in TR recurrence compared with suture TAP (hazard ratio, 0.42; 95% confidence interval, 0.23 to 0.78; P = .005). There were no significant differences in TR recurrence were observed between flexible band and suture TAP or flexible band and rigid ring TAP. CONCLUSIONS This network meta-analysis demonstrated significant reduction in TR recurrence for rigid ring TAP compared with suture TAP, although no significant differences were observed between suture and flexible band TAP or between flexible band and rigid ring TAP. There were no significant mortality differences among suture, flexible band, and rigid ring TAP procedures.
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Nosair A, Elkahely M, Nasr S, Alkady H. Tricuspid three-dimensional ring versus fashioned flexible band annuloplasty in management of functional tricuspid valve regurge: comparative long term study. THE CARDIOTHORACIC SURGEON 2020. [DOI: 10.1186/s43057-020-00023-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Functional tricuspid valve regurgitation due to left sided valve lesions remains a common finding. Nowadays, different types of three-dimensional rings and flexible bands are considered to be the gold standard techniques for repair of such functional regurgitation. Our study aimed for long-term comparison of the durability and effectiveness of those techniques.
Results
The data of 170 adult patients with moderate or more functional tricuspid regurgitation secondary to mitral stenosis or regurgitation receiving tricuspid valve repair using either rigid 3D rings (contour 3D or MC3 ring) or prosthetic fashioned bands (Dacron or PTFE) and mitral valve surgery between March 2013 and September 2018 were collected and analysed. Patients were classified in two matched groups: ring group (group A) consisting of 90 cases and band group (group B) consisting of 80 cases. follow-up period ranged from 55.2 to 78 months (mean 67.2 ± 10.8), during this period New York heart association for dyspnea functional class evaluation and full echocardiographic assessment were done and was scheduled as following: before hospital discharge, after 6 months of surgery and finally, every 2 years. In-hospital mortality was 1(1.1%) and 2 (2.5%) with p value 0.49 after ring or band annuloplasty, respectively. No significant differences in both groups regarding hospital mortality and morbidities. There was statistically significant decrease in NYHA class, degree of TR, and PASP within the 2 groups postoperatively with p value of 0.03, 0.04, and 0.033, respectively, with no statistically significant difference between both groups (p value > 0.05). There was statistically significant difference in the freedom from recurrent TR and need for reoperation during the follow-up period between both groups with lower recurrence and reoperation rates in group A, (p value 0.03 and 0.001, respectively).
Conclusion
Tricuspid valve repair with different annuloplasty rigid three dimensional rings or fashioned flexible bands for functional tricuspid regurgitation offers good long-term outcome. Yet, the rigid rings maintain their benefits on the rate of recurrent TR and the need for reoperation.
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Veen KM, Etnel JRG, Quanjel TJM, Mokhles MM, Huygens SA, Rasheed M, Oei FBS, ten Cate FJ, Bogers AJJC, Takkenberg JJM. Outcomes after surgery for functional tricuspid regurgitation: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 6:10-18. [DOI: 10.1093/ehjqcco/qcz032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/04/2019] [Accepted: 07/05/2019] [Indexed: 11/13/2022]
Abstract
Abstract
Aims
This study aims to provide a contemporary overview of outcomes after tricuspid valve (TV) surgery for functional tricuspid regurgitation (TR).
Methods and results
The literature was systematically searched for papers published between January 2005 and December 2017 reporting on clinical/echocardiographic outcomes after TV surgery for functional TR. A random effects meta-analysis was conducted for outcome variables, and late outcomes are visualized by pooled Kaplan–Meier curves. Subgroup analyses were performed for studies with a within-study comparison of suture vs. ring repair and flexible vs. rigid ring repair. Eighty-seven publications were included, encompassing 13 184 patients (mean age: 62.1 ± 11.8 years, 55% females). A mitral valve procedure was performed in 92% of patients. Pooled mean follow-up was 4.0 ± 2.8 years. Pooled early mortality was 3.9% (95% CI: 3.2–4.6), and late mortality rate was 2.7%/year (95% CI: 2.0–3.5), of which approximately half was cardiac-related 1.2%/year (95% CI: 0.8–1.9). Pooled risk of early moderate-to-severe TR at discharge was 9.4% (95% CI: 7.0–12.1). Late moderate-to-severe TR rate after discharge was 1.9%/year (95% CI: 1.0–3.5). Late reintervention rate was 0.3%/year (95% CI: 0.2–0.4). Mortality and overall (early and late) TR rate were comparable between suture vs. ring annuloplasty (14 studies), whereas overall TR rate was higher after flexible ring vs. rigid ring annuloplasty (6 studies) (7.5%/year vs. 3.9%/year, P = 0.002).
Conclusion
This study shows that patients undergoing surgery for functional tricuspid regurgitation (FTR) have an acceptable early and late mortality. However, TR remains prevalent after surgery. The results of this study can be used to inform patients and clinicians about the expected outcome after surgery for FTR and can results serve as a benchmark for the performance of emerging transcatheter TV interventions.
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Affiliation(s)
- Kevin M Veen
- Department of Cardiothoracic Surgery, Thoraxcenter, Rg-619, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, GD Rotterdam, Netherlands
| | - Jonathan R G Etnel
- Department of Cardiothoracic Surgery, Thoraxcenter, Rg-619, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, GD Rotterdam, Netherlands
| | - Thijs J M Quanjel
- Department of Cardiothoracic Surgery, Thoraxcenter, Rg-619, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, GD Rotterdam, Netherlands
| | - Mostafa M Mokhles
- Department of Cardiothoracic Surgery, Thoraxcenter, Rg-619, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, GD Rotterdam, Netherlands
| | - Simone A Huygens
- Department of Cardiothoracic Surgery, Thoraxcenter, Rg-619, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, GD Rotterdam, Netherlands
| | - Moniba Rasheed
- Department of Cardiothoracic Surgery, Thoraxcenter, Rg-619, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, GD Rotterdam, Netherlands
| | - Frans B S Oei
- Department of Cardiothoracic Surgery, Thoraxcenter, Rg-619, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, GD Rotterdam, Netherlands
| | - Folkert J ten Cate
- Department of Cardiology, Thoraxcenter, Rg-619, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, GD Rotterdam, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Thoraxcenter, Rg-619, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, GD Rotterdam, Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Thoraxcenter, Rg-619, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, GD Rotterdam, Netherlands
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13
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Calafiore AM, Foschi M, Kheirallah H, Alsaied MM, Alfonso JJ, Tancredi F, Gaudino M, Di Mauro M. Early failure of tricuspid annuloplasty. Should we repair the tricuspid valve at an earlier stage? The role of right ventricle and tricuspid apparatus. J Card Surg 2019; 34:404-411. [DOI: 10.1111/jocs.14042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 03/04/2019] [Accepted: 03/19/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Antonio M. Calafiore
- Department of Cardiac Surgery and CardiologyPrince Sultan Cardiac CenterRiyadh Saudi Arabia
| | | | - Hatim Kheirallah
- Department of Cardiac Surgery and CardiologyPrince Sultan Cardiac CenterRiyadh Saudi Arabia
| | | | - Juan J. Alfonso
- Department of Clinical ResearchPrince Sultan Cardiac CenterRiyadh Saudi Arabia
| | | | - Mario Gaudino
- Department of Cardio‐Thoracic SurgeryWeill Cornell MedicineNew York New York
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14
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Clinical outcomes after tricuspid surgery : The role of previous cardiac surgery. Herz 2018; 45:586-593. [PMID: 30276479 DOI: 10.1007/s00059-018-4761-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/21/2018] [Accepted: 09/08/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The aim of our study was to assess the outcomes of surgical treatment for severe tricuspid regurgitation according to whether cardiac surgery had been performed before the tricuspid valve intervention. METHODS Between 1996 and 2013, 201 consecutive patients with severe tricuspid regurgitation underwent tricuspid surgery at our center. Patients were classified according to whether or not they had undergone previous cardiac surgery, which 33% of the sample had. Perioperative as well as long-term morbidity and mortality were analyzed. RESULTS Mean patient age was 62.3 years. 32.8% underwent suture annuloplasty, 41.3% underwent ring annuloplasty, 15.4% received a bioprosthesis, and 10.4% received a mechanical prosthesis. There were no significant differences in perioperative mortality between the group that had not undergone previous cardiac surgery and the group that had (12.7% vs. 17.9%, respectively; p = 0.32). The long-term mortality rate (median follow-up time: 53 months) was 43.3%. Long-term survival curves showed no significant differences between the two groups (p = 0.884), and previous cardiac surgery was not a predictive factor for long-term mortality (hazard ratio = 1.211; p = 0.521). CONCLUSION In a series of patients who underwent tricuspid valve surgery, no significant differences were observed in perioperative mortality or in long-term survival according to whether or not subjects had undergone previous cardiac surgery.
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15
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Kawada N, Naganuma H, Muramatsu K, Ishibashi-Ueda H, Bando K, Hashimoto K. Redefinition of tricuspid valve structures for successful ring annuloplasty. J Thorac Cardiovasc Surg 2018; 155:1511-1519.e1. [DOI: 10.1016/j.jtcvs.2017.12.045] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 11/20/2017] [Accepted: 12/11/2017] [Indexed: 11/27/2022]
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16
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Shim H, Hwang JW, Jeong DS, Sung K, Kim WS, Park PW. Serial Changes of Transmitral and Transtricuspid Pressure Gradients After Simultaneous Mitral and Tricuspid Ring Annuloplasty. Heart Lung Circ 2018; 28:647-654. [PMID: 29588110 DOI: 10.1016/j.hlc.2018.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/30/2017] [Accepted: 03/04/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although flexible-ring annuloplasty is more inclined to increase the transmitral gradient over time, its effect on the tricuspid annulus is unknown. This study was conducted to evaluate serial changes in mean pressure gradient (mPG) across tricuspid and mitral valves after simultaneous dual implantation of flexible bands. METHODS Seventy-one (71) patients (median age, 61.6 years; IQR: 50.8-69.0 years) underwent simultaneous mitral/tricuspid annuloplasties using St. Jude Tailor rings. Serial mPGs across mitral and tricuspid valves were evaluated at three postoperative time points: predischarge, 3 years, and 5 years. To gauge the effects and clinical outcomes of prophylactic intervention, patients were categorised as tricuspid regurgitation (TR)≥moderate or TR<moderate. The median follow-up period was 125 months (IQR: 109-137 months). RESULTS Unlike transmitral mPG, which increased over time (predischarge, 2.94; 3 years, 3.61; 5 years, 3.87; p<0.0005), transtricuspid mPG did not change (predischarge, 1.65; 3 years, 1.69; 5 years, 1.69; p=0.906). Preoperative TR grade had no impact on serial changes in transtricuspid mPG (TR≥moderate, p=0.542; TR<moderate, p=0.608). Three observed late recurrences of TR≥moderate degree displayed TR≥moderate at baseline, and overall mortality was higher in the TR≥moderate group (p=0.01). CONCLUSIONS Flexible-band annuloplasty did not promote stenosis of tricuspid valves at mid-term follow-up. These findings confirm the safety of prophylactic tricuspid annuloplasty (via flexible band) as an adjunct to mitral annuloplasty.
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Affiliation(s)
- Hunbo Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Won Hwang
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Seop Jeong
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wook Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Pyo Won Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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17
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Mid-term results of three dimensional annuloplasty ring repair in treating functional tricuspid valve regurgitation. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.jescts.2017.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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18
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Riki-Marishani M, Gholoobi A, Sazegar G, Aazami MH, Hedjazi A, Sajjadian M, Ebrahimi M, Aghaii-Zade Torabi A. Effects of a 3D segmental prosthetic system for tricuspid valve annulus remodelling on the right coronary artery: a human cadaveric coronary angiography study. Interact Cardiovasc Thorac Surg 2017; 25:350-355. [PMID: 28510720 DOI: 10.1093/icvts/ivx102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/07/2017] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES A prosthetic system to repair secondary tricuspid valve regurgitation was developed. The conceptual engineering of the current device is based on 3D segmental remodelling of the tricuspid valve annulus in lieu of reductive annuloplasty. This study was designed to investigate the operational safety of the current prosthetic system with regard to the anatomical integrity of the right coronary artery (RCA) in fresh cadaveric human hearts. METHODS During the study period, from January to April 2016, the current prosthetic system was implanted on the tricuspid valve annulus in fresh cadaveric human hearts that met the study's inclusion criteria. The prepared specimens were investigated via selective coronary angiography of the RCA in the catheterization laboratory. The RCA angiographic anatomies were categorized as normal, distorted, kinked or occluded. RESULTS Sixteen specimens underwent implantation of the current prosthetic system. The mean age of the cadaveric human hearts was 43.24 ± 15.79 years, with vehicle accident being the primary cause of death (59%). A dominant RCA was noticed in 62.5% of the specimens. None of the specimens displayed any injury, distortion, kinking or occlusion in the RCA due to the implantation of the prostheses. CONCLUSIONS In light of the results of the present study, undertaken on fresh cadaveric human heart specimens, the current segmental prosthetic system for 3D remodelling of the tricuspid valve annulus seems to be safe vis-à-vis the anatomical integrity of the RCA. Further in vivo studies are needed to investigate the functional features of the current prosthetic system with a view to addressing the complex pathophysiology of secondary tricuspid valve regurgitation.
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Affiliation(s)
- Mohsen Riki-Marishani
- Department of Cell Biology and Anatomy, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Arash Gholoobi
- Department of Cardiology, School of Medicine, Mashhad University of Medical Sciences, Imam Reza University Hospital, Mashhad, Iran
| | - Ghasem Sazegar
- Department of Cell Biology and Anatomy, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mathias H Aazami
- Department of Cardiology, School of Medicine, Mashhad University of Medical Sciences, Imam Reza University Hospital, Mashhad, Iran.,Cardiac Surgery and cardiology Departments, Javad Al-Aemeh Heart Hospital, Mashhad, Iran.,Cardiac Anesthesia Research Center, Mashhad University of Medical Sciences, Imam Reza University Hospital, Mashhad, Iran
| | - Aria Hedjazi
- Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
| | - Maryam Sajjadian
- Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
| | - Mahmoud Ebrahimi
- Department of Cardiology, School of Medicine, Mashhad University of Medical Sciences, Imam Reza University Hospital, Mashhad, Iran.,Cardiac Surgery and cardiology Departments, Javad Al-Aemeh Heart Hospital, Mashhad, Iran
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19
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Wang N, Phan S, Tian DH, Yan TD, Phan K. Flexible band versus rigid ring annuloplasty for tricuspid regurgitation: a systematic review and meta-analysis. Ann Cardiothorac Surg 2017; 6:194-203. [PMID: 28706862 DOI: 10.21037/acs.2017.05.05] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Up to 20% of patients have pre-discharge residual moderate to severe tricuspid regurgitation (TR) after tricuspid repair. Reoperations for recurrent TR carry high mortality rates, which emphasizes the importance of identifying the optimal technique for the surgical management of TR. The present study is a systematic review and meta-analysis that aims to compare short and long term survival and freedom from TR of flexible band ring versus rigid ring for annuloplasty of TR. METHODS We conducted a systematic review and meta-analysis of comparative studies to evaluate these procedures. A systematic search of the literature was performed from six electronic databases. Pooled meta-analysis was conducted using odds ratio (OR) and weighted mean difference (WMD). RESULTS The rates of in-hospital mortality were not different between the two groups, with cumulative rates of 6.9% for flexible band and 7.3% for rigid ring (OR: 0.92; 95% CI: 0.49-1.71). Rates of stroke were also similar with 1.7% of flexible band and 1.3% of rigid rings suffering a perioperative stroke (OR: 1.29; 95% CI: 0.74-2.23). Rigid ring had significantly better freedom from grade ≥2 TR at 5 years (OR: 0.44; 95% CI: 0.20-0.99) and overall (P=0.005). There was no significant difference in overall rates of reoperation (P=0.232) and survival (P=0.086) between flexible band and rigid ring. CONCLUSIONS Both rigid ring and flexible band offer acceptable outcomes for the treatment of TR. Compared to flexible band, rates of TR are stable after rigid ring annuloplasty and long term freedom from TR are superior for rigid ring devices. Large prospective randomized trials are required in order to validate these findings and assess for improvements in patient survival.
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Affiliation(s)
- Nelson Wang
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Steven Phan
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - David H Tian
- Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
| | - Tristan D Yan
- Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Kevin Phan
- Sydney Medical School, University of Sydney, Sydney, Australia.,Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
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20
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Ito H, Mizumoto T, Sawada Y, Fujinaga K, Tempaku H, Shimpo H. Determinants of recurrent tricuspid regurgitation following tricuspid valve annuloplasty during mitral valve surgery. J Card Surg 2017; 32:237-244. [DOI: 10.1111/jocs.13117] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Hisato Ito
- Department of Cardiothoracic Surgery; Anjo Kosei Hospital; Anjo City Aichi Japan
| | - Toru Mizumoto
- Department of Cardiothoracic Surgery; Anjo Kosei Hospital; Anjo City Aichi Japan
| | - Yasuhiro Sawada
- Department of Cardiothoracic Surgery; Anjo Kosei Hospital; Anjo City Aichi Japan
| | - Kazuya Fujinaga
- Department of Cardiothoracic Surgery; Anjo Kosei Hospital; Anjo City Aichi Japan
| | - Hironori Tempaku
- Department of Cardiothoracic Surgery; Anjo Kosei Hospital; Anjo City Aichi Japan
| | - Hideto Shimpo
- Department of Thoracic and Cardiovascular Surgery; Mie University; Tsu Mie Japan
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21
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Tourmousoglou C, Pitsis A, Nikoloudakis N, Dougenis D. eComment. Is flexible band or rigid ring the best choice for functional tricuspid regurgitation? Interact Cardiovasc Thorac Surg 2016; 23:88-9. [PMID: 27325654 DOI: 10.1093/icvts/ivw165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Antonis Pitsis
- St. Luke's Cardiac Surgery Institute, Thessaloniki, Greece
| | | | - Dimitrios Dougenis
- Department of Cardiothoracic Surgery, University Hospital of Patra, Patra, Greece
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22
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Gatti G. eReply to eComment: Is flexible band or rigid ring the best choice for functional tricuspid regurgitation? Interact Cardiovasc Thorac Surg 2016; 23:89. [PMID: 27325655 DOI: 10.1093/icvts/ivw183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Giuseppe Gatti
- Department of Cardio-Vascular Surgery, Ospedali Riuniti and University of Trieste, Trieste, Italy
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