Long-Term Outcomes of Tricuspid Valve Surgery in Patients With Congenitally Corrected Transposition of the Great Arteries

Replacement of the systemic tricuspid valve in a patient with corrected transposition of the great arteries, ventricular septal defect, and Eisenmenger syndrome

This case report presents a 56-year-old female patient with Eisenmenger syndrome. The diagnosis of corrected transposition of the great arteries with ventricular septal defect (VSD) was established in 1994. Worsening of condition occurred in 2015 and was related to the severe regurgitation on the systemic morphologically tricuspid valve. The main complaints at admission to the Bakoulev Scientific Center for Cardiovascular Surgery in 2017 included fatigue and dyspnea at rest or minimal exercise. The patient was on disability and receiving diuretics. Her condition was considered New York Heart Association (NYHA) class IV. The systemic tricuspid valve demonstrated dilated fibrous annulus as well as thickened and prolapsed leaflets with regurgitation of 3-4 degree. Since regurgitation on the systemic tricuspid valve was considered the main cause of heart failure in the patient with Eisenmenger syndrome, the valve was replaced with the CarboMedics 28-mm mechanical prosthesis, with the VSD left intact. The postoperative period was uneventful. Five and half years after surgery, the patient was in NYHA class II on a specific pulmonary arterial hypertension therapy with no signs of heart failure. The function of the mechanical valve was adequate. Thus, the replacement of the systemic tricuspid valve helped eliminate heart failure and achieve compensation on a specific pulmonary arterial hypertension therapy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-024-01802-w.

Long-term outcome of patients with transposition of the great arteries and a systemic right ventricle: A systematic review and meta-analysis

BACKGROUND

Patients with a transposition of the great arteries (TGA) and a systemic right ventricle are at risk of heart failure (HF) development, arrhythmia and early mortality. Prognostic evaluations in clinical studies are hampered by small sample sizes and single-centred approaches. We aimed to investigate yearly rate of outcome and factors affecting it.

METHODS

A systematic literature search of four electronic databases (PubMed, EMBASE, Web of Science and Scopus) was conducted from inception to June 2022. Studies reporting the association of a systemic right ventricle with mortality with a minimal follow-up of 2 years during adulthood were selected. Incidence of HF hospitalization and/or arrhythmia were captured as additional endpoints. For each outcome, a summary effect estimate was calculated.

RESULTS

From a total of 3891 identified records, 56 studies met the selection criteria. These studies described the follow-up (on average 7.27 years) of 5358 systemic right ventricle patients. The mortality incidence was 1.3 (1-1.7) per 100 patients/year. The incidence of HF hospitalization was 2.6 (1.9-3.7) per 100 patients/year. Predictors of poor outcome were a lower left ventricular (LV) and right ventricular ejection fraction (RVEF) (standardized mean differences (SMD) of -0.43 (-0.77 to -0.09) and - 0.85 (-1.35 to -0.35), respectively), higher plasma concentrations of NT-proBNP (SMD of 1.24 (0.49-1.99)), and NYHA class ≥2 (risk ratio of 2.17 (1.40-3.35)).

CONCLUSIONS

TGA patients with a systemic right ventricle have increased incidence of mortality and HF hospitalization. A lower LVEF and RVEF, higher levels of NT-proBNP and NYHA class ≥2 are associated with poor outcome.

Tricuspid valve replacement provides better long-term survival and tricuspid valve function than repair in patients with systemic right ventricle

Objective

The purpose of this study is to compare the long-term outcomes of 2 different tricuspid surgeries including valvuloplasty and replacement for significant tricuspid regurgitation in patients with systemic right ventricle.

Method

This is a retrospective study of 34 patients with dextro-transposition of the great arteries or levo-transposition of the great arteries with biventricular circulation and systemic right ventricle undergoing tricuspid valve surgery between April 1979 and April 2022. Patients were divided into 2 groups based on the procedure: tricuspid valvuloplasty (n = 11) and tricuspid valve replacement (n = 23). These groups were compared in terms of survival, tricuspid valve dysfunction, and tricuspid valve-related reoperation.

Results

There was no significant difference between the groups in operative age, body weight, the proportion of dextro-transposition of the great arteries, Ebstein-like tricuspid dysplasia, and preoperative right ventricular volume/function. During the median follow-up of 9.7 years, there was 1 early death (tricuspid valvuloplasty group) and 4 late deaths (3 in tricuspid valvuloplasty group and 1 in tricuspid valve replacement group). There were 7 tricuspid valve dysfunctions, including 6 significant tricuspid regurgitations in the tricuspid valvuloplasty group and 1 prosthetic valve dysfunction in the tricuspid valve replacement group, and 4 tricuspid valve-related reoperations (3 in the tricuspid valvuloplasty group and 1 in the tricuspid valve replacement group) were performed. There were significant differences between the groups in survival (tricuspid valvuloplasty vs tricuspid valve replacement: 72.7 vs 94.7% at 10 years after surgery, P = .0328) and cumulative incidence of tricuspid valve dysfunction at 10 years after tricuspid surgery (tricuspid valvuloplasty vs tricuspid valve replacement: 27.3% vs 0%, P = .0121).

Conclusions

Tricuspid valve replacement provided better long-term survival and tricuspid function in patients with systemic right ventricle compared with tricuspid valvuloplasty.

Management Options for Congenitally Corrected Transposition: Which, When, and for Whom?

Management strategies for congenitally corrected transposition of the great arteries (ccTGA) historically consisted of a physiologic repair, resulting in the morphologic right ventricle (mRV) supporting systemic circulation. This strategy persisted despite the development of heart failure by middle age because of the reasonable short-term outcomes, and the natural history of some patients with favorable anatomy (felt to demonstrate the mRV's ability to function in the long-term), and due to the less-than-optimal outcomes associated with anatomical repair. As outcomes with anatomical repair improved, and the long-term risk of systemic mRV dysfunction became apparent, more have begun to realize its advantages. In addition to the decision on whether or not to pursue anatomical repair, and the optimal timing, studies demonstrating the nuance to morphologic left ventricle retraining have demonstrated its feasibility. Further considerations in ccTGA have begun to be better understood, including: the management of a poorly functioning mRV, systemic tricuspid valve regurgitation, the utility of morphologic left ventricle outflow tract obstruction (native or surgically created) and pacing strategies. While some considerations are apparent: biventricular pacing is superior to univentricular, tricuspid regurgitation must be managed early with either progression towards anatomical repair (pulmonary artery banding if needed for retraining) or tricuspid replacement (not repair) based on the patient's age; others remain to be completely elucidated. Overall, the heterogeneity of ccTGA, as well as the unique presentation with each patient regarding ventricular and valvular function and center-to-center variability in management strategies has made the interpretation of published data difficult. That said, more recent long-term outcomes favor anatomical repair in most situations.

Impact of pregnancy on natural history of systemic right ventricle in women with transposition of the great arteries

In the recent years, the pregnancy trend among women with Congenital Heart Disease (CHD) has increased; this has leaded to a growing demand for specialized care both in mother and in children. Although pregnancy is often well tolerated, maternal CHD may affect in some cases a maladaptive hemodynamic response carrying additional risks of cardiovascular events like arrhythmias, heart failure and, in rare cases, death. The impaired utero-placental perfusion due to maternal cardiac status may result in placental dysfunction, which may be associated with fetal growth restriction, preeclampsia, premature birth and perinatal morbidity. Systemic Right Ventricle (SRV) is one of the main conditions under which pregnancy is challenging. The sub-aortic position of morphological Right Ventricle (RV) is "physiologically" predisposed to fail at the adult age and may be potentially inadequate to support the hemodynamic stress of the pregnancy. Current literature about pregnancy in women with SRV consists of small retrospective series not providing conclusive evidence about the feasibility of a successful pregnancy outcomes. In addition, the long-term effects of pregnancy on SVR are not still adequately investigated and it remains unclear if maternal complications reported are due to pregnancy or to natural history of SVR. The aim of this paper is to offer a critical review of the knowledges at regard and to provide a practice update on the risk assessment and the pregnancy management in women with SRV in order to support the decision making and to optimize outcomes in these patients.

Percutaneous edge-to-edge repair in congenital heart disease: Preliminary results of a promising new technique

Percutaneous edge-to-edge repair has become a valid technique for symptomatic mitral and tricuspid regurgitation in patients with acquired cardiopathies deemed ineligible for surgery. In congenital heart disease (CHD) and more specifically in systemic right ventricle atrioventricular valve regurgitation, it has a pivotal role in the disease course, functional prognosis, systemic ventricular function, and mortality. While medical therapy is not unequivocally effective, surgery (valve repair or replacement) involves discrepant long-term results that depend mainly on pre-operative systemic ventricular function; it can be too risky for patients who have undergone previous open-heart surgery and have other comorbidities. Many case reports of patients with CHD and atrioventricular regurgitation repaired percutaneously have been published. This technique seems safe and yields short-term clinical and hemodynamic improvements. The specifics of each patient's complex anatomy must be considered carefully pre-operatively, and more research is needed to assess the long-term outcomes and precise eligibility criteria.