Long-term results of tricuspid valve replacement in 608 patients: A propensity score matching analysis / 中国胸心血管外科临床杂志

@#Objective     To explore the evolving strategies and compare perioperative and long-term outcomes of tricuspid valve replacement (TVR) in recent 20 years in our hospital. Methods    Between 1998 and 2018, the clinical data of 608 patients who underwent TVR at the Department of Cardiac Surgery, Guangdong Provincial People’s Hospital were retrospectively analyzed. There were 201 males and 407 females, with a median age of 47.0 (36.0, 57.0) years. Patients were divided into a biological tricuspid valve (BTV, n=427) group and a mechanical tricuspid valve (MTV, n=181) group. Propensity score matching was used to balance the baseline difference. Surgical strategy evolving, postoperative and long-term outcomes were analyzed between the two groups. Results    Since 2008, the usage ratio of biological valves was significantly higher than that of mechanical valves. Seventy-nine (13.0%) patients died in hospital after TVR. Before propensity score matching, the postoperative mortality of the BTV group was higher than that of the MTV group (15.2% vs. 7.7%, P=0.012), and there was no statistical difference between the two groups after matching (10.4% vs. 7.2%, P=0.372). The duration of postoperative ventilator support in the BTV group was longer than that in the MTV group [22.0 (15.0, 37.0) h vs. 19.0 (11.0, 27.0) h, P=0.003], and the incidence of postoperative dialysis and re-thoracotomy exploring for bleeding was higher in the BTV group (8.9 % vs. 2.8%, 9.4% vs. 6.6%, respectively). However, there was no statistical difference in mortality after matching. The median follow-up time of discharged patients was 101.0 (65.0, 147.0) months, ranged from 1 to 265 months, and the follow-up rate was 82.2%. During the follow-up period, there were 101 deaths (19.1%) of whom 68 were from the BTV group and 33 from the MTV group. The survival rates at 1 year, 5 years, 10 years, 15 years and 20 years of all patients were 85.0% (95%CI 82.2-87.9), 78.9% (95%CI 75.7-82.4), 71.1% (95%CI 67.3-75.3), 59.7% (95%CI 54.2-65.6) and 51.7% (95%CI 43.3-60.7), and there was no statistical difference between the two groups after matching (P=0.46). The median time of tricuspid valve failure was 84.0 (54.0-111.0) months. Conclusion    TVR is associated with high perioperative risks. There is no statistical difference in early mortality and long-term survival between biological and mechanical valve, while patients with mechanical valve has higher risk of re-operation for valve failure. Therefore, the type of prosthetic valve can be selected according to the patients' age, physical condition and the doctors’ experience.

Anesthetic management for patient with severe cyanosis following bioprosthetic valve stenosis / Manejo anestésico de paciente com cianose grave após estenose de valva bioprotética

Abstract We presented a 39-year-old female patient with life-threatening hypoxemia after tricuspid valve replacement because of Ebstein's anomaly. And the severe cyanosis is due to bioprosthetic valve stenosis and atrial septal defect. Anesthetic management of a patient with severe obstructive prosthetic valve dysfunction can be challenging. Similar considerations should be given to patients with Ebstein's anomaly to maintain the pressure equalized between the right and left atrial. Transesophageal echocardiography and cerebral oxygen saturation provided real time information in perioperative care.

Resumo Apresentamos o caso de uma paciente de 39 anos, com hipoxemia em risco de vida após a substituição da valva tricúspide devido à anomalia de Ebstein e cianose grave devido à estenose de valva bioprotética e comunicação interatrial. O manejo anestésico de um paciente com disfunção obstrutiva grave de prótese valvar pode ser um desafio. Os pacientes com anomalia de Ebstein também precisam de atenção especial para manter a pressão equalizada entre o átrio direito e o esquerdo. A ecocardiografia transesofágica e a saturação cerebral de oxigênio forneceram informações em tempo real nos cuidados perioperatórios.

Two Cases of Bioprosthetic Valve Stenosis of the Aortic Valve Position Found on Weaning of a Nipro Left Ventricular Assist Device / 日本心臓血管外科学会雑誌

The first case was a 67-year-old woman. She had been given a diagnosis of fulminant myocarditis and received a biventricular assist device as a bridge to recovery. A Nipro ventricular assist device (VAD) was implanted into her left heart. She was also found to have moderate aortic insufficiency before the operation, so she received aortic valve replacement (AVR) with a bioprosthetic valve (CEP Magna Ease 21 mm) at the same time. Her cardiac function recovered gradually. Therefore, a weaning operation was scheduled for three months after the VAD implantation. However, her left ventricle motion was very poor when she was taken off of the extracorporeal circulation after removing the VAD, and transesophageal echocardiography (TEE) revealed severe bioprosthetic valve stenosis. When her heart was stopped again and the bioprosthetic valve was observed, the leaflets of the bioprosthetic valve were fused. Commissural fusion of bioprosthetic valve was able to be released using forceps, and the punnus extending under the leaflet was removed. In this way, the function of the bioprosthetic valve was restored. Her cardiac motion became good, and removal from extracorporeal circulation was easily achieved. She left the hospital 100 days after weaning from the VAD. The second case was a 68-year-old woman. She also had fulminant myocarditis. She underwent biventricular assist device implantation and AVR (CEP Magna Ease 19 mm). Her cardiac function recovered, and a weaning operation was scheduled on the 73rd-postoperative day. Preoperative TEE before the weaning of VAD showed severe bioprosthetic valve stenosis. The commissural fusion of the bioprosthetic valve was released and the punnus extending under the leaflet removed at the same time as the VAD was removed. Re-valve replacement was not required. We should therefore consider the possibility of bioprosthetic valve stenosis when VAD implantation and AVR with a bioprosthetic valve are performed at the same time in patients with an extremely reduced cardiac function.

Clinical analysis on tricuspid valve replacement for secondary tricuspid regurgitation late after left-sided valve surgery / 上海交通大学学报（医学版）

Objective·To analyse the outcomes of tricuspid valve replacement (TVR) for secondary tricuspid regurgitation (STR) late after left-sided valve surgery during perioperative period and mid-term follow-up,investigate mechanisms of STR and surgical risk factors.Methods·A total of 85 consecutive patients who underwent the TVR surgery were analyzed.The perioperative and mid-term clinical outcomes were retrospectively investigated.The data were divided into bioprosthesis group (n=50) and mechanical prosthesis group (n=35) according to the prosthesis used,and divided into right anterolateral thoracotomy(RALT) group (n=51) and stemotomy(S) group (n=34) according to the surgical incision.Results·In-hospital mortality was 8.2％ (7/85).There was no significant difference in the mortality with different choice of bioprosthetic or mechanical valve (4/50 vs 3/35,x2=0.009,P=1.000);while there was significant difference between S group and RALT group (6/34 vs 1/51,x2=6.642,P=0.015).Seven cases all died of right heart failure and severe low cardiac output syndrome.Five (5.9％) cases died in perioperative within 30 in-hospital days and 2 (2.4％) cases died after 30 in-hospital days.Seventy-four cases were followed up.With the follow-up of (31.5±23.1) months,there were 4 case of late deaths(5.4％),all of whom were mechanical prosthesis,of whom 3 died in cardiac related death and 1 died in later period bowel cancer.Seventy cases survived in New York Heart Association (NYHA) class Ⅰ-Ⅱ with no coagulated accident and redo-TVR.Conclusion·The perioperative and mid-term clinical outcomes are satisfied in timely and reasonable TVR with the standard follow-up for STR late after left-sided valve surgery.Right anterolateral incision is recommend for isolated TVR.

Preliminary study on the relationship between heart rate and failure of biological valve / 中华胸心血管外科杂志

Objective To study the relationship between heart rate and failure of biological valve,and whether reduce the heart rate could delay the failure of biological valve.Methods Retrospective analysis of 92 bioprosthetic valve replacement cases in our institution from April 1996 to March 2001.The follow-up was carried out through the outpatient service,telephone and letter.The patients were divided into two groups based on the heart rate:Group A:basic heart rate no more than 75 beats per minute;Group B:basic heart rate greater than 75 beats per minute.Blood pressure,heart function,echocardiogram and reoperation rate was collected.Results In group A,the average follow-up time and the longest follow-up time was better than the patients in group B but has no significant difference.Echocardiographic data showed that the proportion of valve leaflets stiffness and calcification in group A was significantly lower than group B(7.7％ vs.17.9％,P ＜0.05).Redo operation rate in group A was lower than those in group B (7.7％ vs.22.6％,P ＜ 0.05).There were only 1 case(1.5 ％) suffering from the tearing in all three valve leaflets in group A while it was 8 cases(8.7％) in group B (2.6％ vs.15.1％,P ＜ 0.05).Conclusion Basic heart rate has a significant effect on the failure of the mitral bioprosthesis.To decrease the basic heart rate can delay the failure of the mitral bioprosthesis and improve the durability.

Tricuspid Valve Replacement in an Adult with Destroyed Tricuspid Valve and Refractory Right Heart Failure.

22 year old woman with no previous heart disease history, presented with progressive worsening of right heart failure symptoms due to severe tricuspid valve regurgitation which had become refractory to medical management. Echocardiogram revealed probable rare case of dysplastic tricuspid valve with large calcified mobile masses attached to leaflets. Calcified masses were thought to be due to healed vegetations from silent infective endocarditis of abnormal tricuspid valve which she had suffered in the past. There were no known acquired causes of tricuspid valve endocarditis. She had successfully undergone tricuspid valve replacement with bio-prosthetic valve along with a right atrial reduction surgery after which her heart failure symptoms improved markedly.

Reoperation in Two Patients with SJM Toronto SPV and Medtronic Freestyle Stentless Bioprosthetic Valves / 日本心臓血管外科学会雑誌

Stentless bioprosthetic valves have been implanted for treatment of aortic valve disease, especially in elderly patients ; these valves have the advantage of durability and excellent hemodynamics compared with stented bioprosthetic valves. Although good long-term results in patients with stentless bioprosthetic valves have been reported recently, reoperation has been gradually increasing. We performed reoperation for the SJM Toronto SPV and Medtronic Freestyle valves in one patient each. The SJM Toronto SPV was used in a 30-year-old woman ; however, 8 years later, the valve showed severe calcification and adhesions, and could not be completely removed (Case 1). The other reoperation case, wherein a 69-year-old man underwent aortic valve replacement with the Medtronic Freestyle 4 years previously, showed no adhesion around the implanted valve, which could be easily removed from the autologous aortic annulus. Consequently, the first patient required reimplantation of a small mechanical valve (SJM #19). In contrast, we were able to use a stentless bioprosthetic valve (Prima Plus #23) for the second patient. Further observations on stentless bioprosthetic valves are required.

Intravalvular regurgitation of the mitral bioprosthetic valve detected by intraoperative transesophageal echocardiography : A case report / 대한마취과학회지

Intraoperative transesophageal echocardiography (IOTEE) is an invaluable diagnostic method for management of cardiac surgical patients, including patients undergoing valve replacement surgery. We report a patient who underwent reoperation for mitral valve replacement due to intravalvular regurgitation following mitral valve replacement with a bioprosthetic valve. The condition was detected by IOTEE and caused by suture entrapment.

A case of bioprosthetic valve endocarditis by corynebacterium in hemodyalysis patients / 대한내과학회지

There has been a number of reports recently describing the pathogen potential of irregular asporogenous gram positive rods (IGPR), also referred as coryneforms or diphtheroids. This may be due to a greater number of opportunistic infections occurring in patients who are immunosuppressed or implanted with prostheses. The documentation of endocarditis caused by IGPR is difficult. Because all the result of culture is not always positive and these cultures need long-period incubation, and there are sometimes pseudo-positive cases due to the contamination in blood sampling. An early diagnosis and adequate treatment are important for the better result. We describe the case of bio prosthetic valve endocarditis in a 61-year-old woman who enduring chronic hemodialysis. This is the first case reported of bioprosthetic valve endocarditis by Corynebacterium in Korea.