Georges Primo

Tricuspid valve replacement: Postoperative and long-term results ☆ ☆☆ ★

A series of 146 consecutive patients who underwent tricuspid valve replacement at the University Brugmann Hospital between 1967 and 1987 was reviewed. Mean age at operation was 51.4 years (+/- 12.1 years). Different types of prostheses were implanted including porcine and bovine pericardial bioprostheses and older and bileaflet mechanical valves. Most patients were severely disabled by their cardiac disease before operation, with 30.1% in New York Heart Association functional class III and 69.9% in class IV. Operative mortality and hospital mortality rates (30 days) were high (16.4%). Incremental risk factors for hospital death included icterus (p < 0.005), preoperative hepatomegaly (p = 0.012), and New York Heart Association functional class IV (p = 0.013). Multivariate analysis only selected preoperative icterus (p < 0.01) as being independently significantly related to hospital mortality. The hospital survivors were followed up for a median of 94 months. A complete follow-up was available for all patients except two for 30 months or more. At 30 months the only two significant parameters were the type of myocardial protection (p = 0.024) and the year of operation (before 1977 or after [precardioplegia era or after], p = 0.011). There were 70 late deaths during the entire follow-up period. The univariate (log-rank statistics) incremental risk factor for late death was the type of tricuspid prosthesis (Smeloff-Cutter and Kay-Shiley versus St. Jude Medical versus bioprosthesis) (p = 0.04). A trend was observed for the type of operative myocardial protection (normothermia and coronary perfusion) (p = 0.06) and preoperative New York Heart Association functional class IV (p = 0.055). Actuarial survival was 74% at 60 months and 23.4% at 180 months. Cumulative follow-up added up to 1015 patient-years. In a more detailed analysis of the effect on survival of the type of tricuspid prosthesis, a significant difference was observed between the bioprostheses and some older mechanical prostheses (Smeloff-Cutter and Kay-Shiley) (p = 0.04) but not between the bioprostheses and the bileaflet valves (p = 0.15). When the follow-up period was stratified according to less than 7 years and more than 7 years of follow-up, no difference was observed for the first period, but for the late follow-up the new mechanical prostheses did better than the bioprostheses (p = 0.05), suggesting a degradation of the bioprostheses after 7 years and favoring mechanical prostheses for those patients with a good long-term prognosis.

Reappearance of a normal circadian rhythm of blood pressure after cardiac transplantation.

Twenty-four-hour blood pressure (BP) and heart rate profiles were recorded in 19 patients 1 and 7 months after cardiac transplantation using noninvasive ambulatory monitors and were analyzed using the periodogram method. These recordings were compared with those of control subjects matched for age, sex and daytime ambulatory BP. One month after transplantation, the nighttime decrease in systolic and diastolic BPs were attenuated in the patients as compared to the control subjects (p less than 0.001). The daily oral dose of prednisolone was inversely correlated with the magnitude of the nighttime decreases in systolic and diastolic BPs (r = -0.47 and -0.53, p less than 0.05). In contrast, 7 months after transplantation, the nighttime decrease in systolic and diastolic BPs reappeared in the patients and was of similar magnitude as that in the control subjects. When the immunosuppressive regimens during the 2 periods of recordings were compared, the reduction in the daily oral dose of prednisolone administered to the patients 7 months after transplantation was correlated with the observed increase in the day-night systolic and diastolic BP difference (r = 0.61, p less than 0.01 and r = 0.51, p less than 0.05). Thus, data show the reappearance of normal circadian BP profiles in patients with long-term heart transplants, and suggest that glucocorticoid administration may contribute to the abnormal nocturnal BP profiles observed 1 month after transplantation.

The valve choice in tricuspid valve replacement: 25 years of experience

This study reviews 146 consecutive patients who underwent tricuspid valve replacement (TVR) with 69 bioprostheses (porcine and bovine pericardial) and 77 mechanical ball, disc or bileaflet valves between 1967 and 1987. The mean age was 51.4 +/- 12.1 years. Preoperatively, 97% were in New York Heart Association (NYHA) functional class III or more and over 40% had undergone previous cardiac surgery. Hospital mortality was high (16.1%). Incremental risk factors for hospital death were preoperative icterus (P < 0.01), hepatomegaly (P = 0.02), NYHA functional class IV (P = 0.02) and male sex (P = 0.04) (univariate analysis). Ninety-eight percent of the hospital survivors were followed up for a mean of 92 months. Cumulative follow-up added up to 955 patient-years. There were 70 late deaths. The actuarial survival rate was 74% at 60 months and less than 25% at 14 years. Incremental risk factors for late death indicated by univariate analysis were the type of tricuspid prosthesis (Smel-off-Cutter and Kay-Shiley prostheses) (P = 0.04), the type of operative myocardial protection (normothermia and coronary perfusion) (P = 0.05) and preoperative NYHA functional class IV (P = 0.05). We conclude that TVR carries a high operative risk and poor long-term survival, both influenced by preoperative and perioperative variables. Bearing in mind the poor prognosis for TVR, we prefer a large-sized bioprosthesis, in view of its initial good durability and low risk of valve-related events. However, in patients with good life expectancy, a bileaflet mechanical prosthesis may be an acceptable alternative.

Normally and abnormally functioning left-sided porcine bioprosthetic valves after long-term implantation in patients: Distinct spectra of histologic and histochemical changes

This morphologic study (X-ray examination of gross specimens, histologic study and histochemical staining) compares two groups of explanted left-sided bioprosthetic valves: group I, 6 valves with normal cusp function and group II, 10 valves with significant dysfunction. Implantation periods ranged from 26 to 79 months. A computerized descriptive statistical method (principal component analysis) is used to analyze the qualitative results. Although qualitatively identical alterations are observed in both groups, the findings in the deep layers of the cusps of severe collagen breakdown, intensive fibrin penetration and various degrees of calcification are restricted to group II. Other findings of interest in both groups include amyloid deposits (four cases) and layering of fusiform host cells on the cusp surface (three cases). The computerized study shows that individuals of one clinical group are morphologically different from those of the other. Mechanical stress may contribute to surface alterations early after implantation, while further collagen breakdown and macrophagic activity result in deep penetration of plasma components and fibrin. Subsequent calcification is likely to be dystrophic rather than metabolic. Colonization of the cuspal surface by endothelial cells after long-term implantation of bioprosthetic valves expresses a new type of relation between host and bioprosthesis.

Tricuspid Valve Replacement—A Comparative Experience with Different Valve Substitutes

The need for tricuspid valve surgery remains a difficult problem for the cardiac surgeon. Conservative repair is always preferable in the treatment of tricuspid valve disease, but tricuspid valve replacement (TVR) is a necessity in some cases.

Traumatic Rupture of the Ascending Aorta: A Case Report

A patient with a rupture of the ascending aorta after a non-penetrating chest trauma is presented. The aortic tear, angiographically demonstrated, was situated just above the left coronary ostium. Only three examples of angiographically established cases of rupture of the ascending aorta were found in the literature. The point that the distal tip of the catheter should be placed proximally in the ascending aorta, is emphasized. After operation the patient went well.

A 60-Month Experience with the ST. JUDE MEDICAL ® Prosthesis at University Hospital, Brugmann

The success of heart valve replacement depends on several conditions. Refinements in patient selection, in surgical technique, in the availability of valve substitutes and in postoperative care have markedly reduced operative mortality.

Performance of Four Different Types of Mechanical and Two Bioprosthetic Valves in the Tricuspid Position

Experience with tricuspid valve replacement (TVR) was reviewed in 145 patients, operated on from June 1967 until December 1981 (28 single VR, 101 double VR, 21 triple VR). Eighty-five mechanical valves(15 KAY-SHILEY®, 23 BJORK-SHILEY®, 31 SMELOFF-CUTTER®, and 16 ST. JUDE MEDICAL®) and 65 bioprostheses (29 HANCOCK®, 36 CARPENTIER-EDWARDS® porcine) were implanted. Overall early mortality was 16.6% and late mortality 7.5% per patient-year. Minimum follow-up was 5.5 years; maximum 16 years. In the mechanical valve group, valve thrombosis occurred in 6 patients at 18-months postimplantation and was fatal in 5 cases. Late p annus formation occurred in 9 patients at 90-months postimplantation and was fatal in 5. Reoperation was performed in 7 patients receiving mechanical valves and was fatal in 2. The bioprosthesis group (implantation between 1975 and 1980) was free from thrombotic complications, except in 1 patient who had a reoperation for mitral valve replacement (MVR) and acute thrombosis of the tricuspid bioprosthesis, treated successfully by thrombectomy. Six other MVR/TVR patients needed MVR for primary valve dysfunction. One patient presented with tricuspid bioprosthetic valve degeneration with subsequent TVR. Following tricuspid valve replacement, actuarial survival is 60% at 9 years for bioprostheses and 75% at 6.5 years for ST. JUDE MEDICAL valves. Functional status is satisfactory. The actuarial probability of freedom of valve thrombosis is 96% for CARPENTIER-EDWARDS and 100% for HANCOCK at 8 and 9 years, respectively, and 92% for ST. JUDE MEDICAL valves at 6.5 years. We conclude that late survival is strongly influenced by the type of prosthesis used. The bioprosthesis performs best in the tricuspid position, and primary valve failure is of much lesser concern than in the mitral position. Of the mechanical substitutes used, only the ST. JUDE MEDICAL prosthesis has an adequate performance and a lower thrombosis occlusion rate at up to 6.5 years.

Myocardial Protection With Combined Selective Profound Hypothermia and Hyperkaliemic Cardioplegic Arrest In Aortic Valve Replacement

To analyse the results of combined profound myocardial hypothermia and cardioplegic hyperkalemic arrest for aortic valve replacement a series of 100 consecutive patients undergoing isolated or combined aortic valve replacement was reviewed. There was no operative or early postoperative mortality, only one patient presented with low cardiac output syndrome. Inotropic support was used in 8, vasodilator therapy in 4 and external pacing in 8 instances. Reoperation for bleeding occurred twice. Postpericardiotomy syndrome was present in 7 patients; requiring surgical drainage in 2. Conduc tion defects ( > 48 H) were present in 3 and supraventricular arrhythmias in 15 patients successfully treated with medical therapy in 5 and D.C. countershock in 10. The clinical results confirm that this simple myocardial protection technique provides an excellent myocardial preservation for all patients operated for sin gle or combined aortic valve replacement.