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De Vega annuloplasty versus Carpentier-Edward ring
annuloplasty for secondary tricuspid regurgitation
Mohamed Khairy MD*, Alaa Gafar MD*, Yousry El-Saied MD*, Yousy Shaheen MD*,
Ayman Gabal MD˚, Mahmoud Abd Raboh MD˚ and Aly Hasan MD".
*Department of cardiothoracic surgery, Benha Faculty of Meddicine, Benha University,˚Department of
cardiothoracic surgery, Zagazig Faculty of Meddicine, Zagazig University, "National Heart Institute in Cairo.
Abstract
BACKGROUND AND AIM OF THE STUDY: Residual or recurrent tricuspid regurgitation
(TR) has been reported after several types of surgical tricuspid repair. The development of late
TR is an important complication of left heart surgery. The results of De Vega annuloplasty were
compared with those obtained after Carpentier-Edwards ring (CE ring) annuloplasty in patients
with secondary TR.
METHODS: The study was carried out on 126 patients who underwent surgery for secondary
TR between January 1998 and November 2007. Eighty patients underwent De Vega
annuloplasty (group I), and 46 had a CE ring annuloplasty (group II). The groups were similar
with respect to associated cardiac lesions. No significant preoperative differences were observed
in NYHA functional class, TR grade, and pulmonary artery pressure between the two groups.
RESULTS: All patients were followed-up for an average of 43±17 (range, 1 to 96) months.
There were eight in-hospital and eighteen late deaths. Including operative deaths, actuarial
overall survival in group I at 5 years was 78.8% versus 80.5%, in group II (P =0.7654),and
tricuspid valve related mortality was (14.6%) in group I versus 0% in group II (P=0.000072).
Postoperative NYHA class I or II symptoms were present in 88.8% of group I versus 97.2% of
group II (P=0.134). Echocardiographic studies showed that TR was well controlled within grade
2+ in nearly 70% of group I versus 92% of group II (P=0.01). The improvement of TR was not
adversely affected by commonly recognized risk factors for tricuspid repair failure in group2
patients versus those in group I. The tricuspid valve reoperation-free survival rate at 5 years was
93.7% (4/63) in group I versus 0% in group II (P=0.01).
Conclusions: Placement of an annuloplasty ring during tricuspid valve repair is associated with
a decreased recurrence of TR, and with improved long-term survival and event-free survival. An
annuloplasty ring should therefore be used more routinely in tricuspid valve surgery.
Introduction
Ten percent to 50% of patients with severe mitral stenosis or mitral regurgitation (1) have
tricuspid regurgitation (TR), which is generally functional in nature. Uncorrected functional TR
after repair of left-sided valvular lesion has been reported to have an adverse effect on early and
late results (2). Thus, surgical management of moderate to severe functional TR is now widely
recommended to achieve better early and late clinical outcome (3). Functional TR secondary to
annular dilation may be repaired with or without an annuloplasty ring. Current literature on
recommendation of either repair technique remains controversial. The current study was
therefore undertaken to examine the outcomes of TV repair with or without an annuloplasty ring.
Patients and methods
From January 1998 to November 2007, a total of 126 consecutive patients with significant TR
and dilatation of the right-sided cardiac chambers due to mitral valve disease (on maximum
diuretic therapy) underwent tricuspid annuloplasty using a De Vega technique in 80 patients
(group I) and C-E ring in 46 patients (group II). There were 67 male patients and 59 female
patients whose ages ranged from 22 to 38 years (mean, 26.8 years). Seven patients (5.6%) were
in New York Heart Association (NYHA) functional class II, 75 (59.5%) in class III, and 44
(34.9%) in class IV. Two patients had had prior percutaneous mitral valvuloplasty. Right heart
dilatation and tricuspid disease were assessed preoperatively by means of two-dimensional
transthoracic and Doppler echocardiography. Preoperative right atrial maximum end-systolic
area index (right atrial maximum end-systolic area indexed by body surface area), measured by
reviewing recorded echocardiographic examinations, was >10 cm2·m-2 in all patients (range of
normal values 4.5–10.5) (4) with no correlation with the degree of TR. The severity of TR was
assessed in four grades based on the distance in the four-chamber view from the cardiac apex:
1+, less than 15 mm; 2+, 15 to 30 mm; 3+, 30 to 45 mm; 4+, over 45 mm. Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure more than 59 mm Hg and
diagnosis was made by Doppler echocardiography (5, 6, 7). The right ventricular shortening
fraction was measured by reviewing recorded echocardiographic examinations .The groups were
similar with respect to associated cardiac lesions. No significant preoperative differences were
observed in NYHA functional class, TR grade, and pulmonary artery pressure between the two
groups (Table I). On the basis of clinical and intraoperative data, tricuspid lesions were
considered functional in all patients (dilation of the valvular ring without valvular lesion). The
surgical technique of De Vega and C-E ring annuloplasty was performed as described in reviews
(8, 9). Postoperative echocardiography was done at hospital discharge and almost every 6
months after leaving the hospital.
2
Differences between the two groups were analyzed using SPSS windows (student t- test for mean
values where P is significant if value is ≤ 0.05 and Z- test for ratios where P is significant if
value is ≥ 1.96).
Table I: Preoperative Characteristics of the 126 Patients Who Underwent Tricuspid Valve
Repair.
Data
Age
NYHA class II
NYHA class III
NYHA class IV
TR 2+
TR 3+
TR 4+
Systolic
PAP>59mmHg
Right atrial
maximum endsystolic area/BSA.
Right ventricular
SF<35%
Left ventricular EF
Left ventricular
EF<50%
Atrial fibrillation
Jugular venous
distension
Hepatomegaly
Group I(n=80)
26±4
5(6.2%)
47(58.7%)
28(35%)
4(5%)
46(57.5)
30(37.5%)
51(63.7%)
Group II(n=46)
25±6
2(4.3%)
28(60.8%)
16(34.7%)
2(4.3%)
28(60.9%)
16(34.8%)
28(60.8%)
16.7±3.5
15.9±4.3
20(25%)
13(28.2%)
P Value
0.653
0.816
0.974
0.869
0.711
0.760
0.764
0.688
56±8
16(20%)
55±9
9(19.5%)
0.956
32(40%)
37(46.2%)
19(41.3%)
21(45.6%)
0.844
0.949
39(48.7%)
23(50%)
0.893
NYHA, New York Heart Association; TR, tricuspid regurgitation; PAP, pulmonary artery
pressure; BSA, body surface area , SF, shortening fraction, EF, ejection fraction.
Results
All patients were followed-up for an average of 43±17 (range, 1 to 96) months. Follow-up
durations were not different for the 2 groups (41±13 in group I, and 45±11 in group II).
3
Mortality and causes of death
Eight patients (6.3%) died within 30 days of operation (5 patients after De Vega and 3 patients
after C-E ring) (P-value=0.949). The causes of death were postoperative bleeding in two patients
and low cardiac output syndrome in six patients.
Among 118 surviving patients, 18 died during the late follow-up (15.2%), 12/75 patients (16%)
after De Vega and 6/43 patients (14%) after C-E ring (P-value=0.765). Death due to congestive
heart failure occurred only in group I in 11 patients. Two patients in group II died due to stuck
mitral valve prosthesis, and noncardiac related death occurred in 5 patients. Including operative
deaths, actuarial overall survival in group I at 5 years was 78.8% versus 80.5%, in group II (P
=0.7654),and tricuspid valve related mortality was 11/75(14.6%) in group I versus 0% in group
II (P=0.000072).
Follow-up clinical outcome
New York Heart Association (NYHA) class I or II symptoms were present in 56/63(88.8%) of
group I versus 36/37(97.2%) of group II (p=0.134).The evolution of TR was different across
time between the two groups. According to the most recent echocardiography in survivors, TR
was rated as grade 0-2+ in 44 patients (69.9%), grade3+ in11 patients(17.4%) and grade 4+ in
8(12.7%) patients after De Vega annuloplasty, but it was grade 0-2+ in 34 patients(91.9%) and
grade 3+ in 3 patients(8.1%) after C-E ring annuloplasty. In the 6 late death patients with C-E
ring, the regulation of TR was excellent during the follow-up period as well. In group I, 40 out of
63 survivors (63.4%) had pulmonary hypertension before operation, of them 18 (45%) remained
pulmonary hypertensive after operation, and those patients included 10 patients with TR grade
3+ and 8 patients with TR grade 4+. In group II, 23 out of 37 survivors(62.1%) had pulmonary
hypertension before operation, 10 patients of them (43.4%) remained pulmonary hypertensive
after operation, and those patients included 9 patients with TR grade 0-2+ and 1 patients with TR
grade 3+ Table 2. No other complications were recorded during follow-up, and atrioventricular
conduction defects were notably absent.
4
Table 2: Grades of TR after annuloplasty.
TR grade
Group I (n=63)
Group II (n=37)
P-value
0-2+
44(69.9%)
34(91.9%)
0.010
3+
11(17.4%)
3(8.1%)
0.193
4+
8(12.7%)
0
0.023
The improvement of TR was not adversely affected by commonly recognized risk factors for
tricuspid repair failure in group2 patients versus those in group I (Table 3, 4).
Table 3 Changes in the degree of TR after annuloplasty in the presence of commonly
recognized risk factors for tricuspid repair failure in group I.
Preoperative
Patients
Preoperative
Postoperative
P value
variables
N=63
TR
TR
Systolic
40 (63.4%)
44±10
40±9
0.0677
Permanent AF
19(30.1%)
38±8
35±9
0.7887
Left atrial
26(41.2%)
36±12
38±10
0.2254
12(19%)
36±10
34±10
0.409
13(20.6%)
48±12
46±10
0.2254
PAP>59mmHg
maximum endsystolic
dimension>60mm
Left ventricular
EF<50%
Right ventricular
SF<35%
Values are absolute number of cases with percentages in parentheses, or mean ± S.D.
5
Table 4 Changes in the degree of TR after annuloplasty in the presence of commonly
recognized risk factors for tricuspid repair failure in group II.
Preoperative
Patients
Preoperative
Postoperative
P value
variables
N=37
TR
TR
Systolic
23(62.1%)
48±8
14±6
0.00037
Permanent AF
10(27%)
42+/-10
16±8
0.0019
Left atrial
14(37.8%)
38±6
16±8
0.1126
6(16.2%)
44±8
14±10
0.00147
8(21.6%)
46±10
18±8
0.00169
PAP>59mmHg
maximum endsystolic
dimension>60mm
Left ventricular
EF<50%
Right ventricular
SF<35%
Values are absolute number of cases with percentages in parentheses, or mean ± S.D.
Reoperation of the tricuspid valve
In group I, late tricuspid valve reoperation was performed on 4 (6.3%) patients, of them 2
patients underwent isolated tricuspid reoperation (TR was +4),and the other 2 patients had
associated mitral valve reoperation due to moderate to severe paravalvular leak (TR was +3).
The procedures for tricuspid reoperations were tricuspid replacement by bioprosthesis in the two
patients with isolated tricuspid reoperation and re-De Vega annuloplasty in the other two
patients. In group II, no patient underwent tricuspid reoperation. The tricuspid valve reoperationfree survival rate at 5 years was 93.7% (4/63) in group I versus 0% in group II (P=0.01075).
6
Discussion
In patients with secondary TR concomitant with mitral valve disease, correcting the mitral valve
lesion without treating the TV may improve or even alleviate mild TR(10). However,
uncorrected moderate and severe TR may persist or even worsen after mitral valve surgery,
leading to progressive heart failure and death (11, 12) In addition; reoperation for residual TR
carries significant risks and may suggest a poor prognosis (13-15). It has therefore been
recommended that a more aggressive approach should be taken in cardiac surgery patients with
concomitant TR (11, 12, 16 ). Though fairly well agreed in principle, such an attitude hardly
takes any uniform conversion into practice, probably due to the uncertainty as to the degree of
TR that is significant enough to warrant correction. In addition, the potential for persisting TR is
easily underestimated once medical therapy is upgraded following a clinical episode of failure. A
single, semiquantitative ultrasonographic assessment of regurgitation severity, when the
extremes of severity are excluded, remains basic but probably insufficient information to this
end, as it is seriously affected by a number of clinical and hemodynamic variables such as the
circulating blood volume, pulmonary vascular resistances, right ventricular volume and
contractility, and venous tone (4). Perhaps, more weight should be given to historical clinical and
echocardiographic assessment of tricuspid incompetence, to the history and the severity of
symptoms of right heart failure, to the drugs and dosages necessary for their control, and to
objective, direct (17) or ultrasonographic (18) measurements such as the dimensions of the rightsided cardiac chambers and tricuspid annulus, and to descriptors of right ventricular function.
Still, tricuspid annular dimension, tricuspid valve tethering area, and right ventricular
eccentricity index are generally considered good ultrasonographic parameters to grade the
severity of functional tricuspid incompetence (15).
The optimal technique to repair the TV remains uncertain. Bicuspidalization (ie, plication of the
posterior leaflet) is now rarely performed even though reported outcomes have been reasonable,
7
especially for rheumatic patients (19).The De Vega suture annuloplasty technique involves
plication of the annulus surrounding the anterior and posterior leaflets and is the most commonly
used TV repair technique(7). A number of series have reported its short and long-term success
(20-22). However, other investigators have reported its a relatively high recurrence rate
particularly in patients with severe tricuspid annular dilation and/or pulmonary hypertension, so
it has been recommended that such patients should undergo TV repair with an annuloplasty ring
(15, 23). It has been shown that ring annuloplasty remodels the annulus, decreases tension on
suture lines, increases leaflet coaptation, and prevents recurrent annular dilatation, all reasons to
prefer prosthetic over simple suture annuloplasty in the presence of risk factors for tricuspid
repair failure, such as significant right heart dilatation and dysfunction (15, 23, 24).
We
therefore undertook the current study to compare results in patients undergoing TV repair with
and without an annuloplasty ring. Patients studied had moderate or severe TR associated with
mitral valve disease, though cases with mild TR were similarly treated in the presence of
significant dilatation of right heart chambers as shown from preoperative right atrial maximum
end-systolic area index when it was >10 cm2·m–2 .
Our results revealed that an annuloplasty ring confers significant improvements over the De
Vega repair as regards survival and recurrence of TR and this may be related to prevention of
annular dilation, right ventricular volume overload, and right ventricular failure, which was the
most common cause of late death in patients with De Vega repair. Regurgitation was well
controlled within grade 0-2+ in about 92% of survivors with ring annuloplasty. The actuarial rate
of freedom from tricuspid valve reoperation after 5 years was 100% for all patients with ring
annuloplasty versus 93.7% in patients with De Vega repair. This was in agreement with other
studies that showed that tricuspid valve repair by annuloplasty ring was associated with
improved survival and event-free survival (25, 26, 27).
A prospective randomized study of 159 patients conducted by Rivera et al comparing the De
Vega suture to Carpentier ring annuloplasty demonstrated a higher recurrence of moderate and
severe TR in the De Vega group at 45-month follow-up (Carpentier 4 of 40, De Vega 14 of 41;
P<0.01) (23). Similarly, in a study of 790 patients who underwent TV repair for secondary TR,
McCarthy et al; (16) reported an earlier recurrence and progressive increase of moderate and
8
severe TR after pericardial and De Vega suture repairs (P=0.002 and P=0.06, respectively,
compared with the Carpentier ring). A similar study in 45 patients by Matsuyama et al showed a
45% recurrence of 2+ to 3+ TR in De Vega compared with only 6% in the Carpentier repair
group (P=0.027). Freedom from moderate and severe TR at a mean follow-up of 39±23 months
was 45% in the De Vega group and 94% in the Carpentier group (28).
Theoretically, persistent pulmonary hypertension may have affected the non-ring repairs and
allowed the annulus to gradually redilate because right ventricular systolic pressure did not
importantly decrease during late follow-up. In our study 10 patients had residual PH, but there
were no patients with significant TR over follow-up period. Therefore, our findings suggest that
C-E ring tricuspid annuloplasty is an acceptable method for secondary TR, especially if there is
PH preoperatively. Several studies showed that C-E ring tricuspid annuloplasty demonstrated
excellent results in regulation of secondary TR, and control of TR even in cases with residual PH
and/or the deterioration of the residual disease of the mitral valve on a long-term basis (26, 2729).
Our results showed that tricuspid regurgitation significantly improved even in patients at higher
risk for tricuspid repair failure or with persisting left ventricular dysfunction. Gatti, et al; showed
also that improvement of TR was not adversely affected by commonly recognized risk factors for
tricuspid repair failure (4).
A problem for C-E ring annuloplasty is the loss of tricuspid annular contraction involved in right
ventricular function. To resolve the problem, a flexible ring was developed to preserve
physiologic annulus function. However, there have been no reports indicating a relationship
between right ventricular function and rigid or flexible rings in the tricuspid position. The effect
of prosthetic rings even in the mitral position on left ventricular function is still controversial, as
indicated in several reports (30, 31). It is more difficult to evaluate the effect of prosthetic rings
in the tricuspid position on right ventricular function because left-sided surgery and left heart
condition have a significant effect on right ventricular function. Unfortunately, we did not record
whether patients underwent a classic or modified De Vega repair (ie, with pledgets between
every suture) in the current study and are therefore unable to comment on this technique. It is
possible that the long-term results may be better in patients who underwent a modified De Vega
9
repair, because this technique has been reported to lower the risk of suture dehiscence and
recurrent TR (32).
In conclusion placement of an annuloplasty ring during tricuspid valve repair is associated with a
decreased recurrence of TR, and with improved long-term survival and event-free survival. An
annuloplasty ring should therefore be used more routinely in tricuspid valve surgery.
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12
‫الملخص العربي‬
‫دراسةةم ارنر ةةم بةةخد اسةةيخةاد فرجرةةم دجخخاةةن ق اسةةيخةاد لرةةم نرب يخخةة ‪-‬ادقرد فةةح ةةن‬
‫ا رتانع الثن وى للصمند ذق الثالث شرفن‬
‫تهدف هذه لددالةذا لدذج لءذملا نة ايذا سذخد لةذريدل يميةذا يسخخذ لةذريدل تيةذا اس رخخذ ‪-‬‬
‫ل ا فذذج جذذحا تذ تج لتاتخذ ى لدصذ يذو ديثذ ا لدذذصحج يذذمف جا ذذد ءميذ لددالةذذا‬
‫جيج ‪621‬نميض تم تةسخ هم لدج نخ ذجرخد‪:‬‬
‫لت دج ي ي ‪08‬نميض تم جحءهم سطميةا يسخخ‬
‫لدص يخا ي ي ‪61‬نميض تم جحءهم سطميةا لةريدل تيةا اس رخخ ‪-‬ل ا‬
‫ن نرذةط ج ذم لد مىذج‪ 21 22‬ج نذ فذج لد خ ذذجرخدا ذد هذمج لددالةذا ن اءذا‬
‫لتاتخ ى د تحس فج ‪ %22‬ند لدح تج س ةريدل تيةا اس رخخذ ‪-‬ل ا نة سذ تحسذد ‪%08‬‬
‫نذذد لدحذذ تج س ةذذريدل يميةذذا يسخخذذ ا يسذذريي نذذد هذذهل لدثحذذه يذذ يخذذم لةذذريدل تيةذذا‬
‫اس رخخ ‪-‬ل ا سطميةا ا تخ خا فج ت تج لتاتخ ى لدص يذو ديث ا لدصحج يمف ج‪8‬‬
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