Central Annals of Vascular & Research

Research Article *Corresponding author Guglielmo Saitto, Department of Cardiac , Tor Vergata University of Rome, Viale Oxford 81, Rome, Tricuspid Valve Annuloplasty Italy, Tel: 390620908235; Fax: 390620903868; E-mail:

Submitted: 04 April 2016 during Surgery: A Accepted: 15 April 2016 Published: 19 April 2016 Risk or an Additional Benefit? ISSN: 2378-9344 Copyright Guglielmo Saitto1*, Marco Russo1, Paolo Nardi1, Valentina © 2016 Saitto et al. Gislao1, Antonio Scafuri1, Antonio Pellegrino1 and Giovanni OPEN ACCESS Ruvolo1 Department of , Tor Vergata University of Rome, Italy Keywords • Tricuspid valve Abstract • Mitral valve • Right The association of Tricuspid Regurgitation (TR) to left side valve diseases is • Surgical risk common but surgical indications during left side heart surgery is still controversial and tricuspid valve annuloplasty (TVA) ranging from more than 60% to 6% depending on each single institution strategy. This study aims to evaluate clinical and instrumental results of adjunctive TVA during left side surgery also in case of non-severe TR but only annular dilation. We retrospectively analyzed 20 consecutive patients (mean age 71±7 yo, 70% females) who underwent during 2015 to adjunctive TVA by means of De Vega (12 patients) or Kay (8 patients) techniques during left side heart operation for mitral valve regurgitation or steno insufficiency: 14 patients underwent mitral (6 combined operation: 2 CABG, 2 AVR and 2 PFO) and 6 to repair (one combined for PFO). Mean CBP and cross clamp time was 126±34 and 101±27minutes respectively. Mean Euroscore II was 4.9±4.4%. In- mortality was 5%. No postoperative MI or were noticed. Three patients had a new atrial fibrillation (15%), but no onset of BAV was noticed and no PPMK was necessary. At discharge, 18 patients (90%) had no TR more than 1+, and only 1 patient had mild (2+). Mean postoperative in hospital stay was 13±18 days. At short term follow up (8.7±3.8 months) no patients had a TR >2+. In conclusion additional TVA takes short operative time and seems to be a low-risk procedure with stable good results at short term follow up.

ABBREVIATIONS of concomitant tricuspid valve annuloplasty ranging from more AVR: ; BAV: AtrioVentricular Block; CABG: Coronary Artery Bypass Grafting; CPB: Cardiopulmonary than 60% to <6% depending on more or less aggressive strategy point of view of each single institution [4-7] The safety and efficacy of tricuspid annuloplasty [8-10] associated to the high Bypass; CVVH: ContinuosVeno-Venous Hemofiltration; ECC: incidence of significant TR after isolated MV operation [11,12] Extracorporeal Circulation; FU: Follow-up; IABP: Intra Aortic to the adverse impact of TR on long-term mortality [11,13,14] Ballon Pump; ICU: Intensive Care Unit; MI: Myocardial Infarction; morbidity [8,13] and functional outcome [11] led more and more MVR: ; MVRep: ; to perform a TVR also on less than severe TR in case PAH: Hypertension; PFO: Patent Forame Ovale; of annulus dilation [15]. Data on the effect and on the benefits AnnuloplastyPPM: Patient Prosthesis Mismatch; PPMI: Permanent Pacemaker of concomitant tricuspid annuloplasty on progression of TR, Implantation; TR: Tricuspid Regurgitation; TVA: Tricuspid Valve , and pulmonary artery hypertension INTRODUCTION (PAH) and clinical status after degenerative MV repair are lacking. The aim our study was to retrospectively analyze the impact on clinical outcomes of adjunctive TVR procedure at time Surgical indications in tricuspid regurgitation (TR) in of left heart valve surgery performed in our center during 2015 patients with less than severe tricuspid regurgitation that are toMATERIALS evaluate the need AND and METHODS the benefits of this procedure. undergoing left side heart surgery are still controversial. Usually TR is associated to mitral regurgitation (MR), mitral , and aortic stenosis [1]. Approximately 30% to 50% of patients with In 2015, at Cardiac Surgery Unit of Tor Vergata University of severe MR have significant FTR [2,3]. In these settings the range Rome, 20 consecutive patients (mean age 71±7 yo, 70% females) Cite this article: Saitto G, Russo M, Nardi P, Gislao V, Scafuri A, et al. (2016) Tricuspid Valve Annuloplasty during Mitral Valve Surgery: A Risk or an Additional Benefit? Ann Vasc Med Res 3(1): 1026. Saitto et al. (2016) Email: Central

underwent left side heart surgery for mitral valve regurgitation a hematic warm cardioplegic solution administered via the or steno insufficiency received a concomitant tricuspid valve aortic root for 4 min and repeated every 20 min according to annuloplasty (TVA). 15 patients (65%) had indication for surgery directlyCalafiore inprotocol. aortic The root other or in 10 coronary patients (50%) ostia inhad case a single of aortic dose for severe mitral valve regurgitation: in 9 of there a concomitant of crystalloid solution by means of Custodiol HTK administered surgery was needed for in 2 cases, aortic valve stenosis (1 patient) or regurgitation (1 patient) and for regurgitation. After valve reconstruction and weaning from ECC, patent of foramen ovale in 3 cases; 5 patients had mitral valve protamine was administered to antagonize the effect of heparin. steno insufficiency. Among the patients, 4 (20%) were in NYHA In the patient who underwent minimally invasive surgery (MVRp class II, 16 (80%) were in NYHA class III or IV. No patients were and TVP), the cardio- pulmonary bypass system was connected symptomatic for angina in Canadian Cardiothoracic Society by cannulating the femoral vessels. A venous cannula was class III/IV. Hypertension was present in 15 (75%) patients. No advanced into the (tubing system, Edwards patient had a history of previous myocardial infarction. 2 patients Life sciences Ltd, Irvine, CA, USA) and a second venous cannula (10%) had a coronary artery disease needing CABG. 7 (35%) was percutaneously placed into the internal jugular vein. After had diabetes mellitus dependent by insulin. 5 (25%) patients commencing ECC, a right anterolateral mini- was had chronic renal failure no one required preoperative dialysis. performed. Additionally, two incisions were made for the camera No one patient had chronic pulmonary disease. Preoperative port, the left atrial retractor. The aortic Endo-clamp (Edwards Life atrial fibrillation was present in 14 patients (70%). Just one sciences Ltd, Irvine, CA, USA) was used and cardioplegic arrest patient (4%) had a history of cerebral and previous was achieved by instilling via the aortic root a Custodiol HTK cardiac surgery. One patient (4%) had a previous percutaneous solution, once. All patients affected by mitral stenoinsufficiency mitral valvulopasty. All patients (100%) ha moderate to severe underwent MVR. In case of mitral regurgitation the decision to pulmonary hypertension at the preoperative perform repair or replacement and the prostheses used were at with a mean value of 61±22 mmHg. The mean EuroSCORE II the ’s discretion. The left was opened through the was 4.9±4.4. The main preoperative features for the patients are interatrial sulcus in all cases. In the two case of concomitant AVR; listed in (Table 1). a biological prosthesis was used in both cases. Concomitant CABG was performed before valvular procedure on main coronary All patients underwent conventional sternotomy except vessels or branches that displayed luminal stenoses of 70% one who had minimally invasive surgery by means of right or more on preoperative angiography. Left Internal Thoracic thoracotomy. In patients underwent conventional sternotomy, Artery was used in one of two patients who underwent CABG for the heart was exposed through a median longitudinal sternotomy. anterior descending artery. Other grafts were performed with After heparinization and aortic cannulation, a venous cannula autologous saphenous vein. For exposure of tricuspid valve an was placed into the superior and into the inferior vena cava. oblique right atriotomy was made in all patients. Kay procedure The extra- corporeal circulation (ECC) system comprised a was performed by a 2-0 polyester suture passed through the roller pump and a membrane and a tubing system. tricuspid annulus at the anteroposterior commissure and Following aortic cross- clamping, in 10 patients (50%) we used Table 1 then at the center of the posterior leaflet and than through the annulus at the posteroseptal commissure. A second suture was : PreoperativeCharacteristic Characteristics. passed for reinforcement. De Vega technique was perfomed by means of a 2-0 polyester suture passed counterclockwise Age, years 71±7 and then clockwise as a circular stitch in the tricuspid annulus Male gender, n.(%) 6 (30) starting from 1 cm medial to the posteroseptal commissure to New York Heart Association class, n(%) the base of the anterior leaflet 2cm medial to the anteroseptal I 0(0) commissure with a single pladgets incorporated at each end. II 4(20) Than the suture was tightened and tied after sizing new annular III 11(55) dimension. The mean duration of the adjunctive TVA procedure IV 5(25) was 5±2 and 6±3 minutes for Kay and De Vega procedures Hypertension, n.(%) 15(75) respectively. All Intraoperative variables are shown in (Table Smoking habit, n.(%) 8(40) 2). Statistical analysist was performed with the Stat View 4.5 program (SAS Institute Inc, Abacus Concepts, and Berkeley, CA, Diabetes mellitus, n.(%) 7(35) USA). The Student’s test was used pto analyze continuous data. Hyperlipidemia, n.(%) 7(35) All continuous variables were expressed as mean plus or minus Chronic renal dysfunction, n.(%) 5(25) 1 standard deviation of the mean. A Value less than 0.05 were Previous stroke, n.(%) 1(5) RESULTSconsidered statistically significant. Previous pacemaker implantation, 0(0) n.(%) Atrial Fibrillation Rhythm, n.(%) 14(70) One patient had in-hospital mortality (5%) in the XV Pulmonary hypertension, *n.(%) 20(100) postoperative days for low cardiac output and subsequently *= + Previous cardiac surgery, n.(%) 1(4) cardiogenic . No myocardial infarction or cerebral stroke EuroSCORE II, mean 4.9±4.4 Abbreviations: SD was noticed. Three patients (15%) had an acute kidney injury in SD the postoperative stay and in two patients (8%) a postoperative : Standard Deviation CVVH was needed. No atrio-ventricular conduction Ann Vasc Med Res 3(1): 1026 (2016) 2/5 Saitto et al. (2016) Email: Central

Table 2:

Intra-operativeVariable Variables. variable by many factors such as echocardiographic window tes used, instrument setting and hemodynamics. The most recent American Heart Association (AHA)/American College of Cardiopulmonary By-pass, minu 123±32 (ACC) guidelines [16] have evolved to the one from Aortic X-clamp, minutes 100±25 + AVR the European Society of Cardiology and the European Association Mitral Valve+ CABG Replacement 14 (60) for [17] and suggest a much more 2 aggressive approach to tricuspid valve surgery. This changed 2 point of view is probably due to many recent articles and results + PFO closure 2 1 showed a higher freedom from moderate TR at long term follow Mitral Valve Repair 6 (26) up and an improved recovery of right ventricle function and + PFO closure a reduction of pulmonary systolic artery pressure [5,15,18] Tricuspid associated surgical 20(100) procedures, n.(%) especially when performing during mitral valve surgery [10]. 8 (40) Kay The vena contracta width has been included in the latest ACC/ 12 (60) De Vega AHA and European Society of Cardiology/European Association Mean duration of TVA procedures, min of Cardio- Thoracic Surgery guidelines as a method for judging Kay 5±2 the severity of TR and also in the recent ACC/AHA guidelines De Vega 6±3 vena contact a width >7.0 mm is used to judge a TR as severe Mitral valve prostheses implanted: but is usually difficult to measure for multiple jet or elliptic valve Abbreviations:Mechanical, AVR: Aortic n.(%) Valve Replacement; CABG:5 Coronary(35) Artery Biological, n.(%) 9 (65) Table 3 Annuloplasty : PreoperativeVariable v/s DischargePreoperative EchocardiographicDischarge Values.P Value Bypass Grafting; PFO: Patent Forame Ovale; TVA: Tricuspid Valve Left ventricular end-diastolic * ns

Left ventricular end-systolic 56±11 49±9 diameter, mm * ns disturbance was noticed and no patients needed a permanent Left ventricular end-diastolic 38±10 36±10 pacemaker implantation. A new onset of atrial fibrillation was diameter, mm * ns noticed in three patients (15%). One patient needed a mechanical Left ventricular end-systolic 121±65 101±66 circulatory assistance by means of postoperative IABP (5%). In volume, ml * ns three patients (15%) a pulmonary dysfunction was noticed and Left ventricular septum 55±52 54±50 prolonged was needed. Mean ICU stays volume, ml 11 11 * ns was 5.9 days (range 1–63) and the mean postoperative stay was 11±2 11±2* ns 13.9 days (range 6–89). At time of discharge a postoperative thickness, mm Left ventricular ejection echocardiograpy was performed in all patients and no patients Posterior wall thickness, mm ±2 ±2 * ns showed a tricuspid regurgitation >2/4+. In 10 patients there 59±13 52±11 were trivial TR, in 8 patientsvs was 1+ and in one patients was 2+. fraction, (%) ° The mean systolic pulmonary artery pressure was significantly Systolic Pulmonary Art. 61±22 31±7 0,000029 reduced (31.4+7.3 mmHg) , preoperative value (p<0.0001). Pressure, mmHg ° No differences were found between the two surgical techniques Tricuspid Regurgitation, mean 7e-12 2.9±1 0.5±0.6 - in terms of residual TR. Comparison between preoperative and value/4+ echocardiographic variables at Hospital Discharge is shown in Tricuspid Regurgitation >2+ 13 0- - *p (Table 3). Tricuspid Annulus, mm 43±4 °p At short follow up (mean follow up 8±3 months) we = ns vs. preoperative found no cardiac death or late death. No patients experienced <0.0001 vs. preoperative thromboembolic events or endocarditis. No new permanent Table 4: At Follow pacemaker implantation was needed. No patients needed a re- Functional ClassPreoperative and TR value Dischargeat follow-up. p Value intervention. We found a significantly improvement of symptoms up and functional class, mean NYHA class value at FU was 1.5±0.5 - * Association class (p<0.0001 vs preoperative) and at FU echocardiography we New York Heart 3±1 1.5±0.5 <0.0001 found a significantly reduction of mean systolic pulmonary artery ° ° pressure, mean value 32.6±9mmHg (p<0.0001 vs preoperative; Tricuspid similar to discharge value). No patients had at follow up a TR Regurgitation, mean 2.9±1 0.5±0.6 0.6±0.6 value >2+ with a mean value of TR of 0.6±0.6 (p<0.0001 vs value/4+ preoperative). Functional class improvement and tricuspid Tricuspid Systolic Pulmonary 13 0 0 regurgitationDISCUSSION value at follow-up is shown in (Table 4). Regurgitation >2+, n. ° ° * 61±22 31±7 32±9 Art. Pressure, mmHg °p The assessment of severity of TR is usually based on preoperative vs. follow up value <0.0001 vs. preoperative qualitative method like color flow visualization but this is often Abbreviations: TR: Tricuspid Regurgitation Ann Vasc Med Res 3(1): 1026 (2016) 3/5 Saitto et al. (2016) Email: Central

2 orifice. Also a TA > 40 mm (or 21 mm/m diameter indexed to Prevalence, diagnosis, and comparison of preoperative clinical body surface area) is mentioned in the most recent (ACC/AHA; and hemodynamic features in patients with and without tricuspid regurgitation. J Thorac Cardiovasc Surg. 1987; 94: 481-487. ESC) guidelines, as a Level IIa indication for a tricuspid surgical annuloplasty when associated with mild or moderate TR [16,17]. 4. Castillo JG, Anyanwu AC, Fuster V, Adams DH. A near 100% repair A lot of study showed that without surgical treatment any TR rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines. J Thorac Cardiovasc Surg. 2012; will worsen at long term follow up and won’t disappear after 144: 308–312. left heart surgery, after successful mitral valve repair [5,19]. In the last decades the approach to FTR is so changed and now is 5. Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid considered not a benign condition also when less than severe; in regurgitation or dilatation: which should be the criteria for surgical repair?. Ann Thorac Surg. 2005; 79: 127-132. a recent meta-analysis of 2488 patients with mild to moderate FTR Kara et al. showed how TVA is associated to an higher 6. Gillinov AM, Mihaljevic T, Blackstone EH, George K, Svensson LG, freedom from progression to significant FTR and death at follow Nowicki ER, et al. Should patients with severe degenerative mitral up [20]. The benefits of adjunctive TVA, especially in mitral regurgitation delay surgery until symp- toms develop? Ann Thorac Surg. 2010; 90: 481-488. valve surgery, result in a decreased risk of cardiac mortality and hospitalization for heart failure in patients with preoperative 7. Seeburger J, Borger MA, Falk V, Kuntze T, Czesla M, Walther T, et al. TR>2+ [21]. The risk factors for recurrent TR after TVA appear to Minimal invasive mitral valve repair for mitral regurgitation: results be the lack of a ring annuloplasty, atrial fibrillation and the new of 1339 consecutive patients. Eur J Cardiothorac Surg. 2008; 34: 760- 765. valvesignificant replacement left sided one valvular more consideration lesion, primarily could a development be done on of mitral valve regurgitation after MVRep [22]. In case of mitral 8. McCarthy PM, Bhudia SK, Rajeswaran J, Hoercher KJ, Lytle BW, Cosgrove DM, et al. Tricuspid valve repair: durability and risk factors patient prosthesis mismatch (PPM). PPM is equated to residual for failure. J Thorac Cardiovasc Surg. 2004; 127: 674-685. mitral stenosis and could be associated to late TR and PAH 9. Filsoufi F, Salzberg SP, Coutu M, Adams DH. A three-dimensional ring especially during follow up after mitral valve replacement; for annuloplasty for the treatment of tricuspid regurgitation. Ann Thorac these reasons when PPM is anticipated at the time of operation Surg. 2006; 81: 2273-2277. an adjunctive TVA could find its surgical indication for the low 10. Benedetto U, Melina G, Angeloni E, Refice S, Roscitano A, Comito C, et al. surgical additive risk [23]. We need a longer follow up to assess Prophylactic tricuspid annuloplasty in patients with dilated tricuspid the possible role and effect of PPM on development of recurrent annulus undergoing mitral valve surgery. J Thorac Cardiovasc Surg. ò TR and PAH in our patients. 2012; 143: 632-638. 11. Calafiore AM, Gallina S, Iac AL, Contini M, Bivona A, Gagliardi M, et In these settings we can imagine that a surgical procedure moderate-or-more tricuspid regurgitation be treated? a propensity and some surgeons suggest a more aggressive strategy of an early al. Mitral valve surgery for functional mitral regurgitation: should on TV can bring just benefits without incremental of surgical risk score analysis. Ann Thorac Surg. 2009; 87: 698-703. repair also in moderate or mild TR at time of left heart surgery for 12. Van de Veire NR, Braun J, Delgado V, Versteegh MI, Dion RA, Klautz mitralCONCLUSION valve in case of annular dilation [15]. RJ, et al. Tricuspid annuloplasty prevents right ventricular dilatation and progression of tricuspid regurgitation in patients with tricuspid annular dilatation undergoing mitral valve repair. J Thorac Cardiovasc In case of left heart valve surgery in which adjunctive TVA Surg. 2011; 141: 1431–1439. is needed, also in case of high risk and long surgery we found 13. outcomeSagie A, Schwammenthal in patients undergoing E, Newell JB, percuta- Harrell L, neous Joziatis balloon TB, Weyman mitral DeVega or Kay procedure, a secure and reproducible techniques AE, et al. Significant tricuspid regurgitation is a marker for adverse that requires very short additional operative time with low grade of TR at short follow up and good clinical improvements in terms valvuloplasty. J Am CollCardiol. 1994; 24: 696-702. of functional class and RV restoration. The operative risk of 14. Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on patients seems to be not so much increased by these adjunctive long-term survival. J Am Coll Cardiol. 2004; 43: 405-409. procedures. Of course our study has a short follow up and is 15. Chikwe J, Itagaki S, Anyanwu A, Adams DH. Impact of Concomitant the cohort of patients is too small but the perioperative results Tricuspid Annuloplasty on Tricuspid Regurgitation, Right Ventricular seem to be encouraging and the short term follow up confirms a Function, and Pulmonary Artery Hypertension After Repair of Mitral stable result. More patients and a longer follow up are required Valve Prolapse. 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Cite this article Saitto G, Russo M, Nardi P, Gislao V, Scafuri A, et al. (2016) Tricuspid Valve Annuloplasty during Mitral Valve Surgery: A Risk or an Additional Benefit? Ann Vasc Med Res 3(1): 1026.

Ann Vasc Med Res 3(1): 1026 (2016) 5/5