Surgical Technique for Tricuspid Valve Replacement – Supra-Annular Position: The Hemodynamic Effects, Morbidity and Mortality

Background:
In cases when tricuspid valve (TV) annuloplasty is not feasible, TV replacement (TVR) is done. Supra-annular TV replacement (SATVR) technique may be an attractive alternative approach to standard TVR by reducing post-operative conduction blocks, complete preservation of the native TV with its sub-valvular apparatus and by that reducing structural deterioration of the bio-prosthesis and preserving the contraction of the base of the right ventricle.

Objectives:
The aim of the study is to evaluate the clinical outcomes and the hemodynamic changes in patients who underwent SATVR.

Methods:
Between October 2013 and October 2016, 43 patients underwent TVR, 14 of them underwent SATVR. The surgical technique involves placement of interrupted pledgeted sutures, non-everted, above the coronary-sinus form the anteroseptal commissure till the posteroseptal commissure then following tricuspid annulus.

Results:
14 patients (Age 61±16,males 29%) underwent SATVR. Patients were followed for an average of 8.7±11months. In this high risk population (logEuroscore 12.7±6.4,reoperations 64%, associated procedures in 57%) in hospital mortality was 7%. Postoperatively only 1 patient needing implantation of a permanent pacemaker and 1 patient with CVA. Postoperative echocardiography was done to all patients except one due to early postoperative mortality. Preoperative TV regurgitation was estimated as moderate(7%), severe(86%) and (7%)stuck mechanical prosthetic TV. There was a decrease in TR in 31% to mild TR and 69% with no residual TR[p=0.001]. Right ventricle dysfunction preoperatively was estimated as normal(65%), mild(7%) moderate(21%) and severe(7%). There was no deterioration postoperatively (54%,38%,8%,0% respectively[p=0.558]). Right ventricle enlargement preoperatively was estimated as normal(42%), mild(29%) moderate(29%) and severe(0%). There was no deterioration postoperatively (69%,15%,15%,0% respectively[p=0.0.063]). The mean gradient of the bioprosthetic TV was 4.2±1.5mmHg.

Conclusion:
Bioprosthetic SATVR can be performed with very good clinical and hemodynamic outcomes in this high risk population when TVA is not feasible. Further investigation and comparison to standard TV replacement approach is needed.