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TRICUSPID PROSTHESIS WHEN IS IT NECESSARY? Miguel Such. Cirujano Cardiovascular. Jefe de la Unidad de Cirugía Cardiaca. Área del Corazón del Hospital Universitario Virgen de la Victoria, Málaga. Área del Corazón del Hospital Xanit Internacional de Málaga. WHEN TO IMPLANT A TRICUSPID PROSTHESIS? ¡¡¡NEVER!!! ¿NEVER? BASE DE DATOS TRICÚSPIDES Tricuspid valve surgery: The past 10 years from the Nationwie Inpatient Sample (NIS) database. Christina M. Vassileva, MD, John Shabosky, BA, Theresa Boley, MSN, Stephen Markwell, MA, and Stephen Hazelrigg, MD. (J Thorac Cardiovasc Surg 2011;-:1-7) 28,726 admissions for tricuspid valve surgery EVOLUTION OF PROCEDURES At follow-up: 10.8% of patients had a pace- maker (PM) induced rhythm; the mean TRICUSPID PROSTHESIS BASE DE DATOS TRICÚSPIDES Tricuspid valve surgery: The past 10 years from the Nationwie Inpatient Sample (NIS) database. Conclussions • There has been dramatic increase in tricuspid interventions over time. •Increase in tricuspid repair rates. •Increase use of bioprostheses for tricuspid replacement. •The majority of tricuspid operations with other cardiac procedures FATAL PARADOX MANAGEMENT OF TRICUSPID VALVE REGURGITATION Manuel J Antunes, John B Barlow. Heart 2007;93:271–276 • Hospital mortality for repeat tricuspid valve surgery in patients who had a prior cardiac operation may reach 50%. Surgery in patients with isolated organic TR should, therefore, be delayed. • High functional class, severe right heart failure, low right ventricular ejection fraction, high pulmonary pressure and pulmonary arterial resistance are additional risk factors when repeating tricuspid surgery. ESTUDIO A 30 AÑOS Tricuspid valve surgery: a thirty-year assessment of early and late outcome. Thomas Guenther, Christian Noebauer, Domenico Mazzitelli, Raymonde Busch, Peter Tassani- Prell , Ruediger Lange. European Journal of Cardio-thoracic Surgery 34 (2008) 402—409 • 416 consecutive patients >18 years with acquired TV disease operated on between 1974 and 2003. • Tric. valve was repaired in 310 patients (74.5%) and replaced in 106 (25.5%). • Biological prosthesis was used in 68 patients (64%). • Patients undergoing replacement showed a significant higher incidence of risk factors for operative mortality. • Prosthetic valve replacement: these patients face a high risk of operative DURABILITY OF THE REPAIR Tricuspid valve repair with an annuloplasty ring results in improved longterm outcomes. Tang GHL, David TE, Singh SK, Maganti MD, Armstrong S, Borger MA. Circulation 2006;114 (Suppl. I):I577—81. •702 patients underwent TV repair at our institution (1978 to 2003) •Concomitant procedures consisted of mitral valve surgery in 80% of patients. •Clinical and echocardiographic follow-up data were obtained. •Follow-up was 99% complete and was 5.9 ± 4.9 (mean ± SD) years long. DURABILITY OF THE REPAIR Tricuspid valve repair with an annuloplasty ring results in improved longterm outcomes. Tang GHL, David TE, Singh SK, Maganti MD, Armstrong S, Borger MA. Circulation 2006;114 (Suppl. I):I577—81. Echocardiographic examination Ring group: 30% had moderate to severe TR No ring group: 36% had moderate to severe TR CONCLUSSION 30—36% of the patients presented with moderate or severe regurgitation at latest follow-up Right-Sided Valve Disease Deserves a Little More Respect Charles J. Bruce and Heidi M. Connolly Circulation 2009;119;2726-2734 Kaplan–Meier survival curves for 5223 consecutive patients with TR undergoing echocardiography at 1 of the 3 laboratories at the Palo Alto (Calif) Veterans Affairs Heath Care System between August 1998 and July 2002. Survival is significantly worse in patients with moderate and severe TR. RISKS OF REDOS Tricuspid valve repair: durability and risk factors for failure. McCarthy PM, Bhudia SK, Rajeswaran Haercher KJ, Lytle BW, Cosgrove DM, Blackstone EH J Thorac Cardiovasc Surg 2004;127:674—85. The discrepancy between the high recurrence rates of TV regurgitation and the low re-operation rates may be explained by the fact that TV re-operation is associated with a high mortality and thus, these patients are managed medically as long as possible before referral to surgery. TRICUSPID PROSTHESIS Tricuspid valve surgery: The past 10 years from the Nationwie Inpatient Sample (NIS) database. Christina M. Vassileva, MD, John Shabosky, BA, Theresa Boley, MSN, Stephen Markwell, MA, and Stephen Hazelrigg, MD. (J Thorac Cardiovasc Surg 2011;-:1-7) Concomitant tricuspid replacement was associated with significantly higher hospital mortality than was isolated tricuspid replacement. (16.1% vs 10.1% ;P = 0.0001). ISOLATED TRICUSPID PROSTHESIS Tricuspid valve surgery: The past 10 years from the Nationwie Inpatient Sample (NIS) database. MORTALIDAD POR AÑOS Tricuspid valve surgery: The past 10 years from the Nationwie Inpatient Sample (NIS) database. CURRENT SITUATION Preoperative Factors Associated With Adverse Outcome After Tricuspid Valve Replacement Yan Topilsky, MD; Amber D. Khanna, MD; Jae K. Oh, MD; Rick A. Nishimura, MD; Maurice Enriquez-Sarano, MD; Yang B. Jeon, MD; Thoralf M. Sundt, MD; Hartzell V. Schaff, MD; Soon J. Park, MD (Circulation. 2011;123:1929-1939.) Conclusions—Tricuspid valve replacement for severe tricuspid regurgitation can be performed with an acceptable operative mortality (10%) if patients undergo surgery before the onset of advanced heart failure symptoms. Late mortality is associated with a high preoperative Charlson index, short right index of myocardial performance ratio, and advanced New York Heart Association class. Preoperative Factors Associated With Adverse Outcome After Tricuspid Valve Replacement. (Circulation. 2011;123:1929-1939.) MORTALITY BY FUNCTIONAL CONDITION CONCLUSIONS 1. CURRENT MORTALITY OF CONCOMITANT TRICUSPID PROSTHESIS IMPLANTATION (NOT REDO) IS ABOUT 10%. 2. MORTALITY OF ISOLATED TRICUSPID PROSTHESIS IMPLANTATION (INCLUDING REDOS) IS ALSO ABOUT 10%. 3. MORTALITY IS MAINLY RELATED TO THE CLINICAL CONDITION OF THE PATIENT. DELAY IN THE INDICATION IS THE MAIN CAUSE OF DEATH. CONCLUSIONS • SIGNIFICATIVE RESIDUAL T.R. AFTER REPAIR HAS AN UNACCEPTABLE MORTALITY IF LEFT ALONE. • A GOOD REPLACEMENT IS BETTER THAN A BAD REPAIR. • THERE ARE NOT RANDOMIZED STUDIES COMPARING TRICUSPID REPAIR VERSUS REPLACEMENT. WHICH PROSTHESIS SHOULD WE IMPLANT? Biological or Mechanical Prostheses in Tricuspid Position? A Meta-Analysis of Intra-institutional Results Giulio Rizzoli, MD, FETCS, Igor Vendramin, MD, Georgios Nesseris, MD, Tomaso Bottio, MD, Cosimo Guglielmi, MD, and Laura Schiavon, Dstat. Ann Thorac Surg 2004;77:1607–14 Conclusions. There is not a gold standard in tricuspid prostheses replacement. Prosthetic choice is left to the surgeon’s clinical judgment, taking into considerationeach patient’s characteristics and needs. WHICH PROSTHESIS SHOULD WE IMPLANT? CONSIDERATIONS AVERAGE AGE (HISTORICAL) 49,9 ± 11,43 AÑOS AVERAGE AGE (RECENT) 67.5 ± 11.3 AÑOS Comparative studies between mechanical and biological prosthesis have been accomplished in historical series. WHICH PROSTHESIS SHOULD WE IMPLANT? CONSIDERATIONS WITH THE AGES OF OUR CURRENT PATIENTS, IMPLANTATION OF MECHANICAL PROSTHESIS DOES NOT SEEM TO BE JUSTIFIED. THERE ARE OTHER FACTORS THAT INFLUENCE THE DECISION TO IMPLANT A BIOLOGICAL PROSTHESIS. PACEMAKERS AND TRICUSPID PROSTHESIS Clinical mid-term results after tricuspid valve replacement. Giorgio Viganò, Andrea Guidotti, Maurizio Taramasso, Andrea Giacomini, Ottavio Alfieri Interactive Cardiovascular and Thoracic Surgery (2010) Volume: 10, Issue: 5, Pages: 709-713 •Between January 1992 and May 2007, 81 consecutive patients underwent TVR (54 re-interventions, 66.7%; 46 procedures, associated with a left-sided operation, 56.8%). •At follow-up: 10.8% of patients had a pace-maker (PM) induced rhythm. PACEMAKERS AND TRICUSPID PROSTHESIS Pacemaker Therapy After Tricuspid Valve Operations: Implications on Mortality, Morbidity, and Quality of Life Janne J. Jokinen, Anu K. Turpeinen, Otto Pitkänen, Mikko J. Hippeläinen and Juha E.K. Hartikainen Ann Thorac Surg 2009;87:1806-1814 The need for a pacemaker after TV operation was high—21% of the operated-on patients---. Conclusions. The need for pacemaker implantation after tricuspid valve operations was high. Unexpectedly, the life expectancy of the patients who needed a pacemaker postoperatively was higher compared with those who did not PACEMAKERS AND TRICUSPID PROSTHESIS Survival curves of the patients who needed a pacemaker (PM solid line) and those who did not (PM, dashed line). Early mortality (deaths within 30 days after the operation) is excluded. CONCLUSIONS • BIOLOGICAL PROSTHESIS ALLOW THE IMPLANTATION OF PACEMAKERS AND PROBABLY ICDs. • THERE ARE NO LONG TERM EVIDENCE ABOUT DAMAGES IN THE BIOLOGICAL PROSTHESIS. • PERICARDIAL PROSTHESIS SHOULD NOT BE AFECTED. PERCUTANEOUS ALTERNATIVES Percutaneous Tricuspid Valve Replacement for a Stenosed Bioprosthesis Philip Roberts, MB, ChB; Roberto Spina, MB, BS; Michael Vallely, MB, BS; Michael Wilson, MB, BS; Brian Bailey, MB, BS; David S. Celermajer, MB, BS, PhD Circ Cardiovasc Interv 2010;3;e14-e15; Melody Medtronic Valve PERCUTANEOUS ALTERNATIVES Percutaneous Tricuspid Valve Replacement for a Stenosed Bioprosthesis Philip Roberts, MB, ChB; Roberto Spina, MB, BS; Michael Vallely, MB, BS; Michael Wilson, MB, BS; Brian Bailey, MB, BS; David S. Celermajer, MB, BS, PhD Circ Cardiovasc Interv 2010;3;e14-e15; •We describe a case of percutaneous transjugular TVR with a 22-mm valve in a 28-year-old woman with a history of bioprosthetic tricuspid valve replacement (27-mm Medtronic Mosaic valve, Minneapolis, Minn). •Under fluoroscopic guidance, a percutaneous Medtronic Melody pulmonary valve was deployed using a 22-mm Ensemble delivery system. PERCUTANEOUS TRICUSPID PROSTHESIS Percutaneous tricuspid valve replacement in congenital and acquired heart disease. Roberts PA, Boudjemline Y, Cheatham JP, Eicken A, Ewert P, McElhinney DB, Hill SL, Berger F, Khan D, Schranz D, Hess J,Ezekowitz MD, Celermajer D, Zahn E. J Am Coll Cardiol. 2011 Jul 5;58(2):117-22 Procedural success was achieved in all 15 patients with the Melody percutaneous pulmonary valve (Medtronic, Inc., Minneapolis, Minnesota). All had prior TV surgery and significant stenosis and/or regurgitation of a bioprosthetic TV. CONCLUSIONS: In selected cases, patients with prior TV surgery may be candidates for percutaneous TV replacement. PERCUTANEOUS TRICUSPID PROSTHESIS Heterotopic transcatheter tricuspid valve implantation: ﬁrst-in-man application of a novel approach to tricuspid regurgitation. Alexander Lauten, Markus Ferrari, Khosro Hekmat, Ruediger Pfeifer,Gudrun Dannberg, Andreas Ragoschke-Schumm, and Hans R. Figulla European Heart Journal (2011) 32, 1207–1213 Transcatheter treatment of severe TR by caval valve implantation is feasible resulting in an immediate abolition of IVC regurgitation and mid-term clinical improvement CHOICE OF THE PROSTHESIS CONCLUSIONS •THERE ARE NO DIFFERENCES IN THE RESULTS BETWEEN MECHANICAL AND BIOLOGICAL PROSTHESIS IN RETROSPECTIVE STUDIES. •ANTICOAGULATION LIMIT QUALITY OF LIFE •BIOLOGICAL PROSTHESIS (OR RINGS) ALLOW THE IMPLANTATION OF PACEMAKERS, ICDs AND PERCUTANEOS PROSTHESIS. IMPLANTATION OF MECHANICAL PROSTHESIS IN THE TRICUSPID POSITION IS NO LONGER JUSTIFIED. TRICUSPIDE SURGERY HCVV HEART TEAM HUVV SERIES 119 PATIENTS (1996-2010) 84 REPAIRS AND 35 PROSTHESIS FOLLOW UP (58,1±45,5 months) OPERATIVE MORTALITY IS 18,5% AND 13,7% IN THE FU ECHO FU OF 74 PATIENTS (76,3%) SEVERE TR IN FOLLOW UP 26% TRICUSPID PROSTHESIS WHEN IS NECESSARY? MAYBE MORE... AND EARLIER THANK YOU Miguel Such. Cirujano Cardiovascular. Jefe de la Unidad de Cirugía Cardiaca. Área del Corazón del Hospital Universitario Virgen de la Victoria, Málaga. Área del Corazón del Hospital Xanit Internacional de Málaga.
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