Mechanical Tricuspid Valve Replacement Is Not Superior in Patients Younger Than 65 Years Who Need Long-Term Anticoagulation

doi:10.1016/j.athoracsur.2011.11.075

The Annals of Thoracic Surgery

Volume 93, Issue 4, April 2012, Pages 1154-1160

https://doi.org/10.1016/j.athoracsur.2011.11.075 Get rights and content

Background

We evaluated long-term results of tricuspid valve replacement (TVR) with mechanical valves and bioprostheses in patients less than 65 years old who needed anticoagulation therapy irrespective of TVR.

Methods

Among 156 patients who underwent TVR from January 1996 to April 2010, 119 patients younger than 65 years who needed anticoagulation therapy independent of the TVR were studied. Anticoagulation therapy was needed owing to left-sided mechanical valves (n = 11), atrial fibrillation (n = 13), or both (n = 95). Seventy patients underwent mechanical TVR, and 49 underwent bioprosthetic TVR. The follow-up duration was 68 ± 38 months. Propensity score-adjusted analyses were performed.

Results

Early postoperative outcomes were similar between groups, with an operative morality rate of 6.7% (8 of 119). Overall survival rates at 5 and 10 years were 86.4% and 80.3%, respectively. There were no differences in propensity score-adjusted overall survival rates between the two groups (p = 0.291). Freedom from the composite endpoint of thrombosis, embolism, and bleeding was lower in the mechanical TVR group than in the bioprosthetic TVR group (76.3% and 70.0% at 5 and 10 years, respectively, versus 97.6% and 97.6%, p = 0.020). Five- and 10-year valve-related event-free survivals were also lower in the mechanical TVR group than in the bioprosthetic TVR group, although not statistically significant (75.0% and 61.7% versus 89.2% and 80.3%, p = 0.129).

Conclusions

Even in younger patients who need anticoagulation therapy irrespective of TVR, mechanical TVR is not superior because of increased occurrence of valve-related events, especially the composite of thrombosis, embolism, and bleeding.

Section snippets

Patient Characteristics

The study protocol was reviewed by the Institutional Review Board and approved as a minimal risk retrospective study (approval number H-1106-087-366) that did not require individual consent based on the institutional guidelines for waiving consent.

From January 1996 to April 2010, tricuspid valve procedures were performed in 659 patients (tricuspid valvuloplasty or annuloplasty, or both, in 503 patients and TVR in 156 patients) at our institution. Among them, 119 (aged 53.0 ± 8.8 years, 28 men,

Early Results

The operative mortality rate was 6.7% (8 of 119); 8.6% (6 of 70 patients) in the MTV group and 4.1% (2 of 49 patients) in the BTV group (p = 0.468). Postoperative morbidity included low cardiac output syndrome (n = 17, 14.3%), acute renal failure (n = 10, 8.4%), respiratory complication (n = 8, 6.7%), postoperative bleeding (n = 4, 3.4%), stroke (n = 2, 1.7%), and mediastinitis (n = 1, 0.8%). Complete atrioventricular conduction block occurred in 3 patients (2.5%). No patient underwent

Comment

Our study demonstrated that even in patients younger than 65 years who need oral anticoagulation therapy irrespective of TVR, implantation of a mechanical valve at the tricuspid position was not superior to insertion of a bioprosthetic valve because of an increased occurrence of tricuspid valve-related events, especially the composite endpoint of thrombosis, embolism, and bleeding.

Tricuspid valve surgery accounts for fewer than 10% of all cardiac procedures [7, 8]. In addition, most patients

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Cited by (36)

Reply: Do not hesitate to implant a mechanical valve in tricuspid valve position for fear of later stroke and valve thrombosis in young-aged patients
2023, JTCVS Open
Tricuspid valve replacement: The old and the new
2022, Progress in Cardiovascular Diseases
Citation Excerpt :
Mechanical TVR is associated with a higher incidence of valve thrombosis, thromboembolism and bleeding due to anticoagulation than bioprosthetic TV. Observed rates of mechanical valve thrombosis ranged from 3% to 18%.16,20,25,36,39,51,52 In a recent study, 10- and 15-year rates of freedom from thromboembolism and major bleeding were 78% and 66%, respectively (84% and 68% respectively in the bioprosthetic TV group versus 72% and 63% respectively in the mechanical TV group).
Tricuspid regurgitation is a frequent and serious condition but tricuspid valve (TV) surgery, that may be a valve replacement when a repair is not feasible, is rarely performed. Recent development of transcatheter TV interventions offers new options for those high-surgical risk patients, especially TV replacement for patients who are not eligible for transcatheter TV repair. In this review, we describe indications and outcome after surgical TV replacement, and devices available or in development for transcatheter TV replacement.
Fifteen-Year Outcomes After Bioprosthetic and Mechanical Tricuspid Valve Replacement
2020, Annals of Thoracic Surgery
This study was conducted to compare long-term clinical outcomes of mechanical and bioprosthetic tricuspid valve replacement (TVR).
Two-hundred twenty-six TVR patients were enrolled; 120 patients underwent bioprosthetic TVR (BTV group) and 106 underwent mechanical TVR (MTV group). Early results and long-term clinical outcomes were compared. The median follow-up duration was 99 months (range, 1-295). Propensity score (PS) analyses including PS-adjusted Cox regression models and 1:1 PS matching were performed.
Mean ages of the MTV and BTV groups were 50.5 ± 10.3 and 60.8 ± 12.0 years, respectively. There were no significant differences in early mortality (4.9% in total) and postoperative complications between the 2 groups. The overall survival and freedom from cardiac death in the MTV group were similar to those in the BTV group (reference, BTV group; hazard ratio [HR], 0.82 [95% confidence interval {CI}, 0.44-1.53] and 0.91 [95% CI, 0.44-1.87], respectively). The risk of a composite of thromboembolism and bleeding was significantly higher in the MTV group (HR, 2.35; 95% CI, 1.16-4.77; P = .018). However the tricuspid valve reoperation rate was significantly lower in the MTV group (HR, 0.11; 95% CI, 0.02-0.53; P = .007). Overall TV-related event rates in the MTV group were similar to those in the BTV group (HR, 0.79; 95% CI, 0.49-1.28). PS matching extracted 69 pairs. Comparative analyses of early- and long-term outcomes from the matched groups yielded similar findings to those from the entire patient groups.
The outcomes of bioprosthetic TVR were comparable with those of mechanical TVR in terms of long-term survival and tricuspid valve-related events over a 15-year postoperative follow-up.
Cardiac electronic implantable devices after tricuspid valve surgery
2018, Heart Rhythm
Citation Excerpt :
Treatment options for TV surgery include valve repair with or without an annuloplasty ring and, in the case of unrepairable valvular lesions or late failed repair, TV replacement with a bioprosthesis or a mechanical valve. The 2 types of valves have similar long-term clinical outcomes.6–9 In clinical practice, like for left heart valves, bioprostheses are generally preferred in patients older than 65 years and mechanical valves in younger patients with the need for continuous anticoagulation.
The demand for tricuspid valve (TV) surgery has increased continuously in the last years. Recent registry data have confirmed that TV repair or replacement carry an increased risk of conduction disorders requiring permanent pacemaker implantation, specifically for patients having multivalve surgery. The implantation of an endocardial right ventricular lead in those patients may impair TV function, and some other approaches may be discussed to avoid traversing the valve. This contemporary review describes the different options currently available for patients requiring pacemaker or defibrillation leads implantation after TV surgery.
Isolated Tricuspid Valve Surgery <sup>∗</sup>
2017, Journal of the American College of Cardiology
Appraisal of long-term outcomes of tricuspid valve replacement in the current perspective
2016, Annals of Thoracic Surgery
We address the differential long-term results of tricuspid valve replacement and late valve-related events among bioprostheses versus mechanical prostheses.
In a single-institution investigation, we reviewed the patients’ prospectively collected data and performed a clinical follow-up. Both the Kaplan-Meier (actuarial) and the competing risks (actual) methodologies were used.
Overall, 188 tricuspid valve replacements were performed during 1971 to 2012. In this complex population (reoperations, 48.1%; associated procedures in 71.3%), operative mortality was 27.6% (significantly declining in recent years). A bioprosthesis was used in 82.4%. Follow-up was 10.2 ± 9.1 years (as long as 37.3 years, or 1,270 patient-years; 91.2% complete). At 15 years, freedom from structural valve deterioration was 93.3% ± 6.4% (competing risks 94.7 ± 5.1%) in the mechanical group and 85.2% ± 5.4% (competing risks 92% ± 2.9%) in the bioprostheses group (p = 0.19). Freedom from any valve-related adverse events was lower among mechanical valves versus bioprostheses (although not statistically significant). Mechanical valves showed significantly lower freedom from thromboembolic events (actuarial 62.3% ± 14.3% versus 97.7% ± 1.6%; competing risks 74.1% ± 10% versus 98% ± 1.4%; p < 0.001) and earlier adverse events (4.9 ± 4.5 versus 11.1 ± 9.4 years) than bioprostheses. There were 11 reoperations for bioprosthetic structural valve deterioration (89.8% and 94.3% actuarial and actual freedom, respectively).
Bioprostheses for tricuspid valve replacement have a very good long-term durability. Mechanical valves display earlier and more severe morbidity at follow-up.

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Original articleAdult cardiacMechanical Tricuspid Valve Replacement Is Not Superior in Patients Younger Than 65 Years Who Need Long-Term Anticoagulation

Background

Methods

Results

Conclusions

Section snippets

Patient Characteristics

Early Results

Comment

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

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

Eur J Cardiothorac Surg

Original article
Adult cardiac
Mechanical Tricuspid Valve Replacement Is Not Superior in Patients Younger Than 65 Years Who Need Long-Term Anticoagulation