Mid-term clinical and echocardiographic follow up of patients with CarboMedics valves in the tricuspid position.

BACKGROUND AND AIM OF THE STUDY: Debate continues regarding tricuspid valve replacement (TVR) with a mechanical prosthesis. Experience with bileaflet prostheses is limited; hence the study aim was to explore early and mid-term outcome and hemodynamic data in patients with bileaflet CarboMedics prosthetic valves in the tricuspid position.

METHODS

The study population included 25 patients (21 females, four males; mean age 50.5 +/- 13.4 years) who underwent TVR with a CarboMedics valve over a six-year period. Routine clinical examinations and details of transthoracic echocardiography (TTE) were reviewed. Additional TTE, transesophageal echocardiography (TEE) and fluoroscopy were performed as indicated. The number of previous cardiac operations was zero, one and two in 36%, 32% and 32% of patients, respectively. Previous tricuspid surgery was performed in eight cases (32%); concurrent mitral valve replacement was performed in 17 (68%). The hospital mortality rate was 24% and late mortality rate 12%. Seventeen early survivors (13 females, four males) were followed up for 46 +/- 28 months (range: 4-96 months).

RESULTS

Among early survivors, the mean and peak transvalvular gradients were 4.0 +/- 1.7 and 7.9 +/- 3.3 mmHg, respectively. Commonly observed INR levels were >2.5 in seven patients (41%), and >3.0 in only three (18%). Five patients (29% of mid-term survivors) experienced a total of 13 episodes of obstructive valve thrombosis, mostly with inappropriate anticoagulation. One patient required emergency re-do surgery; the others responded initially to thrombolysis or intensified antithrombotic treatment, but experienced at least two additional relapses. Aside from thrombotic episodes, all patients but two were in NYHA functional class II-III, and all but four required diuretics.

CONCLUSION

TVR with bileaflet mechanical valves carries a high perioperative mortality and mid-term morbidity. Among patients with poor or fair anticoagulation, these valves were associated with a high incidence of obstructive valve thrombosis. If poor patient compliance is anticipated, insertion of a bioprosthesis should be encouraged.