Functional tricuspid regurgitation is referred to tricuspid regurgitation due to enlargement of right ventricular and dilation of tricuspid annulus. Patients with chronic progressive tricuspid regurgitation have poor prognosis, poor quality of life and heavy economic burden. This article provides a comprehensive review of functional tricuspid regurgitation in terms of anatomical basis, pathological stage, imaging assessment and surgical decision making.
Thoracoscopic minimally invasive technology has been used in mitral valve plasty since 1990s. Totally thoracoscopic mitral valve plasty has the advantages of small trauma, beautiful incision and rapid postoperative recovery. It is favored by more and more patients and cardiac surgeons. However, according to the reports, the proportion of totally thoracoscopic mitral valve surgery in China is still low. Mitral valve plasty via the totally thoracoscopic approach is still controversial in terms of population adaptation, perioperative complications and long-term prognosis. In addition, the technical difficulty and the long training cycle of surgeons also limit the popularization of this technology. By summarizing the existing literature, this paper analyzes the application and development of totally thoracoscopic approach in comparison with the traditional median thoracotomy mitral valve plasty.
Red blood cell (RBC) transfusions are frequently used in cardiac surgery. A minority of patients assume most of the blood products transfusion during and after cardiac operations. Observational analysis of transfusion in patients undergoing cardiac surgery has uniformly demonstrated that RBC transfusion is associated with a significantly increasing risk of all-cause mortality and other serious adverse outcomes. In addition, it is an established fact that such patients can tolerate relatively low hemoglubin (Hb) levels. Consequently, it becomes widely accepted that appropriate limitation of transfusions could confer a substantial benefit to patients and decrease the use of limited resource. As a result, a restrictive threshold for blood transfusion is likely to be favored under most circumstances. However, an increasing amount of data differing from the observational analysis shows that clinical outcomes in patients who received transfusions with restrictive thresholds for Hb level are not superior to those with liberal thresholds. It has created a new uncertainty regarding the use of a restrictive threshold for transfusion during the perioperative period of cardiac surgery.
Mitral valve prolapse (MVP) is a common heart valve disease that affects 2%-3% of the general population. It can be manifested as mitral valve regurgitation and is the main indication for mitral valve surgery. MVP includes two forms of syndrome and non-syndrome. Syndromic MVP is associated with connective tissue diseases, such as Marfan syndrome. Non-syndromic MVP includes diffuse myxomatous mitral valve disease or Barlow’s disease and fibroelastic deficiency. MVP is a common disease in which late systolic clicks or mitral valve leaflets shift upward into the left atrium during ventricular systole, with or without mitral regurgitation. Echocardiography defines MVP as the prolapse of one or two leaflets of the mitral valve into the left atrium during systole, exceeding the level of the annulus line by more than 2 mm. In recent years, the development of genomics and imaging technology has enabled us to better understand the pathogenesis of MVP and provide possibilities for further prevention and treatment. This article reviews the research progress of MVP in epidemiology, etiology, histopathology, diagnosis and genetics.
Objective To summarize the early results and clinical experience of using the J-Valve for transcatheter valve-in-valve implantation in patients with degenerated bioprosthesis at different anatomic positions. Methods A retrospective analysis was conducted to evaluate the short-term outcomes of 39 consecutive patients who underwent transcatheter valve-in-valve implantation using the J-Valve System in the Department of Cardiac Surgery of Guangdong Provincial People’s Hospital from April 2020 to August 2021 due to bioprosthetic degeneration at different anatomic positions. Among them, 35 patients underwent transcatheter mitral valve-in-valve (TMViV) implantation, 1 transcatheter aortic valve-in-valve (TAViV) implantation, 1 transcatheter tricuspid valve-in-valve (TTViV) implantation, 1 TMViV implantation with simultaneous TAViV implantation, and another one TMViV implantation with simultaneous transcatheter aortic valve replacement (TAVR) and perivalvular leakage (PVL) closure. Results Among the 35 patients who underwent isolated TMViV implantation, 17 were male and 18 were female with a mean age of 72.6±10.8 years. Mean duration between two operations was 10.5±2.7 years. The mean Society of Thoracic Surgeons and EuroSCORE Ⅱ scores were 12.95%±9.61% and 13.91%±8.94%, respectively. The device success rate was 97.1% and no death occured during the operation. One patient was transferred to thoracotomy due to device displacement, 1 was re-opened for uncontrolled bleeding, and 1 presented left ventricular outflow tract obstruction. One patient underwent craniotomy due to intracranial hemorrhage within 30 days after surgery, and no other complications occurred including death, stroke, permanent pacemaker implantation, cardiac tamponade, or re-hospitalization. The mean follow-up time was 6.0±4.4 months, the mean mitral valve gradient was significantly improved (10.4±2.0 mm Hg vs. 5.5±1.2 mm Hg, P<0.05), and the New York Heart Association class≤Ⅱ in all the patients at the last follow-up. Among the other 4 patients who did not undergo isolated TMViV implantation, the transapical TAViV implantation and the trans-right atrium TTViV implantation were successful without intra- or post-operative complications. The patient who underwent TMViV and TAViV implantation simultaneously via transapical approach died of severe pulmonary hemorrhage and multiple organ failure 16 days after surgery. The other patient who underwent transapical TMViV combined with TAVR and PVL closure died of septic shock 10 days after the surgery. Conclusion Transcatheter valve-in-valve implantation using the J-Valve system is shown to be a safe and effective procedure to treat mitral, aortic and tricuspid bioprosthetic valve dysfunction in high-risk patients, providing a new alternative to surgical surgery for degenerated bioprosthesis at different anatomic positions. However, simultaneous different valves intervention should be very cautious.
A 23-year-old male patient was diagnosed with congenitally corrected transposition of the great arteries (ccTGA) at the age of 3 during a routine physical examination. Due to the absence of significant symptoms, the patient was managed conservatively with follow-up without surgical treatment. He developed chest tightness one year prior to admission, with symptom exacerbation in the recent month. Echocardiography demonstrated significantly worsened morphological tricuspid regurgitation. The patient presented to Guangdong Provincial People’s Hospital for surgical evaluation. Given the patient’s age and clinical presentation, a totally thoracoscopic morphological tricuspid valve replacement was performed. Postoperative assessment showed good prosthetic valve function, with no regurgitation or paravalvular leakage; the electrocardiogram confirmed sinus rhythm without atrioventricular block. Extubation occurred within 12 hours postoperatively, and the patient was transferred from the intensive care unit (ICU) on postoperative day 2. At the three-month follow-up, the patient was asymptomatic and had resumed normal activities. This report describes the first case of a totally thoracoscopic morphological tricuspid valve replacement in a ccTGA patient in China. This initial experience suggests that the totally thoracoscopic approach for morphological tricuspid valve replacement in ccTGA patients is a feasible, safe, and effective minimally invasive option associated with rapid recovery.
Objective To explore the evolving strategies and compare perioperative and long-term outcomes of tricuspid valve replacement (TVR) in recent 20 years in our hospital.MethodsBetween 1998 and 2018, the clinical data of 608 patients who underwent TVR at the Department of Cardiac Surgery, Guangdong Provincial People’s Hospital were retrospectively analyzed. There were 201 males and 407 females, with a median age of 47.0 (36.0, 57.0) years. Patients were divided into a biological tricuspid valve (BTV, n=427) group and a mechanical tricuspid valve (MTV, n=181) group. Propensity score matching was used to balance the baseline difference. Surgical strategy evolving, postoperative and long-term outcomes were analyzed between the two groups.ResultsSince 2008, the usage ratio of biological valves was significantly higher than that of mechanical valves. Seventy-nine (13.0%) patients died in hospital after TVR. Before propensity score matching, the postoperative mortality of the BTV group was higher than that of the MTV group (15.2% vs. 7.7%, P=0.012), and there was no statistical difference between the two groups after matching (10.4% vs. 7.2%, P=0.372). The duration of postoperative ventilator support in the BTV group was longer than that in the MTV group [22.0 (15.0, 37.0) h vs. 19.0 (11.0, 27.0) h, P=0.003], and the incidence of postoperative dialysis and re-thoracotomy exploring for bleeding was higher in the BTV group (8.9 % vs. 2.8%, 9.4% vs. 6.6%, respectively). However, there was no statistical difference in mortality after matching. The median follow-up time of discharged patients was 101.0 (65.0, 147.0) months, ranged from 1 to 265 months, and the follow-up rate was 82.2%. During the follow-up period, there were 101 deaths (19.1%) of whom 68 were from the BTV group and 33 from the MTV group. The survival rates at 1 year, 5 years, 10 years, 15 years and 20 years of all patients were 85.0% (95%CI 82.2-87.9), 78.9% (95%CI 75.7-82.4), 71.1% (95%CI 67.3-75.3), 59.7% (95%CI 54.2-65.6) and 51.7% (95%CI 43.3-60.7), and there was no statistical difference between the two groups after matching (P=0.46). The median time of tricuspid valve failure was 84.0 (54.0-111.0) months.ConclusionTVR is associated with high perioperative risks. There is no statistical difference in early mortality and long-term survival between biological and mechanical valve, while patients with mechanical valve has higher risk of re-operation for valve failure. Therefore, the type of prosthetic valve can be selected according to the patients' age, physical condition and the doctors’ experience.
ObjectiveTo examine the safety, efficacy and durability of totally endoscopic minimally invasive (TEMI) mitral valve repair in Barlow’s disease (BD). MethodsA retrospective study was performed on patients who underwent mitral valve repair for BD from January 2010 to June 2021 in the Guangdong Provincial People’s Hospital. The patients were divided into a MS group and a TEMI group according to the surgery approaches. A comparison of the clinical data between the two groups was conducted. ResultsA total of 196 patients were enrolled, including 133 males and 63 females aged (43.8±14.9) years. There were 103 patients in the MS group and 93 patients in the TEMI group. No hospital death was observed. There was a higher percentage of artificial chordae implantation in the TEMI group compared to the MS group (P=0.020), but there was no statistical difference between the two groups in the other repair techniques (P>0.05). Although the total operation time between the two groups was not statistically different (P=0.265), the TEMI group had longer cardiopulmonary bypass time (P<0.001) and aortic clamp time (P<0.001), and shorter mechanical ventilation time (P<0.001) and postoperative hospitalization time (P<0.001). No statistical difference between the two groups in the adverse perioperative complications (P>0.05). The follow-up rate was 94.2% (180/191) with a mean time of 0.2-12.4 (4.0±2.4) years. Two patients in the MS group died with non-cardiac reasons during the follow-up period. The 3-year, 5-year and 10-year overall survival rates of all patients were 100.0%, 99.2%, 99.2%, respectively. Compared with the MS group, there was no statistical difference in the survival rate, recurrence rate of mitral regurgitation, reoperation rate of mitral valve or adverse cardiovascular and cerebrovascular events in the TEMI group (P＞0.05). ConclusionTEMI approach is a safe, feasible and effective approach for BD with a satisfying long-term efficacy.
Objective To evaluate the efficacy of a combination of beating-heart minimally invasive approach and leaflets augmentation technique treating severe tricuspid regurgitation (TR) after cardiac surgery. Methods From January 2015 to August 2017, patients undergoing reoperative tricuspid valve repair (TVP) with minimally invasive approach and leaflets augmentation were enrolled. Cardiopulmonary bypass (CPB) was established via femoral vessels and the procedures were performed on beating heart with normothermic CPB. A bovine pericardial patch was sutured to leaflets to augment the native anterior and posterior leaflets. Other repair techniques, such as ring implantation and leaflet mobilization, were also applied as needed. Results A total of 28 patients (mean age 55.6±10.1 years, 5 males, 23 females) were enrolled. One patient was converted to median sternotomy due to pleural cavity adhesion. Twenty-seven patients underwent totally endoscopic TVP with leaflets augmentation. No patients was transferred to tricuspid valve replacement. Two patients died in hospital. All patients were followed up for 7.4±5.0 months and there was no late death and reoperation. Regurgitation area was converted from 20.7±10.1 cm2 to 3.3±3.3 cm2 after TVP according to the latest echocardiography (P<0.001). Conclusion Minimally TVP with leaflets augmentation is effective in treating severe isolated TR after primary cardiac surgery. It can significantly increase success rate of tricuspid valvuloplasty and decrease the surgical trauma.
ObjectiveTo summarize the early outcomes of totally thoracoscopic minimally invasive aortic valve replacement (AVR) and double valve replacement (DVR).MethodsThe clinical data of patients who underwent totally thoracoscopic minimally invasive AVR or DVR in Guangdong Provincial People’s Hospital from April 2020 to January 2021 were retrospectively analyzed. The patients were divided into an AVR group and a DVR group according to the surgical method, and the clinical data of the two groups were compared.ResultsFinally 22 patients were enrolled, including 14 males and 8 females with an average age of 50.0±11.2 years at operation. Eight patients were degenerative disease, 8 were rheumatic heart disease combined with valvular disease, and 6 were bicuspid aortic valve. Out of the 22 patients, 16 underwent AVR alone, and 6 underwent DVR. All patients completed the operation successfully, and there was no death. Perivalvular leakage during surgery occurred in 2 patients. The average cardiopulmonary bypass time was 187.0±39.9 minutes, and aortic cross-clamping time was 117.0 (99.0, 158.0) minutes. Duration of mechanical ventilation and intensive care unit stay was 9.5 (4.8, 18.3) hours and 41.0 (34.0, 64.0) hours, respectively. The volume of chest drainage at the first 24 hours after surgery was 214.0±124.6 mL, and the postoperative hospital stay was 5.5 (4.0, 8.3) days. The cardiopulmonary bypass time and aortic cross-clamping time in the DVR group were longer than those in the AVR group, and the volume of chest drainage at 24 hours after surgery was more than that in the AVR group, with a statistical difference (P＜0.05). Echocardiography before hospital discharge showed paravalvular leakage in 1 patient. There was no death during follow-up of 5.9±3.0 months. ConclusionThe early outcome of totally thoracoscopic minimally invasive AVR and DVR is satisfactory, and the approach of surgery is worth exploring.