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Interact CardioVasc Thorac Surg 2007;6:551-557. doi:10.1510/icvts.2007.159277 © 2007 European Association of Cardio-Thoracic Surgery
Should the tricuspid valve be replaced with a mechanical or biological valve?
a Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK Received 8 May 2007; accepted 9 May 2007
*Corresponding author. Tel./fax: +44-780-1548122.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients requiring tricuspid replacement should have a mechanical or a biological valve. Using the reported search, 561 papers were identified. Thirteen papers represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, weaknesses, results and study comments were tabulated. We conclude that there are no major differences between the insertion of a mechanical or biological tricuspid valve. Aggregating the available data it is found that the reoperation rate is similar with bioprosthetic degeneration rate being equivalent to the mechanical thrombosis rate. Conversely up to 95% of patients with a bioprosthesis still receive anticoagulation. Survival in over 1000 prostheses pooled by meta-analysis was equivalent between biological and mechanical valves.
Key Words: Tricuspid valve; Artificial valve; Thoracic surgery; Tricuspid valve replacement
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
You are about to operate on a 32-year-old i.v. drug abuser who has been under the care of your cardiologists for eight weeks with tricuspid valve endocarditis. She has successfully undergone six weeks of antibiotic therapy and three blood cultures off antibiotics have all been negative. However, she has severe tricuspid regurgitation with hepatic congestion and peripheral oedema and requires tricuspid replacement. You wonder whether to use a biological or mechanical valve.
In patients requiring a [tricuspid valve replacement] is a [mechanical valve or a biological valve] better for [long-term survival and lower morbidity].
Medline 1950–April 2007 using the OVID interface. [exp Tricuspid Valve/OR tricuspid valve.mp] AND [exp Heart Valve Prosthesis/OR valve replacement.mp. OR exp Heart Valve Prosthesis Implantation/] AND [survival.mp OR outcome.mp OR mortality.mp] LIMIT to Human/english.
A total of 561 papers were found of which thirteen papers were relevant (Table 1).
The published series are few and are limited by small sample size, often spanning from the 1960s through 1990s. We identified thirteen papers which have compared both biological and mechanical valves in the tricuspid position including a meta-analysis. The meta-analysis by Rizzoli et al. [2] comparing 646 biological and 514 mechanical prostheses from 11 studies did not find a difference in the early and late survival, or reoperations. The meta-analysis included series starting in the 1960s and included patients with first-generation valve prostheses. Among 391 patients discharged with mechanical prostheses, the pooled 1-, 5-, 10-, and 15-year survival of the hospital-discharged patients was 86.9%, 73.5%, 60.2%, and 47.8%, respectively; among 477 patients discharged with tricuspid bioprostheses, survival was 86.5%, 73.6%, 62%, and 46.7%, respectively. Five-year survival was identical. Differences were trivial, favouring mechanical prostheses at 1-year and at 15-year, favouring biological prostheses at 10-year. The median incidence of mechanical tricuspid valve thrombosis reported in the meta-analysis was 1.28% patient-years. There was a large variability in the incidence of thrombosis reported in these series. The series of Ratnatunga [3] and Farinas [4] report the lowest incidence; Do [5] and Carrier [6] report the highest. The series of Ratnatunga [3], Farinas [4], and Munro [7] reported lower incidence of structural valve deterioration; Do [5] and Carrier [6] reported the highest. Overall, 21 mechanical valve thromboses and 37 deterioration episodes were reported in the meta-analysis. The incidence rate of thrombosis was 0.87% patient/year (in comparison to MVR: 0.54%/patient-year and AVR: 0.33%/patient-year) and the incidence of valve deterioration was 1.02% patient/year. The difference was not significant (P=0.25). The risk of reoperation reported was 4.7%/patient-year for bioprostheses and 2.2%/patient-year for mechanical prostheses. Filsoufi [8] reported 81 cases of tricuspid valve replacement of which 34 were biological and 47 were mechanical, (25 isolated). They had an overall mortality of 22%. The common cause of death was heart failure in both early and late death. Survival at 2.5, 5 and 10 years for biological prostheses were 80%, 60% and 45%, and 84%, 69% and 59% for mechanical prostheses. There was no clear superiority of one prosthesis over another. Carrier et al. [6] reported 97 patients with tricuspid valve replacement, of which 82 were biological and 15 were mechanical. Mortality in the biological group was 17% and 20% in the mechanical group. Congestive heart failure was the most significant cause of long-term death. One- and 5-year survival rates were 67±5% and 56±6% with bioprostheses and 60±13% and 60±13% in the mechanical group. They favoured biological prostheses. Kaplan et al. [9] reported 122 patients with tricuspid valve replacement, which included biological prostheses in 32 patients and mechanical prostheses in 97 patients. Early mortality was 24.5% and 9.7% late mortality. Mean survival time was 159±19 months for mechanical prostheses and 85.7±12.1 months for biological prostheses. They recommend mechanical valve prostheses. Dalrymple et al. [10] reported 87 patients with tricuspid valve replacement of which 53 were biological and 35 were mechanical. They reported an early mortality of 10.3% which is the lowest of all the papers documented. Six mechanical valves needed re-operation, five for prosthetic valve thrombosis and one for mechanical failure secondary to pannus formation. Five biological prostheses needed re-operation, two for prosthetic valve endocarditis and three for prosthetic valve degeneration. They recommend the use of biological prostheses because of its initial durability and low re-operation rate. Ratnatunga et al. [3] from the United Kingdom did a retrospective UK Heart Valve registry study of all the valves done between 1986 to 1997 and reported 425 patients with tricuspid valve replacement (225 biological and 200 mechanical). Early mortality was 17.3% and mortality for biological was 18.6% and 15.6% for mechanical prostheses. One-, 5- and 10-year survival was 70.5%, 61.5% and 47.7% for biological prostheses and 74%, 57.9% and 33.9% for mechanical prostheses. The remaining studies which were tabulated, didn't find any difference between the prostheses. In summary, two series recommend biological prostheses and one series recommends mechanical prostheses. The overall mortality for TVR ranged from 10.3% to 27%. Most of these studies did not find any superiority between the prostheses used. Rizzoli et al. [2] made the following observations after their meta-analysis. ‘(1) Tricuspid position is no exception to the rule that patients more than 65–70 years obtain the largest advantage from bioprostheses and younger patients from mechanical prostheses. (2) The extent and the severity of cardiac disease might suggest, in some cases, a limited expectation of life and, therefore, might favour the use of biological prostheses in younger patients, as concluded by Carrier et al. [6]. On the other hand, concomitant use of left-sided mechanical prostheses favours the same valve for the right heart. (3) Small-size patients with small right ventricles may benefit from the superior haemodynamics of the low profile bileaflet valve as opposed to the ‘largest’ bioprostheses, which is prone to develop mural cusp pannus and thrombosis. (4) Rizzoli et al. [2], in their study found that 97% of living patients with biological tricuspid prostheses receive anticoagulant treatment, making the need for anticoagulation an unreliable choice of valve type’.
There are no major differences between the insertion of a mechanical or biological tricuspid valve. Aggregating the available data it is found that the reoperation rate is similar with bioprosthetic degeneration rate being equivalent to the mechanical thrombosis rate. Conversely up to 95% of patients with a bioprosthesis still receive anticoagulation. Survival in over 1000 prostheses pooled by meta-analysis was equivalent between biological and mechanical valves.
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Abstract
1. Introduction
