Partial replacement of the tricuspid valve using cryopreserved tricuspid homograft: 20-year outcomes

Abstract

Objectives: There is limited consensus on the optimal strategy for surgical treatment of severe tricuspid valve pathology. At our institution, we have implemented a unique technique of using a tricuspid homograft with its supporting apparatus for partial replacement of the native tricuspid valve. We now present the long-term outcomes of these patients.

Methods: We analysed a cohort of patients who underwent partial tricuspid valve replacement using tricuspid homograft. Yearly clinical and echocardiographic follow-up was performed. Fine-Gray methods were used to estimate freedom from death and reoperation and reverse Kaplan-Meier methods were used to calculate follow-up.

Results: Fourteen patients were included (age range 15 days to 73 years). Indications included congenital anomalies (n = 9, 64%) and infective endocarditis (n = 5, 36%). The median follow-up was 17 years (95% confidence interval (CI) 10-21 years). Two patients (14%) died due to causes unrelated to the primary tricuspid valve surgery, and three (21%) underwent redo tricuspid valve operations. In the remaining cohort, seven (50%) were asymptomatic and two (14%) reported class II dyspnoea, while none had severe tricuspid regurgitation on echocardiogram. Estimated freedom from death was 93% at 10 years and 83% at 15 and 20 years, while estimated freedom from reoperation was 77% at 10, 15 and 20 years.

Conclusions: Partial replacement of the tricuspid valve using tricuspid homograft tissue effectively restores the anatomical conformity of the native tricuspid valve and has durable long-term survival and freedom from severe tricuspid regurgitation in patients with congenital anomalies and infective endocarditis.

Keywords: cardiac surgery; homograft; treatment outcome; tricuspid valve.

Graphical abstract

Figure 1:

Partial replacement of tricuspid valve using homograft. (A) Tricuspid valve homograft includes all its leaflets and associated papillary muscles which are prepared as per standard cryopreservation technique. (B) The homograft papillary muscle was attached to free wall and/or native papillary muscle of the right ventricle using polypropylene monofilament mattress suture buttressed with pledgets. (C) Subsequently, the homograft leaflet was sewn into the TV annulus by continuous polypropylene monofilament suture. Note—image in A taken by author BS, Image B and C reproduced under license from Beth Croce

Figure 2:

Decision-making schema for selecting tricuspid homograft for partial valve replacement

Figure 3:

Histology of dehisced tricuspid homograft tissue. Microscopy of the 2-year-old implanted tricuspid homograft revealed surface fibrin, fibrosis and neo-vascularization

Figure 4:

Cumulative subhazard for death (A) and reoperation (B) in overall cohort using the Fine–Gray method. The number at risk is shown in below the x-axis