TRICUSPID VALVE REPLACEMENT IN INTRAVENOUS DRUG USERS
Alfredo Giuseppe Cerillo, MD1, Bruno Chiarello,
MD1, Manlio Acquafresca, MD2,
Valentina Scheggi, MD3, Niccolò Marchionni,
MD3,4, Pierluigi Stefano, MD1,4.
Division of Cardiac Surgery (1), Radiology (2), and Cardiology (3),
Careggi University Hospital, Florence, Italy. Department of Experimental
and Clinical Medicine, University of Florence, Italy (4)
Funding: none
Conflict of interest: none
Word Count: 1498
Correspondence to Dr Alfredo Giuseppe Cerillo, SOD Cardiochirurgia, AOU
Careggi, Largo Brambilla 3, 50139 Firenze, Italy. Phone: 00390557947022;
email: acerillo@yahoo.com.
ABSTRACT
Tricuspid valve replacement for infective endocarditis (TVE) in
intravenous drug abusers (IVDAs) may pose special clinical challenges,
since mechanical prostheses require lifelong anticoagulation therapy,
and bioprostheses degenerate over time, especially in young patients.
The Inspiris aortic bioprosthesis has been designed to reduce the rate
of structural valve deterioration (SVD) and to improve durability. We
describe three IVDAs with TVE undergoing tricuspid valve replacement
with an inverted Inspiris valve, and discuss the potential advantages of
this approach.
Background
he choice of valve prosthesis for tricuspid valve replacement in
intravenous drug abusers (IVDAs) may pose special clinical challenges,
since IVDAs are usually young, poorly adherent to therapy, and prone to
continuing drug abuse. Mechanical prostheses are rarely preferred, since
IVDAs with TVE are scarcely compliant to anticoagulation therapy. On the
other hand, bioprostheses degenerate over time, especially in young
patients (1, 2).
The Inspiris aortic bioprosthesis (Edwards Lifesciences, Irvine, Ca) is
a bovine pericardial valve with a specific anticalcification treatment
(RESILIATM) implemented to reduce the rate of
structural valve deterioration (SVD) and to improve durability. Indeed,
this prosthesis proved to be completely free from SVD at five-year
follow-up (3). We describe three IVDAs undergoing tricuspid valve
replacement (TVR) with an inverted Inspiris valve, and discuss the
potential advantages of this approach. Informed consent was obtained.
IRB approval was waived.
Case 1
A 20-year-old patient with a history of IVDA and endocarditis underwent
TVR with a Magna Ease (Edwards Lifesciences, Irvine, Ca) bioprosthesis.
At the 4-year follow-up, the prosthesis showed signs of SVD. One year
later, the patient developed dyspnea and fatigue. Echocardiography
showed severe tricuspid stenosis and regurgitation. Cardiac CT excluded
coronary artery disease (Figure 1). The patient refused oral
anticoagulants. Considering his very young age (26 years at redo
surgery) and the early failure of the previously implanted
bioprosthesis, we offered him the off-label use of an Inspiris valve.
Written informed consent was obtained.
The operation was performed through a right minithoracotomy on the
beating heart, with femoro-femoral cardiopulmonary bypass. An inverted
29 mm Edwards Inspiris valve was implanted with pledgeted Ticron
sutures. To avoid sutures’ entrapment and facilitate the prosthesis
housing, the tip of the three prosthesis struts was approximated with a
3/0 prolene suture, which was removed after tying the valve (Figure 2).
The patient was easily weaned from bypass and the operation completed as
usual.
The postoperative course was uneventful, and the patient was discharged
on postoperative day 7. At the 3-years follow-up, the patient was alive
and in good conditions. At the last echocardiogram there was no
regurgitation and the mean transprothesic gradient was 4 mmHg. Cardiac
CT excluded the presence of subclinical thrombosis and/or calcific SVD
(Figure 1).
Case 2 and 3
Following the promising results obtained with the 1stcase, we adopted the same strategy in two further patients. The first
was a 35-year-old man undergoing his fifth operation for re-infection of
the prosthetic valve with tricuspid stenosis. He had insulin-dependent
diabetes and a history of lower limb ischemia with gangrene of the left
toe. The second one was a 46-year-old woman with massive tricuspid
regurgitation and pulmonary embolism. She had acute cardiogenic shock
and was on high-dose inotropes on admission. The procedures were
successful, and both patients were discharged to a rehabilitation
facility on the 7th and 8thpostoperative day, respectively. The control echocardiogram at follow-up
(9 and 12 months, respectively) was satisfactory in both cases.
Comment
The choice of the prosthetic valve in IVDA requiring TVR is challenging,
since both mechanical and biologic prostheses have major limitations in
this population. We have observed excellent early haemodynamics in three
IVDA patients receiving an inverted Edwards Inspiris bioprosthesis in
the tricuspid position. More importantly, promising results, including
normal valve kinetics at transoesophageal echocardiogram in the absence
of calcification / thrombosis at CT, were observed in the first patient
at 3 years. Interestingly, in this same patient the previously implanted
conventional pericardial bioprosthesis had shown evidence of severe
calcific SVD as early as 4 years postoperatively.
IVDA patients with TVE are often young and scarcely adherent to the
medical therapy. As a result, the re-infection rate with the consequent
need for reoperation can be as high as 20-30%, and many of these
patients finally require valve replacement (1). In a recent report on
6815 patients undergoing valve replacement for infective endocarditis, a
history of IVDA was associated with reduced long-term survival and
higher reoperation rate, irrespective of the prosthesis type (2).
Mechanical prostheses are rarely preferred in this population, since the
management of anticoagulation therapy may be problematic. Moreover, the
reduced pressure regimen of the right heart may increases per sethe risk of valve thrombosis (4).
In recent years, several factors have promoted a wider adoption of
stented bioprostheses at younger ages. Anti-mineralization treatments
have improved durability; transcatheter valve-in-valve implantation has
reduced the number of anticipated redo procedures; and, last but not
least, young patients are well informed, and often ask for a biologic
substitutes to avoid anticoagulation and maintain an active lifestyle.
However, bioprostheses are rarely recommended in patients younger than
50, since younger age at the time of surgery is one of the main risk
factors for SVD (5).
SVD is a multifactorial process, promoted by the aldehyde moieties and
phospholipids that remain after fixation, leading to the deposition of
calcium salts in the prosthetic leaflets’ tissue (5). The
RESILIATM pericardium undergoes a phospholipids
removal process and stable capping that permanently blocks calcium
binding sites. The RESILIATM tissue was highly
effective in reducing leaflets calcification in animal models and showed
excellent performance and safety in two clinical trials, and is
currently investigated in a registry of patients younger than 60 years
(6).
In the lack of dedicated tricuspid valve substitutes, mitral
bioprostheses are implanted in the tricuspid position, since aortic
bioprostheses have a higher profile. However, the implantation of the
Inspiris valve did not require any special attention in our patients,
demonstrating the feasibility and safety of this approach. The
prosthesis was implanted as usual, with pledgetted mattress sutures on
the atrial side. At the level of the atrioventricular node, the sutures
were passed through the base of the septal leaflet to mininmize the risk
of conduction disturbances.
Even if very encouraging, our results should be interpreted with
caution, since they are derived from only 3 patients (with only one of
them with a follow-up longer than 1 year). However, the very good
haemodynamics and the absolute absence of calcium deposition at 2-year
CT imaging, along with the history of rapid-onset calcific SVD of the
previously implanted bioprosthesis in the same patient, in our opinion
support a wider adoption of the Inspiris valve in IVDAs needing TVR.
Further studies with longer follow-up are needed to validate this
strategy.
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Figure legends.
Figure 1. a: pre-operative cardiac CT demonstrating severe calcific SVD
(c). b: 2-years follo-up cardiac CT (inspiris bioprosthesis). There are
no signs of leaflets’ calcification or thrombosis and the valve is
normofunctioning (d).
Figure 2. a. The tricuspid valve is approached trough a right
minithoracotomy. After removal of the degenerated bioprosthesis, 2/0
tycron pledgetted mattress sutures have been passed through the annulus.
b. The sutures are passed upside-down in the inverted bioprosthesis. (c)
A prolene suture is passed through the tip of the prosthesis struts and
exteriorized through the prosthesis, to be cut and removed after tying
the valve (d).