Repair or Replace
The last factor pertaining to tricuspid valve surgery is whether to replace or repair the valve, how to repair and whether to use a bioprosthetic or mechanical prosthesis whenever we replace. Singh et al. have shown in their seminal report that tricuspid valve repair is associated with better peri-operative, midterm and event-free survival than tricuspid valve replacement, at least in patients with organic tricuspid disease. Despite more TR in the repair group during follow up, reoperation rates and functional class were similar. Thus, it is common practice that repair should be pursued whenever possible in patients with TR.25 In terms of the mode of repair, the debate continues, with most surgeons preferring placement of an annuloplasty ring because it is associated with improved survival and event-free survival compared with De Vega annuloplasties.26,27 Nevertheless, others believe that bi-cuspidisation annuloplasty is equally effective as ring annuloplasty at eliminating TR, but is simpler and less expensive.28
However, the durability of tricuspid valve repair, even when using annuloplasty rings may be limited in some patients. The Cleveland Clinic group has shown that increased preoperative tricuspid leaflet tethering height and area, low LVEF and increased RV pressure were related to worse TR during follow up, and predicted early and mid-term adverse outcomes of ring annuloplasty. Thus patients with significant tethering, significant distortion of the valve, LV and RV dysfunction or severe pulmonary hypertension may require tricuspid valve replacement to avoid long-term repair failure and adverse clinical outcomes. A recent meta-analysis tried to address the question of whether patients requiring tricuspid replacement should have a mechanical or a biological valve. Surprisingly, there were no major differences between the insertion of a mechanical or biological tricuspid valve. The reoperation rate was similar with bio-prosthetic degeneration rate being equivalent to the mechanical thrombosis rate. Conversely, up to 95 % of patients with a bio-prosthesis still received anticoagulation. Survival was equivalent between biological and mechanical valves, thus a mechanical tricuspid prosthesis is reasonable in patients less than 60 years of age who do not have a contraindication to anticoagulation, just like in patients undergoing aortic or mitral valve replacement.29