|Home | About | Journals | Submit | Contact Us | Français|
The decision to proceed with triple-valve surgery should take into account reasonable estimates of the risk of the surgery and of the potential benefit to be gained. In the present study, we reviewed our experience with triple-valve surgery, focusing on short-term death and morbidity, mid-term survival, and postoperative quality of life.
Among 107 patients with multiple-valve disease who underwent triple-valve surgery at Tehran University Heart Center from January 2002 through December 2007, 100 patients with complete, recorded data were entered into the study. Demographic and clinical characteristics and in-hospital postoperative complications were considered. Among 66 patients whose mid-term operative outcomes we were able to determine, these results were evaluated, together with their quality of life, during a mean follow-up period of 45.0 ± 12.4 months.
In-hospital mortality and morbidity rates were 5% and 61%, respectively. The Kaplan-Meier survival rate for the 66 monitored patients was 82.6%. Freedom from readmission was 77.3%, and freedom from rehospitalization was 89.4%. Freedom from thromboembolism was 87.8%, and freedom from anticoagulant-related hemorrhage was 91.3%. In the quality-of-life assessment, suitable physical and social activities were reported in 65.1% and 60.6% of patients, respectively. Although 63.6% of patients were satisfied with the results of the operation, only 51.5% were able to continue their work.
Despite patients' satisfaction with early outcomes of triple-valve surgery and their acceptable mid-term survival rates, the improvement of quality of life after surgery is still far from ideal.
The medical, interventional, and surgical management of patients who have combined valvular disease is guided by the relative severity of each individual lesion and by the severity of concomitant nonvalvular myocardial disease. Indeed, the severity of all coexisting lesions must be fully understood before deciding for or against a specific form of therapy, because coexisting lesions can seriously complicate cardiac surgery or prevent the expected postoperative improvement.1 The need to replace or repair more than 1 valve should be known in advance, and the decision to proceed should take into account reasonable estimates of the risk of surgery and of the potential benefit to be gained. Single-valve replacement can usually be performed with an acceptable in-hospital mortality rate of less than 5%, but triple-valve replacement has an in-hospital mortality rate of 19%.2 Early in the experience with triple-valve surgery, the mortality rate was 20% for patients in New York Heart Association (NYHA) functional class III and 40% for patients in class IV.3
Triple-valve surgery is a long and complex operation. Although patients who undergo this type of surgery can show substantial clinical improvement during the early postoperative period, reported results of early outcomes have varied.4–6 In the present study, we reviewed our experience with triple-valve surgery with a focus on short-term mortality and morbidity rates, mid-term survival, and patients' postoperative satisfaction and quality of life.
Study Population. From January 2002 through December 2007, 107 consecutive patients with multiple-valve disease underwent triple-valve surgery at Tehran University Heart Center. Seven patients were excluded from the study because their recorded information was incomplete. From the records of the remaining 100 patients, we compiled the preoperative, operative, and postoperative variables, reviewed them, and transcribed them into a computerized database.
The variables for analysis were demographic characteristics, preoperative risk factors, cardiac status, operative details, early postoperative complications, and in-hospital mortality and morbidity rates.7 All patients underwent Doppler examinations at our institute, including transthoracic echocardiography (TTE), to determine the type of valve disease according to Carpentier's classification8 and to evaluate it for possible repair.
Surgical Techniques and Postoperative Anticoagulation Therapy. All operations were performed through a median sternotomy with the patient on standard cardiopulmonary bypass. Myocardial protection was achieved with the administration of cold crystalloid cardioplegic solution or cold blood. Heparin was infused intravenously for 24 hours, beginning immediately after the operation. After the suspension of heparin, the prothrombin time was checked and if it exceeded 16 seconds, warfarin was administered until the drug reached therapeutic concentrations. Warfarin was then continued throughout the patient's life. The Thrombotest level was kept at around 0.20 or the prothrombin time at 2.0 to 2.5 the time of the control value.
Follow-Up. Mid-term outcomes were determined from clinic records when available or by means of written correspondence with patients' physicians and telephone interviews directly with the patients or with family members. Follow-up data, collected by our research personnel, were completed for 66 of the 100 patients. The mean follow-up duration was 45.0 ± 12.4 months (range, 1 mo–5 yr). Related data—pertaining to patients who had been referred to our hospital from clinics or other hospitals throughout the country—involved follow-up on their adherence to outpatient treatment protocols, on rehospitalizations, on mid-term survival, and on their lifestyles during the follow-up period.
For the evaluation of postoperative self-perception of health and quality of life, we used a self-administered questionnaire that consisted of 4 queries, concerning the patient's physical activity, social functioning, satisfaction with the operation, and ability to continue working. Suitable physical activity was defined as the performance of routine activities with little or no physical difficulty. Suitable social functioning was defined as good social relationships with relatives and friends and participation in social programs.
Statistical Analysis. Descriptive statistics were reported as mean ± SD for continuous variables and as absolute frequencies and percentages for categorical variables. Survival rate was determined by using the Kaplan-Meier method.
Demographic characteristics and preoperative clinical data are shown in Table I. The mean age of patients was 47.4 ± 12.2 years (range, 12–73 yr), and about one third of the 100 patients were male. Most patients in our study group had a history of congestive heart failure (mean NYHA functional class, 2.57 ± 0.86). More than one third of these patients suffered preoperatively from various types of cardiac arrhythmia. The mean left ventricular ejection fraction (LVEF) was 0.48 ± 0.07; most patients had an LVEF of between 0.40 and 0.59.
Table II lists the diseased valves by type of presentation, the most common of which was regurgitation. As shown in Table III, the most common disorder of aortic and mitral valves was rheumatic valve disease. In contrast, the most common tricuspid valve disorder was functional regurgitation secondary to left heart disease, followed in incidence by rheumatic valve disease.
The severity of valvular regurgitation is shown in Table IV. Moderate insufficiency was the most common finding among the 3 types of valves. According to the echocardiographic reports, the mean left ventricular end-diastolic diameter was 49.0 ± 7.6 mm, and the mean left ventricular end-systolic diameter was 34.0 ± 8.8 mm.
The operative variables for all patients are listed in Table V. Among these variables, aortic and mitral valve replacements were performed in 98% and 57% of patients, respectively, and more than half of the patients underwent tricuspid annuloplasty. The most frequent type of triple-valve surgery was the replacement of aortic and mitral valves, accompanied by tricuspid repair. Thirty-five percent of patients underwent concurrent coronary artery bypass surgery; other additional procedures were rarely found in our search. In 7% of the patients, surgery was performed on an emergency basis. Among all triple-valve surgeries performed in our center during this time, there were no instances of pulmonic valve replacement or repair.
Among the 100 patients in our study group, there were 5 in-hospital deaths—4 because of cardiac arrhythmia and 1 because of multiorgan failure and sepsis. The postoperative morbidity rate was 61%. Five patients required re-intubation during their stay in the intensive care unit. Other morbid conditions included atrial fibrillation (AF) in 51 patients (those who had preoperative AF continued to have AF after surgery), renal failure in 5 patients, heart block in 20 patients, and pulmonary emboli in 1 patient. Other complications, such as cerebral stroke and pulmonary embolism, did not occur in the study patients.
At 45.0 ± 12.4 months of follow-up for the 66 patients whose outcomes we were able to determine, there were 2 mid-term deaths: 1 from congestive heart failure and the other from sudden death of unknown cause. The mid-term survival rate was 82.6% (Figs. 1 and and2).2). Thromboembolic events occurred in 12.2%, and anticoagulation-related hemorrhage was confirmed in 8.7%. The outpatient follow-up rate among the 66 patients whose outcomes we were able to determine was 22.7%, and the rehospitalization rate was 10.6%. All rehospitalized patients underwent reoperation. In the assessment of quality of life, suitable physical and social activities were reported in 65.1% and 60.6% of the 66 patients, respectively. In addition, 63.6% of the 66 were satisfied with the operation. However, only 51.5% were able to continue their work.
Management of multiple-valve disease of various origins can be quite challenging and is the subject of ongoing controversy. In order to establish operative procedures for triple-valve disease and to improve the outcomes of surgical therapy, we need to consider the results of these procedures. In the present study, we tried to describe our experiences with triple-valve surgery in a consecutive series of 100 patients who suffered from triple-valve diseases; we were able to obtain mid-term follow-up on 66 of these patients.
Review of recent studies of early and late results of triple-valve operations indicates that in-hospital mortality rates range from 2.5% to 20% and that late mortality rates (during follow-up of 5–10 years) range from 4.7% to 31.2% (Table VI).4–6,9–15 Most of these studies confirm that triple-valve surgery offers satisfactory short- and mid-term results and improves patients' quality of life. However, some studies, perhaps due to small sample size, reported no sequelae, such as thromboembolic events and anticoagulation-related hemorrhage.11,15
In our present study, early and late mortality rates were 5% and 3%, respectively, which falls within the range of previously reported results.4–6,9–15 According to the results of some studies,10,14 the most common predictors of high long-term mortality rates among patients undergoing triple-valve surgery are a history of renal failure or peripheral vascular disease, a high NYHA functional score, and a low LVEF. In our study, the incidences of preoperative renal failure and peripheral vascular disease were quite low, and LVEFs in most of our patients were within the normal range. Furthermore, only 17% of our patients were in NYHA functional class IV. These factors might account for the low long-term mortality rate in our study, in comparison with those of previous studies. In addition, most of our patients were comparatively young. Advanced age is associated with decreased physiologic reserve and increased comorbidity.9 As a result, we believe that operation at younger ages may be advantageous for better surgical outcomes. This could be the main reason for the better survival rate in our complex group of patients.
Although the quality of life in patients who have undergone heart valve surgery has been investigated before, few studies have evaluated the lifestyles of patients who have undergone triple-valve surgery. In our study, only two thirds of all 66 patients who underwent mid-term follow-up had acceptable levels of physical and social activity; more than half of the 66 were able to continue their work. In a study by Lunel and colleagues,16 in which 67.9% of patients returned to their jobs after valve surgery, the main factors associated with failure to return to work were age greater than 50 years, a high NYHA functional score, and a long hiatus from work before surgery. Another study17 found that preoperative employment status was the single most important factor for postoperative return to work. We also believe that the rate of return to work and the overall quality of life after triple-valve surgery may, to a large degree, be dependent upon fear of unemployment and of the loss of insurance support; this is a topic that should be investigated further. Other influential factors that should be considered in further studies are the patient's lifestyle, occupational status, mental health, neighborhood and physical environment, and perception of health benefits.
Ours was a retrospective study, except for those aspects of follow-up that involved contacting patients by telephone. Because our hospital is a referral center for cardiology and cardiac surgery that admits patients from all over the country, we were able to perform mid-term follow-up on only 66 of the 100 patients in our study group. Any future study would benefit from greater sample size and more complete follow-up data.
We conclude that despite improvements in early and mid-term outcomes of triple-valve surgery during recent years, the improvement in patients' quality of life after surgery is still unsatisfactory. Consequently, the design and implementation of lifestyle-improvement programs among these patients are needed.
The authors would like to thank both the interviewers from Tehran University of Medical Sciences who collected the information and the participants who gave their time to the study.
Address for reprints: Saeed Davoodi, MD, Tehran Heart Center, Tehran University of Medical Sciences, North Kargar Street, Tehran 1411713138, Iran. E-mail: gro.retnectraehnarheT@idoovaD
This research project has been supported by Tehran University of Medical Sciences.