Risk Factors for Development of Tricuspid Regurgitation after Heart Transplantation and Long-term Outcome of Tricuspid Valve Surgery

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1 Risk Factors for Development of Tricuspid Regurgitation after Heart Transplantation and Long-term Outcome of Tricuspid Valve Surgery Roland Hetzer Anja Claudia Baier Eva Maria Delmo Walter 29 April 2015

2 Background Tricuspid valve regurgitation has been observed as a postoperative complication after orthotopic heart transplantation. Its incidence has been reported at a rate up to 84%. During the last 20 years, it has been attributed to biatrial anastomosis technique; hence the bicaval anastomosis technique has been preferred and become routine. In our experience, tricuspid regurgitation has remained infrequent even with biatrial anastomosis. Objectives This report aims to identify predisposing factors which promote the development of tricuspid regurgitation (TR) after heart transplantation. Likewise, it aims to evaluate outcomes of tricuspid valve surgery for post-transplant TR. AATS 2015 Post-transplantation TR/Seattle

3 Patient Selection Between 1986 and heart transplantations on 1748 patients 1552 heart transplantation performed with biatrial anastomosis 252 heart transplantations with bicaval anastomosis 86 patients developed TR III/IV 31 patients underwent TV surgery All had heart transplantation with biatrial technique 1 patient was lost to follow-up Group I: 30 patients Tricuspid valve surgery Follow up after TV-surgery Comparison Perioperative data Echo results Clinical performance Catheter findings DHZB TR after heart transplantation Seattle, April 28th patients medically managed successfully Group II: Control 30 patients matched for: Underlying disease Age Gender Anastomosis Transplantation date TR 1 3

4 Overall survival post-transplantation AATS 2015 Post-transplant TR Seattle

5 Perioperative transplantation data of recipients and donors No significant differences AATS 2015 Post-ttansplant TR Berlin

6 Significant differences Number of biopsies Number of rejections AATS 2015 Post-transplant TR Berlin

7 Clinical status Signs of right heart failure DHZB TR after heart transplantation Seattle, April 28th

8 Data of 30 patients who underwent tricuspid valve surgery TR III-IV was diagnosed at a median of 6.8±6 ( ) years after heart transplantation. Tricuspid valve surgery was performed at a median of 1.6±4 (0-15.6) years after diagnosis. DHZB Titel der Präsentation Berlin

9 Operative data of 30 patients who underwent tricuspid valve surgery Leaflet and chordal damage were found in 25/30 patients (1 with TV endocarditis) Annular dilatation/distortion in 5/30 Concomitant procedures: coronary bypass graft (n=6) pulmonary lobe resection (n=2) coronary fistula closure (n=2) VSD closure (n=1) Mitral valve replacement (n=1) AATS 2015 Post-transplant TR Seattle

10 Number of Biopsies after Heart Transplantation Deutsches Herzzentrum Berlin ,471 heart biopsies [n] '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 HBx DHZB Titel der Präsentation Berlin

11 Tricuspid valve surgery Mechanical valve replacement in 8/30 Xenograft valve replacement in 7/30 Reconstruction in 15/30 Modified devega annuloplasty: 8 Double orifice valve: 3 Kay Wooler annuloplasty: 1 Cosgrove Edwards ring: 1 Chordal and leaflet repair: 2 DHZB Titel der Präsentation Berlin

12 Outcome of tricuspid valve surgery In-hospital deaths: n=6 (20%) after TV replacement (2 mechanical, 2 xenograft) and TV repair Causes of death: cardiac failure (2), sepsis (3), myocardial infarction (1) One retransplantation on the 1st postop day after mechanical valve replacement and coronary bypass grafting. Renal function improved in 3 patients and deteriorated in 9 Significant improvement of edema and ascites after 1 year Median postoperative survival was 3.47 years (3d yrs) Recurrent TR > II was seen in 6 (4 repair and 2 replacement) Long term complications: mechanical valve thrombosis (n=1), xenograft valve endocarditis (n=1) AATS 2015 Post-transplant TR Berlin

13 Survival after TV Surgery AATS 2015 Post-transplantation TR Seattle

14 NYHA Functional Class after tricuspid valve surgery AATS 2015 Post-transplant TR Berlin

15 Conclusions The number of biopsies and rejections were the only predisposing factors for TR after heart transplantation in this series. There was a very low incidence of TR which could be attributed to distortion of TV geometry in biatrial anastomosis. Tricuspid valve surgery improves symptoms of right heart failure. Early mortality is high, but long-term survival has been observed. AATS 2015 Post-transplantation TR Seattle

16 Thank you for your attention!

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