CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 2, May – August 2024 76 AFRICA = 1). The last follow up was performed by review of the results of any recent examinations at our institution in 2020. Early operative management in our centre typically includes the simpler and more familiar method, which is repair or replacement of the TV and plication of the atrialised RV, concomitant with correction of the associated anomaly. Tricuspid repair, which is the main goal of surgery, evolved through various modifications. The integrity of the anterior leaflet and the attachment location are the first steps to be checked for successful repair. Initially, correct physiological anatomy of the valve was achieved by bringing the hinge line of the septal and posterior leaflet parallel to the annulus, by transverse plication of the atrialised RV (Hunter–Lillehei–Hardy technique, n = 2). Subsequently, we carried out posterior free-wall plication of the RV and reduction of the right atrium (RA), causing a form of monocuspid valve with/ without anterior papillary muscle approximation to the septum, which was centred (classical/modified Danielson technique, n = 3/9). Later, the techniques targeted the leaflets instead of the ventricle for reconstruction of the valve. The plan was switched to re-attach the anterior leaflet to the true annulus by enforcing it with a ring. The posterior wall was longitudinally plicated to obtain sufficient coaptation (Carpentier technique, n = 3). Additionally, Kay annuloplasty, reinforcing with a flexible ring, was utilised in two patients. Valve repair without a ring was performed in patients with minimal annular dilation and less severe pulmonary hypertension. In cases of severe RV dysfunction and more severe PHT, ring annuloplasty was chosen to form annular stabilisation, avoiding inevitable redilatation with deterioration of valve repair. The repair was checked with a saline test, as well as intra-operative echocardiography. Unfulfilled leaflet coaptation can be repaired either by bicuspidisation or reshaping of the valve with a pericardial patch. Consequently, valve replacement (n = 9) with a tissue prosthesis at the level of the true tricuspid annulus was preferred when repair was not feasible. The valve tissue adjacent to the RV outflow tract was excised to avoid obstruction of the tract. A flow chart of interventions can be seen in Fig. 1. Surgical procedures are documented in Table 3. Since postoperative ventricular arrhythmias were common, we preferred to plicate or resect the thin, atrialised ventricle to maintain contractility. Precautions were typically taken on suture lines to avoid injury to the conduction system or right coronary artery. One patient underwent MVR due to severe regurgitation. Radiofrequency ablation was utilised in one patient (3.6%) with chronic atrial fibrillation (AF). Mean cardiopulmonary bypass time was 106.3 ± 30.7 minutes with a mean aortic cross-clamp time of 65.2 ± 19.5 minutes. Statistical analysis Descriptive statistics for categorical variables are given as frequency and percentage, and continuous variables as mean ± SD or median (min–max). Variables of pre- and post-operative echocardiographic evaluations were compared with either the paired samples t-test or Wilcoxon–rank sum test, as appropriate. Survival was estimated using the Kaplan–Meier method and age- and gender-matched groups were compared using the log-rank test. Analyses were performed with SPSS 15.0.1 for Windows (SPSS Inc, Chicago, IL, USA) and p < 0.05 was considered statistically significant. Results Follow up was available for 21 of the 23 survivors (91.3%) and confirmed by clinical evaluation, outside physician report or death notice. The mean age of patients was 33.7 ± 17.7 years (range: 13–54), of whom 15 (53.6%) were female. Most patients were in sinus rhythm pre-operatively. One patient was in chronic Table 1. Clinical characteristics of patients (n = 28) Patient characteristics Mean ± SD or number (%) Age (years) 33.7 ± 17.7 Gender (female) 15 (53.6) NYHA class: III 9 (32.1) IV 17 (60.7) Dyspnoea 23 (82.1) Oedema 11 (39.2) Cyanosis 5 (17.8) Palpitations 21 (75) NYHA: New York Heart Association. Table 2. Pre-operative echocardiographic evaluation of patients Parameters Number (%) or mean ± SD Echocardiographic data TR ≥ 3 PHT (mmHg) RAD (cm) RVESD (mm) RVEDD (mm) RVEF (%) Low LVEF (%) Carpentier classification A–B C–D 23 (82.1) 52.7 ± 12.6 6.1 ± 0.6 37.7 ± 11 52.4 ± 14.1 60.3 ± 5.8 2 (7.1) 23 (82.1) 5 (17.8) Associated cardiac anomalies ASD PFO VSD MR AR 10 (35.7) 1 (3.6) 2 (7.1) 4 (14.3) 3 (10.7) Arrhythmias Atrial fibrillation RBBB Supraventricular tachycardia 1 (3.6) 5 (17.8) 10 (35.7) Prior cardiac surgery MVR + TVR AVR + MVR AMK + tricuspid reconstruction 3 (10.7) 1 1 1 ASD: atrial septal defect; AR: aortic regurgitation; LVEF: left ventricular ejection fraction; MR: mitral regurgitation; PFO: patent foramen ovale; PHT: pulmonary hypertension; RAD: right atrial diameter; RV: right ventricle; RVEDD: right ventricular end-diastolic diameter; RVEF: right ventricular ejection fraction; RVESD: right ventricular end-systolic diameter; TR: tricuspid regurgitation; VSD: ventricular septal defect. Table 3. Operative data Operative data Number (%) Tricuspid valve repair Hardy Danielson/modified Danielson Carpentier Kay annuloplasty Tricuspid valve replacement ASD closure VSD closure MVR 19 (67.9) 2 (10.5) 3/9 (63.2) 3 (15.8) 2 (10.5) 9 (32.1) 11 (39.3) 2 (10.5) 1 (3.6) ASD: atrial septal defect; MVR: mitral valve replacement; VSD: ventricular septal defect.
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