CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 2, May – August 2024 AFRICA 79 characteristic. One patient underwent concomitant radiofrequency ablation due to AF. Atrioventricular block was observed in six patients (21.4%) following surgery; one patient who underwent Danielson repair eventually needed a permanent pacemaker, and five more patients recovered to sinus rhythm before discharge. Two patients experienced AF and managed medically during follow up. Renal failure was observed in three patients, and one needed haemodialysis and died of multi-organ failure. Two of three patients with bleeding needed re-exploration for pericardial tamponade. Postoperative complications are shown in Table 5. Discussion Numerous variants of EA have been challenging for the surgeon since the earliest repair techniques. Advances in techniques have improved the early and late survival of patients. It is crucial to determine an appropriate time for surgical intervention.7 The pathological process, deformity and displacement of the TV cause severe TI and RA dilatation, in addition to conduction abnormalities or atrioventricular accessory conduction pathways.8 Patients may present with different forms of arrhythmia. Studies show 17 to 30% of patients presented with tachycardia or accessory pathways.9,10 Most of the patients, except five with supraventricular tachycardia, had sinus rhythm in our study. Of the five, one patient who underwent TVR, died showing ventricular pre-excitations. Ventricular dysrhythmias appear to be lethal in postoperative patients who also have massive cardiomegaly, and are associated with poorer long-term results.11,12 Right-sided or bi-atrial maze is the best option for AF,13 but it also can be managed with radiofrequency ablation, which we preferred in one patient. Various TV repair techniques have been described and commonly include the cone technique, Carpentier repair, and modifications of the Danielson technique.1,4,5,14 Although valve replacement can be done safely, repair of the deformed TV is the goal of surgical therapy due to the risk of thromboembolism and valve failure.15,16 Even though the modern approach of cone reconstruction is safely applicable and showed favourable impact on right ventricular remodelling, it is not feasible to perform in all patients because of significant valve abnormalities such as inadequate size or attachment of the free edge of the leaflet to the ventricular wall, massive RV and PHT, and relatively older age.17-19 Our approach mainly focused on the monocusp repair technique in severely displaced anterior leaflets and plication of the atrialised RV with satisfactory survival and freedom from re-operation rates. We did not perform cone repair because of anatomical variability [left ventricular ejection fraction in two patients, presence of severe right atrioventricular dilatation in three patients, lack of septal leaflet tissue in five patients] and an inadequate learning curve due to the rarity of the procedure. Initial simplified methods did not improve the anatomical anomaly, however, we achieved satisfactory results by eliminating TI. We prefer these methods to extirpate the progressive RV failure by avoiding surgical/myocardial injury, and this approach may be preferred, especially in patients with advanced age. In the presence of severe TV annulus or RV dilatation and in the absence of a complete septal leaflet, TV replacement should be considered to reduce cross-clamp time.15,17,20 Both mechanical and biological valves were used with similar re-operation rates,15,21 but with higher survival rates in favour of a biological prosthesis.20 It is crucial not to underestimate the increased mortality and complication rate with valve replacement as a risk factor.8 As TVR is a general risk factor, our study showed no statistically significant difference in the impact of procedural intervention on survival (p = 0.094). Due to the increased interest in valve-in-valve procedures and avoidance of chronic anticoagulation, bioprosthetic valves generally were preferred, with good durability.20 Currently, early mortality rates range from 2.4 to 9%, whereas late mortality rates are reported up to 31%.14,22,23 In our study, early and late mortality rates were 10.7 and 7.1%, respectively. These survival rates are acceptable. Even the largest series reported 94, 90, 86 and 76% late survival rates at five, 10, 15 and 20 years, respectively, in patients undergoing modern cone repair.22 It would not be right to analyse the risk factors related to peri-operative mortality in our study due to limited functional assessment. However, in other studies, pre-operative RV and LV function have been accepted risk factors for mortality.22 Mitral regurgitation, RV outflow tract obstruction and more than moderate ventricular function were reported to be the predictors of late mortality.13 A slightly increased early mortality rate was observed in three patients in our study because two of the patients had pre-operative biventricular failure and the third underwent redo operation. In all cases undergoing TV repair, we had low incidence of recurrent TI, as well as good RV function in the long term. In our institutional experience, freedom from re-operation was 71.1% at 20 years (Fig. 5) and no patients required early re-operation for recurrent TI. Limitations with the design of this study are the variability of procedures performed in the repair group, and the lack of variables in echocardiographic parameters and recent modern examinations [such as magnetic resonance imaging (MRI) or exercise testing]. Despite these limitations, Table 4. Echocardiographic evaluation of the patients Parameters Pre-operative Postoperative p-value TI (degree) 3.5 ± 0.5 1.6 ± 0.6 < 0.001 PH (mmHg) 52.7 ± 12.6 41.9 ± 6.8 0.002 RA size (cm) 6.1 ± 0.6 4.4 ± 0.5 < 0.001 RVEF (%) 60.3 ± 5.8 63.8 ± 2.9 0.001 NYHA (class) 3.7 ± 0.5 1.4 ± 0.7 < 0.001 NYHA: New York Heart Association; PH: pulmonary hypertension; RA: right atrium; RVEF: right ventricular ejection fraction; TI: tricuspid insufficiency, Table 5. Postoperative complications Complications Number (%) Inotropic agents 8 (28.6) Intra-aortic balloon pump 3 (10.7) Bleeding 3 (10.7) Arrhythmia 6 (21.4) Pacemaker implantation 5 (17.9) Respiratory failure 4 (14.3) Cerebrovascular accident 1 (3.6) Renal failure 3 (10.7) Low cardiac output syndrome 3 (10.7) Infection 2 (7.1) Mortality 5 (17.9) In-hospital mortality 2 (7.1)
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