Tricuspid Valve Replacement

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Introduction

The tricuspid valve is a tri-leaflet conduit between the right atrium and the right ventricular. Its leaflets can be damaged or diseased, and they may not function as expected. The valve’s importance is to provide the pressure required to move blood through to the right atrium and, ultimately, the pulmonary system (1, 3).  

Three main issues can occur with the tricuspid valve: atresia, regurgitation, and stenosis. Medical treatment is the initial treatment for mild to moderate tricuspid valvular conditions; however, surgical interventions are required to prevent complications from the cardiac system having to overcompensate for the dysfunction of the right heart. Symptoms typically worsen over time, progressing from fatigue and weakness to hepatic involvement, palpitations, and edema (1, 2). 

History/Background 

As heart surgery advanced with innovative treatments and improved outcomes, valve management expanded beyond medical therapy. The tricuspid valve is the most difficult to treat, with the highest mortality rates. Traditionally, repairs were attempted for moderate valve disease; however, surgical replacement is required for severe valvular heart disease. For 1.6 million Americans who are affected by mild to severe tricuspid disease, the only option was surgery to repair or replace the valve in conjunction with medical management (8).  

Valve repairs had been successfully executed since the 1920s; however, valve replacement was impossible until the heart-lung bypass machine was developed. With this innovative medical advancement, open heart surgery became a reality. The first mechanical valve repair occurred in 1952 at Georgetown University (7).  

The first mechanical valve was designed as a tube with a ball inside to block the opening when pressure decreased. Towards the end of the decade, advances were made with the ability to utilize donor grafts. There are two types of biological grafts, made of harvested tissue. An allograft is garnered from a deceased human donor, while a xenograft is a prosthesis that is obtained from pig or cow tissue (7). 

Until 2020, replacing the tricuspid valve required open heart surgery. Another option available to patients with higher surgical risks or who have already had a sternal approach is transcatheter tricuspid valve replacement. This minimally invasive approach decreases the recovery time, reduces infection risk, and may be an alternative for patients when surgery is contraindicated (8). 

General Information 

Tricuspid valve replacement is considered a high-risk procedure as these patients are often medically complex with comorbidities that carry their own risk of morbidity and mortality. Most patients that undergo the risk are because valve repair has already been attempted and resulted in complications such as right ventricular dysfunction (5). Long-term studies have shown superlative outcomes with valve replacement over repair for survival rates and function of the tricuspid valve (10). 

Tricuspid valve surgery inherently carries a higher risk of thromboembolic manifestations when mechanical devices are used. This risk is higher when hypokinesis of the right ventricle is present. On the other hand, biological prostheses are prone to tissue dysfunction and rapid degeneration in younger patients. Older patients who develop carcinoid syndrome or have renal failure have an increased risk of prosthesis degeneration as well. Cardiovascular surgeons often attempt to repair the tricuspid valve rather than replace it, as it can reduce the need for long-term anticoagulation therapy (5).  

Guideline-directed medical therapy may manage symptoms without intervention until they are intolerable to the patient. When symptoms become severe, stages C and D, there are limited options for adequate treatment unless repair or replacement is attempted (15). Research has shown the benefit of continued medical therapy in combination with tricuspid valve replacement. This group showed improved clinical outcomes and had an overall lower rate of any cause of mortality (8). 

Specific comorbidities have been found to coincide with tricuspid dysfunction. These include hypertension, hyperuricemia, cerebrovascular disease, and certain arrhythmias. Common arrhythmias include complete atrioventricular block, atrioventricular nodal reentrant tachycardia, sick sinus syndrome, and atrial fibrillation (10). 

Pathophysiology 

The cardiac system has four valves separating the four chambers of the heart: tricuspid, pulmonic, mitral, and aortic. As blood flows from the body, it first passes through the tricuspid valve between the right atrium and the right ventricle. It then moves from the right ventricle to the pulmonary arterial system via a pulmonic valve. Once blood returns to the lungs to the heart, it veers through the mitral valve between the left atrium and ventricle. It finally passes through the aortic valve as the flow continues through the arterial system to transport oxygen and nutrients to vital organs and the peripheral system (2). 

The tricuspid valve is the largest of the four cardiac valves and consists of three leaflets: septal, anterior, and posterior. It may also be referred to as the correct atrioventricular valve. With tricuspid dysfunction, there may be anomalies in the shape or number of leaflets. Approximately 40% of patients have more or fewer leaflets than expected, at times up to 6 (17). Three main conditions affect the tricuspid valve: atresia, regurgitation, and stenosis. 

Tricuspid atresia is a congenital cardiac defect where the infant is born without a tricuspid valve. Congenital heart disease affects approximately 81 per 10,000, with tricuspid atresia being the third most common cyanotic congenital heart disease. It occurs at a rate of about 1.2 live births per 10,000 (4). Surgery is required within the first year of life as the mortality rate is exceptionally high without treatment.  

This heart defect is categorized as cyanotic, as blood flow is restricted, limiting the amount of blood that can flow through to the right ventricle (1). The function of this valve is halted due to the formation of a muscular dimple within the right atrium. It may also involve fusions between the leaflets, causing membranes to develop where the flap should move freely, thereby restricting movement (4).  

Tricuspid regurgitation may occur as a primary or secondary disorder. The abnormal anatomy of the tricuspid valvular apparatus defines the primary category. Secondary is due to dilatation of the right atria or ventricle. This is the most common cause of tricuspid regurgitation seen in adults, with imaging noting that the valvular construction is intact. In addition to the right atrium or ventricular dilatation, this disorder may also be caused by dilatation of the tricuspid annulus or tethering of the tricuspid valve leaflet (1, 12).  

Pulmonary hypertension is a factor as rising proper ventricular systolic pressures lead to the cavity enlargement of the right ventricle and dilatation of the annulus. Thus, the tricuspid leaflets cannot adapt to the structural modifications. Specific cardiomyopathies that lead to pulmonary hypertension include hyperthyroidism, atrial fibrillation, pulmonic valve stenosis, and left-sided heart disease (13). 

In tricuspid stenosis, the valve is narrowed or impeded. This may occur in conjunction with regurgitation. The right atrium enlarges as the blood flow is restricted and proper ventricular pressures are low. This prevents blood from circulating to the lungs to deliver oxygen (1). 

 Overwhelmingly, the cause of tricuspid stenosis is due to rheumatic fever. Other causes may be carcinoid syndrome, systemic lupus erythematosus, infectious vegetation, and congenital defects. Involvement of the mitral valve is commonly seen to coincide with rheumatic heart disease.  

It can also be the result of implantable cardioversion/defibrillation leads becoming fused to the subvalvular structures in the presence of continuous pacing. Regardless of the root cause, the effects are unbalanced pressures between the right atrium and right ventricle with accompanying systemic fluid overload (14).  

For patients with particular characteristics, such as post-lead implantation of a cardiac implantable electronic device, multivalvular disease, and left heart failure, the presence of tricuspid regurgitation is correlative to poor outcomes and increased mortality. If left untreated, follow-up at 1, 2, and 4 years has respective mortality rates of 30, 50, and 70% (17). 

Signs and Symptoms 

The signs and symptoms of tricuspid valve dysfunction may vary depending upon the severity of clinical presentation. Mild tricuspid atresia or regurgitation dysfunction may cause fatigue, heart murmurs, palpitations, and chest discomfort or pain. These may be managed with medications such as diuretics, anti-arrhythmics, and treatment aimed at alleviating heart failure. 

Valve disease is staged, and treatment will differ, requiring increasingly aggressive treatment to manage symptoms as it progresses. The four categories and characteristics of valvular dysfunction are described as follows (all from 15): 

• Stage A – The patient has risk factors for valve disease by being asymptomatic, 
• Stage B – Present disease is mild to moderate but not causing symptoms. 
• Stage C –  Heart valve disease is severe, but the symptoms are managed.  
• Stage D – Valve disease is severe, as is the source of symptoms. 

As the patient progresses to Stage D, symptoms are caused by right-sided heart failure that inevitably occurs. Symptoms can include the following: 

• Low cardiac output, especially during exertion 
• Shortness of breath and dyspnea 
• Elevated jugular venous pressure 
• Pleural effusions 
• Ascites 
• Edema 
• Arrhythmias 
• Fatigue 
• Chest pain 
• Dizziness and syncope 
• Hemoptysis 
• Cyanosis 

Diagnostic Testing and Evaluation 

The patient’s clinical presentation guides treatment. Regular follow-ups will monitor for changing signs or symptoms. Patients with valvular disease should be educated to notify their primary care provider of increasing symptoms or feeling unwell that cannot be attributed to any other disease process or event.  

A thorough history and physical will develop the patient’s baseline and symptom presence and determine if the disease has progressed to signs that align with valve dysfunction and heart failure. The healthcare team will also want to establish a baseline electrocardiograph reading to record cardiac electrical activity and assess for cardiac arrhythmias that may be currently present. This will also assist with determining the effectiveness of treatments or medicinal therapy (15). 

The first test typically used to assess valvular dysfunction is transthoracic echocardiography (TTE). This will reveal the valve chambers’ functionality, size, shape, and severity based on their effects on pulmonary and systemic blood flow.  

Further testing may include a chest X-ray. This is especially important for patients who have developed symptoms. This imaging will show the heart size, pulmonary involvement via the presence or absence of pulmonary vascular congestion, and visualization of the pericardium or aorta calcifications. 

A transesophageal echocardiogram (TEE) is a diagnostic ultrasound that can produce intricate heart images. This differs from a TTE as rather than imaging from outside the body, through the chest, a slender wand with a small transducer is passed through the oral cavity into the esophagus. This allows imaging with greater detail and captures the posterior of the heart. Doppler ultrasound and color Doppler are adjunctively used for improved visualization of blood flow through the chambers.  

A TEE may also identify any abnormal masses, anomalies in structure, or other abnormal findings, such as atrial thrombus, especially within the left atrial appendage that is prone to restrictive flow or any intracardiac abscesses (15) 

Cardiac magnetic resonance imaging (MRI) is an alternative method for evaluating left ventricular volumes and function, aortic disease, or severity of valve malfunction. For imaging that would identify vegetation, infection, or inflammation as a possible cause or reason for symptom exacerbation, a Positron Emission Tomography (PET) is the gold standard if there is exertional dyspnea only as a symptom, a nuclear stress test may be ordered to assess for exercise capacity.  

The healthcare team may order a right heart cardiac catheterization to evaluate valves more closely. This diagnostic study uses a femoral or radial approach to guide a catheter to the superior vena cava and into the cardiac chambers for hemodynamic monitoring, visualization of the chamber with fluoroscopy and contrast, and evaluation for pulmonary pressures.  

Diagnostic testing via cardiac catheterization in Stages A and B shows no clinically or diagnostic significant changes in cardiac pressures or discernable symptoms. Stage C elicits hemodynamic changes in a dilated right ventricle (RV) and right atrium (RA). The waveform for the RA will be elevated with a “c-V” wave. Symptoms that coincide with these findings include elevated venous pressures; however, the patient does not exhibit any symptoms. With Stage D, the hemodynamic monitoring will be similar to Stage C, yet the patient will be considerably more symptomatic. Common clinical symptoms and presentation include elevated venous pressures, dyspnea on exertion, edema, ascites, and fatigue (15). 

Suppose the decision is made to proceed with surgery. In that case, testing specific before valve intervention includes dental examination, which will rule out possible sources of infection so that this may be treated and reduce the risk of postoperative complications. Further CTs and other diagnostic testing will be done to assess chamber and valve measurements to select the correct sizing for mechanical or biological prosthetic placement.  

Types of Surgeries/Procedures 

Open Heart 

Open heart surgery is a major medical procedure that is performed under general anesthesia. The chest is surgically opened, exposing the sternum. A sternotomy is performed, cutting through the breastbone and separating to open the chest, revealing the heart and lungs. Blood flow is bypassed via a cardiopulmonary bypass pump. This biomedical equipment is operated by a healthcare provider called a Perfusionist.  

Venous blood is removed from the patient to a reservoir that oxygenates and filters. The oxygenated blood is then returned to the arterial system for the perfusion of organs while the heart is kept in stasis (9). Bypass perfusion is established via the ascending aorta with drainage from the bicameral or right atrium. Hypothermia may be induced if clinically indicated.  

Hypothermia is the induction of a body core temperature below 35 ° C. It is used in cardiac surgery to prevent ischemic injury of organs and the central nervous system. This is accomplished by decreasing oxygen consumption and energy demand, which leads to decreased cellular metabolism (11). A circulatory arrest can be achieved by slowing the metabolic system required to perform complex cardiac surgery. 

A secondary open approach is to incision through the right thoracic cavity. This is referred to as a lateral thoracotomy, creating a window to the patient’s chest cavity. A heart-lung bypass is still required. As a smaller area is opened, operative time, bleeding risk, and chest tube insertion time are lessened. There are fewer complications, and the post-surgical intensive care unit days of admission were reduced (4, 5).  

Transcatheter  

Transcatheter tricuspid valve replacement is an alternative treatment that is less invasive and has a shorter recovery time than the open heart approach. Instead, the introduction site for catheters to deploy this device may be transfemoral, trans jugular, or transatrial. After approximately 10 years of trials and studies, this approach is becoming more common at extensive medical facilities.  

A range of different types and companies provide these valve devices with up to 90% success. There are some downfalls to this approach, such as, depending on the manufacturer, higher rates of success with severe tricuspid regurgitation versus mild, as well as high mortality rates in hospitals. The rate of conversion to surgical intervention was as high as 5%. All devices available for a transcatheter approach are mechanical (17). 

Types of Valves 

At five years, there was no statistical difference in failure rate between the bioprosthetic and mechanical valves. There was also noted to be no difference in the need for reoperation between the two valves (5). After five years, some studies suggest mechanical valves are more likely to fail than bioprosthetic valves. In the past, mechanical valves were connected to electric disturbances and arrhythmia, such as atrial fibrillation.  

With bioprosthetic valves, both porcine and bovine are prone to critical tears and stenosis due to calcification and leaflet thickening. This occurs more often with porcine than bovine. It is also more likely that these patients receiving a bovine or porcine valve will require pacemaker insertion (5). 

Mechanical valves require long-term anticoagulation due to a higher risk of thromboembolic events. The need for blood thinners also leads to a higher risk of gastrointestinal and cerebral bleeding overall. It is recommended that the patient receiving mechanical valves be placed on optimal anticoagulation therapy with close monitoring to prevent complications (5). 

Risk and Complications 

The primary risks associated with tricuspid valve replacement include surgical complications that are associated with any surgical or procedural intervention. Patients may experience complications related to anesthesia, the potential for valve malfunction, and the need for lifelong anticoagulation therapy, mainly if a mechanical valve is used.  

There is also the risk of developing subsequent cardiac issues, such as right heart failure, even after successful surgery. In addition to the previously discussed risks and complications related to the specific surgical or procedural approach or type of valve placed, the postoperative period has unique challenges. These include the following potential risks and complications (all from 15): 

• Bleeding or hemorrhage 
• Infection 
• Thrombosis 
• Arrhythmias 
• Myocardial infarction 
• Peripheral or mesenteric ischemia 
• Organ dysfunction 
• Stroke 
• Renal failure 
• Requiring tricuspid valve re-intervention 
• Access site/vascular complication 
• Cardiac structural complications such as perforation, cardiac tamponade,  
• Need for pacemaker or cardiac implantable electronic device (defibrillator) related to new arrhythmias or conduction disorders 
• Death from cardiovascular cause or any cause 

Post Op Monitoring

The post-cardiac surgical patient will be cared for in an intensive care unit for at least a few days before transferring to a step-down unit.

In the immediate postoperative phase, paying close attention to hemodynamics and optimizing myocardial oxygen supply and demand is essential. The cardiac index (CI) provides optimal systemic perfusion at greater than 2.2 L/min/m2. The patient will return with a Swan-Ganz catheter, which can be used to obtain cardiac pressure, draw blood to test for mixed venous oxygen saturation and assess the adequacy of tissue perfusion. A fiber-optic oximetric pulmonary artery catheter placement may continuously monitor this measurement.

Low cardiac output is an early indication of acute right heart failure. For these patients, this requires prompt detection and intervention. This is determined by right ventricular dilatation and dysfunction and can be measured via pulmonary artery pressures, which decrease from the baseline of systemic arterial pressures. Even subtle changes should be communicated with the surgical team and cardiologist immediately to prevent decompensation and hemodynamic instability.

Cardiogenic shock can occur quickly and is associated with inferior post-surgical outcomes. Medications used to treat include inotropic support and vasopressors. Common medications administered include dobutamine, levosimendan, epinephrine, or milrinone should be rapidly installed, possibly combined with vasopressor. Supportive care with afterload reduction may be accomplished with inhaled or systemic pulmonary vasodilators (3, 8, 15, 16, 17).

Hypothermia is defined as a temperature below 36°C. Patients are often cooled during cardiac surgery to slow cellular metabolism and will require slow rewarming to prevent complications. This can affect blood glucose levels, coagulation factors, electrolyte imbalances, and neurological responsiveness (11).

Renal failure is a concern after cardiopulmonary bypass and with an elevated risk of low cardiac output. Strict input and output documentation is essential to identify a change in urine output. At least 0.5-1.5 mL/kg/hour is usual; however, this may be lower after surgical intervention. The nurse should promptly report output under 0.5 ml/kg in an hour (15, 17).

The cardiac patient will likely return from surgery with femoral venous and arterial sheaths in place. These must be removed as soon as possible to prevent infection. This can be safely done by a trained nurse or cardiovascular technicians once coagulation factors have reached optimal levels to control hemorrhage.

Refer to unit protocol and orders for guidance, as this may differ between the healthcare provider’s preference and facility policy. The activated clotting time is typically used to guide this process, with a level of 150 or below being standard for removing an arterial sheath (15, 17, 18).

Pain is initially kept under control with opioid and non-opioid medications as well as non-pharmaceutical methods.

Staff and visitors must enforce strict hand hygiene to prevent infection of the approach site, whether it is open sternal, via thoracotomy, or a peripheral transcatheter vascular insertion.

Nursing Considerations 

Pre-surgical  

Whether the choice for valve replacement is through open heart surgery, thoracotomy, or transcatheter, each carries several risks and requires the same preoperative workup. The patient should be prepared for the latter two options to potentially transition to open heart surgery if there are complications (17, 18). 

A full history and physical must be taken to assess the patient’s cardiovascular and pulmonary systems and note any comorbidities, including renal issues, coagulopathies, and previous surgeries. 

Diagnostic testing is likely to occur several weeks before planned surgeries. An echocardiogram and right heart catheterization to assess valve structure and function are standard procedures (17, 18, 19). 

Laboratory testing will include a complete blood count, metabolic panel, and coagulation factor tests. 

Post-surgical 

After the surgery or procedure, several nursing interventions will improve patient outcomes. Aiming nursing interventions to promote sleep, reduce stress, and increase activity can exponentially enhance outcomes. 

Vital signs must be frequently monitored and promptly documented, with critical results outside parameters communicated to the advanced care team. Signs of hemodynamic instability, fluid overload, or altered perfusion must be assessed closely. The nurse must also frequently assess the patient’s level of consciousness and neurological status, especially in the immediate postoperative period, to recognize any signs of stroke or altered perfusion (17, 19). 

Patient and caretaker teaching will be fundamental and should continue throughout the patient’s entire healthcare stay to improve the patient’s quality of life and health progression.  

Patient/Family Education 

Post-cardiac procedure education is essential for patients and their families to facilitate recovery and improve outcomes. After a cardiac procedure, patients may experience a range of physical and emotional changes. It is essential to understand the importance of adhering to post-procedure instructions provided by the multidisciplinary healthcare team (17, 18, 19). 

Patients and their caretakers must understand the signs of potential complications such as chest pain, shortness of breath, bleeding from incisional or access sites, or signs of infection. The nurse must ensure that these symptoms are reported to their provider immediately and to seek assistance for any medical emergency.  

Education must also be aimed at understanding the importance of taking ordered medications as prescribed. These medications, such as anticoagulation and treatment to prevent heart failure, are critical for preventing complications and promoting heart health (15, 17, 19). 

Lifestyle modifications play a fundamental role in recovery. Patients should be encouraged to adopt a heart-healthy diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats, with salt and sugar intake restrictions. Regular physical activity, tailored to the individual’s capacity and guided by a healthcare provider, is also essential. Patients should aim to gradually increase their activity levels, focusing on aerobic exercises that can enhance cardiovascular endurance (19). 

Follow-up appointments with healthcare providers are necessary for ongoing evaluation and adjustments to the treatment plan. Empowering patients and families with knowledge and resources enhances their engagement in recovery and helps cultivate a supportive environment conducive to healing. In summary, comprehensive education and support for patients and families are instrumental in achieving successful recovery results in post-cardiac procedures (18, 19). 

Upcoming/Current Research Findings 

As rheumatic fever is one of the highest causes of valvular heart disease, there is ongoing research into preventative treatment, such as vaccine development and methods to halt disease progression. A secondary cause is disease caused by calcification of the leaflets, for which there are no current therapies to prevent this. Other research is focused on identifying the optimal time to intervene as this is currently subjective and driven by effects on patient lifestyle due to symptom progression. It is often thought that this is too late in the process to improve the high morbidity and mortality rates associated with tricuspid valve dysfunction. A more proactive approach may be to base intervention timing on myocardial structure, function, and left ventricular involvement rather than waiting until the patient becomes symptomatic (15). 

Conclusion

Effective patient care for tricuspid valve replacement involves a multidisciplinary approach, encompassing thorough preoperative assessment, patient education, and focused postoperative monitoring. Discussions about the potential risks and benefits must be personalized, considering the patient’s overall health status, underlying conditions, and symptom effects on the patient’s well-being and ability to participate in daily activities. Long-term follow-up care and medical management are required to manage complications and monitor the prosthetic valve’s function.

Ultimately, the decision to proceed with tricuspid valve replacement should be based on carefully evaluating patient-specific factors, aligning clinical goals with the patient’s needs and preferences, and ensuring a comprehensive plan for perioperative and postoperative care.

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