No previous meta-analysis has studied the effect
of the BH versus AH technique for isolated TVS
in randomized or nonrandomized trials. A few
retrospective observational studies have reported the
outcomes of the comparison of the two techniques
for isolated TVS.[
7-
11] The study by Russo et al.[
11]
suggested that the BH technique was associated
with significant benefits in terms of long-term
survival and reintervention. However, early mortality
and postoperative outcomes were comparable in
all published studies.[
7-
11] Isolated TVS remains
challenging due to high mortality rate. In the
articles included in this meta-analysis, the operative
mortality of isolated tricuspid surgery ranged from
5.8 to 20.7%.[
9,
11]
Previously published studies on TVS techniques
have mostly focused on tricuspid valve replacement or tricuspid valve repair.[17,18] Although the BH and
AH techniques for right-sided cardiac surgery have
been described for a long time, there are few studies
in the literature comparing the BH technique with
the AH technique in isolated TVS.[19,20] The first
article was published by Pfannmüller et al.[7] in
2012. However, the number of patients included was
limited, as in all subsequent articles. We performed
this meta-analysis due to the limited number of
available studies. To the best of our knowledge,
this is the first meta-analysis to examine the
postoperative outcomes of BH and AH techniques
in TVS.
The main findings of this study were that there
was no difference between the postoperative results
of BH and AH techniques in isolated TVS. The
mortality of tricuspid valve repair is lower than
that of tricuspid valve replacement.[17] Since the
replacement and repair patients were homogeneously
distributed in the meta-analysis groups, it is not
expected to affect the mortality analysis. In this
analysis, we think that the BH technique was mostly
used in more complex patients since EuroSCORE II,
the most widely used risk scale in cardiac surgery,
was higher in the BH patients. The preoperative
clinical condition of isolated TVS patients is one of
the most important factors in terms of postoperative
mortality, as well as in patients undergoing acute
aortic dissection surgery.[21] Therefore, the hospital
mortality results of this meta-analysis should be
carefully considered so as not to reach a definitive
conclusion.
A permanent pacemaker may be required after
isolated TVS.[22] In TVS performed with the BH
technique, the theoretical effect of sutures passed
through the annulus of the tricuspid valve on the heart rhythm can be directly monitored. It is expected
that severe heart blocks will not be encountered by
taking precautions when the stitch disruption of the
rhythm is noticed. However, according to the results
of the meta-analysis, we can say that this advantage
of the BH technique has no effect on the reduction
of permanent pacemaker implantation in the early
postoperative period.
Freedom from reoperation after TVS demonstrates
the success of the surgical technique and is reported
in most series on the tricuspid valve.[23] Saran et al.[24]
showed that tricuspid valve replacement increased
the need for reoperation in the long term compared
to repair. In the BH technique, placement of annular
sutures is challenging due to the movement of the
heart and may increase ring and valve dehiscence.
Such situations may cause the need for reoperation
for the tricuspid valve in the long-term follow-up.
However, in this meta-analysis, there was no
difference between the need for reoperation in the
long-term follow-up of patients who had TVS with
the BH technique and the AH technique.
As demonstrated in our meta-analysis, the
preoperative demographic data of patients operated
with the BH and with AH techniques were different.
The main reason for this might be that all five
studies included in the analysis were retrospective,
and the choice of AH and BH technique might
be biased according to patient characteristics. It
was found that patients who underwent TVS with
the BH technique were older and had a higher
EuroSCORE II. However, the New York Heart
Association functional classification of both patient
groups was similar. The BH technique was preferred
more in patients with a history of previous cardiac
surgery. In the AH technique, an aortic cross clamp
must be placed. The BH technique may have been
preferred in most patients with a history of previous
cardiac surgery to avoid the removal of periaortic
mediastinal adhesions and to prevent possible aortic
injuries. Tricuspid valve surgeries can be performed
with right mini-thoracotomy or sternotomy.[25,26] Right
mini-thoracotomy was preferred more in the BH
technique than in the AH technique. Furthermore,
right mini-thoracotomy may have been preferred in
isolated TVS in cardiac reoperations to reduce sternal
reentry injuries.[27,28]
Beating heart surgery was preferred less in patients
operated for tricuspid valve infective endocarditis. The leaflets are mobile, and it is more difficult
to examine the ventricular faces of the leaflets
in the BH technique. The most common cause
of tricuspid valve endocarditis is intravenous drug
use.[29] Other causes include cardiac implantable
electronic devices, long-term central venous access
catheters, and congenital heart disease.[30,31] Slaughter
et al.[32] reported that postoperative mortality in
tricuspid valve infective endocarditis was 2% in repair
patients, 3% in replacement patients, and 16% in
valvectomy patients.
There are some limitations to this study. This
study is based on a low level of evidence from
five observational studies (one adjusted and four
unadjusted). A single study provided 45.6% of
the patients included in the analysis. This can be
associated with a potential selection bias related
to the type of surgical approach, such as repair or
replacement, as well as the techniques used during
those procedures. The data showed that the BH
technique was mostly used in more complex patients.
Publication bias, which is the common limitation of
all meta-analyses, is probably valid for this metaanalysis.
This study was performed to make a current
data analysis and to have a conclusion for clinicians
and future studies.
In conclusion, isolated TVS with beating and AH
techniques are associated with similar postoperative
outcomes. From available data, the BH technique
generally tends to be used in more complex patients.
Ethics Committee Approval: Since this is a metaanalysis
study, there is no ethics committee requirement.
The data used in the study are publicly available. The study
was conducted in accordance with the principles of the
Declaration of Helsinki.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: Concept/design: Z.M.D.; Data
analysis/interpretation: Z.M.D., M.B., E.Y., D.A., S.Ş.;
Drafting article: Z.M.D., B.T.; Critical revision of article:
B.O., Approval of article: B.O.; Statistics and data collection:
Z.M.D., E.Y., A.R., D.A., S.Ş.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.