Tricuspid valve detachment for ventricular septal defect closure: A meta‐analysis of existing evidence

Abstract

Background Ventricular septal defect (VSD) is one of the most common congenital cardiac defects. However, in some cases, VSD sites are difficult to expose due to obstruction from chordal attachments and leaflets of the tricuspid valve (TV). To systematically review the efficacy and safety of tricuspid valve detachment, (TVD) versus conventional surgical repair (non‐TVD) in the treatment of ventricular septal defect (VSD). This article is aimed to compare the many outcomes from existing studies and provide evidence regarding the necessity of performing TVD. Methods We searched the following databases: PubMed via NCBI, the Cochrane Central Register of Controlled Trials (no date restriction), Medline via Ovid (from 1966 to May 2020); Embase via Ovid (no date restriction), and China National Knowledge Infrastructure for studies comparing the efficacy of TVD and other surgical techniques in VSD repair. Cardiopulmonary bypass time, Cross‐clamp time; postoperative complications including residual defect, postoperative atrioventricular block, implantation of pacemakers, tricuspid regurgitation; length of stay (LOS), length of intensive care unit (ICU) stay were analyzed. Results Only nine studies were included after selection, including seven retrospective cohort studies, one respective cohort study, and one prospective observational study, a patient pool of 1404 patients with 374 underwent TVD and 1030 underwent non‐TVD procedures, met the inclusion criteria. Meta analysis has drawn to the following conclusions. First, TVD prolongs CPB time (MD = 7.75, 95% confidence interval [CI] = 2.60–12.89, p = .003) and cross‐clamp time (MD = 7.77, 95% CI = 4.76–10.78, p < .001) compared with non‐TVD techniques in VSD repair surgeries. Second, no significant difference exists in LOS, length of ICU stay, postoperative atrioventricular block, implantation of pacemakers, incidence of ≥mild tricuspid valve regurgitation (TR) postoperatively and at discharge, as well as the incidence of ≥small residual VSD after surgery and during follow‐up (all p ＞ .05). Third, application of TVD increases the risk of TR during follow‐up (odds ratio [OR] = 2.42, 95% CI = 1.55–3.76, p < .001). Conclusion VSD closure using TVD technique results in longer CPB and cross‐clamp time, and increases risk of TR during follow‐up. TVD provides equally viable and safe alternative in treating VSD.

Impact of the Tricuspid Valve Detachment Technique on Hard-to-Expose Ventricular Septal Defect Closure

“…In the current study, the TVD technique was associated with a longer duration of cardiopulmonary bypass and cross-clamp time; however, it did not increase perioperative mortality or risk of prolonged ICU stay. Tese results were consistent with those of a previous study [11].…”

“…months for Group A vs. 4[2][3][4][5][6][7][8][9][10][11][12] months for Group B) or body weight(7.1 [4.8-14.4] kg for Group A vs. 5.4 [4.2-7.3] kg for Group B). Preoperatively, 6 (35%) and 15 (9.4%) patients had TR of moderate or greater severity in Groups A and B, respectively (p � 0.012).…”

Tricuspid Apparatus Detachment for Exposure of Ventricular Septal Defect: A Justified Approach?

“…However, there are multiple factors that need consideration and addressal in the given study. Repair of VSD is one of the commonest congenital cardiac surgeries performed globally, and trans right atrial (RA) approach is a globally accepted uniform norm owing to lesser complications and better outcomes in comparison to other approaches [ 2 ] . The authors in the given study second that and compare trans RA approach in three subgroups, i.e.…”

“…, approach with retraction of tricuspid leaflet, tricuspid septal detachment (TSD) approach, and tricuspid chordal detachment (TCD) approach. The standard recommended technique is retraction of tricuspid leaflet while preserving native geometry of tricuspid apparatus, the TSD and TCD approach are reserved to circumstances with difficult VSD margin exposure and as a last resort to interfere with native tricuspid valvular apparatus [ 2 ] . The authors, in their study, have used a very high incidence of around 31% of patients undergoing TSD approach while 20.5% patients underwent TCD approach, summing up to more than half the cases, which is surprisingly high [ 3 ] .…”