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Tricuspid Valve Replacement

  I have a question about the duration of a tissue valve placed in the tricuspid position. I was recently assessed at a major medical center with a specialized adult congenital heart team; but am seeking information from more than one site.
  I am a 46 y/o with surgically corrected ostium prium defect (partial A/V canal) Mitral valve repaired once; then replaced with a Bjork Shiley mechanical valve 20 yr ago. Functions well with a small paravalvular leak since surgery. ASD repair x2; intact. Chronic atrial fib with 3 Bundle of His Ablations (3)  creating complete block--VVI pacer implanted x 2.
  Basically, things have been going well until several months ago w the development of R sided failure and several echos show severe regur of the tricuspid valve; the leaflets don't close at all. Tricuspid replacement with a tissue valve (rather than mechanical) is recommended but my concern is the placement of a tissue valve due to my age.  These valves do not last that long and if I consent to this surgery; it means 1 or 2 more open hearts are in the future, not including the additional pacer surgeries I will have to have. I think this is an awful lot for a patient to endure.
  I was told the reason for the tissue valve has to do with the pacer lead and my hx of hemorraghing due to coumadin; I was told another mechanical valve would mean an increase in the coumadin dose. Even knowing that, I do not want repeated surgeries over thru a lifetime and am wondering just how long these valves really do last -- and if mechanical valves are ever placed in the tricuspid position.  Is there a way I can find statistics on these surgical outcomes?  Thank you.  Marjorie  
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Dear Majorie,
I apologize for the delay, however this is a very controversial subject, there
have been quite a few studies that have compared bioprosthetic (tissue) and
mechanical tricuspid valve replacement, and the majority have shown that the
tissue valve is better.   Now whether this is because the mechanical valve has
a tendency to thrombose (form a clot/blockage) or simply because the heart (especially
the right ventricle) does better with a tissue valve I am not sure.  I can say that
some other studies have shown the tissue valve to have durability (long life) and
a very low thrombosis rate, however as I have said before there is really no general
consensus.  One important aspect of the decision that you must know about is that
there is much more to the surgical decision than just the type of valve to use.
For example, the state of the mitral valve, the presence or absence of pulmmonary hypertension,
and the etiology of the malfunctioning tricuspid valve all factor in to whether you repair, replace, and
even determine the type of replacement valve used.  
So Marjore, even more important than investigating the nebulous statistics out there on tricuspid valve
replacement is what is best for you and this includes the doctors opinion and your opinion at best.
Your concern regarding the need for reoperations in the future is well founded,
however if this is outweighed by your risk of bleeding on coumadin (and bleeding can be fatal)
then it is in your best interest to get the tissue valve.  Please discuss all these
points with your cardiologist and surgeon, a well informed decision is the only way to approach this
surgery.  It is possible that your doctors feel that your failing right ventricle will fair better with
the more natural tissue valve than with a mechanical.  Good Luck.
Information provided in the heart forum is intended for general medical informational purposes only, actual
diagnosis and treatment can only be made by your physician(s).

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