Fate of Tricuspid Valve Regurgitation after Pulmonary Endarterectomy in Chronic Thromboembolic Pulmonary Hypertension

Abstract

<h3>Purpose</h3> Pulmonary thromboendarterectomy (PTE) is a standard procedure for the treatment of chronic thromboembolic pulmonary hypertension. PTE decreases pulmonary hypertension, though its effect on secondary tricuspid regurgitation (TR) is unclear. <h3>Methods</h3> We retrospectively reviewed patients who received PTE from June 2009 to July 2019 at our center. Echocardiographic assessments of tricuspid regurgitation peak valve gradient (TRPG), right ventricular (RV) systolic dysfunction, and degree of TR were tracked longitudinally after PTE (1 month, 6 months, 12 months, 24 months, 36 months). Mixed effects longitudinal analysis was used to determine changes in echocardiographic parameters and risk factors for residual TR. The effect of moderate-severe TR on survival was assessed by cox proportional hazards analysis. <h3>Results</h3> In the 235 patients that underwent PTE, the mean pulmonary artery pressure at time of surgery was 43 +/- 14 mmHg. Preoperatively, 54 patients (23%) had trace TR, 59 (25%) mild, 42 (18%) mild-moderate, 50 (21%) moderate, 19 (8%) moderate-severe, and 9 (4%) severe. TR decreased at all time points postoperatively (p < 0.001). The mean preoperative TPRG was 64 mmHg (IQR 46 - 79) and significantly decreased after PTE below 40 mmHg at all time points (p < 0.001). TRPG was significantly correlated with degree of TR (p < 0.001 at each time point). Preoperative moderate-severe RV systolic dysfunction and female sex were associated with residual TR in multivariable analysis (p = 0.011 and p = 0.007, respectively). Preoperative moderate-severe TR was associated with decreased survival after PTE in multivariable analysis (HR 3.42, p = 0.005, Figure 1). Residual TR at six months postoperatively was not (p = 0.47). <h3>Conclusion</h3> TR improved significantly three years after PTE with the exception of patients with residual pulmonary hypertension, preoperative RV dysfunction, and female sex. Preoperative but not postoperative TR may be a marker of poor prognosis after PTE.