Isolated tricuspid valve surgery: beyond the idea of a high-mortality surgery.

Abstract

Management and treatment of patients with isolated tricuspid regurgitation (TR) remains a controversial issue. In patients with isolated TR, when should surgery be performed at a low risk, and when does it become a high-mortality intervention? This issue of EJCTS contains a retrospective, single-centre study by Weiss et al. [1] assessing clinical outcome and functional capacity following isolated tricuspid valve (TV) surgery performed on 43 patients over a 6-year interval. Within the study, patients with severe right or left heart failure, severe pulmonary hypertension, end-stage renal disease and liver disease were excluded from open-heart surgery. No in-hospital mortality was reported and, at 1-year follow-up, 9% mortality was documented, with a significant improvement in functional capacity, together with a reduction of clinically apparent peripheral oedema and daily oral furosemide therapy. These findings strongly support the message that the cardiac surgery community has recently tried to deliver regarding ‘early referral and treatment’ in TR. Indeed, it has now become evident that outcomes following isolated TV surgery are almost exclusively dependent on the baseline patient’s profile [2]. The population of patients treated by Weiss et al. [1] was highly selected and not extremely advanced in disease progression, resulting in good short-term outcomes and improved functional capacity. Nevertheless, despite a good prognosis, a small percentage of patients experienced rehospitalizations and death within a year, underlining the importance of thorough preoperative evaluation. These findings are in line with the surgical experience at San Raffaele Hospital, Milan, as well as those of other centres [3–5]. Patients operated upon in early stages of the disease, before the occurrence of prominent symptomatology, right ventricular dilation and dysfunction and end-organ damage, most frequently receive TV repair with no in-hospital mortality, fewer postoperative complications and shorter length-of-stay [6]. Furthermore, at 5 years, patients experience 100% survival and no further hospitalizations for right heart failure. On the contrary, patients medically managed for many years and referred late to TV correction, when the disease is more advanced and the number of comorbidities grows, experience high morbidity and mortality after surgery [7, 8]. This contributes to further supporting the erroneous belief that isolated TV surgery is always a high-risk procedure with a dismal outcome.