Concomitant Tricuspid Valve Research Articles

Permanent pacemaker implantation after concomitant mitral and tricuspid valve surgery.

Permanent pacemaker implantation after concomitant mitral and tricuspid valve surgery.

Is concomitant tricuspid valve repair in patients undergoing robotic mitral valve repair safe and effective?

ObjectivesRobotic-assisted mitral valve repair (MVr) is a well-established procedure for management of degenerative mitral valve disease. Limited data regarding concomitant robotic-assisted tricuspid valve repair (TVr) is available. This review investigates prevalence and outcomes of concomitant robotic-assisted mitral and tricuspid valve repair. MethodsFrom 2014 to 2022, 839 patients underwent robotic-assisted MVr, including 76 patients with moderate or greater tricuspid regurgitation and/or tricuspid annular dilatation ≥40 mm. Among the 76 patients, 19 (25%) underwent isolated MVr and 57 (75%) had concomitant mitral and tricuspid valve repair. Outcome data between the 2 groups were analyzed. ResultsIn the MVr/TVr group, tricuspid regurgitation grades were mild in 4 (7%) patients, moderate in 44 (77%) and severe in 9 (15.7%). Significant tricuspid annular dilatation ≥40 mm was present in all patients. In the isolated MVr group, 3 (15.7%) patients had mild tricuspid regurgitation and 16 (84.2%) had moderate tricuspid regurgitation with significant tricuspid annular dilatation present in only 6 patients. Cardiopulmonary bypass and crossclamp time were 130.6 and 91 minutes versus 85 and 55.4 minutes for robotic MVr/TVr group versus MVr group, respectively (P < .05). The intensive care unit and hospital length of stay were similar: 27.7 versus 27.7 hours and 4.4 versus 4.2 days for MVr/TVr versus MVr (P = .24), respectively. There were no perioperative deaths or heart block in either group. Survival and freedom from reoperation with median follow-up of 16 and 46 months for MVr/TVr and MVr groups, respectively were 100%. ConclusionsConcomitant robotic-assisted tricuspid valve repair for functional regurgitation can be safely and effectively performed at the time of mitral valve repair with excellent short-term morbidity and mortality results.

Permanent pacemaker implantation after combined mitral- and tricuspid valve surgery: a nationwide multicentre study.

The threshold to perform concomitant tricuspid valve (TV) repair during primary mitral valve (MV) surgery has decreased, based on recent randomized evidence. Based on these developments, the indication for TV repair during MV surgery is expected to increase further. However, concerns have been raised regarding the risk of permanent pacemaker implantation (PPI) during a concomitant procedure. Therefore, we aim to assess the incidence of PPI in combined MV and TV surgery in a nationwide registry. The current study uniquely cross-linked the Cardiothoracic and Pacemaker/ICD registry of the Netherlands Heart Registration. Patients undergoing primary MV and TV surgery (± atrial septal defect closure, rhythm surgery, coronary artery bypass grafting) between 1 January and 31 December2021 were included. The primary outcome was PPI within 30 days after surgery. Subgroup analyses were performed for isolated MV and TV surgery and MV repair. The association between concomitant TV surgery and PPI was assessed using multivariable binary logistic regression analyses. A total of 1060 patients (n = 833 MV, n = 227 MV + TV) were included. The overall incidence of PPI was 4.3%. No significant difference in PPI between MV and MV + TV surgery were found (3.7% vs 6.6%, P = 0.06). Concomitant TV surgery was not an independent risk factor for PPI after surgery after adjustment for covariates. These results were robust after sensitivity analyses. The current study was not able to find a statistical difference between the PPI rate in MV surgery patients and MV + TV surgery patients. Extension of the waiting period prior to PPI, may result in decreased PPI rates.

Commentator Discussion: Is Concomitant tricuspid valve repair in patients undergoing robotic mitral valve repair safe and effective?

Commentator Discussion: Is Concomitant tricuspid valve repair in patients undergoing robotic mitral valve repair safe and effective?

The long-term impact of lesion set in the surgical ablation of atrial fibrillation during mitral valve surgery: multi-center propensity-score weighted study

ObjectiveThis study aimed to assess the effect of the lesion sets for surgical ablation (SA) of atrial fibrillation (AF) on long-term outcomes and identify the optimal lesion set. MethodsBetween 2005 and 2017, 1825 patients underwent SA concomitant to mitral valve (MV) surgery in the participating institutions. Of these, 529 underwent left atrial (LA) ablation, whereas the remainder had biatrial (BA) ablation. The clinical and rhythm outcomes were compared, considering death as a competing event. Inverse probability treatment weighting (IPTW) was used to mitigate the selection bias. ResultsThe patients undergoing LA ablation were younger and less frequently had long-standing AF with a shorter duration or required concomitant tricuspid valve surgery. Adjusted analysis showed that LA ablation was associated with a lower risk of early pacemaker implantation (odds ratio, 0.16; 95% confidence interval [CI], 0.07-0.38; p<0.001) than BA ablation. Over a median follow-up of 70.4 months (interquartile 44.1-111.2 months), the LA ablation group presented a higher risk of AF recurrence (subdistribution hazard ratio [SHR]1.26; 95% CI 1.12-1.41; p<0.001), with a 5-year cumulative incidence of 34.2% compared to 28.6% in the BA group. The risk of late mortality (SHR, 1.17; 95% CI, 0.74-1.86; p=0.507) and stroke (SHR, 1.21; 95% CI, 0.82-1.79; p=0.345) did not differ between the groups ConclusionIn patients undergoing SA concomitant to MV surgery, both lesion sets provided comparable incidence of mortality and stroke. However, BA ablation was associated with a superior rhythm outcome at the expense of a higher risk of early pacemaker implantation.

Mitral regurgitation evolution after transcatheter tricuspid valve interventions - a sub-analysis of the TriValve Registry.

Transcatheter tricuspid valve interventions (TTVI) are increasingly used to treat patients with significant tricuspid regurgitation (TR). The evolution of concurrent mitral regurgitation (MR) severity after TTVI is currently unknown and may be pivotal for clinical decision-making. The aim of this study was to assess the evolution of MR after TTVI and to identify predictors of MR worsening and improvement. This analysis is a substudy of the Trivalve Registry, an international registry designed to collect data on TTVI. This substudy included all patients with echocardiographic data on MR evolution and excluded those with a concomitant tricuspid and mitral transcatheter valve intervention or with a history of mitral valve intervention. The co-primary outcomes were MR improvement and worsening at two timepoints: pre-discharge and 2-month follow-up. This analysis included 359 patients with severe TR, mostly(80%) treated with tricuspid transcatheter edge-to-edge repair(T-TEER). MR improvement was found in 106(29.5%) and 99(34%) patients, while MR worsening in 34(9.5%) and 33(11%) patients at pre-discharge and 2-month follow-up, respectively. Annuloplasty and heterotopic replacement were associated with MR worsening. Independent predictors of MR improvement were: atrial fibrillation, T-TEER, acute procedural success, TR reduction, LVEDD>60 mm and beta-blocker therapy. Patients with moderate-to-severe/severe MR following TTVI showed significantly higher death rates. MR degree variation is common after TTVI, with most cases showing improvement. Clinical and procedural characteristics may predict the MR evolution, in particular procedural success and T-TEER play key roles in MR outcomes. TTVI may be beneficial even in the presence of functional MR.

Long-term outcomes of minimally invasive concomitant mitral and tricuspid valve surgery with surgical ablation.

We compared the outcomes of a right mini-thoracotomy (RMT) versus those of a sternotomy for concomitant mitral and tricuspid valve surgery and surgical ablation. We analysed patients who underwent concomitant mitral and tricuspid valve surgery and surgical ablation at a single institution (mean follow-up: 7 years) after propensity score matching. The primary and secondary outcomes were all-cause death, composite major adverse events (including stroke, reoperation, readmission, permanent pacemaker insertion) and recurrence of atrial fibrillation (A-fib). A subgroup analysis was performed. A total of 797 procedures (mean age: 61.6 years; RMT: 45.2%; female: 66.5%; mitral valve repair: 33.6%) were done; 267 pairs were matched. The 5- and 10-year overall survival in the matched cohort was 92.7% and 86.9% for the RMT group and 92.1% and 83.1% for the sternotomy group (P = 0.879). Significant differences were not observed in major adverse events (P = 0.273; hazard ratio: 0.76) and A-fib recurrence (P = 0.080; hazard ratio: 0.72). The RMT group had lower rates of postoperative low cardiac output syndrome (P = 0.019) and acute renal failure (P = 0.003). Atrial fibrillation high-risk factors (including long-standing A-fib, enlarged left atrium, old age) exhibited significant interactions (P for interaction = 0.002) with the approach regarding A-fib recurrence. In this study, an RMT exhibited no significant differences in long-term outcomes compared to a sternotomy, but it could remain a clinically reasonable option. Patients with a high risk of A-fib may have favourable ablation outcomes with a sternotomy.

Cluster analysis of Model for End-stage Liver Disease and European System for Cardiac Operative Risk Evaluation for predicting operative mortality after concomitant tricuspid valve surgery

ObjectivePatients requiring concomitant tricuspid surgery represent a heterogeneous cohort with significant comorbidities and varying degrees of organ and right ventricular dysfunction. However, surgeons can rely on little beyond intuition and experience when discussing operative risks. The objective of the study is to assess how the Model for End-stage Liver Disease score complements the European System for Cardiac Operative Risk Evaluation II in risk assessment. MethodsWe performed a single-center retrospective cohort study of 369 consecutive patients who underwent concomitant tricuspid valve surgery from 2011 to 2020. Multivariate analysis of factors affecting operative mortality was performed, producing 2 multivariate risk prediction models, one consisting of European System for Cardiac Operative Risk Evaluation II components and the other consisting of both European System for Cardiac Operative Risk Evaluation II components and Model for End-stage Liver Disease. The models were compared by measuring c-statistic using the Hanley-McNeil method. This was further evaluated with category-free net reclassification improvement index. K-means clustering was performed using Model for End-stage Liver Disease and European System for Cardiac Operative Risk Evaluation II values after scalar transformation as independent variables and operative mortality as the dependent variable. ResultsThe Model for End-stage Liver Disease is an independent predictor of operative mortality, with an adjusted odds ratio of 1.286 per point. Inclusion of the Model for End-stage Liver Disease improves the discriminatory power of the European System for Cardiac Operative Risk Evaluation II for operative mortality, with a difference in area under the curve of 0.128 [0.0341-0.222] (P = .0076). The net reclassification improvement index of incorporating Model for End-stage Liver Disease with European System for Cardiac Operative Risk Evaluation II was 0.959 [0.515-1.392], indicating significant improvement in risk reclassification. Cluster analysis identified a unique cohort of patients with intermediate-to-high Model for End-stage Liver Disease, not previously identified with European System for Cardiac Operative Risk Evaluation II alone, who experienced high operative mortality. ConclusionsModel for End-stage Liver Disease score as a quantifier of hepatorenal dysfunction complements European System for Cardiac Operative Risk Evaluation II in predicting operative mortality after tricuspid valve surgery.

Concomitant tricuspid valve surgery in patients with significant tricuspid regurgitation undergoing left ventricular assist device implantation: A systematic review and meta-analysis.

Significant tricuspid regurgitation (TR) is a predictor of right heart failure (RHF) and increased mortality following left ventricular assist device (LVAD) implantation, however the benefit of tricuspid valve surgery (TVS) at the time of LVAD implantation remains unclear. This study compares early and late mortality and RHF outcomes in patients with significant TR undergoing LVAD implantation with and without concomitant TVS. A systematic search of four electronic databases was conducted for studies comparing patients with moderate or severe TR undergoing LVAD implantation with or without concomitant TVS. Meta-analysis was performed for primary outcomes of early and late mortality and RHF. Secondary outcomes included rate of stroke, renal failure, hospital and ICU length of stay. An overall survival curve was constructed using aggregated, reconstructed individual patient data from Kaplan-Meier (KM) curves. Nine studies included 575 patients that underwent isolated LVAD and 308 patients whom received concomitant TVS. Both groups had similar rates of severe TR (46.5% vs. 45.6%). There was no significant difference seen in risk of early mortality (RR 0.90; 95% CI, 0.57-1.42; p = 0.64; I2 = 0%) or early RHF (RR 0.82; 95% CI, 0.66-1.19; p = 0.41; I2 = 57) and late outcomes remained comparable between both groups. The aggregated KM curve showed isolated LVAD to be associated with overall increased survival (HR 1.42; 95% CI, 1.05-1.93; p = 0.023). Undergoing concomitant TVS did not display increased benefit in terms of early or late mortality and RHF in patients with preoperative significant TR. Further data to evaluate the benefit of concomitant TVS stratified by TR severity or by other predictors of RHF will be beneficial.

Concomitant tricuspid valve regurgitation repair in patients with minimally invasive mitral valve surgery: a single-centre experience in Vietnam

Background: This study aims to present the early and mid-term outcomes of combining minimally invasive mitral valve surgery (MIMVS) with tricuspid valve repair (TVR) at the authors’ centre. Methods: From January 2017 to March 2022, our centre treated a total of 67 patients with both MIMVS and TVR. Among these patients, 41 were women (61.2%), and 26 were men (38.8%). The average Euro SCORE II was 2.67±1.54%, and the patients had an average follow-up period of 25.45±16.2 months. Results: Pre-discharge echocardiography revealed no or mild TR in 82.8% of cases. The overall 30-day mortality rate was 4.5%, with 3 deaths. Five-year survival was 94.5%±3.2%. In patients with mild or moderate preoperative tricuspid regurgitation (TR), the 5-year survival rate was 95.7%±4.3%, while for those with severe TR, it was 93.7%±4.5% (P=0.947). Conclusions: The authors’ 5-year experience demonstrates that the combination of MIMVS and TVR can be routinely performed with favourable perioperative and postoperative outcomes in patients undergoing non-high-risk surgery. Additionally, there is no significant difference in five-year survival between the severe TR and mild to moderate TR groups preoperatively.

Tricuspid valve surgery for acute infective endocarditis can be performed with very low operative mortality

ObjectiveTricuspid valve surgery historically has been perceived as having elevated operative risk, prompting the recent development of transcatheter therapies including aspiration vegetectomy for endocarditis. The opioid epidemic has exacerbated tricuspid valve endocarditis, particularly in people who inject drugs. We sought to evaluate contemporary outcomes of tricuspid valve surgery in real-world practice. MethodsAn institutional multidisciplinary endocarditis database inclusive of clinical, microbiologic, and echocardiographic data was analyzed for those undergoing isolated or concomitant tricuspid valve surgery for acute active endocarditis. Consecutive patients between 2016 and 2021 were followed for longitudinal outcomes. ResultsA total of 283 patients with tricuspid valve endocarditis underwent tricuspid valve repair (n = 137, 48.4%) or replacement (n = 146, 51.6%). Median age was 31 (27-37) years, 63.1% were female, and 257 (90.8%) were active people who inject drugs. The leading indications for surgery were severe valvular insufficiency (71.2%), vegetation size greater than 2 cm (51.3%), or septic shock (23.3%). Concomitant procedures were performed in 44 patients (15.5%). In patients who underwent isolated tricuspid valve surgery (n = 239), no patient required permanent pacemaker after tricuspid valve repair, whereas 13.3% required permanent pacemaker after tricuspid valve replacement. Overall and isolated tricuspid valve surgery operative mortality were 1.8% and 1.3%, respectively. Overall and isolated tricuspid valve surgery 1-year survivals were 89.3% and 89.7%, respectively. ConclusionsTricuspid valve surgery for endocarditis has low operative mortality. When feasible, repair is preferred over replacement. In an era of promulgation of investigational therapies, heart teams should note that tricuspid valve surgery is low risk and remains the first-line beyond antibiotics.

Isolated Tricuspid Valve Surgery for Functional Tricuspid Regurgitation.

Severe tricuspid regurgitation (TR) adversely affects long-term survival; however, isolated tricuspid valve (TV) surgery has been rarely performed due to high operative mortality. In addition, the previous literature included heterogeneous TR etiologies. Therefore, we aimed to elucidate early and long-term outcomes of isolated TV surgery for functional TR. An electronic search was performed to identify all relevant studies. Baseline characteristics, perioperative variables, and clinical outcomes were extracted and pooled for meta-analysis. This meta-analysis included seven studies. Pooled analyses showed that 68% (35, 89) of patients had preoperative atrial fibrillation or flutter, and 58% (11, 94) had a history of left-sided valve surgery. Seventy-three percent (65, 80) of patients had at least one physical exam finding of right-sided heart failure, and 57% (44, 69) were in New York Heart Association class III or IV. TV replacement was more common than repair. In TV replacement, bioprosthetic valve (39%, 13, 74) was more common than mechanical prosthesis (22%, 18, 26). The early mortality rate was 7%. Twenty percent of patients required a permanent pacemaker postoperatively. The overall 1- and 5-year survival rates were 84.5 and 69.1%, respectively. More than half of the patients who underwent isolated TV surgery for functional TR had undergone left-sided valve surgery and had significant heart failure symptoms at the time of surgery. Further studies on the surgical indication for concomitant TV surgery at the time of left-sided valve surgery and the appropriate timing of surgery for isolated functional TR are needed to improve survival.

Risk of Pacemaker Implantation After Degenerative Mitral and Concomitant Tricuspid Valve Surgery

BackgroundA recent multicenter trial showed a reduction in tricuspid regurgitation (TR) progression when tricuspid annuloplasty was performed at the time of surgery for degenerative mitral regurgitation (MR), but with a 14% permanent pacemaker (PPM) rate. We present real-world outcomes at a high-volume center for degenerative MR surgery with/without tricuspid annuloplasty. MethodsPatients undergoing first-time degenerative mitral surgery between 2011 and 2021 were identified (n = 1738). After excluding patients undergoing aortic, aortic valve, or tricuspid replacement procedures, patients were stratified into mitral surgery alone (n = 1068) vs mitral surgery plus tricuspid annuloplasty (n = 417). Outcomes, including operative mortality, new PPM implantation, postoperative length of stay, and risk-adjusted overall mortality, were compared. ResultsAmong 1485 patients in this study, 98% underwent mitral repair. Compared with concomitant tricuspid annuloplasty patients, those undergoing mitral surgery alone were 6 years younger and had lower median The Society of Thoracic Surgeons predicted risk of mortality. Among concomitant tricuspid repair patients, 85% (355 of 417) had moderate or less preoperative TR, whereas 15% (61 of 417) had severe TR. Operative mortality was 1.4%. The incidence of new PPM implantation was 0.7% (7 of 1068) in the mitral only group and 5.5% (23 of 417) in the concomitant tricuspid group (P < .001). Although unadjusted cumulative survival was lower in the concomitant tricuspid group, after risk adjustment, concomitant tricuspid surgery was not associated with worse overall mortality (hazard ratio, 0.80; 95% CI, 0.53-1.19; P = .27). ConclusionsConcomitant tricuspid annuloplasty is safe, with no difference in mortality and a <6% PPM rate at a high-volume mitral center. These data provide real-world context for concomitant tricuspid annuloplasty.

Predictors of late outcomes after concomitant tricuspid valve repair with left-sided valve surgery.

Concomitant tricuspid valve (TV) repair is a safe and effective procedure to protect against late moderate or greater tricuspid regurgitation (TR) after left-sided valve surgery, but studies regarding its late outcomes and recurrent TR are limited. This study aimed to reveal the late outcomes and explore the predictors of mortality and recurrent TR among patients who underwent concomitant TV repair with left-sided valve surgery. This study included 645 patients (mean age, 69.7years; 44% male) who underwent concomitant TV repair with left-sided valve surgery (mitral valve surgery in 594 cases, aortic valve surgery in 172 cases) from 2006-2020. Preoperative TR was grade 4, 3, and less than 2 in 85, 235, and 325 patients, respectively. The median follow-up period was 4.6 (IQR 1.7-7.8) years. The in-hospital or 30-day mortality was 1.7% (n = 11). Regarding long-term outcomes after TV repair, 90.3% and 80.8% achieved 5- and 10-year survival, respectively, while 96.1% and 88.8% achieved 5- and 10-year freedom from recurrent TR, respectively. The following were independent predictors of overall mortality on multivariate analysis in patients with preoperative TR grade ≥ 3: prior pacemaker implantation, preoperative renal dysfunction, diabetes mellitus and NYHA class ≥ 3. Also, suture annuloplasty and ring type of ring annuloplasty were not independent risk factors for recurrent TR, classified as grade ≥ 3. Concomitant TV repair with left-sided valve surgery had acceptable outcomes in terms of survival and TR durability. In patients with preoperative TR grade ≥ 3, preoperative patient status had negative impacts on prognosis.

(591) - Outcomes of Concomitant Tricuspid Valve Repair with Contemporary Ventricular Assist Device Implantoutcomes Outcomes of Concomitant Tricuspid Valve Repair with Contemporary Left Ventricular Assist Device Implant

(591) - Outcomes of Concomitant Tricuspid Valve Repair with Contemporary Ventricular Assist Device Implantoutcomes Outcomes of Concomitant Tricuspid Valve Repair with Contemporary Left Ventricular Assist Device Implant

The evaluation of simultaneous combined surgery of the heart and thyroid - own experience

Background: Patients referred for cardiac surgery usually also have other comorbidities. These include thyroid disease, which is relatively common in patients with heart problems. Objective: The aim of the study was to evaluate the feasibility of combined cardiac surgery and thyroidectomy. Material and methods: Six patients (age range: 54-74 years) qualified for elective, simultaneous surgeries on the heart and the thyroid were included in the study. In preparation for thyroidectomy, three patients were diagnosed with diseases requiring cardiac surgery. Two patients, initially referred for coronary artery bypass surgery in one case, and surgery for recurrent fluid in the pericardial sac with concomitant mitral and tricuspid valve regurgitation and atrial fibrillation in the other, were diagnosed in large hyperactive goitre. The last patient with a history of oncology (lung tumour), admitted to the Department of Cardiology due to a heart attack, had a CT scan of the chest, which revealed retrosternal goitre narrowing the lumen of the trachea to 9 mm. All patients underwent combined heart and thyroid operation and were discharged home 8-27 days after surgery. Conclusions: Although preoperative qualification requires a very cautious and individual approach, simultaneous surgeries in patients requiring thyroid and heart interventions are expedient and should be promoted.

One-year postprocedural quality of life following mitral valve surgery: data from The Netherlands heart registration.

The aim of surgical treatment of mitral valve disease is to reverse heart failure and to restore life expectancy and quality of life (QoL). In mitral valve surgery, QoL has not been studied extensively, especially regarding the surgical approach. The current study aimed to evaluate QoL after mitral valve surgery through full sternotomy and a minimally invasive approach (MIMVS). All patients undergoing mitral valve surgery between 2013-2018 through sternotomy or a MIMVS approach (right anterolateral mini-thoracotomy, sternal-sparing), with or without concomitant tricuspid valve surgery, surgical ablation, or atrial septal defect closure were eligible for inclusion in this multicentre nationwide registry in the Netherlands. Quality of life was measured using the 12- and 36-item short form surveys, before surgery and postoperatively at 1 year. Independent predictors for loss of QoL were evaluated. 485 patients were included (full sternotomy: n = 276, and MIMVS: n = 209). Overall, patients experienced a significant increase in physical component score (56 [42-75] vs 74 [57-88], p < 0.001) and mental component score at 1-year (63 [52-74] vs 70 [59-86], p < 0.001). Baseline QoL scores and new onset of atrial arrhythmia were independently associated with a clinically relevant reduction in physical and mental QoL. Mitral valve surgery is associated with significant improvement in physical and mental QoL. Baseline QoL scores and new onset of atrial arrhythmia are associated with a clinically relevant reduction in postoperative QoL.

Early and long-term outcomes following redo mitral valve surgery in patients with prior minimally invasive mitral valve surgery.

The frequency of minimally invasive mitral valve surgery (MVS) has steadily increased over the last decades and therefore surgeons are now encountering an increasing number of patients requiring mitral valve (MV) reoperations post-minimally invasive MVS. The aim of this study was to analyse the early postoperative outcomes and the long-term survival in patients who undergo reoperative MVS following previous minimally invasive surgery. Patients who underwent redo MVS following prior minimally invasive MVS between January 2002 and December 2021 were included in our analysis. Study data were prospectively collected and retrospectively analysed. The primary outcomes were 30-day mortality and long-term survival. Among the 187 included patients, 34 (18.2%) underwent repeat MV repair and 153 (81.8%) MV replacement. The median age was 66 years (interquartile range 56-74) and 80 (42.8%) patients were female. Redo MVS was performed through median sternotomy in 169 patients (90.4%). A total of 77 (41.2%) patients had additional concomitant procedures. The median intensive care unit stay was 1 day (1-5). The 30-day mortality was 6.4% (12/187). Estimated survival at 5 and 12 years was 61.8% and 38.3%, respectively. Preoperative stroke (hazard ratio 3.28, 95% confidence interval 1.37-7.85, P = 0.007) as well as infective endocarditis (hazard ratio 1.85; 95% confidence interval 1.09-3.11, P = 0.021) were independent predictors of long-term mortality. Redo MVS following prior minimally invasive MVS can be performed safely with low early perioperative mortality and acceptable long-term survival. Preoperative stroke, infective endocarditis and concomitant tricuspid valve surgery are independent predictors of long-term mortality.

Tricuspid regurgitation: Frequency, clinical presentation, management and outcome among patients with severe left-sided valvular heart disease in Europe. Insights from the ESC-EORP Valvular Heart Disease II survey.

Tricuspid regurgitation (TR) is commonly observed in patients with severe left-sided valvular heart disease (VHD). This study sought to assess TR frequency, management and outcome in this population. Among 6883 patients with severe native left-sided VHD or previous left-sided valvular intervention enrolled in the EURObservational Research Programme prospective VHD II survey, moderate or severe TR was very frequent in patients with severe mitral VHD (30% when mitral stenosis, 36% when mitral regurgitation [MR]), especially in patients with secondary MR (46%), and rare in patients with severe aortic VHD (4% when aortic stenosis, 3% when aortic regurgitation). An increase in TR grade was associated with a more severe clinical presentation and a poorer 6-month survival (p < 0.0001). Rates of concomitant tricuspid valve (TV) intervention at the time of left-sided heart valve surgery were high at the time of mitral valve surgery (50% when mitral stenosis, 41% when MR). Concordance between class I indications (patients with severe TR) for concomitant TV surgery at the time of left-sided valvular heart surgery according to guidelines and real-practice decision-making was very good (88% overall, 95% in patients operated on for MR). In this large international prospective survey among patients with severe left-sided VHD, moderate/severe TR was frequent in patients with mitral valve disease and was associated with a poorer outcome as TR grade increased. In patients with severe TR, compliance to guidelines for class I indications for concomitant TV surgery at the time of left-sided heart valve surgery was very good.

Navigating the challenges of minimally invasive mitral valve surgery: a risk analysis and learning curve evaluation

BackgroundThis study aimed to report the risk and learning curve analysis of a minimally invasive mitral valve surgery program performed through a right mini-thoracotomy at a single institution.MethodsFrom January 2013 through December 2019, 266 consecutive patients underwent minimally invasive mitral valve surgery in our department and were included in the current study. Multiple logistic regression analysis was used for the adverse event outcome. Distribution over time of perioperative complications, defined as clinical endpoints in the Valve Academic Research Consortium-2 (VARC-2) consensus document, as well as CUSUM charts for assessment of cardiopulmonary bypass and aortic cross-clamping duration over time, has been performed for learning curve assessment.ResultsOverall incidences of postoperative stroke (1.1%), myocardial infarction (1.1%), and thirty-day mortality (1.5%) were low. The mitral valve reconstruction rate in our series was 95%. Multivariable analysis revealed that concomitant tricuspid valve surgery (OR 4.44; 95%CI 1.61–11.80; p = 0.003) was significantly associated with adverse event outcomes. Despite a trend towards adverse event outcomes in patients with preexisting active mitral valve endocarditis (OR 2.69; 95%CI 0.81–7.87; p = 0.082), mitral valve pathology did not significantly impact postoperative morbidity and mortality. Distribution over time of perioperative complications, defined as clinical endpoints in the VARC-2 consensus document, showed a trend towards an improved complication rate after the initial 65–100 procedures.ConclusionsMitral valve surgery via right-sided mini-thoracotomy can be implemented safely with low perioperative morbidity and mortality rates. Careful patient selection regarding isolated mitral valve surgery in the presence of degenerative mitral valve disease may represent a significant safety issue during the learning curve.Trial Registration: The cantonal ethics commission of Zurich approved the study (registration ID 2020-00752, date of approval 24 April 2020).