Patients Underwent Tricuspid Valve Surgery Research Articles

Association between left atrial dysfunction and adverse outcomes after tricuspid valve surgery for atrial functional tricuspid regurgitation

Abstract Objectives To identify factors associated with clinical outcomes in patients undergoing tricuspid valve (TV) surgery for atrial functional tricuspid regurgitation (AF- TR). Methods Among 1,670 patients who underwent TV surgery between January 2000 and December 2020, we included 83 AF-TR patients (69.1±9.2 years, 50 women) who had severe TR without any cause other than atrial fibrillation. A comprehensive analysis of right ventricular (RV) and left atrial (LA) function on preoperative and postoperative echocardiography was performed. LA function was evaluated by LA emptying fraction (LAEF), LA reservoir strain, and LA stiffness index. The primary outcome was a composite of all-cause death and heart failure hospitalization during follow up after surgery. Results For a median of 39.9 (interquartile range 19.9 to 55.8) months, the primary outcome occurred in 20 (24.1%) patients. Patients with a primary outcome showed significantly lower LAEF (9.7±7.3 vs. 21.8±6.7 %, p<0.001) and LA reservoir strain, and higher LA stiffness index than those without. However, there was no difference in RV chamber size and functional parameters according to the occurrence of a primary outcome. The restricted cubic spline plot exhibited a significant relationship between LAEF and primary outcome. The low baseline LAEF (<17%) group showed a poorer outcome than the high LAEF group (log rank p<0.001). In the Cox regression analysis, the low LAEF (<17%) was independent predictor for primary outcome (adjusted hazard ratio 13.5, 95% confidence interval 3.1–58.6). Conclusion In patients undergoing TV surgery with AF-TR, preoperative LA dysfunction was independently associated with adverse outcomes.Figure1

Durability of annuloplasty in patients with atrial functional mitral regurgitation associated with atrial fibrillation

ObjectiveTo determine the durability of mitral valve repair (MVr) with complete ring or flexible band annuloplasty in patients with atrial functional mitral regurgitation (AFMR) due to atrial fibrillation (AF) and identify risk factors associated with postoperative recurrence of mitral regurgitation. MethodsBetween January 1, 2000, and January 1, 2023, 194 adults with a history of AF underwent MVr with annuloplasty alone for moderate/severe AFMR. Exclusion criteria were prior cardiac surgery, additional repair techniques, ejection fraction <45%, ischemic heart disease, aortic valve disease, mitral annular calcification, and concomitant procedures other than surgical ablation or tricuspid repair/replacement. The durability of annuloplasty was assessed using longitudinal analysis of postoperative echocardiographic data. ResultsComplete ring annuloplasty was performed in 126 of 194 patients (65%); partial ring (posterior band) in the other 68 (35%). Concomitantly, 124 of the 194 patients underwent tricuspid valve surgery, and 173 (89%) had a procedure for AF, including biatrial Cox-Maze III/IV lesion set in 152 (88%) and pulmonary vein isolation in 21 (12%). All patients were discharged with no/trace MR. Freedom from moderate/severe MR after repair with annuloplasty alone was 89% at 10 years, and no significant differences were noted between complete and partial ring annuloplasty (early, P = .41; late, P = .92). Forty-eight percent of patients developed AF at 3 months or longer after surgery, and the presence of postoperative AF was not associated with a greater likelihood of recurrence of MR (P = .15). Freedom from mitral reintervention was 96% at 10 years. ConclusionsIn appropriate patients with AFMR, the long-term durability of annuloplasty is excellent with complete ring and posterior band annuloplasty techniques.

Preoperative Predictors of Postoperative Pulmonary Complication Following Isolated Tricuspid Valve Surgery

Background: Postoperative pulmonary complications (PPC) are the most frequently observed complications following cardiac surgery, leading to extended hospital stays and significant medical and economic burdens. Although surgical interventions for tricuspid valve disease are increasingly common, few risk factors for PPC in the context of tricuspid valve surgery have been identified. Uncovering these factors would have valuable clinical implications in terms of prognosis. Methods: We conducted a single-center retrospective study to evaluate preoperative factors associated with susceptibility to PPC in patients undergoing tricuspid valve surgery between 2018 to 2023. Independent predictors of PPC were identified using regression analysis. Results: Of the 147 patients included in the study, 29.9% (44 cases) experienced PPC. No statistically significant differences were observed in surgical procedures between the groups. Regression analysis identified smoking status (odds ratio [OR]: 7.69, p = 0.01), severity grade of tricuspid regurgitation (TR) (OR: 26.56, p &lt; 0.01), recent respiratory infection (OR: 78.52, p &lt; 0.01), and pulmonary hypertension (OR: 13.60, p &lt; 0.01) as independent risk factors for PPC following tricuspid valve surgery. Conversely, the 6-minute walk distance (6MWD) (OR: 0.99, p = 0.01) and tricuspid annular plane systolic excursion (TAPSE) (OR: 0.61, p &lt; 0.01) were identified as independent protective factors. Conclusion: The incidence of PPC following tricuspid valve surgery was determined to be 29.9%. The identified predictors—smoking status, severity of tricuspid regurgitation, recent respiratory infections, pulmonary hypertension, as well as protective factors like 6MWD and TAPSE—can offer valuable insights for optimizing the preoperative physiological conditions in patients undergoing tricuspid valve surgery.

Incidence and risk factors for permanent pacemaker implantation in patients undergoing tricuspid valve surgery

Abstract Background Bradyarrhythmias requiring permanent pacemaker (PPM) implantation are commonly described after cardiac surgeries. Numerous studies evaluated the demographic and clinical risk factors for PPM placement following aortic and mitral valve surgeries. However, a paucity of data exists when it comes to tricuspid valve surgery (TVS). Purpose Our study aimed to evaluate the incidence of PPM placement after TVS and investigate the demographic, clinical, and procedural risk factors associated with the need for a PPM. Methods We included 13 294 patients from the Medicare database who underwent isolated TV repair (N=1319 (10%)), isolated TV replacement (N=2123 (16%)), or concomitant TV repair or replacement with different combinations of surgical aortic valve replacement (SAVR), mitral valve repair or replacement (MVR), and coronary artery bypass graft (CABG). Patients who underwent TV surgery for endocarditis were excluded. The primary exposure of interest for the study was new pacemaker placement after TV surgery and before discharge, or within 30 days from discharge date. Each patient from the pacemaker group was matched to up to 3 controls from the no pacemaker group. Results Among the included patients, 2518 (18.9%) required a PPM placement after TVS. In the logistic regression including patients’ variables, subjects who needed PPM implantation were more likely to be women (64.4% vs. 57.6%, P&amp;lt;0.001) and had a higher prevalence of prior sternotomy (P=0.01), chronic kidney disease (P=0.03), heart failure (P=0.04) and tumor (P=0.02). Patients who underwent isolated TV replacement and TV replacement with concomitant surgeries had a significantly higher risk of PPM implantation when compared to isolated TV repair and TV repair with concomitant surgeries (P&amp;lt;0.0001) (Table). Conclusion Post-procedural PPM implantation is a very frequent complication of TVS, especially in TV replacement with or without concomitant left-sided heart surgeries. Numerous demographic and clinical factors are associated with an increased risk of PPM placement. Adequate risk stratification and counseling of patients before surgery decision is essential.Demographic &amp; Surgical Risk Factors

Outcomes following permanent pacemaker implantation in patients undergoing tricuspid valve surgery

Abstract Background PPM implantation are commonly described after cardiac surgeries and notably after tricuspid valve surgery (TVS). Purpose Our study aimed to compare outcomes in patients who underwent PPM placement versus patients who did not following TVS. Methods We included 13 294 patients from the Medicare database who underwent isolated TV repair (N=1319 (10%)), isolated TV replacement (N=2123 (16%)), or concomitant TV repair or replacement with different combinations of surgical aortic valve replacement (SAVR), mitral valve repair or replacement (MVR), and coronary artery bypass graft (CABG). Patients who underwent TV surgery for endocarditis were excluded. The primary exposure of interest for the study was new pacemaker placement after TV surgery and before discharge, or within 30 days from discharge date. Each patient from the pacemaker group was matched to up to 3 controls from the no pacemaker group. The primary study outcome was all-cause mortality in follow-up in patients who underwent pacemaker placement after TV surgery versus patients who did not. The study’s secondary outcomes included 1-year mortality and the risk of hospital readmission with a diagnosis of endocarditis or heart failure (HF) in follow-up. Results Among the included patients, 2518 (18.9%) required a PPM placement after surgery. PPM placement was associated with a longer length of hospital stay (median 12 days (IQR 8-19 days) vs. 10 (7-17 days), P&amp;lt;0.001). It was not associated with a difference in risk of 1-year mortality (18.9% vs. 20.7%, OR 0.90, 95% CI 0.79-1.03, P=0.1). After a median follow-up of 3.1 years (IQR 1-5.5 years), PPM placement was also not associated with a significant increase in the risk of mortality in comparison to patients who did not require PPM (HR 1.02, 95% CI 0.93-1.12, P=0.7) (Figure 1). However, it was associated with a higher risk of HF readmission in follow-up (HR 1.28, 95% CI 1.14-1.43, P&amp;lt;0.001) when compared to no PPM (Figure 2). Finally, PPM was not associated with any difference in risk of endocarditis in follow-up (HR 1.03, 95% CI 0.74-1.45, P=0.8). Conclusion Post-procedural PPM implantation is a frequent complication of TVS. While mortality is not increased, PPM placement leads to higher HF hospitalization rates. Adequate risk stratification and counseling of patients before surgery decision is essential.Survival after TVSHeart Failure after TVS

Tricuspid regurgitation impact on outcomes (TRIO) score: an evaluation tool for patients undergoing tricuspid valve surgery?

Abstract Background Isolated tricuspid regurgitation (TR) repair or replacement carries significant operative mortality risk mainly due to delayed referral. We have recently developed the Tricuspid Regurgitation Impact on Outcomes (TRIO) score to assess risk in TR based on 8 simple variables (age, sex, severe TR, creatinine&amp;gt;2 mg/dl, history of heart failure, history of chronic lung disease, AST &amp;gt;40 units/L, heart rate &amp;gt;90). Whether this score can be used in assessment of TR surgical risk and long term outcome is unknown. Purpose To examine the impact of TRIO scores on the postoperative outcomes of isolated tricuspid valve surgery. Methods Adult patients with severe functional TR who underwent isolated tricuspid valve replacement or repair between 2000-2022 were identified. Postoperative outcomes were compared across low (0-3), intermediate (4-6), and high (7-12) TRIO risk score groups. Results 177 patients were included. Mean age was 70.7 ± 12.2 years, 69 (39%) were male, 34 (19%) were low TRIO score, 111 (63%) intermediate score and 32 (18%) high score. Tricuspid repair was performed in 43 (24.3%) and valve replacement in 134 (75.7%), reflecting the advanced disease stages of this patient cohort. At short term, higher TRIO scores were associated with more frequent need for urgent surgery, prolonged ventilation (&amp;gt;72h) and postoperative dialysis (p&amp;lt;0.05 for all). Perioperative 30-day mortality increased with the TRIO risk score (low: 0%; intermediate: 4.5%; high: 9.4%) but differences did not reach statistical significance (p=0.187). Low risk patients had a shorter hospital and ICU stay (Figure 1A-B). During a mean follow-up of 5.2 ± 3.2 years, 98 (55.4%) patients died. At long term follow-up, lower TRIO scores were associated with improved survival after tricuspid surgery (Figure 1C). Conclusions Patients with higher TRIO scores have more postoperative complications, require longer hospital stay and have higher all-cause mortality at long-term follow-up. Our findings suggest that TRIO score may also be used for risk stratification in patients considered for surgical management of isolated functional TR.

The relation of right ventricular outflow tract measurements with in-hospital clinical outcomes after tricuspid valve surgery.

Right ventricular (RV) function is a determining factor for clinical outcomes in patients undergoing tricuspid valve surgery (TVS). Our aim was to investigate the importance of the function of the right ventricular outflow tract (RVOT), which is an important anatomical region of the RV, in patients underwent TVS. 104 patients who underwent TVS were analyzed retrospectively. Patients with previous cardiac surgery, congenital heart disease, or heart failure were excluded. The parasternal short-axis view at the level of the aortic root was used to measure RVOT dimensions and RVOT fractional shortening (RVOT-FS). The effect of RVOT diameter and function on major adverse cardiac events (MACE) after TVS was investigated. In our study, MACE, consisting of pacemaker implantation, acute kidney injury, postoperative atrial fibrillation and mortality, was developed at 44 (42.3%) patients.We compared the predictive performances of RVOT end-systolic (RVOTs) diameter, RVOT end-diastolic (RVOTd) diameter, RVOT-FS and RV diameters in prediction of MACE. The model including the RVOTs had higher AUC, R2 and likelihood ratio X2 values (0.775, 0.287 and 25.0, respectively) than RVOTd (0.770, 0.279 and 24.2, respectively) and RVOT-FS (0.750, 0.215 and 18.1, respectively). RVOT diameters showed better performance in predicting MACE than RV diameters. Moreover, there was statistically significant association between RVOTs, RVOTd and MACE (p value were 0.014 and 0.027, respectively), while no association between RVOT-FS and MACE (p value was 0.177). In summary, we determined that the RVOT diameters are important predictors for the in-hospital clinical outcomes of patients who underwent TVS.

Effect of venoarterial extracorporeal membrane oxygenation initiation timing on tricuspid valve surgery outcomes

ObjectivesTricuspid valve surgery is associated with high rates of shock and in-hospital mortality. Early initiation of venoarterial extracorporeal membrane oxygenation after surgery may provide right ventricular support and improve survival. We evaluated mortality in patients undergoing tricuspid valve surgery based on the timing of venoarterial extracorporeal membrane oxygenation. MethodsAll consecutive adult patients undergoing isolated or combined surgical tricuspid valve repair or replacement from 2010 to 2022 requiring venoarterial extracorporeal membrane oxygenation use were stratified by initiation in the operating room (Early) versus outside of the operating room (Late). Variables associated with in-hospital mortality were explored using logistic regression. ResultsThere were 47 patients who required venoarterial extracorporeal membrane oxygenation: 31 Early and 16 Late. Mean age was 55.6 years (standard deviation, 16.8), 25 (54.3%) were in New York Heart Association class III/IV, 30 (60.8%) had left-sided valve disease, and 11 (23.4%) had undergone prior cardiac surgery. Median left ventricular ejection fraction was 60.0% (interquartile range, 45-65), right ventricular size was moderately to severely increased in 26 patients (60.5%), and right ventricular function was moderately to severely reduced in 24 patients (51.1%). Concomitant left-sided valve surgery was performed in 25 patients (53.2%). There were no differences in baseline characteristics or invasive measurements immediately before surgery between the Early and Late groups. Venoarterial extracorporeal membrane oxygenation was initiated 194 (23.0-840.0) minutes after cardiopulmonary bypass in the Late venoarterial extracorporeal membrane oxygenation group. In-hospital mortality was 35.5% (n = 11) in the Early group versus 68.8% (n = 11) in the Late group (P = .037). Late venoarterial extracorporeal membrane oxygenation was associated with in-hospital mortality (odds ratio, 4.00; 1.10-14.50; P = .035). ConclusionsEarly postoperative initiation of venoarterial extracorporeal membrane oxygenation after tricuspid valve surgery in high-risk patients may be associated with improvement in postoperative hemodynamics and in-hospital mortality.

Right coronary artery deformation and injury following tricuspid valve surgery.

Due to its close anatomical proximity to the annular plane of the tricuspid valve (TV), the right coronary artery (RCA) is at risk of injury and distortion during surgical and interventional repair. Recently, reversible, non-flow limiting, purse-string like deformations of the RCA following percutaneous TV annuloplasty have been described. In contrast, there are only anecdotal reports on RCA deformation following conventional TV surgery. A retrospective analysis of all patients undergoing TV surgery in our hospital between 2009 and 2019 was performed including all patients who received a post-operative coronary angiography (POCA). Angiographic footage was reviewed for RCA affections. A total of 1,383 patients underwent TV surgery (replacement and repair) for tricuspid regurgitation in our center. TV repair was performed in 1,248 (90.2%) patients and 135 (9.8%) patients underwent isolated TV surgery. Sixty-five patients (4.7%) underwent POCA within 48 h after surgery due to suspected myocardial ischemia, representing the final study population. Mean age was 70.3 ± 11.3 years, 56.3% were female. Mean EuroSCORE II was 9.8 ± 11.6%. Patients with the need for POCA due to suspected myocardial injury suffered from a higher mortality compared to event-free patients over the long-term follow up period (median 2.9 years) regardless of the observed coronary status. RCA affections were observed in 24 (36.9%) patients. A new RCA deformation without flow-impairment or vascular damage was found in 16 (24.6%) of the cases and was managed conservatively. There was no significantly worse outcome observed as compared to patients without RCA affections. Six (9.2%) patients showed an RCA deformation accompanied by subtotal occlusion. A complete RCA-occlusion was observed in 2 (3.1%) patients. Revascularization by percutaneous coronary intervention could be successfully performed in these patients. RCA deformation occurred exclusively after TV repair while no cases were observed after TV replacement. Right coronary artery deformation without flow-limitation following surgical TV repair is a specific/typical phenomenon which might not impair patients' outcome and could be managed conservatively in most of the cases. RCA injury indicating further interventional therapy is a rare complication of TV surgery. However, the need for immediate POCA in general appears to be associated with a worsened intermediate-term outcome.

255 Tricuspid regurgitation in the community by routine echocardiography

Abstract Aims Tricuspid Regurgitation (TR) is quite frequent in the community and often overlooked in routine clinical practice. This study aims to convey the TR rate of diagnosis and impact on survival in a geographically defined population of an Italian referral centre, considering five different clinical contexts. Methods The study included consecutive outpatients with comprehensive echocardiography and complete clinical evaluation over 7 years of practice. Outpatients with TR greater than moderate were included, and the different clinical contexts evaluated: patients with concomitant significant mitral regurgitation (MR-TR), heart failure (HF-TR), previous open-heart surgery (postop-TR), pulmonary hypertension (PHTN-TR) and isolated TR (isolated-TR). Results Among all consecutive echocardiograms performed in routine practice (N=6797) in a geographically defined community, moderate or severe TR was found in 4.8% (N = 327; mean age 76±10, 56% female). Median follow-up was 6.1 [2.2–8.9] years. TR severity was an independent determinant of survival: risk ratio for mortality of severe TR vs. moderate was 1.72 [95% CI 1.06–2.77; P = 0.03] univariate and 1.76 [95% CI 1.02–3.01; P = 0.04] after adjusted for age, sex, MR, PHTN and EF. Only 2.8% of patients underwent tricuspid valve surgery during follow-up. Outpatients with MR-TR or HF-TR held the worst prognosis (Figure). As compared to isolated-TR, the mortality risk was 2.67 [95% CI 1.05–6.78; P = 0.04] for HF-TR and 2.04 [95% CI 1.00–4.14; P = 0.05] for MR-TR. Risk ratios for mortality vs. postop-TR were 3.66 [95% CI 1.19–11.26; P= 0.02] for HF-TR and 2.79 [95% CI 1.08–7.21; P = 0.03] for MR-TR. There was no interaction between the TR clinical context and the survival impact of TR (P=0.09). Conclusions Significant TR is frequent in our community, comparable to key epidemiological studies. TR severity independently impacts survival in all clinical settings, and it is associated with an absolute high event-rate when present with concomitant MR or HF. These results give importance to early diagnosis with grading to be performed through accurate echocardiography and renew the interest in new and safe, less invasive percutaneous intervention to improve patients' survival.

Impact of maze procedure in patients with severe tricuspid regurgitation and persistent atrial fibrillation

ObjectivePatients with severe tricuspid regurgitation and persistent atrial fibrillation may not be good candidates for maze procedure due to preoperative atrial remodeling and various comorbidities. We attempted to evaluate the rhythm and clinical outcomes of maze procedure in these patients. MethodsPatients with severe tricuspid regurgitation and persistent atrial fibrillation who underwent tricuspid valve surgery between January 1994 and December 2017 at a single tertiary center were analyzed. The primary end point was sinus rhythm restoration. The key secondary end point was major adverse cardiovascular and cerebrovascular event rate, which is the composite event of stroke, cardiac death, major bleeding, and readmission for heart failure. Propensity score matching analysis was used. ResultsA total of 388 patients underwent tricuspid valve surgery, and among them 172 patients (44%) underwent concomitant maze procedure. The maze group had sinus rhythm restoration rate of 56% in 9 years. Further, in the matched cohort, the maze group had higher freedom from major adverse cardiovascular and cerebrovascular event rate at 10 years than the nonmaze group (55.6% vs 36.2%; P = .047). Preoperative left atrial diameter (hazard ratio, 1.022; 95% CI, 1.012-1.033; P < .001) and right atrial diameter (hazard ratio, 1.012; 95% CI, 1.003-1.022; P = .013) were independent risk factors for failure of sinus rhythm. ConclusionsMaze procedure in severe tricuspid regurgitation and persistent atrial fibrillation had acceptable rates of sinus rhythm restoration and reduced major adverse cardiovascular and cerebrovascular events in the long-term. Careful patient selection considering preoperative atrial diameters is needed to enhance maze success rate and long-term clinical outcomes.

Feasibility and reproducibility of right ventricle stress echocardiography and its capability to assess the right ventricle contractile reserve of patient with at least trivial tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND. Stress echocardiography (SE) is widely used for the assessment of left ventricular (LV) function, diagnostic and prognostic stratification of patients with coronary artery disease and for assessment of mitral and aortic valve disease. However, the assessment of the right ventricle (RV) in general, and in particular in regard to the contractile reserve of the RV in patients with tricuspid valve (TV) disease is an area that has not been previously explored in adult patients. The physiology and function of the RV is different than that of the LV and the use of SE provides the possibility to test both systolic and diastolic function of the RV in response to increased loading conditions. This can potentially be used to assess the RV function prior to surgery and to predict which subset of patients may benefit from intervention on the TV before the RV displays signs of failure PURPOSE. We therefore propose a study to investigate the potential use of SE for the assessment of RV function in adult patients. The aim is to evaluate the feasibility of RV SE in any patients with more than trivial tricuspid regurgitation (TR) and to assess the presence and degree of RV contractile reserve. METHODS. We enrolled 81 patients undergoing a phisical or dobutamine SE for CV risk stratification or chest pain. Inclusion criteria were age≥ 18 years, normal baseline RV function (FAC&amp;gt; 35%, TAPSE&amp;gt; 16 mm). Exclusion criteria were presence of RV dysfunction, pulmonary stress hypertension, positive stress test for left myocardial ischemia, presence of moderate or severe valvular disease, grade III or higher diastolic dysfunction at baseline, severe respiratory, renal or hepatic dysfunction. We evaluated the average values of TAPSE, fractional area change (FAC), S wave, sPAP (pulmonary systolic blood pressure), RV strain during baseline and at the peak of the effort. We also assessed the reproducibility of these measurement between two different expert operators (blind analysis). RESULTS. We were able to measure the RV parameters both during baseline and at the peak of the effort in all patients, demonstrating an excellent feasibility. Differences in parameters collected at baseline and at peak were assessed using paired Wilcoxon signed rank test. All variables showed a statistical significant increase (p &amp;lt; 0.001) at peak compared to the baseline. Average percentage increases at peak were 31.1% for TAPSE, 24,8% for FAC, 50,6% for S wave, 55,2% for PAPS and 39.8 % for RV strain. Bland-Altman method was used to evaluate the agreement between measurements collected by two separate operators and it showed good Intraclass Correlation Coefficients (Figure). CONCLUSIONS. RV SE proved to be feasible and showed little inter-operator variability in patients with at least trivial TR. It provided valuable informations about RV contractile reserve that may help stratifying the risk of RV failure in patients undergoing TV surgery. Abstract Figure

Surgical treatment of tricuspid valve disease due to permanent pacemaker lead

Objective: To summarize the etiology and surgical treatment experience of tricuspid valve disease due to permanent pacemaker lead. Methods: The medical records of 22 patients who underwent tricuspid valve operation for tricuspid valve disease due to permanent cardiac pacemaker lead from January 2008 to December 2017 were retrospectively reviewed. There were 12 males and 10 females, with a mean age of (62.6±12.1) years old (45-82 years old). All patients underwent tricuspid valve surgery via open thoracotomy under general anesthesia, including 8 patients through median thoracotomy approach, 4 patients through right mini-thoracotomy approach, and 10 patients with endoscopy-assisted and totally endoscopic technique. Moreover, 8 patients underwent tricuspid valve replacement, and 14 patients received tricuspid valve repair. Results: During the operation, 10 cases of severe tricuspid regurgitation were detected due to valve and subvalvular structures dysfunction involved in the pacing electrode, 7 cases showed tricuspid annulus dilation, and pacing electrode-related infective endocarditis were involved in the tricuspid valve of 5 cases. Compared with conventional median thoracotomy surgery, the amount of postoperative drainage fluid and hospitalization time after minimally invasive surgery (including right mini-thoracotomy and endoscopic surgery) were significantly reduced [281(120, 489) ml vs 368(180, 560) ml, P=0.02; 9.2(4.8, 14.5) d vs 11.2(6.3, 16.9) d, P=0.03]. Postoperative echocardiographic data showed that the size of the right atrium and ventricle in these patients was significantly reduced compared with preoperative data, and their cardiac function were normal. There was no difference of pacing electrode parameters between pre-and postoperative period. All 22 patients were cured and discharged, with no valve-and pacemaker-related complications. Conclusions: Patients with tricuspid valve disease due to permanent cardiac pacemaker lead should actively undergo surgery including tricuspid replacement or repair according to different etiologies, which exhibit satisfactory outcomes. Minimally invasive endoscopic tricuspid surgery is a new technique for the treatment of isolated tricuspid valve disease, with less surgical trauma and faster recovery.

In-Hospital Outcomes and Trends of Tricuspid Valve Surgery in Heart Transplant Patients

Introduction: Tricuspid valve (TV) regurgitation is the most common valvular pathology after orthotopic heart transplant (OHT). The number of transplants being performed is increasing with patients living longer after heart transplant. Data on TV surgery in OHT recipients is limited. Methods: We sought to analyze the outcomes of patients undergoing TV surgery from a large diverse, multicentric, nationwide cohort using the Nationwide Inpatient Sample (NIS) database. Results:A total of 42,766 TV repair or replacement (bioprosthetic and mechanical) involving adult patients (age ≥18 years) between 2007 and September 2015 were identified. Of these, 366 were performed in patients with OHT. TV repair was the most common surgery performed in both groups (OHT group and native heart group). Compared to the native group, patients with OHT had a significantly higher incidence of cardiogenic shock (20 vs. 11%, p = 0.024), acute kidney injury (AKI) (59 vs. 30%, p < 0.001), and AKI requiring hemodialysis (13 vs. 4%, p < 0.001). Also, the mean length of stay for the index admission was significantly longer in the OHT group (27 vs. 17 days, p = 0.008). The mortality rate was similar between the two groups (7 vs. 8%, p = 0.753). The number of TV surgeries performed in OHT patients from 2007 to 2014 have remained stable (p = 0.803) compared to those in native heart patients which showed a significantly increasing trend (p = 0.019) during the same time period. Conclusions: TV surgery remains an important treatment modality among the OHT population and carries a similar mortality during index hospitalization as that in native heart patients undergoing TV surgery.

Endoscopic Tricuspid Valve Surgery is a Safe and Effective Option.

Isolated tricuspid surgery through median sternotomy can be associated with a high morbidity and mortality. Reports of minimally invasive isolated tricuspid valve operations are rare, but the outcomes are encouraging. We present our experience of endoscopic isolated tricuspid valve surgery. In our institution, 452 patients underwent endoscopic minimal access cardiac surgery between August 2008 and December 2018. A total of 90 patients underwent tricuspid valve surgery whether isolated or with other cardiac procedure. We further selected patients who had isolated tricuspid valve surgery (n = 24). Of these patients, 13 (54%) had more than one previous sternotomy. Tricuspid repair was performed in 18 patients (75%) with the remaining 6 (25%) having bioprosthetic tricuspid replacement. Three (12.5%) were performed with a beating heart, the remaining with endoaortic clamping and cardioplegia. There were no conversions to sternotomy. None of the patients had reoperation for bleeding, tamponade, or valve issues. Three patients (12.5%) required blood transfusion, 3 patients (12.5%) required renal dialysis, and 7 patients (29%) had respiratory complications such as chest infection, requiring continuous positive airway pressure (CPAP) with 2 being re-intubated. One patient (4.1%) died within 30 days from chest sepsis leading to multi-organ failure. Mean hospital stay was 11.1 ± 8.9 days (median of 8). All patients had mild or less regurgitation on follow-up echo at 6 months. Isolated tricuspid valve surgery can be performed through an endoscopic minimally access approach, with good results. It appears to provide better results than a sternotomy approach. A high repair rate can be achieved, and the procedure is particularly valuable in redo-surgery with low mortality and morbidity compared to historical sternotomy case series.

Long-term outcomes of patients undergoing tricuspid valve surgery†.

Limited literature is available on the best management strategy for tricuspid valve (TV) disease in adults. We sought to review our long-term outcomes of TV surgery with regard to survival and reoperation. A retrospective analysis of all patients ≥18 years of age [n = 2541, aged 67 ± 13years, 1433 (56%) females] who underwent first-time TV surgery between January 1993 and December 2013 was done. There were 1735 patients who received TV repair and 806 patients underwent replacement. A gradient boosting machine model was used to derive a propensity score for predicting replacement using 27 preoperative characteristics. Four hundred and eighteen propensity-matched pairs of TV repair and replacement were identified. Cox proportional hazard regression was used on the matched subset to determine the effect of replacement. Functional TV regurgitation was present in 54% (n = 1369). A bioprosthesis was used in 84% (n = 680) of replacements, while 54% (n = 934) of TV repairs were ring annuloplasties. Operative mortality was 8% (n = 212). Overall survival was 54%, 29% and 13% at 5, 10 and 15 years, respectively. After propensity score matching, replacement was significantly associated with increased mortality [hazard ratio (HR) 1.54, 95% confidence interval (CI) 1.18-2.00; P = 0.001]. The cumulative incidence of TV reoperation was similar between the 2 groups when accounting for the competing risk of death [Fine-Gray HR 1.56, 95% CI 0.9-2.8; P = 0.144]. TV surgery is associated with poor outcomes due to multiple patient comorbidities. TV repair results in better survival compared to replacement in patients with similar comorbidities with no increased risk of getting a reoperation.

Tricuspid annular diameter and right ventricular volume on preoperative cardiac CT can predict postoperative right ventricular dysfunction in patients who undergo tricuspid valve surgery

BackgroundWe investigated the predictive value of preoperative computed tomography (CT)-derived tricuspid annular and right ventricular (RV) parameters for postoperative RV dysfunction in patients undergoing tricuspid valve (TV) surgery. MethodsWe retrospectively reviewed clinical, transthoracic echocardiography (TTE), and CT data of 100 consecutive patients who underwent cardiac CT and subsequently received TV surgery. Preoperative cardiac CT and TTE parameters were analyzed, including TV annulus diameter and RV size. Univariate and multivariate logistic regression analyses were performed to identify significant predictors for postoperative RV dysfunction, both in the entire study population and in the subgroup of patients without preoperative RV dysfunction. ResultsPostoperative RV dysfunction occurred in 46% of all patients. In the multivariate logistic regression analysis, longer TV annulus diameter (>29.3 mm/m2 on four-chamber view; (odds ratio [OR] 3.56, 95% confidence interval [CI] 1.13–11.24), larger RV volume (RV end-diastolic volume/body surface area > 128.8 ml/m2) on CT (OR 3.85, 95% CI 1.24–11.98) and presence of preoperative RV dysfunction on TTE (OR 11.96, 95% CI 2.8–50.99) were independent predictors for postoperative RV dysfunction in the entire study population (P < 0.05). Among patients without preoperative RV dysfunction, longer TV annulus diameter (OR 4.02, 95% CI 1.20–13.41) and larger RV volume on CT (OR 6.09, 95% CI 1.87–19.80) were independent predictors for postoperative RV dysfunction (P < 0.05). ConclusionsPreoperative assessment of cardiac CT imaging–based TV annular diameter and RV volume can provide independent information for predicting postoperative RV dysfunction in patients undergoing TV surgery.

Male-female differences in characteristics and early outcomes of patients undergoing tricuspid valve surgery: a national cohort study in the Netherlands.

This study aims to explore male-female differences in baseline and procedural characteristics, and outcomes of patients undergoing isolated or concomitant tricuspid valve (TV) surgery. All TV procedures registered between 2007 and 2016 in the database of the Netherlands Association for Cardio-Thoracic Surgery were analysed. Logistic regression analyses with interaction terms were used to determine whether sex was associated with hospital mortality. Five thousand five hundred and eighty-two patients underwent TV surgery [isolated: N = 685 (49% male), TVrepair: N = 5286 (50% male) and TVreplacement: N = 250 (46% male)]. In the TVrepair group, females were significantly older, had less prior percutaneous/surgical coronary interventions, less extracardiac arteriopathies, a lower prevalence of renal impairment, less endocarditis, a lower prevalence of preoperative critical condition, less recent myocardial infarction, less concomitant coronary artery bypass grafting (CABG) and, in case of concomitant mitral valve surgery, less concomitant mitral valve repair compared to males. In the TVreplacement group, females more often had a history of prior valve surgery and less prior CABG. Hospital mortality for males and females was 7.0% (N = 183) and 6.1% (N = 163), P = 0.241 in the TVrepair group and 2.6% (N = 3) and 8.8% (N = 12), P = 0.074 in the TVreplacement group. Sex was not associated with hospital mortality (odds ratio (OR) 1.14, 95% confidence interval (CI) 0.88-1.48; P = 0.322). Sex demonstrated a significant interaction with the parameter 'critical preoperative condition' (OR 0.44, 95% CI 0.22-0.90; P = 0.026). Substantial differences in patient and procedural characteristics existed between male and female patients undergoing TV surgery, although sex was not a derterminant for hospital mortality. Nevertheless, sex interacted with a critical preoperative condition, indicating the usefulness of separate risk factor models for males and females requiring TV surgery.

Periprocedural and perioperatory management of patients with tricuspid valve disease.

Tricuspid regurgitation (TR) is a common valvular lesion which may affect morbidity and mortality. It can be related to an intrinsic abnormality of the tricuspid valve leaflets (organic) or secondary to annular dilatation (functional). Often organic and functional TR coexist in the same patient. A long-standing TR is associated with ascites, congestive hepatopathy, peripheral edema, renal failure, and abdominal fullness which significantly affect the outcome. In particular, the perioperative course may be complicated due to both the presence of comorbidities and the development of a severe postoperative right ventricle (RV) dysfunction. In fact, the TR may conceal a preoperative RV dysfunction due to a backflow in in the right atrium, which becomes overt only after the tricuspid valve (TV) repair/replacement (afterload mismatch). In light of this, an appropriate medical treatment before surgery may improve the performance of the RV, maximizing the result of the elective surgical therapy. The perioperative optimization should reduce the right atrial and ventricle overload, decrease the pulmonary vascular resistances, improve RV contractility and treat aggressively the arrhythmias. In doing so, the following rules should be considered: careful fluid administration, β1-agonists favored over α-agonists to treat hemodynamic instability, and maintenance of a normal-to-elevated heart rate. Since the TV repair/replacement needs mechanical ventilation in both open and percutaneous surgery, a careful volume and pharmacological management should be adopted to counteract the detrimental effect of the mechanical ventilation on the top of an already dysfunctional RV. In fact, in the context of RV failure the cardiac output is strictly dependent on the preload and the increase of the intrathoracic pressure, reducing the venous return, may lead to acute heart failure. The intraoperative administration of volume and vasoactive drugs, titrated on the basis of the transesophageal echocardiography, permit to support the RV intraoperatively. Paracorporeal mechanical hemodynamic support should be always available as "bail out" in the event of intractable RV failure. In conclusion the patients undergoing TV surgery are complex and only a detailed anesthesiologic and surgical workup may decrease the perioperative mortality and morbidity.

Impact of Isolated Tricuspid Valve Repair on Right Ventricular Remodelling in an Adult Congenital Heart Disease Population.

Surgical repair of isolated congenital tricuspid valve (TV) disease is rare with no well-defined indication and outcomes. Moreover, the role of right ventricle (RV) in this context has not yet been investigated. We sought to assess the impact of congenital TV repair on cardiac remodelling and clinical-functional status and the importance of the RV function in an adult congenital heart disease (ACHD) population. From January 2005 to December 2015, 304 patients underwent TV surgery in our centre. Of these, 27 (ACHD) patients had isolated TV repair. Patients were evaluated with preoperative and postoperative transthoracic echocardiogram. Survival rate has been investigated with a mean clinical follow-up (FU) of 3.7 ± 2.3 years, whereas the mean echocardiographic FU was 2.9 ± 1.8 years. The clinical and functional status of patients showed a statistically significant improvement after the surgical repair in terms of New York Heart Association class (66.7 vs 7.4%; p < 0.01), clinical signs of heart failure (29.6 vs 7.4%; p < 0.01), and left ventricular function (14.8 vs 7.4%; p < 0.01). The RV and right atrium diameter were significantly reduced after surgery (5.15 ± 1.21 vs 4.32 ± 1.16; p < 0.01) and (44.7 ± 16.7 vs 26.7 ± 9.2; p < 0.01), respectively. The degree of postoperative pulmonary hypertension was also significantly reduced (40.7 vs 7.4%; p < 0.01). The survival rate was 96.3% at 1 year and 93.7% at 5 years. One patient (3.7%) had early failure of the tricuspid repair requiring a reoperation. Isolated TV repair for adult congenital disease significantly improved patients' clinical and functional status and allowed right ventricular remodelling and functional improvement.