Tricuspid Surgery Research Articles

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.

Pacemaker Implantation After Tricuspid Valve Surgery at a High-Volume Regional Reference Center

BackgroundThe rate of permanent pacemaker implantation after tricuspid valve (TV) operation is thought to be high, with some studies quoting rates of 20% to 30%. We identified the rate of pacemaker implantation after TV operation at a high-volume regional reference center to better characterize the contemporary risk of pacemaker. MethodsAll adult patients without preexisting pacemakers undergoing TV operation from 2011 to 2022 were included. Patients were categorized by type of tricuspid operation and concomitant procedures. Bivariable analysis and multivariable logistic and Cox regression were performed to compare outcomes and to identify covariates independently associated with pacemaker implantation and long-term mortality. ResultsA total of 1346 patients with no history of pacemaker underwent TV operation. The overall rate of pacemaker was 11% (142/1346), with a 9.2% (113/1235) pacemaker rate with TV repair vs 26% (29/111) rate with TV replacement (P < .001). For isolated TV operations, permanent pacemaker rate was 3.7% (5/135) for repairs vs 23% (18/79) for replacement (P < .001). Need for pacemaker implantation varied significantly by type of operation. Adjusting for patient and operative characteristics, combined aortic root and valve operation, combined mitral and tricuspid surgery, longer cross-clamp time, and tricuspid replacement were independent risk factors for pacemaker. There was no difference in long-term mortality between the groups. ConclusionsIn this large data series, the rate of pacemaker with any TV operation was 11% and ranged from 0% to 33% according to concomitant procedures. Contemporary risk of pacemaker after TV operation at a high-volume center may be lower than previously thought.

Minimally invasive redo tricuspid valve replacement in patient with persistent left superior vena cava.

The management of cardiopulmonary bypass (CPB) is still challenging in certain circumstances, especially for patients with anatomical variations. This challenge is even harder for reoperations, which are associated with increased morbidity and mortality risk. We describe a minimally invasive, beating-heart redo tricuspid valve replacement in a 71-years old woman with persistent left superior vena cava. Preoperative planning via CT-scan, teamwork and custom-made management of CPB are crucial for reoperations with anatomical variations. The perfusionist has a pivotal role in constructing and managing the CPB. We describe a strategy achieving the benefits of minimally invasive endoscopic and beating-heart surgery (avoidance of resternotomy risk and associated morbidity, right ventricular protection) in reoperative tricuspid surgery with persistent upper left vena cava.

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.

Valve Surgery After the Age Of 70: Evaluation Risk Factors for Hospital Mortality

Objective: Valve surgery after the age of 70 is increasingly common in Algeria. The aim of this study was to identify risk factors for in-hospital mortality in this population. Methods: 56 patients with a mean age of 72 years (70-81) underwent valve surgery between 2016 and December 2019. 32 patients (57.4%) had aortic valve replacement, 17 patients (29.7%) had mitral surgery and 07 patients (12.9%) had aorto-mitral surgery. 04 procedures (8%) were urgent. The Euroscore was used to predict operative risk. The mean additive Euroscore was 9.05 and the mean logistic Euroscore was 14.2%. Results: Operative mortality was 3.8%. Preoperative risk factors were: NYHA III class, repeat operations, critical status according to the Euroscore,STS score , PAH, mitral surgery and tricuspid surgery. Post-operative complications were: low flow (12%), supra-ventricular arrhythmia (32.7%), renal dysfunction (14.6%), pulmonary (11%), intestinal (3.5%), infection (4%) and surgical re-exploration (6.5%). Post-operative risk factors for mortality were low flow, renal dysfunction, gastrointestinal complications and surgical re-exploration. Conclusion: Valve surgery after the age of 70 is a low-risk procedure. Our data are correlated with the Euroscore.

Use of perioperative telotristat in a patient with carcinoid heart disease.

Carcinoid heart disease is a rare complication of carcinoid syndrome, resulting in right-sided valvular heart disease and subsequent heart failure due to long-term exposure to vasoactive substances. The management of this condition is complex, often requiring surgical intervention. Current perioperative regimens entail the use of prophylactic somatostatin analogs to prevent carcinoid crisis; however, regimens vary widely among practitioners and evidence supporting their efficacy in this clinical setting is mixed. This case report describes the perioperative management of a 65-year-old man with carcinoid heart disease requiring tricuspid and pulmonary valve replacement surgery. As an adjunct to somatostatin analog therapy, the novel tyrosine hydroxylase inhibitor, telotristat, was initiated preoperatively. This combination resulted in normalization of preoperative urinary 5-HIAA levels. The patient successfully underwent tricuspid and pulmonic valve replacement without evidence of carcinoid crisis. This clinical case is the first published documenting the use of telotristat in the perioperative period in a patient with carcinoid syndrome and carcinoid heart disease and was associated with a good long-term outcome despite the high-risk nature of the case. Carcinoid crisis is a life-threatening complication of carcinoid syndrome, resulting in hemodynamic instability, bronchospasm, and arrhythmia. Cardiac surgical patients with carcinoid syndrome present a unique challenge as they are subject to physiologic conditions and medications which can potentiate intraoperative carcinoid crisis. Perioperative management of patients with carcinoid syndrome currently entails the use of prophylactic somatostatin analogs; however, these agents do not prevent carcinoid crisis in all cases. Telotristat, a tryptophan hydroxylase inhibitor, shows promise as an adjunctive therapy to somatostatin analogs to reduce the risk of intraoperative carcinoid crisis.

Concomitant Tricuspid Valve Surgery Is Not Associated With Increased Operative Risk During Robotic Mitral Valve Surgery.

The aim of this study was to investigate the outcomes of robotic mitral valve surgery with and without concomitant tricuspid valve surgery. Patients who underwent robotic mitral surgery between March 2010 and September 2022 were included. Patients were grouped according to the presence of concomitant tricuspid interventions. The groups were compared for baseline factors, operative parameters, and early postoperative outcomes. Age- and gender-matched groups were also compared for outcomes. The study included 285 robotic mitral surgery patients. There were 59 patients who underwent concomitant tricuspid interventions. In the concomitant tricuspid surgery group, cardiopulmonary bypass time (150.1 vs 128.4 min, P < 0.001) and cross-clamp time (99.2 vs 82.4 min, P < 0.001) were longer. Prolonged intubation was more frequent in the concomitant tricuspid intervention group (5.2% vs 0.5%, P = 0.029). The groups did not differ in terms of mortality, permanent pacemaker (PPM) requirement, or other morbidities. Perioperative outcomes were similar after matched group analysis. Operative mortality and early adverse outcomes did not increase with the addition of tricuspid intervention in our cohort of robotic mitral surgery patients. The robotic approach for mitral disease and coexisting tricuspid disease may offer safe results without an increased risk of postoperative PPM requirement.

Comparison of Beating-Heart Technique Versus Aortic Cross-Clamping in Tricuspid Valve Surgery.

Tricuspid valve surgery can be performed on a beating heart or on an arrested heart. We aimed to compare the outcomes of tricuspid valve surgery using these two different approaches. Between January 2015 and February 2020, 204 patients who underwent tricuspid valve surgery along with concomitant cardiac surgical procedures were included in the study. Techniques of cross-clamping and beating-heart tricuspid surgery were applied to 103 and 101 patients, respectively. Concomitant valvular and/or coronary interventions were performed under cross clamping in both groups. Results from the preoperative period, immediate postoperative period, and six-month postoperative interval were compared between the groups. There were no differences in demographic characteristics or preoperative grades of tricuspid valve regurgitation between the groups. Duration of mechanical ventilation, and stays in the intensive care unit and hospital were significantly shorter in patients operated on using the beating-heart technique. Additionally, re-exploration surgery and mortality rates were significantly lower in the beating-heart group. Postoperative six-month echocardiography findings related to tricuspid valve regurgitation, maximum and minimum gradients of the tricuspid valve, and pulmonary arterial pressure were also lower in the beating-heart group. Beating-heart tricuspid valve surgery may be preferable to the cross-clamping technique to avoid clamp-induced ischemia, which can lead to worsened postoperative outcomes.

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.

Abstract 19004: Clinical Outcomes Following Treatment for Tricuspid Regurgitation: Repair vs. Replacement

Background: Tricuspid regurgitation (TR). previously regarded as the ‘forgotten valvular disease’, has gained a lot interest lately due to its deleterious effects on the right ventricle and long-term outcomes. Surgical literature on outcomes after isolated tricuspid surgery is limited. Although, the guidelines recommend repair of the tricuspid valve, few studies compare outcomes of replacement with repair. Research Question and Aims: Whether, tricuspid repair or replacement is the optimal therapy for TR is not fully understood. Therefore, we sought to compare outcomes and survival after the two techniques. Methods: Our institutional STS database was queried to identify patients who underwent surgery for TR from 2017-2022. Of the 200 patients identified, 84 were excluded due to major concomitant procedures. After exclusion, 70 patients underwent tricuspid replacement and 46 underwent repair. Pre-, intra- and post-operative characteristics were tabulated and compared using t-tests and fisher’s exact test. 5-year survival was analyzed using Kaplan-Meier curves. Results: Tricuspid repair was notably done in a significantly older patient population compared to replacement (p=0.005) likely due to presence of more endocarditis in the younger population who underwent replacement (Figure 1). Tricuspid repair was associated with a significantly longer cross-clamp time. Post-operative complications including pacemaker implantation rates were not significantly different between the groups. 30-day and 5-year mortality rate was also not found to be significantly different between the two interventions. From the limited mid-term echo follow up, TAPSE reduced to 1.5 from 2.1 in the repair group (p=0.01). Conclusions: Younger patients with endocarditis underwent more replacements than repairs. 30-day outcomes and 5-year survival were not significantly different in the two groups however, RV function seemed to worsen in patients who underwent TV repair.

Tricuspid surgery at time of mitral surgery improves survival free from severe tricuspid regurgitation but not quality of life

ObjectiveThe choice to operate on moderate tricuspid regurgitation (TR) during mitral surgery is challenging owing to limited mid-term data. We assess whether concomitant tricuspid operations improve mid-term quality of life, morbidity, or mortality. MethodsAn institutional database identified mitral surgery recipients with moderate TR at the time of surgery from 2010 to 2019. Patients were stratified by the presence of a concomitant tricuspid operation. Quality of life at the last follow-up was assessed with the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Morbidity was compared using the χ2 test, Mann-Whitney U test, and Student t test. Survival was analyzed with Kaplan-Meier estimation. ResultsOf 210 mitral surgery recipients, 67 (31.9%) underwent concomitant tricuspid surgery. The concomitant tricuspid surgery cohort had greater preoperative dialysis use (10.5% vs 3.5%; P = .043) but similar age, New York Heart Association class, and cardiac surgery history relative to the nonconcomitant cohort (P > .05 for all). The concomitant tricuspid surgery cohort had a longer cardiopulmonary bypass time (144 minutes vs 122 minutes; P = .005) but a similar rate of mitral repair (P = .220). Postoperative KCCQ-12 scores reflected high quality of life in both cohorts (95.1 vs 89.1; P = .167). The concomitant tricuspid surgery cohort trended toward a higher perioperative pacemaker placement rate (22.8% vs 12.7%; P = .088) but were less likely to develop severe TR (0.0% vs 13.0%; P = .004). Overall survival was comparable between the 2 cohorts at 1 year (84.9% vs 81.6%; P = .628) and 5 years (73.5% vs 57.9%; P = .078). Five-year survival free from severe TR was higher in the concomitant cohort (73.5% vs 54.3%; P = .032). ConclusionsConcomitant tricuspid surgery for moderate TR is associated with increased 5-year survival free from severe TR but not with increased quality of life.

Tricuspid valve replacement outcomes in a diverse variety of valve replacement cases: Mortality, mechanical versus biological – A single-center study

Background: The initial trial in tricuspid surgery is repair; however, replacement is done whenever the valve is badly diseased. Tricuspid valve replacement (TVR) as an isolated procedure and combined with other valve replacements presents a challenge as these patients are in the high-risk subset. Materials and Methods: The present retrospective study was performed using the medical records of 42 cases who underwent TVR since 2017 at our institute. The mean age of the participants was 36.3 ± 13.2 years and male–female was 66.7% and 33.3%, respectively. Isolated TVR was done in 35.7% of cases, associated with mitral valve replacement (MVR) in 38.1%, with aortic valve replacement (AVR) in 4.8%, triple-valve replacement (MV, TV, and AV) in 19.0%, and TVR associated with pulmonary valve replacement in 2.4% of cases. This diverse variety of valve replacement cases is the highlight of our study. About 30.9% of participants were undergoing the procedure as a redo surgery. Trial of repair was given in 33.3% of cases. Moreover, bioprosthesis and mechanical valve prosthesis were used in 73.8% and 26.2%, respectively. Results: Early mortality occurred in 8 (19.0%) cases. Cause of death common in all deaths was right ventricular failure in all cases 8/8 (100%) seconded by multi-organ failure in 7/8 cases (87.5%), previous cardiac surgery was a factor in 4/8 (50%) cases, mediastinitis occurred in 2/8 (25%) cases, and both arrhythmias and cerebrovascular accident happened in 1/8 (12.5%) case each. Mortality rate was 3/15 (20.0%) in cases of isolated TV surgery. Mortality rate for concomitant MVR was 3/15 (20.0%), and for concomitant AVR with MVR (triple-valve replacement) was 2/8 (25.0%). No early mortality happened in the concomitant AVR and concomitant pulmonary valve replacement group. Late mortality happened in 11/42 (26.2%) cases during follow-up. Total mortality as per the valve types has been 5/11 (45.5%) in the mechanical valve replacement group and 14/31 (45.2%) for the biological valve group. Conclusions: The patients who require TVR are usually high-risk surgical candidates with high early and late mortality. The most common cause of death was right ventricular failure in this study. TVR associated with other heart valve replacement increases the risk strata of the patient which is the highlight of our study. In the end, we conclude that we had 19.0% early (0–30 days) and 26.2% late mortality (0–1 year) making a composite of 45.2% mortality at the end of 1 year. No difference in the effect of mortality as per the valve type has been observed.

Echocardiographic Progression of Peak Tricuspid Regurgitant Velocity Among Medicare Beneficiaries

BackgroundPeak tricuspid regurgitant velocity (TRV) on transthoracic echocardiography (TTE) is a commonly obtained parameter and robust predictor of subsequent adverse clinical outcomes. ObjectivesThe purpose of this study was to determine the predictors and clinical significance of TRV progression. MethodsWe retrospectively linked consecutive outpatient TTE reports from our institution to 2005 to 2017 Medicare claims. Individuals with prior tricuspid surgery, endocarditis, tricuspid stenosis, missing TRV values, TTEs performed during inpatient hospitalization, or <2 TTEs were excluded. ResultsA total of 4,572 patients (mean age 67.8 ± 11.9 years, 50.4% female) received 13,273 TTEs over a median follow-up of 7.4 (IQR: 4.5-6.9) years. TRV increased by a mean of 0.23 (95% CI: 0.22 to 0.23 m/s/y, P < 0.001) (range, 0.01-0.80 m/s/y). Older age, depressed left ventricular ejection fraction, diabetes, hypertension, hyperlipidemia, atrial fibrillation, heart failure, and chronic kidney disease were associated with faster progression (all P < 0.05). Accounting for 23 demographic, clinical, and TTE variables, faster TRV progression was associated with a stepwise increased risk of all-cause mortality (TRV progression quartile 4 vs 1; adjusted HR: 2.17; 95% CI: 1.74-2.71; P < 0.001). Those with regression of TRV (n = 384 [8.4%]) had a lower mortality risk (adjusted HR: 0.40; 95% CI: 0.28-0.57; P < 0.001). ConclusionsIn this large, multidecade study of Medicare beneficiaries with serial TTEs performed in the outpatient setting, the mean rate of TRV progression was 0.23 m/s/y. Older age, left heart disease, and adverse metabolic features were associated with faster progression. Faster progression was associated with a graded risk for all-cause mortality.

Tricuspid valve replacement provides better long-term survival and tricuspid valve function than repair in patients with systemic right ventricle

ObjectiveThe purpose of this study is to compare the long-term outcomes of 2 different tricuspid surgeries including valvuloplasty and replacement for significant tricuspid regurgitation in patients with systemic right ventricle. MethodThis is a retrospective study of 34 patients with dextro-transposition of the great arteries or levo-transposition of the great arteries with biventricular circulation and systemic right ventricle undergoing tricuspid valve surgery between April 1979 and April 2022. Patients were divided into 2 groups based on the procedure: tricuspid valvuloplasty (n = 11) and tricuspid valve replacement (n = 23). These groups were compared in terms of survival, tricuspid valve dysfunction, and tricuspid valve–related reoperation. ResultsThere was no significant difference between the groups in operative age, body weight, the proportion of dextro-transposition of the great arteries, Ebstein-like tricuspid dysplasia, and preoperative right ventricular volume/function. During the median follow-up of 9.7 years, there was 1 early death (tricuspid valvuloplasty group) and 4 late deaths (3 in tricuspid valvuloplasty group and 1 in tricuspid valve replacement group). There were 7 tricuspid valve dysfunctions, including 6 significant tricuspid regurgitations in the tricuspid valvuloplasty group and 1 prosthetic valve dysfunction in the tricuspid valve replacement group, and 4 tricuspid valve-related reoperations (3 in the tricuspid valvuloplasty group and 1 in the tricuspid valve replacement group) were performed. There were significant differences between the groups in survival (tricuspid valvuloplasty vs tricuspid valve replacement: 72.7 vs 94.7% at 10 years after surgery, P = .0328) and cumulative incidence of tricuspid valve dysfunction at 10 years after tricuspid surgery (tricuspid valvuloplasty vs tricuspid valve replacement: 27.3% vs 0%, P = .0121). ConclusionsTricuspid valve replacement provided better long-term survival and tricuspid function in patients with systemic right ventricle compared with tricuspid valvuloplasty.

Endoscopic aortic valve surgery in isolated and concomitant procedures.

To evaluate early outcomes of endoscopic aortic valve replacement and risks of concomitant procedures done through the same working port. At our institution we performed a data analysis of 342 consecutive patients (from July 2013 to May 2021) that underwent endoscopic aortic valve replacement with or without associated major procedure. Pre-operative, intraoperative, post-operative data were evaluated. Subsequently we perform a comparative analysis between the isolated and concomitant surgery group. The surgical access was a 3-4 cm working port in the second right intercostal space and 3 additional 5 mm mini-ports for the introduction of the thoracoscope, the transthoracic clamp and the vent line. Cardiopulmonary by-pass was achieved through peripheral cannulation. 105 patients (30.7%) underwent combined procedure: 2 coronary artery bypass (1.9%), 21 ascending aorta replacement (19.6%), 41 mitral surgery (38.3%), 16 mitral and tricuspid surgery (15%), 25 other procedure (27%). Death occurred in 1 patient (0.4%) in the isolated group versus 2 patients (1.9%) in the combined group (p = 0.175). Seven strokes were observed, 4 in isolated procedures (1.7%) and 3 in the concomitant ones (2.85%) (p = 0.481). Surgical revision for bleeding was performed always through the same access in 13 patients (5.4%) versus 11 patients (10.4%) (p = 0.096). Pace maker implantation was necessary in 5 patients (2.1%) versus 8 patients (7,6%) (p = 0.014). Median intubation time was 5 [2] hours versus 6 [8] (p < 0.080). Through a single working port made for endoscopic aortic valve replacement a concomitant procedure may be done without affecting in-hospital mortality and post-operative stroke rate.

P342 DEL NIDO VS SERVATOR H CARDIOPLEGIA

Abstract Background and aim One–shot long–lasting cardioplegia is particularly useful during right minithoracotomy mitral valve surgery (RT–MS), and the Servator H cristalloid solution has been widely used in this setting. However, the Servator H cardioplegia requires the administration of large volumes of fluids and the frequent recourse to ultrafiltration. we compared Servator H versus the Del Nido Cardioplegia, that contains blood and requires smaller volumes, in patients undergoing RT–MS. Methods 36 consecutive patients undergoing RT–MS (± tricuspid and AF surgery) were randomly assigned to receive Servator H or Del Nido Cardioplegia. There were no differences between the two groups at baseline. Results Although there were no differences in terms of mortality and incidence of major complications, the use of Servator H cardioplegia was associated with a significantly increased release of CK–MB (but not of TnI) during the early postoperative period. Moreover, patients receiving Servator H were more likely to require defibrillation or pacing after removal of the aortic cross–clamp (8, 40% vs 2, 12.5%), and experienced a significantly higher rate of postoperative atrial fibrillation (10, 50% vs 4, 25%, p &amp;lt; 0.05). Conclusion Our data show that the Del Nido cardioplegia could offer improved myocardial protection during minimally invasive mitral valve surgery, resulting in reduced need for post–cardioplegia defibrillation and of postoperative atrial fibrillation. This is consistent with the results of similar, recent research. Further studies on larger populations are needed to consolidate these data.

Late outcome of coronary artery bypass grafting with or without mitral repair for moderate or moderate-severe ischemic mitral regurgitation.

Operative indication of the additional mitral repair for moderate ischemic mitral regurgitation (MR) in the setting of coronary artery bypass grafting (CABG) is still unclear. This study was designed as the nation-wide multi-center retrospective analysis with additional survival data. CABGs without past heart surgery registered in 2014 and 2015 were included. Concomitant surgery other than tricuspid or arrhythmia surgery, mitral replacement, and off-pump cases, was excluded. Grade 1 or 4 MR, and ejection fraction < 20 or > 50 were excluded. Additional questionnaire was sent to each hospital, regarding the pathology of MR and clinical outcomes. Additional data were registered between May 28, 2021 and Dec 31, 2021, and the primary outcomes were all-death and cardiac death. The secondary outcomes were heart failure and cerebrovascular event requiring admission, mitral re-intervention. Patients underwent on-pump CABG (CABG only group 221 cases) and CABG with mitral repair (CABG + Mitral repair group 276 cases) were enrolled. After Propensity score matching, 362 cases (CABG only 181cases vs CABG + mitral repair 181 cases) were matched. Cox regression model showed no statistical difference in the long-term survival between CABG alone group and combined procedure group (p = 0.52). Cardiac death (p = 1.00), heart failure (p = 0.68), and cerebrovascular event (p -0.80) requiring admission were not different between groups as well. The incidence of mitral re-intervention was very few (2 cases in CABG only group, 4 cases in CABG + mitral repair group). In patients with moderate ischemic MR, additional mitral repair to CABG did not improve long-term survival, freedom from heart failure, or cerebrovascular event.

Prognostic Predictors of Tricuspid Regurgitation Worsening after Mitral Regurgitation Surgery with Mild Tricuspid Regurgitation

We aimed to investigate the prevalence and predictors of postoperative tricuspid regurgitation (TR) worsening in patients with mitral regurgitation (MR) and concomitant ≤mild TR. A total of 620 patients underwent surgery for MR from 2013 to 2017. Of these, 260 had ≤mild preoperative TR and no concomitant tricuspid valve surgery and were enrolled in this single-center retrospective study. The primary endpoint was postoperative worsening of ≥moderate TR. The primary endpoint occurred in 28 of 260 patients (11%) during the follow-up period [median: 4.1 years (interquartile range: 2.9-6.1 years)]. In the multivariable analysis, age, female sex, and left atrial volume index (LAVI) were significant predictors of the primary outcome during intermediate-term follow-up (age: hazard ratio [HR] 1.05 per 1-year increment, 95% confidence interval [CI] 1.02-1.10, P = 0.003; female sex: HR 3.53, 95% CI 1.61-7.72, P = 0.002; LAVI: HR 1.17 per 10-mL/m2 increment, 95% CI 1.07-1.26, P < 0.001). The optimal LAVI cut-off value for predicting postoperative TR worsening was 79 mL/m2 (area under the curve: 0.69). A high LAVI (>79 mL/m²) was significantly associated with a low rate of freedom from postoperative TR worsening compared with a low LAVI (≤79 mL/m²) (82.6% vs 93.9% at 5 years, respectively; log-rank P = 0.008). In patients with ≤mild preoperative TR and no concomitant tricuspid surgery, the rate of postoperative TR worsening was 11% during intermediate-term follow-up. LA enlargement in patients with MR and ≤mild preoperative TR was significantly associated with postoperative TR worsening.

Safety and Efficacy of the Transaxillary Access for Minimally Invasive Mitral Valve Surgery-A Propensity Matched Competitive Analysis.

Background and Objectives: Transaxillary access is a straightforward “single incision—direct vision” concept, based on a 5 cm skin incision in the right anterior axillary line. It is suitable for aortic, mitral and tricuspid surgery. The present study evaluates the hospital outcomes of the transaxillary access for isolated mitral valve surgery compared with full sternotomy. Patients and Methods: The final study group included 480 patients. A total of 160 consecutive transaxillary patients served as treatment group (MICS-MITRAL). Based on a multivariate logistic regression model including age, sex, body-mass-index, EuroScore II and LVEF, a 1:2 propensity matched control-group (n = 320) was generated out of 980 consecutive sternotomy patients. Redo surgeries, endocarditis or combined procedures were excluded. The mean age was 66.6 ± 10.6 years, 48.6% (n = 234) were female. EuroSCORE II averaged 1.98 ± 1.4%. Results: MICS-MITRAL had longer perfusion (88.7 ± 26.6 min vs. 68.7 ± 32.7 min; p < 0.01) and cross-clamp (64.4 ± 22.3 min vs. 49.7 ± 22.4 min; p < 0.01) times. This did not translate into longer procedure times (132 ± 31 min vs. 131 ± 46 min; p = 0.76). Both groups showed low rates of failed repair (MICS-MITRAL: n = 6/160; 3.75%; Sternotomy: n = 10/320; 3.1%; p = 0.31). MICS-MITRAL had lower transfusion rates (p ≤ 0.001), less re-exploration for bleeding (p = 0.04), shorter ventilation times (p = 0.02), shorter ICU-stay (p = 0.05), less postoperative hemofiltration (p < 0.01) compared to sternotomy patients. No difference was seen in the incidence of stroke (p = 0.47) and postoperative delirium (p = 0.89). Hospital mortality was significantly lower in MICS-MITRAL patients (0.0% vs. 3.4%; p = 0.02). Conclusions: The transaxillary access for MICS-MITRAL provides superior cosmetics and excellent clinical outcomes. It can be performed at least as safely and in the same time frame as conventional mitral surgery by sternotomy.

Transcatheter tricuspid valve intervention: to repair or to replace?

The burden of tricuspid regurgitation (TR) is high in the aging population, almost 4% in the age group over 75 have moderate or more TR. This carries a poor prognosis and an increased incidence of mortality, prolonged hospitalization, and rehospitalization in symptomatic patients with severe TR is observed. Percutaneous tricuspid valve intervention has emerged as a viable therapeutic option, with an increasingly large toolbox of both tricuspid repair and replacement devices. The optimal strategy, timing and patient selection for transcatheter intervention are yet to be determined. This review focuses on the current strengths and limitations of transcatheter tricuspid repair vs. replacement, drawing on lessons learned from surgery. Early outcome studies have been published in the last 2 years for many of the new percutaneous tricuspid valve devices. We have summarized these results and compared them to surgical tricuspid valve repair and replacement. We found that surgical data shows a tendency to better outcome with tricuspid valve repair compared to replacement. For transcatheter interventions studies comparing repair and replacement are lacking but both interventions show good procedural success rates and are efficient in reducing the grade of tricuspid regurgitation. Transcatheter tricuspid valve interventions offer a safe and effective alternative to tricuspid surgery or medical therapy. The decision between valve replacement and repair should be based on patient anatomy, operator experience and device availability until head-to-head comparison of different devices are available.