Tricuspid Valve Procedures Research Articles

Atrial Fibrillation Should Guide Prophylactic Tricuspid Procedures During Left Ventricular Assist Device Implantation.

Atrial fibrillation (AF) and tricuspid regurgitation (TR) are common in patients undergoing left ventricular assist device (LVAD) implantation. TR progression is associated with the presence of AF, and questions remain as to who benefits from tricuspid valve procedures (TVPs). We examined the impact of preoperative AF on TR progression after LVAD implantation. From February 2007 to May 2014, 250 patients underwent LVAD implantation at our institution. Patients with concomitant TVP were excluded from this analysis (113 patients). The indication for LVAD was destination therapy in 80 patients (58%) and the etiology of heart failure was ischemic in 73 (53%). Follow-up was available in all early survivors for a total of 393 patient-years of support. Of the 137 non-TVP patients, 52 (38%) had AF preoperatively. Observed overall survival at 1, 3, and 5 years was 82%, 67%, and 55%, respectively. Median grade of TR increased from 2 preoperatively to 3 (p = 0.04) in the AF group and 2.2 (p = 0.75) in the non-AF group at 5 years of follow-up. We also observed a significant difference in the degree of TR between groups at 3 months (p = 0.03) and 12 months (p = 0.01) postimplantation, and a trend toward significance at 18 (p = 0.06) and 24 (p = 0.07) months. The presence of AF is associated with early progression of TR after LVAD implantation. Addition of concomitant TVP in patients with preoperative AF may be considered in patients with less than severe TR. The impact of these findings on right ventricular failure/remodeling remains to be evaluated.

Transcatheter treatment of tricuspid regurgitation using edge-to-edge repair: procedural results, clinical implications and predictors of success.

The aim of this study was to analyse the feasibility, safety and effectiveness of tricuspid valve (TV) repair using the MitraClip system in patients at high surgical risk. Forty-two elderly high-risk patients (76.8±7.3 years, EuroSCORE II 8.1±5.7) with isolated TR or combined TR and mitral regurgitation (MR) underwent edge-to-edge repair of the TV (n=11) or combined edge-to-edge repair of the TV and mitral valve (n=31). Procedural details, success rate, impact on TR severity and predictors of success at 30-day follow-up were analysed. Successful edge-to-edge repair of TR was achieved in 35/42 patients (83%, 68 clips in total, 94% in the anteroseptal commissure, 6% in the posteroseptal commissure). In five patients, grasping of the leaflets was impossible and two patients had no decrease in TR after clipping. In those with procedural success, clipping of the TV led to a reduction in effective regurgitant orifice area by -62.5% (from 0.8±0.4 to 0.3±0.2 cm2; p<0.0001). In both patients with isolated TV and combined procedures, six-minute walking distance improved (from 285±118 to 344±81 m and from 225±113 to 261±130 m, p=0.02 and 0.03, respectively). Predominant anteroseptal or central TR was identified as a predictor of procedural success (p=0.025). Edge-to-edge repair of the TV is feasible with a promising reduction in TR, which could result in clinical improvement.

Single Femoral Venous Drainage Versus Both Vena Cava Drainage in Isolated Repeat Tricuspid Valve Surgery.

To assess the potential advantages of minimally invasive surgery using a single femoral venous drainage method versus femoral venous and superior vena cava or jugular venous drainage method during repeat tricuspid valve surgery.From January 2010 to December 2016, 50 repeat tricuspid valve procedures were performed using a minimally invasive approach without aortic cross-clamping at our institution. The arterial cannula was inserted into the femoral artery, and at the same time, the venous cannula was placed in the femoral vein in 28 patients (FV group) during cardiopulmonary bypass (CPB). The venous cannula was inserted into the femoral vein and the superior vena cava or jugular vein in 22 patients (FSV group).Overall, 36 patients underwent tricuspid valve replacement (TVR) and 14 patients underwent tricuspid valvuloplasty (TVP). The CPB time and operation time, respectively, were 72.96 ± 25.90 minutes versus 78.59 ± 31.95 minutes (P = 0.495) and 170.75 ± 73.31 minutes versus 228.87 ± 61.45 minutes (P = 0.004) in the FV group versus the FVS group. There were no significant differences in the ventilator-assisted time, the first-day LVEF, and the intensive care unit (ICU) stay between the FV group and the FSV group.Both types of drainage were effective and could ensure safety during the operative procedure. The vacuum-assisted single femoral venous drainage method simplified the minimally invasive isolated repeat tricuspid valve surgical process more significantly and is the more appropriate choice.

Hybrid Palliation: Outcomes After the Comprehensive Stage 2 Procedure

The comprehensive stage 2 procedure (CS2) follows initial hybrid stage 1 palliation for patients with single-ventricle physiology. The goal of this study was to describe CS2 outcomes and differences between survivors of CS2 (s-CS2) and nonsurvivors (nons-CS2). All patients in The Society of Thoracic Surgeons Congenital Heart Surgery Database who underwent CS2 as index operation from 2010 to 2016 were included. Preoperative, operative, and postoperative data were analyzed, stratified by operative mortality (in-hospital or within 30 days of the operation), with univariate comparisons using χ2, Fisher exact, or Wilcoxon rank sum tests. Of 209 patients (49 centers) who met inclusion criteria, 141 patients had the diagnosis of hypoplastic left heart syndrome. Overall operative mortality was 12.4% (26 of 209). s-CS2 had a lower prevalence of preoperative extracorporeal membrane oxygenation use (0.0% vs 7.7%, p= 0.02) and less frequently underwent concomitant tricuspid valve procedures at the time of the operation (1.1% vs 11.5%, p= 0.01) than nons-CS2. Postoperatively, the prevalence of any of six The Society of Thoracic Surgeons Congenital Heart Surgery Database major complications was higher in nons-CS2 than in s-CS2 (53.9% vs 23.0%, p < 0.01), including a higher prevalence of renal failure (7.7% vs 0.6%, p= 0.04) and postoperative extracorporeal membrane oxygenation use (46.2% vs 2.7%, p < 0.01). There were no other preoperative, operative, or postoperative differences between the two groups. Operative mortality associated with the CS2 procedure is substantial, especially for patients receiving extracorporeal membrane oxygenation support after CS2. No obvious modifiable variables were noted between patients who died and those who survived.

Long-term results of annuloplasty in trivial-to-mild functional tricuspid regurgitation during mitral valve replacement: should we perform annuloplasty on the tricuspid valve or leave it alone?

The benefits of concomitant tricuspid annuloplasty (TAP) for non-significant functional tricuspid regurgitation (TR) during mitral valve replacement (MVR) are controversial. We evaluated the long-term outcomes-particularly the long-term tricuspid valve (TV) functional outcomes-of MVR with or without tricuspid ring annuloplasty. From 2004 to 2014, 256 patients (56.4 ± 12.1 years) with trivial or mild functional TR who underwent MVR were enrolled. Eighty-two patients underwent concomitant tricuspid ring annuloplasty (TAP group), and 174 patients did not undergo the TV procedure (nTAP group). Propensity score-matched analysis was performed (n = 72 in each group). The follow-up duration was 77.4 ± 42.4 months. The early clinical outcomes were similar between the 2 groups before and after propensity score matching with an early mortality rate of 3.5% (9 of 256). No patients experienced ring-related complications during follow-up. Eleven (6.3%) patients developed significant TR (≥moderate) in the nTAP group, while no patients developed significant TR in the TAP group. There were no significant differences in overall survival between the 2 groups before or after matching. However, propensity score-matched analysis revealed that the freedom from significant TR aggravation and freedom from TV-related event rates were significantly higher in the TAP group than in the nTAP group (P = 0.047 and P = 0.043, respectively). Patients with untreated trivial or mild functional TR accompanied by mitral valve disease can develop significant TR during follow-up. TV ring annuloplasty can be performed without complications and can be beneficial for patients with trivial or mild functional TR who are undergoing MVR.

Surgical outcomes of isolated tricuspid valve procedures: repair versus replacement.

Isolated tricuspid valve (ITV) operations are infrequent and the decision to operate is controversial. We report a series of ITV operations to outline the current disease status requiring this uncommon procedure with an emphasis on the results of tricuspid valve repair (TVr) versus replacement (TVR). Using our prospective cardiac surgery database, 57 patients who underwent ITV operations between 01/02-03/14 were identified. Median follow up time was 3.5 years [interquartile range (IQR), 0.8-6.7 years]. Fifty-seven patients underwent ITV surgery with a mean age of 54.4±14.9 yrs and 61% were women. Baseline characteristics were similar between patients who underwent TVr (n=18) or TVR (n=39). The etiologies of TV dysfunction were: ITV endocarditis 14/57 (25%), persistent TV regurgitation after left-sided valve surgery in 12/57 (21%), traumatic biopsies and iatrogenic injury from pacing leads in 11/57 (19%), orthotopic heart transplant 9/57 (16%), carcinoid syndrome 3/57 (5%), congenital 2/57 (5%) and idiopathic 5/57 (9%). Overall, 32/57 (56%) patients had prior heart surgery; of which 10/32 (31%) were TV procedures. Bioprosthetic prostheses were used in 34/39 (87%) patients. Of those who had repair, 11/18 (61%) had ring annuloplasty, 3/18 (17%) bicuspidization, and 3/18 (17%) De Vega annuloplasty and one had vegetectomy. Operative mortality was 5.1% (n=2) and 16.7% (n=3) for TVR and TVr groups, respectively (P=0.32), with an overall mortality rate of 8.6%. Postoperative complications included new onset renal failure in 6/39 (15%) of TVr and 2/18 (11%) of TVR (P=0.71) and there were no strokes. Overall survival rates and degree of residual RV dysfunction were similar for the two groups (both P=0.3). Five-year survival was 77% and 84% for TVr and TVR respectively (P=0.52). There was no difference in rates of recurrent tricuspid regurgitation for TVr and TVR (35.7% vs. 23.5%, respectively, P=0.4). ITV surgery is associated with improved but still relatively high operative mortality. Mid-term outcomes for TVr and TVR are similar with regards to postoperative complications, survival, and freedom from recurrent tricuspid regurgitation.

Use of Echocardiography for Guiding Percutaneous Tricuspid Valve Procedures

Percutaneous tricuspid valve (TV) repair procedures are emerging therapies for patients with symptomatic severe tricuspid regurgitation (TR) who are deemed inoperable. Some of these procedures target the tricuspid annulus (TA), mimicking the Kay procedure, or the leaflets, mimicking Alfieri stitch

ECHOCARDIOGRAPHIC PREDICTORS OF TRICUSPID RING FAILURE

Background: Secondary or functional tricuspid regurgitation (TR) typically occurs as a result of left-sided heart or pulmonary disease. Selection of the appropriate tricuspid valve procedure for patients with FTR remains a challenging clinical question. The failure rate for tricuspid ring

Outcomes after mitral valve repair: A single-center 16-year experience

ObjectiveTo evaluate outcomes after mitral valve repair. MethodsBetween May 1999 and June 2015, 446 patients underwent mitral valve repair. Isolated mitral valve annuloplasty was excluded. A total of 398 (89%) had degenerative valve disease. Mean follow-up was 5.5 ± 3.8 years. Postoperative echocardiograms were obtained in 334 patients (75%) at a mean of 24.3 ± 13.7 months. ResultsSurvival was 97%, 96%, 95%, and 94% at 1, 3, 5, and 10 years. Risk factor analysis showed age >60 years and nondegenerative etiology predict death (hazard ratio, 2.91; 95% confidence interval, 1.06-8.02, P = .038; and hazard ratio, 1.87; 95% confidence interval, 1.16-3.02, P = .010, respectively). Considering competing risks due to mortality, the cumulative incidence of reoperation was 2.8%, 4.2%, 5.1%, and 9.6% at 1, 3, 5, and 10 years. Competing risk proportional hazard survival regression identified nondegenerative etiology and previous cardiac surgery as predictors of reoperation, and posterior repair was protective (all P < .05). Cumulative incidence of progression of mitral regurgitation (2 or more grades) with mortality as a competing risk was 4.7%, 10.5%, 21.0%, and 35.8% at 1, 3, 5, and 10 years. Patients with previous sternotomy, repair or coronary artery bypass grafting, and concurrent tricuspid valve procedure or isolated anterior leaflet repair were more likely to develop progression of mitral regurgitation (all P < .05), and posterior leaflet repair was protective (P = .038). On multivariate analysis diabetes, previous coronary artery bypass grafting and concurrent tricuspid valve intervention predicted MR progression. ConclusionsMitral valve repair has excellent outcomes. Our results demonstrate failures appear to occur less in those who undergo posterior leaflet repair.

Development and impact of arrhythmias after the Norwood procedure: A report from the Pediatric Heart Network

ObjectivesThe study objective was to determine the predictors of new-onset arrhythmia among infants with single-ventricle anomalies during the post-Norwood hospitalization and the association of those arrhythmias with postoperative outcomes (ventilator time and length of stay) and interstage mortality. MethodsAfter excluding patients with preoperative arrhythmias, we used data from the Pediatric Heart Network Single Ventricle Reconstruction Trial to identify risk factors for tachyarrhythmias (atrial fibrillation, atrial flutter, supraventricular tachycardia, junctional ectopic tachycardia, and ventricular tachycardia) and atrioventricular block (second or third degree) among 544 eligible patients. We then determined the association of arrhythmia with outcomes during the post-Norwood hospitalization and interstage period, adjusting for identified risk factors and previously published factors. ResultsTachyarrhythmias were noted in 20% of subjects, and atrioventricular block was noted in 4% of subjects. Potentially significant risk factors for tachyarrhythmia included the presence of modified Blalock–Taussig shunt (P = .08) and age at Norwood (P = .07, with risk decreasing each day at age 8-20 days); the only significant risk factor for atrioventricular block was undergoing a concomitant procedure at the time of the Norwood (P = .001), with the greatest risk being in those undergoing a tricuspid valve procedure. Both tachyarrhythmias and atrioventricular block were associated with longer ventilation time and length of stay (P < .001 for all analyses). Tachyarrhythmias were not associated with interstage mortality; atrioventricular block was associated with mortality among those without a pacemaker in the unadjusted analysis (hazard ratio, 2.3; P = .02), but not after adding covariates. ConclusionsTachyarrhythmias are common after the Norwood procedure, but atrioventricular block may portend a greater risk for interstage mortality.

The impact of concomitant pulmonary hypertension on early and late outcomes following surgery for mitral stenosis

ObjectivesTo provide initial evidence on the management of mitral stenosis and pulmonary hypertension (PH) based on short-term and long-term outcomes following mitral valve surgery. MethodsConsecutive patients with mitral stenosis (n = 317) who had undergone mitral valve surgery between 1992 and 2014 with recorded pulmonary artery pressure (PAP) data were reviewed. PH severity, based on systolic PAP, was categorized as mild (35 to 44 mm Hg), moderate (45 to 59 mm Hg), or severe (>60 mm Hg). Primary outcomes were 30-day mortality and long-term survival. ResultsThere were no significant between-group differences in age or preoperative comorbidities. Mitral valve surgery included mitral valve replacement (78%) and repair (22%). The severe PH group had more mitral valve replacement (81%; P = .04), severe tricuspid valve regurgitation (31%; P = .003), right heart failure (17%; P = .02), and concomitant tricuspid valve procedures (46%; P < .001). For severe PH, 30-day mortality was 9%, with no significant group differences. Ten- and 12-year survival were significantly worse in the moderate–severe PH group (58% and 51%, respectively) compared with the normal PAP–mild PH group (83% and 79%, respectively) with a hazard ratio of 2.98 (95% confidence interval, 1.55-5.75; P = .001). Ten-year survival after mitral valve surgery for mitral stenosis was inversely associated with preoperative PAP. ConclusionsMitral valve surgery can be performed with acceptable 30-day mortality for patients with mitral stenosis and moderate to severe PH, but long-term survival is impaired by moderate to severe PH. Patients with mitral stenosis and mild PH (systolic PAP 35-44 mm Hg) should be considered for mitral valve surgery.

Durability and clinical impact of tricuspid valve procedures in patients receiving a continuous-flow left ventricular assist device

ObjectivePatients evaluated for a continuous-flow left ventricular assist device frequently present with severe right ventricular dysfunction with tricuspid regurgitation. Long-term outcomes of concurrent tricuspid valve procedures in continuous-flow left ventricular assist device implantation are unclear. MethodsFrom May 2004 to December 2013, 336 patients received continuous-flow left ventricular assist devices. Among these, 8 patients with prior tricuspid valve procedures were excluded. At continuous-flow left ventricular assist device implantation, 76 patients underwent tricuspid valve procedures (group A), including 68 repairs and 8 replacements. The remaining 252 patients did not receive concurrent tricuspid valve procedures (group B). ResultsPreoperatively, group A had higher central venous pressure/pulmonary capillary wedge pressure (P = .032), total bilirubin (P = .009), and percentage of moderate or greater tricuspid regurgitation (98.7% vs 18.8%; P < .001). In group A, cardiopulmonary bypass time (136 ± 52.0 minutes vs 83.9 ± 38.8 minutes; P < .001), intraoperative platelet use (13.6 ± 6.70 units vs 11.7 ± 5.92 units; P = .042), and bleeding requiring reoperation (27.5% vs 16.7%; P = .046) were significantly increased. In-hospital mortality was similar (10.5% vs 6.4%; P = .22). On-device 2-year survival was 73.9% in group A and 74.2% in group B (P = .24). At 2 years, mean cumulative readmissions for right heart failure was 0.21 in group A and 0.27 in group B (P = .95). A generalized linear mixed-effects model showed that tricuspid valve procedures are protective for developing future significant tricuspid regurgitation (odds ratio, 0.38; 95% confidence interval, 0.19-0.76; P = .006). ConclusionsConcomitant tricuspid valve procedures at continuous-flow left ventricular assist device implantation can be performed safely and are protective against worsening tricuspid regurgitation during the first 2 years of support.

(515) - Durability and Clinical Impact of Tricuspid Valve Procedures in Patients Receiving Continuous-Flow Left Ventricular Assist Device

(515) - Durability and Clinical Impact of Tricuspid Valve Procedures in Patients Receiving Continuous-Flow Left Ventricular Assist Device

Percutaneous pulmonary and tricuspid valve implantations: An update.

The field of percutaneous valvular interventions is one of the most exciting and rapidly developing within interventional cardiology. Percutaneous procedures focusing on aortic and mitral valve replacement or interventional treatment as well as techniques of percutaneous pulmonary valve implantation have already reached worldwide clinical acceptance and routine interventional procedure status. Although techniques of percutaneous pulmonary valve implantation have been described just a decade ago, two stent-mounted complementary devices were successfully introduced and more than 3000 of these procedures have been performed worldwide. In contrast, percutaneous treatment of tricuspid valve dysfunction is still evolving on a much earlier level and has so far not reached routine interventional procedure status. Taking into account that an "interdisciplinary challenging", heterogeneous population of patients previously treated by corrective, semi-corrective or palliative surgical procedures is growing inexorably, there is a rapidly increasing need of treatment options besides redo-surgery. Therefore, the review intends to reflect on clinical expansion of percutaneous pulmonary and tricuspid valve procedures, to update on current devices, to discuss indications and patient selection criteria, to report on clinical results and finally to consider future directions.

英国における成人期肺動脈弁置換の現況

To review the recent circumstances for surgical pulmonary valve replacement (PVR) in the United Kingdom, we summarized the clinical data from three di erent levels: 1) statistics in the National Database, 2) experience at a major adult congenital heart center, and 3) experience of a surgeon at the institution. 1) e number of patients who underwent PVR markedly increased during the last decade, and the sum total was 25% of the 7,028 surgical cases with adult congenital heart disease that were registered in the database. 2) e institution had 393 patients of PVR, including 242 with repaired tetralogy of Fallot and 78 a er pulmonary stenosis relief. For the valves, a bioprosthesis was used in 227 patients, a homogra was used in 133, and a conduit bearing a bioprosthesis in 33. 3) e surgeon preferred to use a bioprosthesis in 109 of his 117 patients. e pre-PVR cardiothoracic ratio was smaller in 31 patients in whom the pulmonary valvular hinge had been preserved (p=0.009) than in those who had a trans-annular incision. Concomitantly with PVR, a tricuspid valve procedure was performed in 29 patients, surgical anti-arrhythmic procedure in 13, and an enlargement of the proximal right/le pulmonary artery in 11. e PVR maneuver was performed with a beating heart in 88 patients. Femoral cannulation was required in 8. Two patients died early due to severe right heart failure or sudden ventricular arrhythmia. In the longer term follow-up, no further deaths were noted. Two patients required re-operation. A degree of scoliosis was observed in 30 patients. is review illustrates the current status of PVR practice in the UK.

Identification and management of a coronary sinus catheter fracture.

At facilities that offer cardiac surgery services, minimally invasive cardiothoracic surgery is fast becoming commonplace, particularly in aortic, tricuspid, and mitral valve procedures. Use of a coronary sinus catheter, a specialized central venous catheter, to monitor hypothermic depth and provide retrograde cardioplegia has been widely adopted at Tufts Medical Center. Complications of coronary sinus catheter insertion are considered rare but are well documented. In contrast, complications of catheter removal, such as the catheter fracture that we report here, are not well described in the literature. In this case, the catheter tip was retrieved without further patient harm or additional invasive interventions.

Left ventricular assist device for end-stage heart failure: results of the first LVAD destination program in the Netherlands : Towards LVAD destination therapy in the Netherlands?

Left ventricular assist device for end-stage heart failure: results of the first LVAD destination program in the Netherlands : Towards LVAD destination therapy in the Netherlands?

Clinical outcomes after implantation of a centrifugal flow left ventricular assist device and concurrent cardiac valve procedures.

Cardiac valve procedures are commonly performed concurrently during implantation of left ventricular assist devices, but the added procedural risk has not been studied in detail. Data from patients receiving the HeartWare Ventricular Assist Device in the ADVANCE bridge to transplant (BTT) trial and continued access protocol were reviewed. Of 382 consecutive patients who completed follow-up between August 2008 and June 2013 (mean time on support 389 days, median 271 days), 262 (68.6%) underwent isolated HeartWare Ventricular Assist Device implantation, 75 (19.6%) a concurrent valve procedure, and 45 (11.8%) concurrent nonvalvular procedures. Of the concurrent valve procedures, 56 were tricuspid, 13 aortic, and 6 mitral. Survival was similar between groups (79% for concurrent valve procedures and 85% for HeartWare Ventricular Assist Device only at 1 year; P=0.33). Concurrent valve procedures were also associated with increased unadjusted early right heart failure (RHF). A multivariable analysis for death and RHF (121 total events) identified female sex (odds ratio=2.0 [95% confidence interval, 1.2-3.3; P=0.0053]) and preimplant tricuspid regurgitation severity (odds ratio=2.9 [95% confidence interval, 1.8-4.8, P<0.0001]) as independent predictors while concurrent tricuspid valve procedures (TVP) were not predictors. Furthermore, patients with significant preimplant tricuspid regurgitation who did not receive a TVP experienced an increased rate of late RHF compared with those who received TVP (0.19 versus 0.05 events per patient-year, respectively; P=0.024). Compared with HeartWare Ventricular Assist Device alone, survival was equivalent for the concurrent valve procedure group. Tricuspid regurgitation severity was the most important predictor of increased postoperative RHF, and concurrent TVP was not an independent predictor of RHF overall. Concurrent TVP may reduce the rate of late RHF for patients with significant preimplant tricuspid insufficiency. http://www.clinicaltrials.gov. Unique identifier: NCT00751972.

Concomitant tricuspid valve surgery during implantation of continuous-flow left ventricular assist devices: A Society of Thoracic Surgeons database analysis

Performing concomitant tricuspid valve procedures (TVPs) in left ventricular assist device (LVAD) patients with significant pre-operative tricuspid regurgitation (TR) is controversial, and no studies have been large enough to definitively guide therapy. Between January 2006 and September 2012, 2,196 patients with moderate to severe pre-operative TR from 115 institutions underwent implantation of a continuous-flow left ventricular assist device (LVAD) as reported by The Society of Thoracic Surgeons National Database. Of these, 588 (27%) underwent a concomitant TVP. Inverse probability weighting based on propensity score was used to adjust for differences between the LVAD alone and LVAD+TVP groups, and outcomes were compared. Most patients in the LVAD+TVP group underwent an annuloplasty alone (81.1%). Concomitant TVP did not affect risk of post-operative right VAD insertion (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.49-1.36; p = 0.4310) or death (RR, 0.95; 95% CI, 0.68-1.33; p = 0.7658). However, TVP was associated with an increased risk for post-operative renal failure (RR, 1.53; 95% CI, 1.13-2.08; p = 0.0061), dialysis (RR, 1.49; 95% CI, 1.03-2.15; p = 0.0339), reoperation (RR, 1.24; 95% CI, 1.07-1.45; p = 0.0056), greater total transfusion requirement (RR, 1.03; 95% CI, 1.01-1.05; p = 0.0013), and hospital length of stay > 21 days (RR, 1.29; 95% CI, 1.16-1.43; p < 0.0001). Time on the ventilator and intensive care unit length of stay were also significantly prolonged for the LVAD+TVP group. Performing a concomitant TVP for continuous-flow LVAD patients with moderate to severe TR did not reduce early death or right VAD requirement and was associated with worse early post-operative outcomes. These data caution against routine concomitant TVP based solely on degree of pre-operative TR and suggest that additional selection criteria are needed to identify those patients in whom concomitant TVP may prevent post-operative right ventricular failure.

Fate of functional tricuspid regurgitation in aortic stenosis after aortic valve replacement

Functional tricuspid regurgitation (TR) is found not infrequently in conjunction with aortic stenosis. The aim of the present study was to evaluate the changes in TR and to identify the predictors of late progression after aortic valve replacement. We evaluated 354 patients who had undergone aortic valve replacement for aortic stenosis from January 1995 to December 2009. Patients with mitral regurgitation were excluded. Of the 354 patients, 54 had TR greater than mild. The mean follow-up duration was 4.4±4.3 years (maximum, 15). The serial echocardiographic and clinical data were analyzed. No early mortality occurred, and the late cardiac mortality rate was 3.9% (14 of 354). In the 48 patients with TR greater than mild, TR did not improve in 23 (49.1%) during the follow-up period. Freedom from cardiac mortality at 10 years was lower in those with TR greater than mild than in patients without TR (61.6%±16.7% vs 93.0%±2.9%, P=.008). Left ventricular diastolic function correlated with right ventricular systolic pressure (P<.001) and the degree of TR during follow-up (P=.001). Multivariate analysis showed that postoperative atrial fibrillation (odds ratio, 6.8; P=.001) and the aortic transprosthetic mean pressure gradient (odds ratio, 1.1; P=.028) predicted late TR greater than mild. Not only did TR in patients with aortic stenosis frequently persist after aortic valve replacement, it was progressive in some. This finding was associated with left ventricular diastolic dysfunction. A concomitant tricuspid valve procedure could be considered in selected patients with aortic stenosis to avoid late TR.