Triple Valve Surgery Research Articles

Predictors of Survival After Triple Valve Surgery: A Single Center Analysis

BackgroundTriple valve surgery is a complex operation with high perioperative mortality. Limited data exist regarding the predictors of success associated with this surgery. We report our experience. MethodsA total of 211 sequential patients underwent triple valve surgery at 1 hospital from November 2007 through July 2022. Baseline characteristics, operative details, and mortality outcomes were reviewed. ResultsEighty-two (38.9%) were redo operations and 68 (32.2%) were urgent. Commonly, aortic (n = 194; 91.4%) and mitral (n = 140; 66.4%) valves were replaced, and the tricuspid valve (n = 189; 89.6%) repaired. Concomitant procedures were done in 28% of patients. Thirty-day mortality was 21 of 211 (9.95%). Kaplan-Meyer survival at 1 and 7 years was 86.0% (interquartile range, 79%-93%) and 64.0% (interquartile range, 55%-74%), respectively. On multivariate regression, end-stage renal disease (hazard ratio, 4.16; P = .003) was associated with mortality, and mitral valve replacement (hazard ratio, 0.44; P = .009) was associated with improved long-term survival. ConclusionsDespite the high number of redo and concomitant procedures, we report a 30-day mortality rate under 10% and an 86% 1-year survival. In our series, mitral valve replacement conferred a long-term survival benefit.

20 Years of triple-valve surgery in the UK: demographic and outcome trends.

To describe evolving demographic trends and early outcomes in patients undergoing triple-valve surgery in the UK between 2000 and 2019. We planned a retrospective analysis of national registry data including patients undergoing triple-valve surgery for all aetiologies of disease. We excluded patients in a critical preoperative state and those with missing admission dates. The study cohort was split into 5 consecutive 4-year cohorts (groups A, B, C, D and E). The primary outcome was in-hospital mortality, and secondary outcomes included prolonged admission, re-exploration for bleeding, postoperative stroke and postoperative dialysis. Binary logistic regression models were used to establish independent predictors of mortality, stroke, postoperative dialysis and re-exploration for bleeding in this high-risk cohort. We identified 1750 patients undergoing triple-valve surgery in the UK between 2000 and 2019. Triple valve surgery represents 3.1% of all patients in the dataset. Overall mean age of patients was 68.5 ± 12 years, having increased from 63 ±12 years in group A to 69 ± 12 years in group E (P < 0.001). Overall in-hospital mortality rate was 9%, dropping from 21% in group A to 7% in group E (P < 0.001). Overall rates of re-exploration for bleeding (11%, P = 0.308) and postoperative dialysis (11%, P = 0.066) remained high across the observed time period. Triple valve replacement, redo sternotomy and poor preoperative left ventricular ejection fraction emerged as strong independent predictors of mortality. Triple-valve surgery remains rare in the UK. Early postoperative outcomes for triple valve surgery have improved over time. Redo sternotomy is a significant predictor of mortality. Attempts should be made to repair the mitral and/or tricuspid valves where technically possible.

The Effect of Gender on Triple Heart Valve Surgery Outcomes; Reinforcing Women's Health.

Female gender is a risk factor in several cardiac surgery risk stratification systems. This study explored the differences in the outcomes following triple heart valve surgery in men vs women. The study included 250 patients (males n = 101; females n = 149) who underwent triple valve surgery from 2009 to 2020. BMI (body mass index) was higher in females (29.6 vs 26.5kg/m2, P < .001), and diabetes was more common in males (44 vs 42%, P = .012). The ejection fraction was higher in females (55 vs 50%, P < .001). The severity of mitral valve stenosis and tricuspid valve regurgitation was significantly greater in females (33.11 vs 27.72%, P = .003 and 44.30 vs 19.8%, P < .001, respectively). Mitral valve replacement was more common in females (P < .001), and they had lower concomitant coronary artery bypass grafting (P = .001). Bleeding and renal failure were lower in females (P = .021 and <0.001, respectively). Hospital mortality, readmission, and reintervention were not significantly different between genders. By multivariable analysis, male gender was a risk factor for lower survival [HR (hazard ratio): 2.18; P = .024]. Triple valve surgery can be performed safely in both genders, with better long-term survival in females. Female gender was not a risk factor in patients undergoing triple valve surgery.

Pushing the Boundaries in Totally Endoscopic Cardiac Surgery: Combined Triple Valve Surgery and Ascending Aorta Replacement.

Pushing the Boundaries in Totally Endoscopic Cardiac Surgery: Combined Triple Valve Surgery and Ascending Aorta Replacement.

Potential Rheumatological Heart Disease Causing Triple Valve Replacement: A Case Report

INTRODUCTION: Mechanical valves were identified in the aortic, mitral, and tricuspid valves of an 88-year-old donor. The presence of these valves along with the donor's past medical history and body habitus indicate a triple valve replacement surgery was performed. CASE PRESENTATION: Here we describe our 88-year-old donor’s body habitus during routine anatomical dissection. DISCUSSION: Evidence of a rare triple valve surgery is discussed along with how this type of case report acts as a useful exercise contributing towards medical student education. CONCLUSION: A rare triple valve replacement appears to have been performed on our donor.

Abstract 12851: Severe Right and Left-Sided Multi-Valvular Carcinoid Heart Disease Associated With Ovarian Carcinoid Tumor

Carcinoid tumors are neuroendocrine neoplasms that secrete vasoactive substances, primarily serotonin, and have an incidence of approximately 2 in 100,000 people. Up to 60% of carcinoid tumors result in carcinoid heart disease (CHD), and unlike other carcinoid tumors, ovarian carcinoid tumors can involve the heart without liver metastasis. By bypassing the liver, ovarian carcinoid tumors can result in CHD in the absence of liver metastasis. We present a rare case of a 40-year-old female who presented in cardiogenic shock requiring inotropic support with echocardiographic evidence of preserved left ventricular systolic function (LVEF 50-55%) and multiple retracted leaflets that exhibited poor coaptation resulting in severe mitral regurgitation, torrential tricuspid regurgitation, and moderate-to-severe aortic regurgitation. Her left heart catheterization revealed non-obstructive coronary artery disease. A non-contrast CT torso revealed an isolated large septated left ovarian cystic mass (7.1x5.2 x7.1cm) without any other mass or lesion. In the setting of an elevated CA-125 (536units/mL, normal 0-35units/mL) and 24-hour urinary 5-HIAA (12.1mg, normal 2-9mg) with a normal CEA, CHD was suspected as the most likely diagnosis given the isolated ovarian mass and severe valvular disease. She underwent triple valve surgery in which valvular pathology revealed myxoid degeneration. Her post-operative course was complicated by multi-organ failure requiring multiple inotropes and V-A ECMO shortly thereafter, but the patient unfortunately passed away. While there are a few documented cases of CHD from ovarian carcinoid (less than 0.5% of cases) and left-sided CHD (less than 10% of cases), this is the first documented case, to our knowledge, describing severe right and left-sided CHD associated with a suspected ovarian carcinoid tumor.

Relative Survival After Adult Cardiac Surgery: Analysis of the Italian Nationwide Registry Data

The authors aimed to investigate life expectancy after adult cardiac surgery. Nationwide study including University and non-University hospitals. Consecutive adult patients who underwent heart valve and coronary artery surgery from a nationwide administrative registry. Surgical procedures on the heart valves and coronary arteries. The authors estimated the 10-year relative survival of adult patients who underwent surgery for heart valve diseases and coronary artery disease taken from a nationwide administrative registry. Overall, data on 415,472 patients were available for this study. Among them, 394,445 (94.9%) survived 90 days after surgery, and their 10-year survival was 58.0% (95% CI 57.8-58.3); the expected survival was 70.1%, and the relative survival was 0.83 (95% CI 0.82-0.83). Patients who underwent surgical repair of the mitral valve and aortic valve had relative survival of 0.96 and 0.92, respectively. Isolated coronary artery bypass grafting had a relative survival of 0.88. Surgical replacement of the heart valves had a relative survival below 0.80. Poor results with relative survival <0.70 were observed after complex cardiac surgery. Relative survival was <0.60 in patients who underwent double- or triple-valve surgery combined with coronary artery surgery. The authors observed markedly lower relative survival among women (0.77, 95% CI 0.77-0.78) compared with men (0.86, 95% CI 0.85-0.86) at 10 years. Such a difference was observed after almost all different procedures. The present findings provided a picture of the real expectation in terms of the late survival of patients after having undergone adult cardiac surgery. This information should be communicated to patients and their relatives before surgery, and it may be relevant in the decision-making process and in planning tertiary prevention.

Unexpected TEE Findings During Rheumatic Triple-Valve Surgery: Incidental, Yet Impactful

This E-Challenge highlights an incidental prebypass transesophageal echocardiographic (TEE) finding of a right atrial membrane that impacted cardiac surgical management during triple-valve surgery. Two-dimensional and advanced 3-dimensional (3D) TEE were used in real-time to assist intraoperative decision-making. The findings, clinical course, discussion of the differential diagnosis, final diagnosis, and patient management are detailed here.

Blood versus crystalloid cardioplegia during triple valve surgery: A single center experience.

The efficacy of different cardioplegia solutions on outcomes of complex cardiac operations such as triple valve surgery (TVS) is scarce. Here we compared the outcomes in TVS patients receiving either crystalloid (Bretschneider) or blood (Calafiore) cardioplegia. Screening of our institutional database with prospectively entered data identified 471 consecutive patients (mean age 70.3 ± 9.2 years; 50.9% male), who underwent TVS (replacement or repair of aortic, mitral and tricuspid valve) between December 1994 and January 2013. In 277 patients, cardiac arrest was induced with HTK-Bretschneider solution (HTK, n = 277, 58.8%), whereas 194 received cold blood cardioplegia (BCP) according to Calafiore (n = 194, 41.2%). Comparisons of perioperative and follow up outcomes were made between cardioplegia groups. Preoperative patient characteristics and comorbidities were equally balanced between groups. 30-days mortality was similar between groups (HTK: 16.2%; BCP: 18.2%; p = 0.619). Incidence of the cumulative endpoint (30days mortality, myocardial infarction (MI), arrhythmia, low cardiac output syndrome or need for permanent pacemaker implantation) was also comparable (HTK: 47.6%; BCP: 54.8%, p = 0.149). In patients with reduced left ventricular ejection fraction (LVEF <40%), 30days mortality was higher in the HTK group (HTK 18/71 22.5%; BCP 5/50 10%; p = 0.037). Five-year survival was similar between groups (52 ± 6% for HTK and 55 ± 5% for BCP patients). In-Hospital mortality was best predicted by length of surgery and reperfusion ratio. Decreased age, shorter bypass time, preserved LVEF and concomitant surgical procedures have been found to be protective from long-term mortality. Myocardial protection with HTK shows equivalent outcomes compared to BCP during TVS. Patients with reduced left ventricular function may benefit from BCP during TVS.

Demora en el tratamiento quirúrgico de la insuficiencia tricuspídea grave y resultados en pacientes con valvulopatía izquierda

Introduction and objectivesThe influence of the delay between diagnosis and surgery in severe tricuspid regurgitation (TR) remains controversial. We aimed to analyze the association between delay to surgery and operative and mid-term mortality in patients with severe TR concomitant to left-valve surgery. MethodsWe conducted an observational retrospective study analyzing risk factors in patients undergoing left-valve surgery concomitant with severe TR. The clinical and demographic variables were prospectively collected. The time of first diagnosis of TR was retrospectively collected. ResultsA total of 253 patients were analyzed. TR was functional in 82.6%. The median latency between diagnosis and surgery was 24 months. Operative mortality was 12.2%. On multivariate analysis, higher operative mortality was associated with older age, worse preoperative NYHA functional class, triple valve surgery, hyponatremia, and anemia. The median follow-up was 35 months. Survival at 1 and 5 years was 85.2% and 73.7%, respectively. Mortality during follow-up was associated with male sex, preoperative massive TR, and longer latency between diagnosis and surgery. ConclusionsThe variables related to worse preoperative functional class were associated with increased operative mortality. Lower mid-term survival was associated with longer latency between diagnosis of severe TR and surgery, massive preoperative TR, and older age.

Outcomes Following Triple Cardiac Valve Surgery Over 17-years: A Multicentre Population-Linkage Study.

Studies have reported increasing triple valve surgery (TVS, defined as concomitant aortic, mitral and tricuspid valves surgery) incidence and improved postoperative survival. The epidemiology and outcome of TVS is not known in Australia. From the Admission-Patient-Data-Collection registry, all New South Wales residents who underwent cardiac valve surgery between 1 July 2001 and 31 December 2018 were identified, with cause-specific mortality tracked from the death registry. Triple valve surgery comprised 1.2% (347/28,667 cases) of all valvular surgeries. Volumes rose from eight cases-per-annum in 2002 to a peak of 37 in 2012, and between 23 and 30 cases-per-annum since. Mean (±SD) age of study cohort (n=340 persons) was 68.2±15.2 years (50% male); 20.3% had concomitant coronary-artery-bypass-surgery (males vs females: 29.4% vs 11.2%, p<0.001). Main surgery on aortic and mitral valves was replacement (95.9% and 70.6% respectively). Tricuspid valve annuloplasty was performed in 90.6% of patients. Cumulative in-hospital, 180-day, and total mortality (mean follow-up=4.9±4.0 yrs) was 7.4%, 11.8% and 42.6%, respectively. Heart failure (24.0% in-hospital, 22.5% post-discharge) and sepsis (24.0% in-hospital, 20.0% post-discharge) were the main cause-specific deaths. There was no in-hospital stroke-related death. Age (median >72 yrs; hazard ratio [HR]=1.95, 95%CI=1.37-2.79), malignancy (HR=6.35, 95%CI=2.21-18.26), heart failure (HR=1.79, 95%CI=1.25-2.57) and chronic kidney disease (CKD) (HR=2.21, 95%CI=1.39-3.51) (all p<0.005) were independent predictors during intermediate-term follow-up. Triple valve surgery remains rare in Australia and is associated with high mortality. Multi-centred collaboration and access to comprehensive clinical data are required to identify the drivers of poor outcome.

A challenging triple valve surgery for long-standing pulmonary hypertension in rheumatic heart disease: a case report

Background Pulmonary hypertension is an increase in the mean pulmonary arterial pressure, greater than 25mmHg at rest, or greater than 30mmHg while exercising. In valvular heart disease its presence indicates a decompensated state of the disease. Surgical interventions are the ultimate treatment for the correction of valvular heart disease. Case Report A 38-year-old female was admitted to the Emergency Department (ER) with complaints of shortness of breath, chest pain, palpitations, and history of fainting. The patient was initially scheduled for aortic and mitral valve replacement and tricuspid valve repair at the end of year 2020. However, due to covid-19 pandemic, the patient was re-scheduled for surgery. On the 15th of June 2022, the patient was admitted to the ER of Zainoel Abidin General Hospital, and was consulted to the CTVS division. On the 17th of June 2022, the patient underwent a successful mitral valve replacement using mechanical St. Jude 29 mm valve, mechanical St. Jude 17 mm for aortic valve position, and tricuspid valve repair commissurotomy and using MC3 Edward ring annuloplasty. The patient was hospitalized for seven days and underwent successful first phase cardiac rehabilitation before discharge. The patient has since made remarkable improvements, establishing better quality of life. Conclusion Reduced pulmonary pressures postoperatively are often modest, and persistent pulmonary hypertension (PH) is known to be common and an indicator of poor prognosis. For patients with long-standing pulmonary hypertension due to rheumatic heart disease, valve replacement surgery effectively reduces pulmonary hypertension caused by damage to the left heart valve.

Delay of surgical treatment of severe tricuspid regurgitation and outcomes in patients with left-sided heart valve disease

Introduction and objectivesThe influence of the delay between diagnosis and surgery in severe tricuspid regurgitation (TR) remains controversial. We aimed to analyze the association between delay to surgery and operative and mid-term mortality in patients with severe TR concomitant to left-valve surgery. MethodsWe conducted an observational retrospective study analyzing risk factors in patients undergoing left-valve surgery concomitant with severe TR. The clinical and demographic variables were prospectively collected. The time of first diagnosis of TR was retrospectively collected. ResultsA total of 253 patients were analyzed. TR was functional in 82.6%. The median latency between diagnosis and surgery was 24 months. Operative mortality was 12.2%. On multivariate analysis, higher operative mortality was associated with older age, worse preoperative NYHA functional class, triple valve surgery, hyponatremia, and anemia. The median follow-up was 35 months. Survival at 1 and 5 years was 85.2% and 73.7%, respectively. Mortality during follow-up was associated with male sex, preoperative massive TR, and longer latency between diagnosis and surgery. ConclusionsThe variables related to worse preoperative functional class were associated with increased operative mortality. Lower mid-term survival was associated with longer latency between diagnosis of severe TR and surgery, massive preoperative TR, and older age.

Triple valve surgery: long-term follow-up from a single centre.

The aims of this study were to analyze early and late outcomes of TVS and identify predictors of short and long- term poor prognosis. Single centre retrospective study with 130 patients who underwent TVS between 2007 and 2020. Most of the patients were female (72.3%), mean age of 64.4 years; 61.1% were in New York Heart Association class III/IV, with a EuroSCORE II of 7.5%. Univariable and Multivariable analyses were undertaken to identify predictors of perioperative mortality and morbidity and long-term mortality. In-hospital mortality was 10.8%, of which 7.6% were due to a cardiac cause. Diabetes Mellitus was an in- dependent predictor of increased perioperative mortality. This group had 27.7% rate of major perioperative complications. Elevated systolic pulmonary pressure and obesity were predictors of early morbidity. All-cause mortality was 43.1% for 14 years. The survival at 1, 5 and 10 years was 83%, 60% and 43%, respectively. Diabetes Mellitus was a risk factor for long-term mortality. Patients undergoing TVS have a high surgical risk making TVS an operation associated with high mor- tality and morbidity. This research suggests Diabetes Mellitus, pulmonary hypertension and obesity as risk factors for mortality in TVS.

Association between Right Ventricle-Pulmonary Artery Coupling with In-Hospital Outcome after Triple Valve Surgery in Rheumatic Heart Disease.

Triple valve surgery (TVS) is a relatively higher in-hospital mortality rate than any isolated valve surgery. In advanced-stage valvular heart disease, maladaptation may occur, creating RV-PA uncoupling. Aims To evaluate whether RV-PA coupling is associated with the in-hospital outcome of patients after TVS. From the medical records, clinical and echocardiography data were collected and compared between the survived and patients with in-hospital mortality groups. Patients with the rheumatic multivalvular disease who underwent triple valve surgery were included in the study. Statistical and analysis used Uni and bivariate analysis assessed any association between the RV-PA coupling using TAPSE/PASP and other clinical variables with the in-hospital mortality post TVS. From 269 patients, the in-hospital mortality rate was 10 %. The median value of TAPSE/PASP ratio in all group is 0.41 (0.02-5.79). Impaired RV-PA coupling which value < 0.36 occurs in 38.3 % population. By multivariate analysis, independent predictors of in-hospital mortality were TAPSE/PASP < 0.36 (OR 3.46, 95 % CI 1.21 - 9.89; P 0.02), age (OR 1.04, 95 % CI 1.003-1.094; P 0.035), CPB duration, (OR 1.01, 95 % CI 1.003-1.017; P 0.005). RV-PA uncoupling assessed by TAPSE / PASP ratio < 0.36 is associated with the in-hospital mortality in patients post triple valve surgery. Other factors associated with the outcome were older age and longer CPB machine duration.

Myocardial Protection Using Custodiol versus Cold Blood Cardioplegia in Patients Undergoing Triple Valve Surgery

Background: The use of Custodiol cardioplegia solution may be tempting in cases undergoing long open-heart surgical procedures, given its single dose administration, which offers myocardial protection for a long period. Objective: The aim of the current study is to report our initial experience with the use of Custodial cardioplegia in patients undergoing triple valve surgery, and comparing it with our routinely used cold blood cardioplegia. Patients and Methods: A retrospective observational study including 79 consecutive patients who underwent first-time triple valve surgery in the period between April 2018 and May 2020. Patients were divided into two groups. Group (A) included 31 patients where Custodiol cardioplegia was used, and Group (B) included 48 patients where cold blood cardioplegia was used. The primary endpoint was in-hospital mortality. Secondary endpoints included postoperative levels of CK-Mb, the need for inotropes and the incidence of ventricular fibrillation on aortic declamping. Results: Apart from a higher incidence of ventricular fibrillation on aortic declamping, there was no statistically significant difference between groups in any of the endpoints examined. Conclusion: Custodiol cardioplegia is a safe option for myocardial protection in patients undergoing triple valve surgery. The added cost and the concerns about its efficacy in patients with impaired ventricular function reported by other authors should be borne in mind while considering its use.

WHEN LESS IS MORE: UTILIZATION OF A MULTIDISCIPLINARY APROACH IN THE TREATMENT OF NATIVE TRIPLE-VALVE INFECTIVE ENDOCARDITIS

TOPIC: Palliative Care and End of Life Issues TYPE: Medical Student/Resident Case Reports INTRODUCTION: Infective endocarditis (IE) is an insidious disease with significant hospital mortality rates. While many advances have been made to manage this disease, mortality rates still remain high. These rates worsen with the involvement of multiple valves. We report a case of native triple-valve IE were an appropriate interdisciplinary approach allowed the patient to focus on maximizing his desired outcomes. CASE PRESENTATION: An 85-year-old male with a past medical history of hypothyroidism presented with symptoms of generalized malaise, progressive dyspnea, intermittent blurred vision and left sided axillary pain for five months. Initial vitals showed tachycardia and patient was notably hypoxic. Blood cultures obtained on admission showed Streptococcus gallolyticus (bovis). Transthoracic echocardiography (TTE) revealed several vegetations involving the mitral, tricuspid and aortic valves (Figure 1-3). 4 months prior to admission, the patient had presented to the outpatient clinic with a syncopal episode. Work up at the time included a TTE which revealed a normal ejection fraction and no cardiac pathology. Given the development of new onset heart failure with cardiogenic shock in the setting of multi-valve infective endocarditis, a multidisciplinary team approach was taken. Cardiology, cardiothoracic surgery and palliative medicine work together to address the patient and his families goals. After informed discussion the patient decided against pursuing invasive cardiac surgery, and opted for palliative medical management. He was eventually transitioned to at home hospice. DISCUSSION: Triple valve endocarditis while extremely rare, it is associated with high rates of morbidity and mortality. According to existing literature (1,2), multi-valve IE has been recognized as an independent survival risk factor increasing mortality rate by 3% and a four fold higher rate of in-hospital mortality. The rate of complications such as congestive heart failure and acute renal failure are also higher with involvement of multiple valves, often warranting surgical intervention (3). In these situations the recovery is often prolonged with significant morbidity to the patients. In these situations it is best to approach clinical decision making with the patients goals of care in mind. Often in medicine we jump to aggressive treatments without fully taking the patients long-term goals in mind. Our treatments need to be evaluated to see if their outcomes and associated morbidities align with patients goals. With conversation based on these principles we can provide the patient with the highest level of benevolence, and ensure they receive the outcomes they truly wish. CONCLUSIONS: Triple valve surgery is extremely challenging and confers a poor prognosis. It is necessary to weight the risks and benefits of every intervention we take and make sure they align with the patients values and goals. REFERENCE #1: Sheikh, Azeem S, et al. "Triple-Valve Infective Endocarditis." British Journal of Cardiology, Apr. 2016, pp. 23–65., doi:10.5837/bjc.2016.015 REFERENCE #2: Kim N, Lazar JM, Cunha BA, Liao W, Minnaganti V. Multi-valvular endocarditis. Clin Microbiol Infect 2000;6:207–12. https://doi.org/10.1046/j.1469-0691.2000.00065.x REFERENCE #3: Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129:2440-92. 10.1161/CIR.0000000000000029 DISCLOSURES: No relevant relationships by Anand Buch, source=Web Response No relevant relationships by Tapan Buch, source=Web Response No relevant relationships by Ajinkya Buradkar, source=Web Response No relevant relationships by Pooja Kharbanda, source=Web Response No relevant relationships by jacob miller, source=Web Response No relevant relationships by Humza Quadir, source=Web Response No relevant relationships by Ryan Quirk, source=Web Response No relevant relationships by Mohammed Ul Haq, source=Web Response

Successful Triple Valve Surgery in an Undernourished Patient: What to Prepare?

ABSTRACT Valvular heart disease accountsfor 10% to 20% of all cardiac surgical procedures in the United States. The decision to intervene, as well as the type of intervention for a patient with severe valvular heart disease, should be based on an individual risk-benefit analysis. Once a patient is considered a candidate for cardiac surgery, a comprehensive patient evaluation of medical conditions and comorbidities helps improve operative outcomes and minimize the mortality rate. Patients with severe valvular heart disease with chronic heart failure at times, progressing to malnutrition. Patients undergoing cardiac surgery experience a systemic inflammatory response, which contributes to acute organ injury leading to a higher incidence of comorbidities and worse malnutrition. Therefore, preoperative risk and nutritional assessment are critical in performing safe cardiac surgical procedures. We report a case of a malnourished 17-year-old man with multiple valvular heart disease with optimal preparation, including good nutritional status leading to good outcome of complex cardiac surgery even in the high risk patients. Keywords : valvular heart disease, malnutrition, perioperative assessmentCorrespondence : dr.dianparamita@yahoo.com

Hepatorenal dysfunction predicts operative mortality after triple valve surgery: Utility of MELD-Na.

Despite significant advancements in operative techniques and myocardial protection, triple valve surgery (TVS) remains a formidable operation with a relatively high in-hospital mortality. We evaluated the prognostic value of Model for End-stage Liver Disease score including sodium (MELD-Na) for mortality after TVS and its predictive value when incorporated in the EuroSCORE risk model. We performed a retrospective cohort study of 61 consecutive patients who underwent TVS from November 2005 to June 2016. Demographics, clinical, biochemical, and operative data were collected and analyzed. Median follow-up duration was 8.0 years. The majority (70.5%) of patients suffered from rheumatic heart disease and underwent mechanical double valve replacement with tricuspid valve repair. There were six operative deaths (9.84%), with the most common cause of death being multiorgan failure (83.3%). In 26.2% of the cohort, the MELD-Na score was moderately elevated at 9 to 15. A small fraction (4.9%) had a severely elevated MELD-Na greater than 15. Patients with a MELD-Na greater than 9 had a higher unadjusted rate of operative mortality, prolonged ventilation, need for dialysis and acute liver failure after TVS. Hierarchical logistic regression was performed using logistic EuroSCORE as the base model. After risk adjustment, each point of MELD-Na score increase was associated with 1.405 times increase in odds of operative mortality. The regression analysis was repeated by incorporating individual components of the MELD-Na score, including bilirubin, sodium, and albumin. All three biochemical parameters were significantly associated with operative mortality CONCLUSION: MELD-Na score as a quantifier of hepatorenal dysfunction is sensitive and specific for operative mortality after triple valve surgery.

Right Mini-Thoracotomy for Aortic Plus Mitral with or without Tricuspid Valve Surgery.

Minimally invasive surgery is increasingly performed for isolated aortic or mitral valve procedures. However, combined minimally invasive aortic and mitral valve surgery is rare. We report our initial experience performing multiple valve procedures through a right-sided mini-thoracotomy (RMT) compared with sternotomy. A total of 264 patients underwent aortic and mitral with or without tricuspid valve surgery through RMT (n = 25) or sternotomy (n = 239). Propensity score matching was used for outcome comparisons. Of the 264 patients, 25 (age: 72 ± 10 years; 72% male) underwent double (n = 19) and triple valve surgery (n = 6) through RMT and 239 (age: 71 ± 11 years; 54% male) underwent double (n = 176) and triple valve surgery (n = 63) through sternotomy. Sternotomy patients had more co-morbidities and preoperative risk factors (EuroSCORE II 10.25 ± 10.89 vs. RMT 3.58. ± 4.98; p < 0.001). RMT procedures were uneventful without intraoperative complications or conversions to sternotomy. After propensity score matching, surgical procedures were comparable between groups with a higher valve repair rate in RMT. Despite longer cardiopulmonary bypass times in RMT, there was no evidence for differences in 30-day mortality (RMT: n = 2 vs. sternotomy: n = 2) and there were no significant differences in other outcomes. During 5-year follow-up, reoperation was required in sternotomy patients only (n = 2). Follow-up echocardiography showed durable results after valve surgery. RMT patients showed higher survival probability compared with sternotomy, although this difference was not significant (hazard ratio = 0.33; 95% confidence interval: 0.06-1.65; p = 0.18). Combined aortic plus mitral with or without tricuspid valve surgery can safely be performed through a RMT with a trend toward better mid-term outcomes.