Underwent Tricuspid Valve Replacement Research Articles

RIGHT VENTRICULAR DYSFUNCTION AND TRICUSPID VALVE SURGICAL CORRECTION: ROOM FOR STRESS ECHOCARDIOGRAPHY?

Abstract We report the case of a 50–years–old young woman with multi–operated rheumatic valvular heart disease; aortic, mitral, and tricuspid commissurotomy (1994); aortic valve replacement with bioprosthesis for endocarditis (1998); mitro–aortic replacement with mechanical prosthesis and tricuspid valve plastic repair (1999); mitral valve replacement and re–do of tricuspid plastic repair (2003). Concomitant conduction pathway disease (BAV II type 1 and RBB). The patient was admitted in June 2023 for wet & warm NYHA IV right heart failure with severe peripheral congestion and ascites. On echocardiography: LV with systo–diastolic compression, EF 51%; normo–functioning aortic prosthesis; dilated (TDA 24 cm2), hypokinetic (TAPSE 9mm,S‘ 4 cm/s,FAC 25%) right ventricole (RV), with poor load adaptation (load adaptation index 16, RVCPI 108 mm*mmHg, ePAPI 1.1); torrential IT, caval plethora with systolization of hepatic venous flow. Medical therapy was initiated with intravenous bolus diuretics, nitroglycerin and inotropic support (dobutamine 2.5 y). In order to define the best therapeutic strategy in the persistence of torrential IT and RV dysfunction we performed: trans–oesophageal echocardiography, showed massive IT from ring dilatation and wide flail of the septal flap not suitable for edge–to–edge correction, total–body angioTC, with no relevant findings, right cardiac catheterization, which documented pulmonary pressure and arteriolar resistances within limits (wedge 12 mmHg,PAP25/15/18 mmHg,RAP 11 mmHg,PAPI 0. 9,RVSWI 4.8) with reduced cardiac index (2.14 l/min/cm2) and stress–echocardiography with dobutamine that showed presence of RV contractile reserve (FAC 28%>39%). In consideration of the functional properties of the tricuspid valve, absence of pulmonary hypertension and given the presence of RV contractile reserve, patient underwent tricuspid valve replacement surgery with a bioprosthesis (SJ Epic 27 mm) in mini–thoracotomy with smooth postoperative course. At 3 months follow–up showed functional recovery (NYHA II), with good prosthetic function and partial reverse remodeling of the RV (TDA 14 cm2, FAC of 30%). In conclusion, by documenting right ventricular contractile reserve, stress echocardiography proved to be an important aid in predicting absence of RV failure in the immediate post–surgical period, presenting attractive prospects in the assessment of RV functional reserve in patients undergoing to corrective tricuspidal surgery.

Incidence, Risk Factors, and Outcomes Associated With Permanent Pacemaker Implantation Following Tricuspid Valve Surgery.

Data regarding permanent pacemaker (PPM) implantation following tricuspid valve surgery (TVS) are limited. We sought to evaluate its incidence, risk factors, and outcomes. Medicare beneficiaries who underwent TVS from 2013 to 2020 were identified. Patients who underwent TVS for endocarditis were excluded. The primary exposure of interest was new PPM after TVS. Outcomes included all-cause mortality and readmission with endocarditis or heart failure on follow-up. Among the 13 294 patients who underwent TVS, 2518 (18.9%) required PPM placement. Risk factors included female sex (relative risk[RR], 1.26 [95% CI, 1.17-1.36], P<0.0001), prior sternotomy (RR, 1.12 [95% CI, 1.02-1.23], P=0.02), preoperative second-degree heart block (RR, 2.20 [95% CI, 1.81-2.69], P<0.0001), right bundle-branch block (RR, 1.21 [95% CI, 1.03-1.41], P=0.019), bifascicular block (RR, 1.43 [95% CI, 1.06-1.93], P=0.02), and prior malignancy (RR, 1.23 [95% CI, 1.01-1.49], P=0.04). Tricuspid valve (TV) replacement was associated with a significantly higher risk of PPM implantation when compared with TV repair (RR, 3.20 [95% CI, 2.16-4.75], P<0.0001). After a median follow-up of 3.1 years, mortality was not different in patients who received PPM compared with patients who did not (hazard ratio [HR], 1.02 [95% CI, 0.93-1.12], P=0.7). PPM placement was not associated with a higher risk of endocarditis but was associated with a higher risk of heart failure readmission (HR, 1.28 [95% CI, 1.14-1.43], P<0.001). PPM implantation frequently occurs after TVS, notably in female patients and patients undergoing TV replacement. Although mortality is not increased, it is associated with higher rates of heart failure rehospitalization.

Surgical Treatment Methods for Tricuspid Valve Infective Endocarditis

Introduction: In recent years, there has been a significant increase in the incidence of tricuspid valve infective endocarditis (IE), which is associated with both the increased number of invasive examinations and procedures and the high rates of intravenous drug use. The initial treatment for tricuspid valve IE was surgical removal of the focus of infection and restoration of intracardiac hemodynamics.Reconstructive surgery aimed at preserving the valve is the preferred method of surgical treatment. If a valve-­preserving operation is not possible due to significant valvular apparatus destruction, implantation of artificial heart valves (both mechanical and biological) is the method of choice.Objective: To analyze the results of reconstructive valve-­preserving surgery and tricuspid valve replacement for tricuspid valve IE treatment.Materials and methods: In the Scientific Research Institute – Specialized Cardiac Surgery Clinical Hospital named after Academician B.A. Korolev (Nizhny Novgorod, Russian Federation) 110 patients underwent surgery for tricuspid valve IE. Primary surgery was performed in 97 patients, and 13 patients underwent repeated surgery. The patients were divided into 2 groups based on the chosen surgical method for correcting tricuspid valve disease. Group 1 included 62 patients who successfully underwent tricuspid valve replacement: mechanical prostheses in 10 patients and biological prostheses in 52 patients. Group 2 included 38 patients who underwent reconstructive valve­preserving surgery. All patients underwent De Vega annuloplasty. In 10 patients it was directly associated with bicuspidalization of the tricuspid valve and plastic surgery of intact leaflets. Two patients had suture annuloplasty of the tricuspid valve based on the modified technique. In 2 of 3 patients, an infected right atrial thrombus was removed. Three patients underwent removal of the left ventricular wall abscess and aortic valve replacement for critical stenosis. After translocation of the chords, triangular resection of the anterior leaflet was performed to separate the chord of the left side of the chest and the myxoma of the right and left chest.Results: In the early postoperative period, no valve­related complications were observed in group 1. The most common nonlethal complication was a third­-degree atrioventricular block. Multiple organ dysfunction syndrome occurred in 3 patients; cardiac tamponade was reported in 2 patients, and 1 patient had postoperative bleeding that required resternotomy for serous mediastinitis in the mid­term period and reosteosynthesis. At the hospital stage, 1 patient from group 1 died, whereas there were no deaths in group 2. In­-hospital mortality in the groups of operated patients was 0.9%.Functional ultrasound imaging findings in the postoperative period show that patients from group 1 had the peak gradient across the prosthetic tricuspid valve of 9.4 ± 1.8 mm Hg, while the mean gradient was 5.8 ± 1.75 mm Hg. There was a significant decrease in the estimated right ventricle pressure from 54.0 ± 16.2 to 35.0 ± 5.5 mm Hg. In group 2 tricuspid valve regurgitation was not observed in 27 patients, while mild and moderate regurgitation was reported in 8 and 3 patients, respectively. The peak gradient during the tricuspid valve reconstruction was 6.2 ± 1.7 mm Hg, while the mean gradient was 2.8 ± 0.75 mm Hg. The annulus fibrosus size during tricuspid valve annuloplasty averaged 30.8 ± 2.5 (28­33) mm. There was a decrease in the right ventricle pressure from 44.0 ± 18.4 to 32.0 ± 7.3 mm Hg. In the mid-­term follow­up, surviving patients were classified as NYHA classes I­-II. Of 110 patients discharged from the clinic, we were able to trace the fate of 69 patients, which accounted for 62.7%. In the long-­term period, 3 patients from group 1 died. Thus, long­term mortality in the general group was 2.72%.Conclusions: Reconstructive surgery has significant advantages over tricuspid valve replacement using various artificial heart valve models: lower rates of in-­hospital and long­-term mortality and specific complications, higher quality of life. Compliance with principles and methods of pathogenetic treatment of electrode­induced IE guarantees a success in the cohort of severe patients. The technique of reconstruction and restoration of tricuspid valve structures and functions in case of active tricuspid valve IE with detachment of the chords and destruction of the leaflets demonstrated high surgical efficiency.

Mitral homograft in tricuspid position: indications for implantation and surgical technique

HighlightsThe article presents the latest data on the techniques of implantation of the mitral homograft in the tricuspid position, and identifies groups of patients who are best suited for this method. Moreover, the article describes the evolution of this type of replacement, and highlights that many surgical techniques, although justified, require further study to show demonstrate their advantages. AbstractDespite the general trend in cardiac surgery towards valve-preserving interventions, valve replacements remain relevant, and the search for the perfect prosthetic valve continues. Many believe that tricuspid valve replacement using a mitral homograft can be the method of choice in certain situations. The analysis of the studies found in the PubMed database led the authors to the following conclusions: most of the data on the use of this technique in patients with infective endocarditis (IE), other indications are congenital heart disease (CHD) and rheumatic heart disease. Patients with IE who have undergone tricuspid valve replacement using a mitral homograft have good medium-term prospects, and respond well to medical treatment of recurrent IE. The mitral homograft in the tricuspid position remains intact even after prosthetic endocarditis. In this regard, it is possible to perform reconstructive intervention in case of prosthetic valve dysfunction without the need for repeated replacement. Such interventions are relevant for patients with growing heart for whom annuloplasty at the first stage of surgery is undesirable. Moreover, it is also cost-effective due to the high cost and low availability of homografts. The possibility of repeated tricuspid valve-in-valve replacement is important for patients who may not survive open surgery. To date, there are not enough long-term and short-term data on using a mitral homograft for tricuspid valve replacement, however, it can be assumed that the results of this technique will be positive provided that the appropriate implantation technique and strict patient selection are ensured. Many authors have come to the conclusion that the optimal homograft implantation technique includes sewing of the graft`s papillary muscles into the wall of the myocardium of the right ventricle (RV), fixating them on the outer surface of the RV, anatomical positioning of the homograft (anterior leaflet faces towards the IVS), and the use of an annuloplasty ring.

Evaluation of Risk Factors and Outcomes of Isolated Tricuspid Valve Replacement with a Conventional Surgical Approach: A Retrospective Cohort Study

Introduction. Tricuspid valve (TV) disease is substantially less common than mitral or aortic valve disease, and it is commonly missed due to the tolerability of stenosis or regurgitation. Adults seldom have primary tricuspid valve regurgitation, which is linked to rheumatic heart disease, infectious endocarditis, myxomatous valve disease, congenital heart disease, carcinoid syndrome, and/or infiltrative valvopathy. Materials and Methods. The authors examined the Valve Surgery Data Bank retrospectively to identify all patients who underwent TV replacement without concomitant surgeries between 2004 and 2014. In addition, the exclusion criteria suggested that all instances involving solitary valve repair were eliminated. Through visits or phone interviews, long-term follow-up was collected through the end of June 2022 in order to gather information on postoperative occurrences among the patients. The average follow-up time was 10.7 + 2.1 (5–15) years. Results. The overall survival rate was 90.9%. Survival rate was not significantly different between bioprostheses and mechanical ones (log rank <math xmlns="http://www.w3.org/1998/Math/MathML" id="M1"> <mi>p</mi> <mo>=</mo> <mn>0.05</mn> </math> ). The incidence of endocarditis and valvar thrombosis in short-term was higher in the mechanical group than in the biological group, but the frequency of valve malfunction and redo surgery was higher in the replacement group. We found a higher incidence of valvular thrombosis, GI bleeding, and myocardial infarction rate in mechanical valve complications compared to the bioprosthetic group regarding late complications.

Hyepereosiniphilic syndrome and COVID-19: 2 case reports

BackgroundNearly half of the patients with hypereosinophilic syndrome (HES) have cardiovascular involvement, a major cause of mortality. COVID-19 infection can lead to cardiac involvement, negatively impacting the clinical course and prognosis. We reported two patients with HES complicated by COVID-19, with cardiac involvement and valve replacement.Case presentationOur first patient was a 27-year-old woman admitted due to dyspnea and signs of heart failure. She had severe mitral stenosis and mitral regurgitation on the echocardiogram. Corticosteroid therapy improved her symptoms initially, but she deteriorated following a positive COVID-19 test. A repeated echocardiogram showed right ventricular failure, severe mitral regurgitation, and torrential tricuspid regurgitation and, she underwent mitral and tricuspid valve replacement. Our second patient was a 43-year-old man with HES resulted in severe tricuspid stenosis, which was improved with corticosteroid treatment. He underwent tricuspid valve replacement due to severe valvular regurgitation. He was admitted again following tricuspid prosthetic mechanical valve thrombosis. Initial workups revealed lung involvement in favor of COVID-19 infection, and his PCR test was positive.ConclusionCOVID-19 infection can change the clinical course of HES. It may result in a heart failure exacerbation due to myocardial injury and an increased risk of thrombosis in prosthetic valves or native vessels due to hypercoagulability.

Early and long-term outcomes of bioprosthetic versus mechanical tricuspid valve replacement: A nationwide population-based study

ObjectivesWe compared early and long-term clinical outcomes of bioprosthetic versus mechanical tricuspid valve replacement in a nationwide study based on the database from the National Health Insurance Service. MethodsOf 1425 patients who underwent tricuspid valve replacement from 2003 to 2018, 1241 patients were enrolled after excluding retricuspid valve replacement, complex congenital heart disease, Ebstein anomaly, and age less than 18 years at operation. Bioprostheses (group B) and mechanical prostheses (group M) were used in 562 patients (45.3%) and 679 patients (54.7%), respectively. The median follow-up duration was 5.6 years. Propensity score matching was performed. Subgroup analysis was performed in patients aged 50 to 65 years. ResultsThere was no difference in operative mortality or postoperative complications between the groups. All-cause mortality was higher in group B (7.8 vs 4.6 per 100 patient-years, hazard ratio, 1.75, 95% confidence interval, 1.33-2.30, P < .001). The cumulative incidence of stroke was higher in group M (hazard ratio, 0.65, 95% confidence interval, 0.43-0.99, P = .043), whereas the cumulative incidence of reoperation was higher in group B (hazard ratio, 4.20, 95% confidence interval, 1.53-11.54, P = .005). In terms of the age-dependent hazard of all-cause mortality, group B demonstrated a higher hazard than group M below the age of 75 years, and it was statistically significant between 54 and 65 years of age. In the subgroup analysis, all-cause mortality was also higher in group B. ConclusionsMechanical tricuspid valve replacement demonstrated higher long-term survival than bioprosthetic tricuspid valve replacement. In particular, mechanical tricuspid valve replacement showed significantly higher overall survival between 54 and 65 years of age.

Case of An Isolated Tricuspid Valve Regurgitation Presenting as Right Sided Heart Failure

Trivial to mild tricuspid regurgitation is commonly seen in patients with a normal right heart. It is usually asymptomatic and when severe enough may cause symptoms of right-sided heart failure such as ascites, edema and congestive hepatopathy. We present a case of a 46-year-old female who presented with progressive bipedal edema. Transthoracic echocardiography showed dilated right atrium and right ventricle with severe tricuspid regurgitation. Patient then underwent tricuspid valve replacement with a 29mm bioprosthetic valve. Final histopath report showed myxomatous degeneration of valve leaflets. Post-operatively, patient developed increasing shortness of breath and orthopnea. A repeat transthoracic echo revealed decompensation of right ventricle with decline in right ventricular systolic function. Patient was then given inotropic support with milrinone and norepinephrine and adequate diuresis with IV furosemide. She was gradually weaned off the inotropes. Prior to discharge, a repeat transthoracic echocardiogram done showed improvement of right ventricular systolic function and she was discharged on oral furosemide and spironolactone.

Mechanical Tricuspid Valves Have Higher Rate of Reintervention: A Single Center Experience.

We compared the composite outcome of tricuspid valve (TV) reintervention or heart failure (HF) admission in patients who underwent tricuspid valve replacement (TVR) with tissue vs. mechanical valves. The study included 159 patients who underwent TVR from 2009 to 2019. We grouped the patients according to the valve's type into tissue valve group (n = 139) and mechanical valve group (n = 20). The mean age of patients was 52.4 ± 12.8 years, and 117 patients were females (73.6%). Hospital mortality occurred in 20 patients (12.6%); all of them were in the tissue valve group. The composite outcome of reintervention and HF readmission occurred in 8 patients with mechanical valves (40%) vs. 24 patients with tissue valves (17.3%), (P = 0.018). Predictors of reintervention and HF admission were female (subdistributional hazard ratio [SHR]: 1.38-34.3, P = 0.019), stroke (SHR: 1.25-8.76, P = 0.016), hypertension (SHR: 1.13-5.36, P = 0.024), and mechanical valves (SHR: 1.6-10.7, P = 0.003). In post hoc analysis, the difference in the composite outcome was derived from the difference in the reintervention rate that was higher in mechanical valves. Survival did not differ significantly between groups (P = 0.12). Mechanical TVs have a higher rate of composite outcome of reintervention or HF readmission than tissue TVs that are related mainly to higher rate of reintervention.

Original technique for tricuspid valve replacement by mitral homograft: Step-by-step approach and initial results.

Severe tricuspid regurgitation is associated with the progression of heart failure symptoms and poor survival. Surgical treatment of infective and prosthetic tricuspid valve endocarditis using homografts gives promising early and midterm results. Tricuspid valve replacement with a mitral homograft is a reasonable procedure with a challenging technique. A total of 15 patients underwent tricuspid valve replacement by mitral homograft in two departments from October 2020 to May 2022. The mean age was 36 [31-40.5]. In this article, we describe our original step-by-step technique and initial experience of successful use of native or cryopreserved mitral homografts for surgical treatment of tricuspid valve disease. There were no in-hospital and 30-daymortality, no postoperative bleeding, myocardium infarction, stroke, or sternal wound infection. Only one patient required permanent pacemaker implantation after redo surgery before discharge. The predischarge echocardiogram showed no residual tricuspid regurgitation(TR) in 14 cases (93.3%) and mild TR in 1 (6.7%) patient. All patients were discharged from the hospital without symptoms of endocarditis, with negative blood culture samples. Satisfactory initial clinical and hemodynamic results were achieved utilizing our technique. Mid- and long-term results are required to understand the place of homografts in tricuspid valve surgery.

Contemporary Outcomes of Isolated Tricuspid Valve Surgery

IntroductionIsolated tricuspid valve (TV) surgery is uncommonly performed and has historically been associated with excessive operative mortality. We previously reported improved short-term outcomes at our center. Understanding contemporary outcomes of isolated TV surgery beyond the perioperative period is essential to properly benchmark outcomes of newer transcatheter interventions. MethodsPatients who underwent isolated TV surgery from 2007 to 2021 at a single institution were retrospectively reviewed. Survival was estimated using the Kaplan–Meier method and multivariable Cox proportional hazards regression modeling identified independent risk factors for all-cause mortality. ResultsAmong 173 patients undergoing isolated TV surgery, 103 (60%) underwent TV repair and 70 (40%) underwent TV replacement. Mean age was 60.3 ± 18.9 y and 55 (32%) were male. The most common etiology of TV disease was functional (46%). In-hospital mortality was 4.1% (7/173), with no difference between TV repair and replacement (P = 0.06). Overall survival at 1 y and 5 y was 78.3% (111/142) and 64.5% (53/82), respectively. After median (interquartile range) follow-up of 2.0 (0.6-4.4) y, patients undergoing TV repair experienced a higher unadjusted survival as compared to those undergoing TV replacement (log-rank P = 0.02). However, after adjusting for covariates, TV replacement was not an independent predictor of all-cause mortality (hazard ratio 1.40; 95% confidence interval, 0.71-2.76; P = 0.33). ConclusionsIsolated TV surgery can be performed with lower operative mortality than historically reported. Establishing survival benchmarks from TV surgery is important in the era of developing transcatheter interventions.

S1224 Outcomes of Transcatheter Tricuspid Valve Replacement in Patients With Liver Cirrhosis

Introduction: Patients with liver cirrhosis who undergo cardiac surgery are at increased risk of postoperative mortality and morbidity. Patients with cirrhosis have pathophysiologic changes that put them at an excessive risk of coagulopathy, hemorrhage, infection, and multiorgan dysfunction. The prevalence of tricuspid valve (TV) disease is rising but it is often undertreated due to increased mortality associated with TV surgery. Liver dysfunction is seen in the majority of patients with TV disease, but there is a lack of data regarding the impact of cirrhosis on prognosis after TV surgery. Our study aimed to look at the clinical outcomes of patients with liver cirrhosis undergoing TV replacement. Methods: Data were extracted from the National Inpatient Sample (NIS) database from 2016 to 2019. Using the International Classification of Diseases, 10th revision, and Clinical Modification (ICD-10-CM) codes to obtain baseline demographic data, in-hospital mortality, hospital charges, and hospital length of stay (LOS). Statistical analyses were completed using t-test and Chi-squared analysis. Multivariate analysis for the mortality odds ratio (OR) was calculated after adjusting for possible confounders. Results: A total of 9,360 patients who underwent replacement of TV were identified, and 355 of these patients had liver cirrhosis. The mean age of the cirrhosis vs non-cirrhosis group was 56 years vs. 48 (P < 0.001). There was no difference in gender, race, smoking status, and obesity between both groups. However, the cirrhosis group had more prevalence of congestive heart failure (CHF), atrial fibrillation (Afib), hypertension (HTN), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), and alcohol use compared to the non-cirrhotic group. There was no statistically significant difference in mortality between the two groups (OR 0.72; P = 0.54). There was no difference in total hospital charge ($414,908 vs. 444,556; P < 0.56), or LOS (20 vs. 23 days; P = 0.22). CHF and CKD were independently associated with higher odds of mortality. Conclusion: In our study, we found that cirrhosis did not adversely affect TV replacement outcomes. TV disease is associated with hepatic congestion and TV replacement can potentially improve liver function. So clinicians should consider TV replacement in cirrhotic patients as it is a safe treatment option. However, further large-scale randomized controlled studies are needed to look at the long-term prognosis of these patients.Figure 1.: Multivariate logistic regression for the effect of cirrhosis on patients undergoing TV replacement Table 1. - Demographics and clinical characteristics of the study population Variable No cirrhosis Cirrhosis P-value Age (mean, yr) 48 56 < 0.001 Gender (%) 0.2 Male 41.3% 49.3% Female 58.7% 50.7% Race (%) 0.38 White 71% 63% Black 10% 10% Hispanic 7% 8% Others 12% 19% Comorbidities (%) Alcoholism 3.3% 17% < 0.001 Smoking 45% 42% 0.66 Obesity 11% 17% 0.13 DM 13% 21% 0.056 HTN 44% 60% 0.006 CHF 49% 77% < 0.001 A.Fib 35% 63% < 0.001 HCC 0.11% 0% 0.77 Cachexia 1.8% 1.4% 0.79 COPD 8.8% 19% 0.001 CKD 21% 36% 0.001

Association of longitudinal left atrial strain with mortality after tricuspid valve surgery.

Tricuspid valve (TV) surgery for functional tricuspid regurgitation (TR) is becoming more common, but the associated mortality remains high. Therefore, we evaluated the clinical and echocardiographic parameters associated with all-cause mortality in patients with severe functional TR who underwent TV surgery. A total of 286 patients with severe functional TR who underwent TV replacement or repair was analysed between January 2006 and December 2017. We assessed changes in conventional echocardiographic parameters and strain, such as peak atrial longitudinal strain (PALS). During a median follow-up period of 5.3years, 71 (24.8%) patients died due to any cause. When comparing groups with and without all-cause deaths, there were no significant differences in terms of sex, co-morbidities, medication use, and surgery type. However, patients who died were older and more likely to have refractory atrial fibrillation (AF). With multivariate Cox modelling, age >65years (adjusted hazard ratio [HR], 2.81, 95% confidence interval [CI], 1.59-4.96; P<0.001), refractory AF (adjusted HR, 2.84, 95% CI, 1.36-5.94; P=0.006), lower albumin level (adjusted HR, 0.50, 95% CI, 0.31-0.82), and reduced PALS (adjusted HR, 1.87, 95% CI, 1.06-3.33; P=0.032) were significant determinants of all-cause mortality. PALS decline was associated with refractory AF (adjusted HR, 5.74, 95% CI, 2.81-11.7; P<0.001) and the absence of a Maze procedure (adjusted HR, 2.95, 95% CI, 1.51-5.78; P=0.002). A reduction in PALS was significantly associated with all-cause mortality in our cohort of patients with severe functional TR who underwent TV surgery. This phenomenon is related to refractory AF and more aggressive intervention for AF is necessary concomitant with TV surgery.

Mid-term outcomes of isolated tricuspid valve surgery according to preoperative clinical and functional staging.

This study aimed at assessing mid-term outcomes of patients undergoing isolated tricuspid valve (TV) surgery based on a preoperative baseline clinical and functional classification. All patients treated with isolated TV repair or replacement from March 1997 to May 2020 at a single institution were retrospectively reviewed and assessed for mid-term postoperative outcome according to a novel classification [stages 1-5 related to the absence or presence and extent of right heart failure (RHF)]. Kaplan-Meier survival curves were used to estimate mid-term survival. Competing risk analysis for time to cardiac death and hospitalizations for RHF were also carried out. Among the 172 patients included, 129 (75%) underwent TV replacement and 43 (25%) TV repair. At follow-up (median 4.2 years [2.1-7.5]), there were 23 late deaths. At 5 years, overall survival was 100% in stage 2, 88 ± 4% in stage 3 and 60 ± 8% in stages 4-5 (P = 0.298 and P = 0.001, respectively). Cumulative incidence function of cardiac death at 5 years was 0%, 8.6 ± 3.76% and 13.2 ± 5% for stages 2, 3 and 4 and 5, respectively. At follow-up, cumulative incidence function of re-hospitalizations for RHF was 0% for stage 2, 20 ± 5% for stage 3 and 20 ± 6.7% for stages 4 and 5 (P = 0.118 and P = 0.039, respectively). Both short- and mid-term outcomes support early referral for surgery in isolated TV disease, with excellent survival at 5 years and no further hospitalizations for RHF.

Isolated Reoperative Tricuspid Valve Surgery: Outcomes and Risk Assessment.

ObjectiveTo describe patient characteristics and post-operative outcomes, including early and late mortality, defined by death within 30 days and after 30 days post-surgery, respectively, as well as 20-year survival after isolated reoperative tricuspid surgery.MethodsWe retrospectively analyzed 169 patients who underwent isolated reoperative tricuspid valve surgery at our institution (between 1997 and 2000) and describe post-surgical outcomes including intraoperative, early and late mortality. All patients included completed 21 years of follow-up.ResultsThe majority of our patients were females 147 (87%) with the mean age of 45.9 ± 12.9 years. The mean body mass index (BMI, kg/m2) was 27.4 ± 6.0. Previous cardiac surgeries included tricuspid valve surgeries in 169 (100%) patients, with bioprosthetic valves, mechanical valves, annual rings and tricuspid repair surgeries utilized in 37 (21.9%), 21 (12.4%), 38 (22.4%) and 73 (43.2%) patients, respectively. The indication for previous tricuspid surgery was rheumatic heart disease in 154 (91.5%) patients.The most common cause of reoperative valvular surgery was tricuspid regurgitation (TR) in 139 (82.2%), with 66% of patients having severe TR. Other reasons for reoperative surgery included tricuspid stenosis 22 (13%) and dehiscence 8 (4.7%). For the redo surgery, 125 (74%) patients underwent Tricuspid Valve Replacement (TVR), 90 (53%) of whom received bioprosthetic valves while 35 (21%) received mechanical valves. Forty-four patients (26%) underwent Tricuspid Valve Repair. Mortality within 30 days of surgery was 11.3% (20 patients) and 11.4% after 30 days, with 20 years survival being about 80%.ConclusionsBased on our experience, reoperation for failed isolated tricuspid valve replacement or repair was associated with reasonable mortality and good survival rate over long period of time.

Abstract 14189: Isolated Tricuspid Valve Surgery Repair versus Replacement for Infective Endocarditis: A Nationwide Analysis

Introduction: Incidence of right-sided infective endocarditis (IE) is on rise secondary to opioid epidemic, and increasing use of cardiac devices, central catheters, or AV fistulas. We aimed to compare outcomes of isolated tricuspid valve (TV) repair versus replacement and determine the predictors of mortality after isolated TV surgery for hospitalizations with IE. Methods: We utilized nationwide readmission database (NRD) to identify hospitalizations for IE that underwent isolated TV repair or replacement in 2018. Hospitalizations with concomitant or previous cardiac surgery were excluded. Multivariate logistic regression analysis was performed to determine predictors of mortality after isolated TV surgery for IE. Results: 1463 hospitalizations were identified for IE undergoing either isolated TV repair (n=531, 36.3%) or replacement (n=932, 63.7%). 106 (11.3%) underwent mechanical TV replacement. Patients undergoing TV replacement had increased risk of acute kidney injury (aOR: 1.45 (1.03-2.03), p=0.03) and pacemaker implantation (aOR: 7.03 (3.95-13.45), p&lt;0.001), however there were no significant differences in in-hospital mortality (aOR: 0.80 (0.35-1.83), p=0.59) (Table). Independent predictors of mortality for TV replacement were advanced liver disease (ALD) (5.31 (1.62-17.67), p=0.005), and acute heart failure (3.48 (1.02-18.14), p=0.044) and for TV repair were ALD (5.72 (1.31-24.90), p=0.017), and age (1.07 (1.02-1.14), p=0.026). However, predisposing conditions (drug use, infection of cardiac prosthesis, or vascular device), micro-organisms, and mechanical TV replacement were not associated with mortality in patients undergoing surgery. Conclusions: Our study reinforces that TV repair should be preferred over replacement for right sided IE when feasible, and adds to existing literature that it is the patient’s co-morbidities rather than the predisposing factors or microbiology that is associated with increased mortality.

Durable ventricular assist device implantation for systemic right ventricle: a case series.

BackgroundA systemic right ventricle (RV) after atrial switch in transposition of the great arteries (TGA) or congenitally corrected TGA (ccTGA) often results in advanced heart failure in adulthood.Case summaryFour patients with INTERMACS Class III underwent durable ventricular assist device (VAD) implantation for a systemic RV. Two patients were diagnosed with ccTGA and underwent tricuspid valve replacement, and two were diagnosed with TGA in childhood and underwent Mustard repair. The two patients with ccTGA received an EVAHEART (Sun Medical, Nagano, Japan) and HeartMate 3 (Abbott Laboratories, Abbott Park, IL, USA) at the age of 56 years and 34 years, respectively. Of the patients with TGA, one received a Heartmate II at age 40 years, and one received a HeartMate 3 at age 40 years. All patients were weaned from cardiopulmonary bypass without subpulmonic VAD support and transferred to the intensive care unit with optimum VAD support. No in-hospital deaths, cerebrovascular accidents, or other major complications occurred. The post-VAD right heart catheter study showed a remarkable reduction in pulmonary capillary wedge pressure in all patients.DiscussionThe indications for and surgical technique of durable VAD implantation for a systemic RV after atrial switch of TGA or ccTGA have not been fully established. A durable VAD, including the HeartMate 3, was successfully implanted in four such patients in this study. Pre-operative three-dimensional computed tomography images and intraoperative transoesophageal echocardiography guidance helped to determine the positions of the inflow and pump.

Nationwide cohort study of tricuspid valve repair versus replacement for infective endocarditis.

The aim of this study was to compare the outcomes of tricuspid valve (TV) repair versus replacement for patients with infective endocarditis (IE). In this nationwide population-based cohort study, we identified 704 patients from Taiwan National Health Insurance Research Database who underwent TV surgery due to IE between 2000 and 2013. Of them, 412 (58.5%) underwent TV repair and 292 (41.5%) underwent TV replacement, and their perioperative and late outcomes were analysed. Confounding was reduced using the inverse probability of treatment weighting on propensity score. After inverse probability of treatment weighting, the in-hospital mortality rate between the 2 groups was not significantly different. However, patients who received TV repair had lower rates of perioperative complications, including massive blood transfusion, de novo dialysis and deep wound infection; longer ICU and hospital stays; and higher hospital cost. Regarding late outcomes, TV repair was associated with lower risks of all-cause readmission [subdistribution hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.60-0.78; P < 0.001], readmission for adverse liver outcomes (subdistribution HR 0.75, 95% CI 0.58-0.97; P = 0.025), new permanent pacemaker implantation (subdistribution HR 0.27, 95% CI 0.15-0.48; P < 0.001) and all-cause mortality (HR 0.60, 95% CI 0.51-0.71; P < 0.001) than TV replacement. For IE, TV repair is associated with better early and late outcomes than TV replacement. A repair-first strategy is recommended for patients with IE for whom TV surgery is indicated.

Surgical treatment of tricuspid valve disease due to permanent pacemaker lead

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

Which is the best prosthesis in an isolated or combined tricuspid valve replacement?

The debate concerning the optimal choice of tricuspid position continues. We compared the long-term results of mechanical and biological prostheses in patients who underwent isolated or combined tricuspid valve replacement, at 2 major cardiac surgical centres in central China. From January 1999 to December 2018, 338 patients underwent tricuspid valve replacement. Patients were divided into an isolated group or a combined group according to whether their surgery was combined with a left heart valve surgery. Mechanical tricuspid valve replacement was performed in 142 patients (isolated group: 41 vs combined group: 101), and 196 patients underwent bioprosthetic tricuspid valve replacement (isolated group: 145 vs combined group: 51). Operative results, long-term survival and tricuspid valve-related events were compared. Early mortality in the combined group was higher (n = 6, 4%) than that in the isolated group (n = 3, 2%), but no significant difference was observed between the mechanical and biological subgroups. In the isolated group, there was a higher event-free rate in the biological subgroup than in the mechanical subgroup (P = 0.042) and a similar result was also observed for patients without Ebstein's anomaly (P = 0.039). In the combined group, no significant difference was observed (P = 0.98). Survival rates were similar between the mechanical and biological subgroups in both the isolated (P = 0.54) and combined (P = 0.81) groups. Mechanical valves in isolated tricuspid valve replacement were more prone to valve thrombosis and bleeding. Every decision regarding tricuspid valve prostheses should be individualized, but biological prostheses may be an optimal choice for patients, especially for patients without Ebstein's anomaly, in isolated tricuspid valve replacement.