Concomitant tricuspid valve surgery in patients with significant tricuspid regurgitation undergoing left ventricular assist device implantation: A systematic review and meta-analysis.

BACKGROUND: Significant tricuspid regurgitation (TR) is a predictor of right heart failure (RHF) and increased mortality following left ventricular assist device (LVAD) implantation, however the benefit of tricuspid valve surgery (TVS) at the time of LVAD implantation remains unclear. This study compares early and late mortality and RHF outcomes in patients with significant TR undergoing LVAD implantation with and without concomitant TVS. METHODS: A systematic search of four electronic databases was conducted for studies comparing patients with moderate or severe TR undergoing LVAD implantation with or without concomitant TVS. Meta-analysis was performed for primary outcomes of early and late mortality and RHF. Secondary outcomes included rate of stroke, renal failure, hospital and ICU length of stay. An overall survival curve was constructed using aggregated, reconstructed individual patient data from Kaplan-Meier (KM) curves. RESULTS: Nine studies included 575 patients that underwent isolated LVAD and 308 patients whom received concomitant TVS. Both groups had similar rates of severe TR (46.5% vs. 45.6%). There was no significant difference seen in risk of early mortality (RR 0.90; 95% CI, 0.57-1.42; p = 0.64; I2 = 0%) or early RHF (RR 0.82; 95% CI, 0.66-1.19; p = 0.41; I2 = 57) and late outcomes remained comparable between both groups. The aggregated KM curve showed isolated LVAD to be associated with overall increased survival (HR 1.42; 95% CI, 1.05-1.93; p = 0.023). CONCLUSIONS: Undergoing concomitant TVS did not display increased benefit in terms of early or late mortality and RHF in patients with preoperative significant TR. Further data to evaluate the benefit of concomitant TVS stratified by TR severity or by other predictors of RHF will be beneficial.

Contemporary Outcomes of Isolated Tricuspid Valve Surgery.

INTRODUCTION: Isolated 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. METHODS: Patients 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. RESULTS: Among 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). CONCLUSIONS: Isolated 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.

A rare case of papillary fibroelastoma involving the tricuspid valve. A single center experience over a period of 22 years (1999-2021).

BACKGROUND AND AIM: Papillary fibroelastoma (PFE) represents only 16% of the benign cardiac tumor and approximately 15% of these are located on the tricuspid valve. MATERIALS AND METHODS: Over a period of 22 years (1999-2021) we observed 75 pts with cardiac tumors at our Center over 9650 pts operated on but only one case of a tricuspid valve PFE in a 69-year-old patient. Trans-thoracic echocardiography demonstrated a mobile mass (20 × 10 mm), adhering to the atrial side of the septal leaflet of the tricuspid valve of unknown origin. In consideration of the mobility of the mass and the consequent high embolic risk, surgical removal was made. The patient underwent surgery through a median sternotomy on CPBP. A 'gelatinous' mass adhering to the tricuspid leaflet was found and completely removed. The postoperative course was uneventful. The pathological diagnosis was PFE. CONCLUSIONS: PFEs of the tricuspid valve are rare entities being in most cases found incidentally. In our experience, the incidence of this tumor in this location is 1/10,000 cases of cardiac surgery. Although most patients are asymptomatic, surgical treatment is nevertheless recommended in consideration of the high embolic risk.

Valvular Heart Failure due to Tricuspid Regurgitation: Surgical and Transcatheter Management Options.

Given the independent association of mortality with higher grades of tricuspid regurgitation severity, there is an increasing interest in improving the outcomes of this prevalent valvular heart disease. A new classification of tricuspid regurgitation etiology allows for an improved understanding of different pathophysiologic forms of the disease, which may determine the appropriate management strategy. Current surgical outcomes remain suboptimal and multiple transcatheter device therapies are currently under investigation to give high and prohibitive surgical risk patients treatment options beyond medical therapy.

Surgical approach to combined mitral and tricuspid valve disease: good neighbourhood rules.

Tricuspid regurgitation afflicts more than one-third of patients with mitral valve disease during their clinical history, and negatively affects their outcomes, increasing mortality and hospitalizations for heart failure and reducing the quality of life. A renewed interest in the 'neglected valve' has increased the frequency of the combined treatment of these two diseases. Undoubtedly necessary in patients with degenerative mitral valve disease in the presence of two severe valve defects, tricuspid annuloplasty has proven to be safe and effective even if performed prophylactically, when tricuspid annular dilation coexists with primary mitral dysfunction. In the absence of survival benefits, however, this additional surgical procedure increases the risk of high-grade atrio-ventricular blocks and the need for a definitive pacemaker. On the other hand, the role of surgery has been scaled down in patients with functional mitral and tricuspid regurgitation. In this context, a multidisciplinary approach is needed and transcatheter alternatives are increasingly the chosen treatment option. A new therapeutic algorithm is therefore looming on the horizon. In the future, the treatment of tricuspid and mitral valve disease may be considered two potentially distinct and successive phases of an integrated heart failure patients care process.

Isolated tricuspid valve surgery-Repair versus replacement: A meta-analysis.

OBJECTIVE: There is a paucity of data on outcomes after isolated tricuspid valve surgery. This meta-analysis aims to compile available data on isolated tricuspid valve surgery and compare isolated tricuspid valve repair (iTVr) with isolated tricuspid valve replacement (iTVR) to elucidate outcomes after tricuspid valve surgery. METHODS: A literature search of 6 databases was performed. The primary outcomes was 30-day mortality. Secondary outcomes were early stroke, post-op pacemaker placement, and tricuspid reoperation within 5 years. Publication bias was explored using the funnel plot. RESULTS: Ten retrospective studies involving 1407 patients (iTVr group = 779 patients and iTVR group = 628 patients) were included. A cumulative analysis demonstrated a significant difference favoring iTVr for 30-day mortality (odds ratio [OR]: 10 studies [95% confidence interval [CI]]: 0.34 [0.18-0.66]); 4.7% versus 12.6%, for iTVr and iTVR, respectively. Post-op pacemaker placement favored iTVr (OR: 6 studies [95% CI]: 0.37 [0.18-0.77]). Although stroke rates and TV reoperation favored iTVr, they did not reach statistical significance. No publication bias was identified. CONCLUSIONS: This meta-analysis demonstrates that iTVr has better 30-day mortality and fewer permanent pacemaker placements. Etiology and severity of TR, as well as careful patient selection remain the most important factors for optimal outcomes.

Does concomitant tricuspid valve surgery increase the risks of minimally invasive mitral valve surgery? A multicentre comparison based on data from The Netherlands Heart Registration.

OBJECTIVES: Mitral valve (MV) disease is often accompanied by tricuspid valve (TV) disease. The indication for concomitant TV surgery during primary MV surgery is expected to increase, especially through a minimally invasive surgical (MIS) approach. The aim of the current study is to investigate the safety of the addition of TV surgery to MV surgery in MIMVS in a nationwide registry. METHODS: Patients undergoing atrioventricular valve surgery through sternotomy or MIS between 2013 and 2018 were included. Patients undergoing MV surgery only through sternotomy or MIS were used as comparison. Primary outcomes were short-term morbidity and mortality and long-term survival. Propensity score matching was used to correct for potential confounders. RESULTS: The whole cohort consisted of 2698 patients. A total of 558 patients had atrioventricular double valve surgery through sternotomy and 86 through MIS. As a comparison, 1365 patients underwent MV surgery through sternotomy and 689 patients through MIS. No differences in 30- and 120-day mortality were observed between the groups, both unmatched and matched. 5-year survival did not differ for double atrioventricular valve surgery through either sternotomy or MIS in the matched population (90.1% vs. 95.3%, Log-Rank p = .12). A higher incidence of re-exploration for bleeding (n = 12 [15.2%] vs. n = 3 [3.8%], p = .02) and new onset arrhythmia (n = 35 [44.3%] vs. n = 13 [16.5%], p < .001) was observed in double valve surgery through MIS. Median length of hospital stay (LOHS) was longer in the minimally invasive double valve group (9 days [6-13]) compared with sternotomy (7 days [6-11]; p = .04). CONCLUSION: No differences in short-term mortality and 5-year survival were observed when tricuspid valve was added to MV surgery in MIS or sternotomy. The addition of tricuspid valve surgery is associated with higher incidence of re-exploration for bleeding, new onset arrhythmia. A longer LOHS was observed for MIS compared to sternotomy.

Macro-reentrant atrial tachycardia after tricuspid or mitral valve surgery: is there difference in electrophysiological characteristics and effectiveness of catheter ablation?

BACKGROUND: Macro-reentrant atrial tachycardias (MATs) are a common complication after cardiac valve surgery. The MAT types and the effectiveness of MAT ablation might differ after different valve surgery. Data comparing the electrophysiological characteristics and the ablation results of MAT post-tricuspid or mitral valve surgery are limited. METHODS: Forty-eight patients (29 males, age 56.1 ± 13.3 years) with MAT after valve surgery were assigned to tricuspid valve (TV) group (n = 18) and mitral valve (MV) group (n = 30). MATs were mapped and ablated guided by a three-dimensional navigation system. The one-year clinical effectiveness was compared in two groups. RESULTS: Nineteen MATs were documented in TV group, including 16 cavo-tricuspid isthmus (CTI)-dependent AFL and 3 other MATs at right atrial (RA) free wall, RA septum and left atrial (LA) roof. Thirty-nine MATs were identified in MV group, including15 CTI-dependent AFL, 8 RA free wall scar-related, 2 RA septum scar-related, 8 peri-mitral flutter, 3 LA roof-dependent, 2 LA anterior scar-related, and 1 right pulmonary vein-related MAT. Compared with TV group, MV group had significantly lower prevalence of CTI-dependent AFL (38.5% vs. 84.2%), higher prevalence of left atrial MAT (35.9 vs.5.3%) and higher proportion of patients with left atrial MAT (40 vs. 5.6%), P = 0.02, 0.01 and 0.01, respectively. The acute success rate of MAT ablation (100 vs. 93.3%) and the one-year freedom from atrial tachy-arrhythmias (72.2 vs. 76.5%) was comparable in TV and MV group. No predictor for recurrence was identified. CONCLUSION: Although the types of MATs differed significantly in patients with prior TV or MV surgery, the acute and mid-term effectiveness of MAT ablation was comparable in two groups. TRIAL REGISTRATION: This study was registered as a part of EARLY-MYO-AF clinical trial at the website ClinicalTrials. gov (NCT04512222).

Complicated postoperative course in isolated tricuspid valve surgery: Looking for predictors.

BACKGROUND: This study aims at better defining the profile of patients with a complicated versus noncomplicated postoperative course following isolated tricuspid valve (TV) surgery to identify predictors of a favorable/unfavorable hospital outcome. METHODS: All patients treated with isolated tricuspid surgery from March 1997 to January 2020 at our institution were retrospectively reviewed. Considering the complexity of most of these patients, a regular postoperative course was arbitrarily defined as a length-of-stay in intensive care unit less than 4 days and/or postoperative length-of-stay less than 10days. Patients were therefore divided accordingly in two groups. RESULTS: One hundred and seventy-two patients were considered, among whom 97 (56.3%) had a regular (REG) and 75 (43.6%) a non-regular (NEG) postoperative course. The latter had worse baseline clinical and echocardiographic characteristics, with higher rate of renal insufficiency, previous heart failure hospitalizations, cardiac operations, and right ventricular dysfunction. NEG patients more frequently needed tricuspid replacement and experienced a greater number of complications (p < .001) and higher in-hospital mortality (13% vs. 0%, p < .001). The majority of these complications were related to more advanced stage of the tricuspid disease. Among most important predictors of a negative outcome univariate analysis identified chronic kidney disease, ascites, previous right heart failure hospitalizations, right ventricular dysfunction, previous cardiac surgeries, TV replacement and higher MELD scores. At multivariate analysis, liver enzymes and diuretics' dose were predictors of complicated postoperative course. CONCLUSION: In isolated TV surgery a complicated postoperative course is observed in patients with more advanced right heart failure and organ damage. Earlier surgical referral is associated to excellent outcomes and should be recommended.

Performance of pacemaker leads in alternative lead positions after tricuspid valve replacement.

BACKGROUND: Bradycardic arrhythmias requiring pacemaker (PM) implantation are still common in patients in need of tricuspid valve replacement (TVR). Leaving an existing PM lead in an extravalvular position may represent a helpful alternative in special situations like the implantation of a mechanical TV. This study aimed to examine the short- to mid-term outcome of paravalvular leads concerning lead survival and prosthesis dysfunction in patients after TVR. METHODS: A retrospective case-control study of patients with TVR and ventricular pacing was conducted. Patients from the database of the Leipzig Heart Center were included. Data of the paravalvular lead group (PVG) and coronary sinus lead group (CSG) were compared to a control group with conventional transvalvular leads (TVG). RESULTS: Eighty patients with TVR and cardiac PM (TVG [n = 13], PVG [n = 40], and CSG [n = 27]) were included. The mean follow-up was 2.8 years. The rate of lead revisions (TVG 15.4%, PVG 2.5%, and CSG 7.5%) was lower in PVG but without significance (P = .286). The CSG demonstrated significantly higher pacing thresholds (1.4 V/0.8 ms) than TVG (0.5 V/0.4 ms), P = .004. However, the deterioration of threshold amplitudes during follow-up was similar in CSG (7.4%) and PVG (7.5%) compared with controls (7.7%). Function of TV prosthesis regarding development of stenosis or regurgitation showed a similarity between the groups (regurgitation PVG P = .692, CSG P = 1; stenosis PVG P = .586, CSG P = 0.69). CONCLUSION: Paravalvular positioning of PM leads seems to represent a reasonable alternative to the conventional transvalvular lead positioning concerning the lead and Tricuspid Valve prosthesis's function and durability in selected patients.

Retrospective analysis of tricuspid valve repair using a novel surgical technique: A 7-year single-surgeon experience.

OBJECTIVES: Tricuspid annuloplasty is the optimal surgical repair technique for tricuspid regurgitation which improves mortality and morbidity. Ring annuloplasties is the techniques of choice. Here, we evaluate the efficacy and durability of a new method of interrupted pledgeted suture annuloplasty. METHODS: Between 2011 and 2018, 39 eligible patients underwent tricuspid valve repair using this novel technique. Indication for repair was a grade of regurgitation at moderate or greater, or an annular diameter >40 mm. Patients were assessed both preoperatively and postoperatively by echocardiogram. Follow-up results were split into the first postoperative echocardiogram and most recent postoperative echocardiogram undertaken. RESULTS: There were two in-hospital mortalities and two patients required permanent pacemaker implantation following surgery. At the time of the first postoperative echocardiogram undertaken (median 3 months postoperatively), freedom from moderate-severe regurgitation was 92.3%. At the time of the most recent postoperative echocardiogram undertaken (median 11 months postoperatively); none or mild regurgitation was detected in 24 patients (61.5%), mild-moderate in 11 (28.2%) and moderate-severe in 4 (10.3%) patients. Freedom from moderate-severe regurgitation was 89.7%. Postoperative grade of regurgitation was significantly reduced from preoperative grades (p < 0.001). CONCLUSION: Initial and midterm results of our technique show a good durability of repair. We have demonstrated recurrence rates of regurgitation equal and superior to current forms of suture annuloplasty published in the literature. This novel method of suture annuloplasty can be considered in the surgical repertoire of tricuspid valve repair techniques.

Etiology of tricuspid valve disease is a predictor of bradyarrhythmia after tricuspid valve surgery.

AIMS: The tricuspid valve is situated in close proximity to cardiac conduction tissue and damage to this tissue can affect postoperative rhythm. The aim of this study was to quantify the incidence of pacemaker requirement after tricuspid valve surgery and investigate predictors. METHODS: Data were collected via our operative data collection system and patient files. All patients who underwent surgical procedures of the tricuspid valve from 2004 until 2017 and lacked a pacemaker preoperatively were included in the study. RESULTS: In our cohort of 505 patients 54 required a pacemaker in the first 50 days after surgery. We calculated a 17.5% (95% confidence interval [CI], 13.5-21.3) risk of pacemaker implantation at 4 years postoperatively. Multivariate analysis identified preoperative active endocarditis (odds ratio 3.17; CI, 1.32-7.65; P = 0.010) and "inadequate pacemaker dependent rhythm" (defined as any intrinsic heart rate below 45 per minute requiring pacing) upon admission to the intensive care unit after surgery (odds ratio 5.924; CI, 2.82-12.44; P = 0.001) as predictors for pacemaker requirement in the first 50 days after surgery. Twenty-six pacemakers (48%) were implanted for atrioventricular block, 16 (30%) for sinus node dysfunction and 12 (22%) for atrial fibrillation. Kaplan-Meier analysis showed no difference in survival between the pacemaker and no pacemaker group. CONCLUSION: Surgery of the tricuspid valve has a high burden of postoperative pacemaker requirement. Preoperative active endocarditis and the initial postoperative rhythm are predictors. Understanding this allows for better decision-making regarding further medical/device therapy.

Specific Anatomic Considerations for Tricuspid Interventions.

PURPOSE OF REVIEW: This review discusses the normal anatomy and pathology of the tricuspid valve (TV) and right side of the heart. Emphasis is on those anatomic and pathologic features relevant to interventions intended to restore normal function to the TV in disease states. RECENT FINDINGS: TV pathology is less common than aortic and mitral valve pathology, and treatment and outcomes for interventions face considerable hurdles. New innovations and early data showing safety and efficacy in transcatheter interventions have transformed TV interventions into the next frontier in cardiac valve disease treatment. Certain features of the TV and right heart have presented themselves as potential targets, as well as impediments, for TV intervention. The causes of TV pathology and the anatomy of the TV and right heart bring unique challenges to intervention. Approaches to intervention will continue to progress and change the way we view and treat TV pathology.

Perioperative predictors of permanent pacing and long-term dependence following tricuspid valve surgery: a multicentre analysis.

AIMS: Permanent pacemaker placement (PPM) is often required after valvular surgery and is especially common following tricuspid valve surgery [tricuspid valve repair or replacement (TVR)]. Literature suggests that surgical intervention for isolated tricuspid valve disease is becoming more prevalent. Predictors of PPM dependency following TVR are currently unknown and would be clinically useful from a prognostication standpoint. METHODS AND RESULTS: We conducted a multicentre, retrospective study to assess perioperative factors of TVR that predispose to PPM placement and long-term PPM dependency from 2008 to 2014. Regression analysis was used to determine independent predictors of PPM implantation. A total of 237 patients (age 66 ± 15 years, 29% male) were studied, and the incidence of PPM placement following TVR was 27% (65/237). No significant differences were observed between those who received PPM and those who did not in age (P = 0.092), gender (P = 0.359), and co-morbidities. Regression analysis identified cross-clamp time >60 min (OR 4.1, 95% CI 1.3-12.9, P = 0.015) and concomitant mitral valve surgery (OR 3.8, 95% CI 1.2-12.2, P = 0.026) as independent risk factors for PPM following TVR. Long-term PPM dependency data were only available in 28 patients who received PPM with 14 of these patients developing long-term dependence. The only statistically significant difference noted was an increased frequency of coronary artery disease in the long-term dependent group vs. the non-dependent group (64% vs. 14%, P = 0.018). CONCLUSION: Cross-clamp time >60 min and concomitant mitral valve surgery were independent predictors of PPM implantation following TVR. Long-term PPM dependency is more prevalent after TVR than other types of valvular surgery.

[Tricuspid valve regurgitation : Indications and operative techniques]. / Trikuspidaklappenoperation : Indikationen und Techniken.

Functional tricuspid valve (TV) regurgitation secondary to left heart disease (e.g. mitral insufficiency and stenosis) is observed in 75% of the patients with TV regurgitation and is thus the most common etiology; therefore, the majority of patients who require TV surgery, undergo concomitant mitral and/or aortic valve surgery. Uncorrected moderate and severe TV regurgitation may persist or even worsen after mitral valve surgery, leading to progressive heart failure and death. Patients with moderate to severe TV regurgitation show a 3-year survival rate of 40%. Surgery is indicated in patients with severe TV regurgitation undergoing left-sided valve surgery and in patients with severe isolated primary regurgitation without severe right ventricular (RV) dysfunction. For patients requiring mitral valve surgery, tricuspid valve annuloplasty should be considered even in the absence of significant regurgitation, when severe annular dilatation (≥40 mm or >21 mm/m2) is present. Functional TV regurgitation is primarily treated with valve reconstruction which carries a lower perioperative risk than valve replacement. Valve replacement is rarely required. Tricuspid valve repair with ring annuloplasty is associated with better survival and a lower reoperation rate than suture annuloplasty. Long-term results are not available. The severity of the heart insufficiency and comorbidities (e.g. renal failure and liver dysfunction) are the essential determinants of operative mortality and long-term survival. Tricuspid valve reoperations are rarely necessary and associated with a considerable mortality.

Current Treatment Strategies for Tricuspid Regurgitation.

PURPOSE OF REVIEW: Tricuspid regurgitation is common; however, recognition and diagnosis, clinical outcomes, and management strategies are poorly defined. Here, we will describe the etiology and natural history of tricuspid regurgitation (TR), evaluate existing surgical outcomes data, and review the evolving field of percutaneous interventions to treat TR. RECENT FINDINGS: Previously, the only definitive corrective therapy for TR was surgical valve repair or replacement which is associated with significant operative mortality. Advances in percutaneous valve repair techniques are now being translated to the tricuspid valve. These novel interventions may offer a lower-risk alternative treatment in patients at increased surgical risk. Significant TR adversely impacts survival. Surgery remains the only proven therapy for treatment of TR and may be underutilized due to mixed outcomes data. Early experience with percutaneous interventions is promising, but large clinical experience is lacking. Further study will be required before these therapies are introduced into broader clinical practice.

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

BACKGROUND: Data regarding permanent pacemaker (PPM) implantation following tricuspid valve surgery (TVS) are limited. We sought to evaluate its incidence, risk factors, and outcomes. METHODS AND RESULTS: 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). CONCLUSIONS: 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.

Permanent pacemaker implantation after combined mitral- and tricuspid valve surgery-a nationwide multicentre study.

OBJECTIVES: The threshold to perform concomitant TV repair (TVr) during primary mitral valve (MV) surgery has decreased, based on recent randomized evidence. Based on these developments, the indication for TVr during MV surgery is expected to increase further. However, concerns have been raised regarding the risk of permanent pacemaker implantation (PPI) during a concomitant procedure. Therefore, we aim to assess the incidence of PPI in combined MV and TV surgery in a nationwide registry. METHODS: The current study uniquely cross-linked the Cardiothoracic and Pacemaker/ICD registry of the Netherlands Heart Registration. Patients undergoing primary MV and TV surgery (± ASD closure, rhythm surgery, CABG) between January 1st-December 31st 2021 were included. The primary outcome was PPI within 30 days after surgery. Subgroup analyses were performed for isolated MV and TV surgery and MV repair. The association between concomitant TV surgery and PPI was assessed using multivariable binary logistic regression analyses. RESULTS: A total of 1060 patients (n = 833 MV, n = 227 MV+TV) were included. The overall incidence of PPI was 4.3%. No significant difference in PPI between MV and MV+TV surgery were found (3.7% vs 6.6%, P = 0.06). Concomitant TV surgery was not an independent risk factor for PPI after surgery after adjustment for covariates. These results were robust across subgroup and sensitivity analyses. CONCLUSIONS: The current study was not able to find a statistical difference between the PPI rate in MV surgery patients and MV + TV surgery patients. Extension of the waiting period prior to PPI, may result in decreased PPI rates.

Crossroads of Care: Navigating Injection Drug Use-Associated Endocarditis.

Infective endocarditis (IE), with its high morbidity and mortality, is a frequent complication of injection drug use (IDU). We present a case highlighting the complexities in the management of IDU-associated IE (IDU-IE) in a 46-year-old male with active IDU who presented with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia and a large tricuspid valve vegetation. Urgent tricuspid valve surgery was indicated due to the size of the vegetation measuring up to 4 cm, along with recurrent pulmonary septic emboli. The patient underwent an uncomplicated and successful complete vegetectomy, tricuspid valve repair, and completed a 42-day antibiotic course. During the six-week follow-up, he showed complete recovery and maintained successful abstinence from illicit drug use, supported by an addiction medicine specialist. This case underscores the importance of early recognition, appropriate antibiotic therapy, and individualized surgical intervention in optimizing outcomes. Effective management of IE necessitates a multidisciplinary IE team, including addiction medicine specialists. Addressing the underlying substance use disorder (SUD) is crucial to reducing the risk of recurrent IE.

Tricuspid valve surgery following septal myectomy in patients with a cardiac implantable electronic device.

Background: Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of developing cardiac arrhythmias and have a high prevalence of cardiac implantable electronic device (CIED) use. Tricuspid regurgitation (TR) is a potential complication of device leads and can be severe enough to prompt surgical intervention. Methods: We identified 21 consecutive patients who underwent tricuspid valve (TV) surgery for device lead-induced TR late following septal myectomy (SM) for obstructive HCM. The primary endpoint was long-term all-cause mortality. Results: The median patient age was 63 years (range, 55-71 years), 19 patients (91%) had New York Heart Association class III or IV limitation, and all patients were receiving diuretics for right heart failure. The median interval between device implantation and TV surgery was 4 years (range, 1.5-8.5 years). Eight patients (38%) underwent pacemaker implantation due to complete heart block following SM. Preoperatively, TR was severe in 81% of the patients. The primary mechanism of lead-induced TR was leaflet impingement without adherence (n = 15; 75%). Nine patients (43%) underwent TV replacement, and 12 patients (57%) underwent repair. Only 1 patient died early postoperatively. Patients with lead-induced TR had markedly reduced long-term survival compared to the overall population of patients undergoing SM; 5-year survival was 58%, compared to 96% for the contemporary SM group. Conclusions: Late lead-induced TR is a potential complication of CIEDs in patients with HCM who have undergone SM. Although TV repair and replacement can be done with acceptable early mortality, late patient survival is poor.