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.

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.

Risk stratification for isolated tricuspid valve surgery assisted using the Model for End-Stage Liver Disease score.

OBJECTIVE: Isolated tricuspid valve surgery is perceived as high-risk. This perception is nurtured by patients who often present with substantial liver dysfunction, which is inappropriately reflected in current surgical risk scores (eg, the Society of Thoracic Surgeons [STS] score has no specific tricuspid model). The Model for End-Stage Liver Disease (MELD) has was developed as a measure for the severity of liver dysfunction. We report scores and outcomes for our patient population. METHODS: We calculated STS, European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (ESII), and MELD scores for all of our patients who received isolated tricuspid valve surgery between 2011 and 2020 (n = 157). We determined the MELD score, stratified patients into 3 groups (MELD <10: low, n = 53; 10 to <20: intermediate, n = 78; ≥20: high, n = 26) and describe associated outcomes. RESULTS: Patients were 72 ± 10 years old and 43% were male. Mean STS score was 4.9 ± 3.5% and ESII was 7.2 ± 6.6%. Mortality was 8.9% at 30 days and 65% at latest follow-up (95% CI, 51%-76%). Median follow-up was 4.4 years (range, 0-9.7 years). Although ESII and STS score accurately predicted 30-day mortality at low MELD scores (observed to expected [O/E] for ESII score = 0.8 and O/E for STS score = 1.0) and intermediate MELD (O/E for ESII score = 0.7, O/E for STS score = 1.0), mortality was underestimated at high MELD (O/E for ESII score = 3.0, O/E for STS score = 4.7). This subgroup also had higher incidence of new-onset hemodialysis. Besides MELD category, recent congestive heart failure, endocarditis, and hemodialysis were also associated with 30-day mortality. CONCLUSIONS: For isolated tricuspid valve regurgitation, classic surgical risk stratification with STS or ESII scores failed to predict perioperative mortality if there was evidence of severe liver dysfunction. Preoperative MELD assessment might be useful to assist in proper risk assessment for isolated tricuspid valve surgery.

TRI-SCORE: a single-centre validation study.

OBJECTIVES: The TRI-SCORE is a recently published risk score for predicting in-hospital mortality in patients undergoing isolated tricuspid valve surgery (ITVS). The aim of this study is to externally validate the ability of the TRI-SCORE in predicting in-hospital and long-term mortality following ITVS. METHODS: A retrospective review of our institutional database was carried out to identify all patients undergoing isolated tricuspid valve repair or replacement from March 1997 to March 2021. The TRI-SCORE was calculated for all patients. Discrimination of the TRI-SCORE was assessed using receiver operating characteristic curves. Accuracy of the models was tested calculating the Brier score. Finally, a COX regression was employed to evaluate the relationship between the TRI-SCORE value and long-term mortality. RESULTS: A total of 176 patients were identified and the median TRI-SCORE was 3 (1-5). The cut-off value identified for increased risk of isolated ITVS was 5. Regarding in-hospital outcomes, the TRI-SCORE showed high discrimination (area under the curve 0.82), and high accuracy (Brier score 0.054). This score showed also very good performance in predicting long-term mortality (at 10 years, hazard ratio: 1.47, 95% confidence interval [1.31-1.66], P < 0.001), with high discrimination (area under the curve >0.80 at 1-5 and 10 years) and high accuracy values (Brier score 0.179). CONCLUSIONS: This external validation confirms the good performance of the TRI-SCORE in predicting in-hospital mortality. Moreover, the score showed also very good performance in predicting the long-term mortality.

A comparative study on the results of beating and arrested heart isolated tricuspid valve surgery: A cross-sectional study.

Background and Aims: The isolated tricuspid valve surgery is performed using beating or arrested heart surgery. The present study aimed to evaluate and compare the results of patients who underwent isolated tricuspid valve surgery using the beating and arrested heart techniques. Methods: In this retrospective observational study, all patients undergoing isolated tricuspid valve surgery between 2011 and 2018 were included. The patient's demographic information, echocardiographic, surgery, and hospitalization results were collected, and the EuroSCORE was calculated from the patient's medical records. Results: Fifty-three patients were included in the study of which 21 (39.63%) and 32 (60.37%) underwent a beating heart and arrested heart surgeries, respectively. There were no significant differences between the two studied groups in the echocardiographic results before and after the surgery, total hospitalization days (p = 0.56), and the mortality in the first 30 days after the surgery (p = 0.152). However, the duration of surgery (p < 0.001), EuroSCORE (p = 0.005), and patients who underwent lateral thoracotomy (p = 0.007) were notably lower in the arrested heart than in the beating heart group. In contrast, the duration of cardiopulmonary bypass and hospitalization in an intensive care unit after the surgery was remarkably lower in the beating heart than in the arrested heart group (p < 0.001 for both cases). Conclusion: Although there were some significant differences between the two kinds of surgery techniques, it seems superficial that made a particular decision to consider each method's superiority. Therefore, further studies with larger populations and meta-analyses are required to recommend the preferred method for the surgeons certainly.

Deviations From the Ideal Plasma Volume and Isolated Tricuspid Valve Surgery-Paving the Way for New Risk Stratification Parameters.

Background: Congestion and plasma volume expansion are important features of heart failure, whose prognostic significance has been investigated in a range of surgical and non-surgical settings. The aim of this study was to evaluate the value of the estimated plasma volume status (ePVS) in patients undergoing isolated tricuspid valve surgery. Methods: This study included patients who underwent isolated tricuspid valve surgery at the Vienna General Hospital (Austria) between July 2008 and November 2018. The PVS cut-off was calculated using ROC analysis and Youden's Index. Results: Eighty eight patients (median age: 58 [IQR: 35-70] years; 44.3% male; 75.6% NYHA III/IV; median EuroSCORE II 2.65 [IQR: 1.70-5.10]; 33.0% endocarditis-related regurgitation; 60.2% isolated repair; 39.8% isolated replacement) were included in this study. Patients who died within 1 year following surgery had significantly higher baseline ePVS values than survivors (median ePVS 5.29 [IQR: -1.55-13.55] vs. -3.68 [IQR: -10.92-4.22]; p = 0.005). During a median actuarial follow-up of 3.02 (IQR: 0.36-6.80) years, patients with a preoperative ePVS ≥ -4.17 had a significantly increased mortality (log-rank p = 0.006). Conclusions: ePVS is an easily obtainable risk parameter for patients undergoing isolated tricuspid valve surgery capable of predicting mid- and long-term outcomes after isolated tricuspid valve surgery.

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

OBJECTIVES: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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 tricuspid valve surgery: first outcomes report according to a novel clinical and functional staging of tricuspid regurgitation.

OBJECTIVES: The goal of this study was to assess the applicability of a novel classification of patients with tricuspid regurgitation based on 5 stages and to evaluate outcomes following isolated surgical treatment. METHODS: All patients treated with isolated tricuspid valve repair or tricuspid valve replacement (TVR) from March 1997 to January 2020 at a single institution were retrospectively reviewed. Patients were divided according to a novel clinical-functional classification, based on the degree of regurgitation together with symptoms, right ventricular size and function and medical therapy. A total of 195 patients were treated; however, 23/195 were excluded due to lack of sufficient preoperative data. RESULTS: A total of 172 patients were considered; of these, 129 (75%) underwent TVR and 43 (25%) had tricuspid valve repair. The distribution of patients showed that 46.5% of patients who underwent tricuspid valve repair were in stage 2, whereas 51.9% who underwent TVR were in stage 3. TVR patients were in more advanced stages of the disease, with dilated right ventricles, more pronounced symptoms and development of organ damage. Hospital mortality was 5.8%, in particular 0% in stages 2 and 3 and 15.3% in stages 4 and 5 (P < 0.001). Both intensive care unit and hospital stays were significantly longer in more advanced stages (P < 0.001). Patients in stages 4 and 5 developed more postoperative complications, such as acute kidney injury (3.7-10% in stages 2 and 3 vs 44-100% in stages 4 and 5; P < 0.001) and low cardiac output syndrome (15-50% in stages 2 and 3 vs 71-100% in stages 4 and 5; P < 0.001). CONCLUSIONS: Patients in more advanced stages had higher hospital mortality and longer hospitalizations. Timely referral is associated with lower mortality, short postoperative course and mostly valve repair.

Early and Late Outcomes of Isolated Tricuspid Valve Surgery Following Valvular Surgery.

PURPOSE: Isolated tricuspid valve surgery (TVS) following valvular surgery has been still challenging. We reviewed our experience to determine early and late outcomes. METHODS: We retrospectively analyzed 14 patients (mean age, 57.0 ± 17.8 years old) who underwent isolated TVS after valvular surgery between January 1990 and December 2010. The causes of isolated TVS were structural valve deterioration (SVD) (n = 5) and symptomatic severe tricuspid regurgitation (n = 9). The mean follow-up period was 6.4 ± 5.9 years. RESULTS: At redo, seven patients underwent tricuspid valve replacement (TVR) using a bioprosthesis and the remaining underwent tricuspid valve repair (TVP). Early mortality rate was 7.1% (1/14). Survival rates at 5 and 10 years were 68.8% ± 13.1% and 68.8% ± 13.1%, respectively. Three deaths (two for heart failure and one for cerebral hemorrhage) were observed. Freedom from valve-related events was 58.3% ± 14.2% at 2 and 48.6% ± 14.8% at 5 years. Six events were observed (five for heart failure and one for cerebral hemorrhage). There was no statistically significant difference between TVP and TVR as to freedom from valve-related events (log-rank p = 0.3655). CONCLUSIONS: Early and late outcomes of isolated TVS after valvular surgery seem to be satisfactory. Special attention should be paid to heart failure following TVP.

Non-functional tricuspid valve disease.

Only 75% of severe tricuspid regurgitation is classified as functional, or related primarily to pulmonary hypertension, right ventricular dysfunction, or a combination of both. Non-functional tricuspid regurgitation occurs when there is damage to the tricuspid leaflets, chordae, papillary muscles, or annulus, independent of right ventricular dysfunction or pulmonary hypertension. The entities that cause non-functional tricuspid regurgitation include rheumatic and myxomatous disease, acquired and genetic connective tissue disorders, endocarditis, sarcoid, pacing, RV biopsy, blunt trauma, radiation, carcinoid, ergot alkaloids, dopamine agonists, fenfluramine, cardiac tumors, atrial fibrillation, and congenital malformations. Over time, severe tricuspid regurgitation that is initially non-functional, can blend into functional tricuspid regurgitation, related to progressive right ventricular dysfunction. Symptoms and signs, including a falling right ventricular ejection fraction, cardiac cirrhosis, ascites, esophageal varices, and anasarca, may occur insidiously and late, but are associated with substantial morbidity and mortality. Attempted valve repair or replacement at late stages carries a high mortality. Crucial to following patients with severe non-functional tricuspid regurgitation is attention to echo quantification of the tricuspid regurgitation and right ventricular function, patient symptoms, and the physical examination.