Is tricuspid annuloplasty increasing surgical mortality and morbidity during mitral valve replacement? A single-centre experience

Concomitant Tricuspid Valve Surgery Is Not Associated With Increased Operative Risk During Robotic Mitral Valve Surgery

OBJECTIVE

The aim of this study was to investigate the outcomes of robotic mitral valve surgery with and without concomitant tricuspid valve surgery.

METHODS

Patients who underwent robotic mitral surgery between March 2010 and September 2022 were included. Patients were grouped according to the presence of concomitant tricuspid interventions. The groups were compared for baseline factors, operative parameters, and early postoperative outcomes. Age- and gender-matched groups were also compared for outcomes.

RESULTS

The study included 285 robotic mitral surgery patients. There were 59 patients who underwent concomitant tricuspid interventions. In the concomitant tricuspid surgery group, cardiopulmonary bypass time (150.1 vs 128.4 min, P < 0.001) and cross-clamp time (99.2 vs 82.4 min, P < 0.001) were longer. Prolonged intubation was more frequent in the concomitant tricuspid intervention group (5.2% vs 0.5%, P = 0.029). The groups did not differ in terms of mortality, permanent pacemaker (PPM) requirement, or other morbidities. Perioperative outcomes were similar after matched group analysis.

CONCLUSIONS

Operative mortality and early adverse outcomes did not increase with the addition of tricuspid intervention in our cohort of robotic mitral surgery patients. The robotic approach for mitral disease and coexisting tricuspid disease may offer safe results without an increased risk of postoperative PPM requirement.

Concomitant tricuspid valve repair for mild-moderate tricuspid regurgitation patients undergoing mitral valve surgery? A meta-analysis and meta-regression

The development of tricuspid regurgitation (TR) is a common complication of mitral valve disease. Although severe TR is usually operated on at the same time of mitral valve surgery (MVS), controversies remain regarding whether mild to moderate TR patients should be operated. Concomitant tricuspid valve repair with MVS for mild-moderate TR patients. Electronic databases were searched from inception to November 20, 2022 to include any observational or randomized controlled trials (RCT) that compare concomitant tricuspid repair with MVS versus MVS alone. Mantel-Haenszel method was used to pool study estimates and calculate odds ratios (OR) with 95% confidence intervals (CI). A total of 9813 patients from 25 studies were included. Regarding primary outcomes, concomitant repair group had significantly lower 30 days mortality (OR: 0.66; 95% CI 0.45 to 0.96), all-cause mortality-based on RCTs- (OR: 0.40; 95% CI 0.22 to 0.71), cardiovascular mortality (OR: 0.53; 95% CI: 0.33 to 0.86) and heart failure hospitalizations (OR: 0.41; 95% CI: 0.26 to 0.63). However, was associated with higher permanent pacemaker implantation rates (OR: 2.09; 95% CI: 1.45 to 3.00). There were no significant differences in terms of secondary outcomes: tricuspid valve reinterventions, stroke and acute kidney injury. Furthermore, repair group showed lower risk for TR progression degrees (OR 0.08; 95% CI 0.05 to 0.16) and decreased mean of TR progression (MD -1.85; 95% CI -1.92 to -1.77). Concomitant tricuspid valve repair in mild or moderate TR at time of MVS appears to reduce not only 30 days but also long-term all-cause and cardiovascular mortality weighed against the increased risk of pacemaker implantation.

The best approach for functional tricuspid regurgitation: A network meta-analysis

OBJECTIVE

For many years, functional tricuspid regurgitation (FTR) was considered negligible after treatment of left-sided heart valve surgery. The aim of the present network meta-analysis is to summarize the results of four approaches to establish the possible gold standard.

METHODS

A systematic search was performed to identify all publications reporting the outcomes of four approaches for FTR, not tricuspid annuloplasty (no TA), suture annuloplasty (SA), flexible (FRA), rigid rings (RRA). All studies reporting at least one the four endpoints (early and late mortality, early and late moderate or more TFR) were included in a Bayesian network meta-analysis.

RESULTS

There were 31 included studies with 9663 patients. Aggregate early mortality was 5.3% no TA, 7.2% SA, 6.6% FRA, and 6.4% RRA; early TR moderate-or-more was 9.6%, 4.8%, 4.6%, and 3.8%; late mortality was 22.5%, 18.2%, 11.9%, and 11.9%; late TR moderate-or-more was 27.9%, 18.3%, 14.3%, and 6.4%. Rigid or semirigid ring annuloplasty was the most effective approach for decreasing the risk of late moderate or more FTR (-85% vs. no TA; -64% vs. SA; -32% vs. FRA). Concerning late mortality, no significant differences were found among different surgical approaches; however, flexible or rigid rings reduced significantly the risk of late mortality (78% and 47%, respectively) compared with not performing TA mortality. No differences were found for early outcomes.

CONCLUSIONS

Ring annuloplasty seems to offer better late outcomes compare to either suture annuloplasty or not performing TA. In particular rigid or semirigid rings provide more stable FTR across time.

Effect of Concomitant Tricuspid Annuloplasty on Early Outcomes of Mitral Valve Replacement: A Study on Rheumatic Heart Disease Patients

Introduction

Mitral valve abnormalities in rheumatic heart disease commonly lead to functional tricuspid regurgitation. Tricuspid annuloplasty (TA) is often performed in these cases along with mitral valve replacement (MVR). Our aim was to compare the perioperative morbidity and mortality among those patients that underwent mitral valve replacement with tricuspid annuloplasty versus those that underwent isolated mitral valve replacement.

Methods

A retrospective analysis of 158 patients that underwent mitral valve replacement, with or without tricuspid annuloplasty, secondary to rheumatic heart disease between January 2017 and August 2020. Patients who underwent additional cardiothoracic surgical procedures (aortic valve replacement and coronary artery bypass grafting) were excluded to reduce confounders.

Results

The study group consisted of 158 patients (mean age 41; 73 male, 85 female) that underwent MVR with TA (n=22; 13.9%) or without TA (n=136; 86.1%). Both groups had similar comorbidity frequencies and medication history. Preoperative echocardiography showed a comparable degree of pulmonary hypertension and ejection fraction between the two groups. The TA+MVR group had similar intraoperative (81.8% vs 66.9%; p=0.161) and postoperative (45.5% vs 45.6%; p=0.991) blood products usage compared to the MVR only group. Concurrent TA resulted in similar in-hospital mortality (4.5% vs 4.4%; p=0.977) as well as early postoperative complications, namely, prolonged ICU stay (13.6% vs 10.3%; p=0.639), prolonged ventilation (0 vs 2.2%; p=0.482), re-intubation (9.1% vs 2.9%; p= 0.161), and reopening for bleeding tamponade (0 vs 5.1%; p=0.276).

Conclusions

TA concurrently with MVR does not appear to increase in-hospital mortality or early postoperative complications.

Management and Outcome of Patients Admitted With Tricuspid Regurgitation in France

BACKGROUND

Growing evidence shows a major outcome impact and undertreatment of tricuspid regurgitation (TR), but large and comprehensive contemporary reports of management and outcome at the nationwide level are lacking.

METHODS

We gathered all consecutive patients admitted with a diagnosis of likely functional TR in 2014-2015 in France from the Programme de Médicalisation des Systèmes d'Information national database and collected rate of surgery, in-hospital mortality, 1-year mortality, or heart failure (HF) readmission rates.

RESULTS

In 2014-2015, 17,676 consecutive patients (75 ± 14 years of age, 51% female) were admitted with a TR diagnosis. Charlson index was ≥ 2 in 56% of the population and 46% presented with HF. TR was associated with prior cardiac surgery, ischemic/dilated cardiomyopathy, or mitral regurgitation in 73% of patients. Only 10% of TR patients overall and 67% of those undergoing mitral valve surgery received a tricuspid valve intervention. Among the 13,654 (77%) conservatively managed patients, in-hospital mortality, 1-year mortality, and 1-year mortality or HF readmission rates were 5.1%, 17.8%, and 41%, respectively, overall, and 5.3%,17.2%, and 37%, respectively, among those with no underlying medical conditions (8-fold higher than predicted for age and gender).

CONCLUSIONS

This nationwide cohort of patients admitted with TR included elderly patients with frequent comorbidities/underlying cardiac diseases. In patients conservatively managed, mortality and morbidity were considerably high over a short time span. Despite this poor prognosis, only 10% of patients underwent a tricuspid valve intervention. These nationwide data showing a considerable risk and potential underuse of treatment highlight the critical need to develop strategies to improve the management and outcomes of TR patients.

Predictors of cardiovascular outcomes after surgery in severe tricuspid regurgitation: clinical, imaging and hemodynamic prospective study

INTRODUCTION AND OBJECTIVES

Severe tricuspid regurgitation (TR) is a prevalent valve disease with a high mortality rate. Current guidelines do not define specific thresholds at which patients should be considered for surgery or percutaneous procedures. Thus, patients are usually referred for intervention at a late stage of the disease. This study aimed to assess predictors of cardiovascular outcomes in a prospective cohort of patients with severe TR referred for surgery.

METHODS

This was an observational, prospective, nonrandomized study. All patients underwent surgery for severe TR based on current clinical guidelines. Complete anamnesis, blood test, echocardiogram, cardiovascular magnetic resonance and right and left catheterization were performed. Patients were followed up in the outpatient department and a combined endpoint (hospitalization for heart failure and cardiovascular mortality) was registered.

RESULTS

Forty-three consecutive patients were included (age: 66.9 ± 9.6 years, 67.4% female). Tricuspid annuloplasty was performed in all patients. After a median follow-up of 38 months, 12 patients (27.9%) showed the combined endpoint and 7 (16.3%) died. Above all clinical, blood and imaging data, the indexed right ventricular end-diastolic volume constituted the best predictor of the combined endpoint (HR, 1.1; P = .02) and cardiovascular mortality (HR, 1.1; P = .05). Furthermore, indexed right ventricular end-diastolic volume was associated with TR recurrence after surgery, with no impact on clinical outcomes.

CONCLUSIONS

In patients with severe TR referred for surgery, right ventricular remodeling assessed by cardiovascular magnetic resonance constituted the best independent predictor of cardiovascular outcomes at follow-up.

Tricuspid Intervention Following Pulmonary Valve Replacement in Adults With Congenital Heart Disease

BACKGROUND

Tricuspid regurgitation (TR) is common among adults with corrected tetralogy of Fallot (TOF) or pulmonary stenosis (PS) referred for pulmonary valve replacement (PVR). Yet, combined valve surgery remains controversial.

OBJECTIVES

This study sought to evaluate the impact of concomitant tricuspid valve intervention (TVI) on post-operative TR, length of hospital stay, and on a composite endpoint consisting of 7 early adverse events (death, reintervention, cardiac electronic device implantation, infection, thromboembolic event, hemodialysis, and readmission).

METHODS

The national Canadian cohort enrolled 542 patients with TOF or PS and mild to severe TR who underwent isolated PVR (66.8%) or PVR+TVI (33.2%). Outcomes were abstracted from charts and compared between groups using multivariable logistic and negative binomial regression.

RESULTS

Median age at reintervention was 35.3 years. Regardless of surgery type, TR decreased by at least 1 echocardiographic grade in 35.4%, 66.9%, and 92.8% of patients with pre-operative mild, moderate, and severe insufficiency. In multivariable analyses, PVR+TVI was associated with an additional 2.3-fold reduction in TR grade (odds ratio [OR]: 0.44; 95% confidence interval [CI]: 0.25 to 0.77) without an increase in early adverse events (OR: 0.85; 95% CI: 0.46 to 1.57) or hospitalization time (incidence rate ratio: 1.17; 95% CI: 0.93 to 1.46). Pre-operative TR severity and presence of transvalvular leads independently predicted post-operative TR. In contrast, early adverse events were strongly associated with atrial tachyarrhythmia, extracardiac arteriopathy, and a high body mass index.

CONCLUSIONS

In patients with TOF or PS and significant TR, concomitant TVI is safe and results in better early tricuspid valve competence than isolated PVR.