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Thourani VH, Bonnell L, Wyler von Ballmoos MC, Mehaffey JH, Bowdish M, Kurlansky P, Jacobs JP, O'Brien S, Shahian DM, Badhwar V. Outcomes of Isolated Tricuspid Valve Surgery: A Society of Thoracic Surgeons Analysis and Risk Model. Ann Thorac Surg 2024:S0003-4975(24)00339-4. [PMID: 38723881 DOI: 10.1016/j.athoracsur.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND To provide patients and surgeons with clinically relevant information, The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was queried to develop a risk model for isolated tricuspid valve (TV) operations. METHODS All patients in the STS Adult Cardiac Surgery Database who had undergone isolated TV repair or replacement (N = 13,587; age 48.3 ± 18.4 years) were identified (July 2017 to June 2023). Multivariable logistic regression accounting for TV replacement vs repair was used to model 8 operative outcomes: mortality, morbidity or mortality or both, stroke, renal failure, reoperation, prolonged ventilation, short hospital stay, and prolonged hospital stay. Model discrimination (C-statistic) and calibration were assessed using 9-fold cross-validation. RESULTS The isolated TV study population included 41.1% repairs (N = 5,583; age 52.6 ± 18.1 years) and 58.9% replacements (N = 8,004; age 45.3 ± 18.0 years). The overall predicted risk of operative mortality was 5.6%, and it was similar in TV repairs and replacements (5.5% and 5.7%, respectively), as was the predicted risk of composite morbidity and mortality (28.2% and 26.8%). TV replacements were generally performed in younger patients with a higher endocarditis prevalence than TV repairs (45.7% vs 21.1%). The model yielded a C-statistic of 0.81 for mortality and 0.76 for the composite of morbidity and mortality, with excellent observed-to-expected calibration that was comparable in all subcohorts and predicted risk decile groups. CONCLUSIONS An STS risk model has been developed for isolated TV surgery. The current mortality of isolated TV operations is lower than previously observed. This risk prediction model and these contemporary outcomes provide a new benchmark for current and future isolated TV interventions.
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Affiliation(s)
- Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia.
| | - Levi Bonnell
- The Society of Thoracic Surgeons, Chicago, Illinois
| | - Moritz C Wyler von Ballmoos
- Department of Cardiovascular and Thoracic Surgery, Texas Health Harris Methodist Hospital, Fort Worth, Texas
| | - J Hunter Mehaffey
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Michael Bowdish
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Paul Kurlansky
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Sean O'Brien
- Duke Clinical Research Institute, Durham, North Carolina
| | - David M Shahian
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
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Samim D, Dernektsi C, Brugger N, Reineke D, Praz F. Contemporary Approach to Tricuspid Regurgitation: Knowns, Unknowns, and Future Challenges. Can J Cardiol 2024; 40:185-200. [PMID: 38052301 DOI: 10.1016/j.cjca.2023.11.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023] Open
Abstract
Severe tricuspid regurgitation (TR) worsens heart failure and is associated with impaired survival. In daily clinical practice, patients are referred late, and tricuspid valve interventions (surgical or transcatheter) are underutilised, which may lead to irreversible right ventricular damage and increases risk. This article addresses the appropriate timing and modality for an intervention (surgical or transcatheter), and its potential benefits on clinical outcomes. Ongoing randomised controlled trials will provide further insights into the efficacy of transcatheter valve interventions compared with medical treatment.
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Affiliation(s)
- Daryoush Samim
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland.
| | - Chrisoula Dernektsi
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Nicolas Brugger
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - David Reineke
- Department of Cardiac Surgery, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
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3
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Diab M, Bonaros N, Doenst T. Immortal Time Bias: the hidden confounder in assessing cardiosurgical treatment effects. Eur Heart J 2023; 44:3149-3151. [PMID: 37178179 DOI: 10.1093/eurheartj/ehad251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/15/2023] Open
Affiliation(s)
- Mahmoud Diab
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Am Klinikum 1, 07747 Jena, Germany
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Akintoye E, Wang TKM, Nakhla M, Ali AH, Fava AM, Akyuz K, Popovic ZB, Pettersson GB, Gillinov AM, Xu B, Griffin BP, Desai MY. Quantitative Echocardiographic Assessment and Optimal Criteria for Early Intervention in Asymptomatic Tricuspid Regurgitation. JACC Cardiovasc Imaging 2023; 16:13-24. [PMID: 36274042 DOI: 10.1016/j.jcmg.2022.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/11/2022] [Accepted: 08/04/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Significant tricuspid regurgitation (TR) is associated with poor outcome and high operative mortality resulting from late presentation. Yet, the optimal timing for intervention is unknown. OBJECTIVES The purpose of this study was to evaluate the prognostic value of echocardiographic parameters to inform early intervention in asymptomatic TR. METHODS Using the Cleveland Clinic echocardiography database 2004 to 2018, the authors identified a consecutive cohort of asymptomatic patients with moderate to severe (3+) or severe (4+) TR. Quantitative TR and right heart parameters were retrospectively determined, and their prognostic utility for all-cause mortality was assessed. RESULTS In 325 asymptomatic patients (mean age: 67.9 years; 79.4% female) with at least 3+ TR, there were 132 deaths (40.6%), with a median survival time of 9.9 years (95% CI: 7.9-12.7 years). By contrast, the median survival time in an age- and sex-matched cohort of symptomatic TR patients was 4.4 years (95% CI: 2.8-5.9 years). Among all the echocardiographic parameters evaluated, right ventricle free wall strain (RVFWS) and tricuspid regurgitant volume (RVol) were the strongest predictors of mortality in asymptomatic TR. The optimal discriminatory thresholds for these parameters were RVFWS <-19% and RVol >45 mL. The 5-year survival rates by number of risk factors (RF) were 93% (95% CI: 86%-96%), 65% (95% CI: 55%-74%), and 38% (95% CI: 26%-49%) for no RF, 1 RF, and both RFs, respectively. Compared with symptomatic TR, mortality was lower for asymptomatic TR with no RF (HR: 0.10; 95% CI: 0.04-0.29) or 1 RF (HR: 0.29; 95% CI: 0.14-0.58), but similar for asymptomatic TR with both RFs (HR: 1.11; 95% CI: 0.56-2.19). CONCLUSIONS RVFWS and RVol are key prognostic markers that can be serially monitored to inform optimal timing of intervention for severe asymptomatic TR.
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Affiliation(s)
- Emmanuel Akintoye
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio, USA
| | - Tom Kai Ming Wang
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio, USA
| | - Michael Nakhla
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio, USA
| | - Adel Hajj Ali
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio, USA
| | - Agostina M Fava
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio, USA
| | - Kevser Akyuz
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio, USA
| | - Zoran B Popovic
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio, USA
| | - Gosta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio, USA
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio, USA
| | - Bo Xu
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio, USA
| | - Brian P Griffin
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio, USA
| | - Milind Y Desai
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio, USA.
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5
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Wang TKM, Akintoye E. Atrial Functional Tricuspid Regurgitation: Do We Blame the AF, Right Atrium, or Both? JACC Cardiovasc Imaging 2022; 16:588-590. [PMID: 36752438 DOI: 10.1016/j.jcmg.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Tom Kai Ming Wang
- Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| | - Emmanuel Akintoye
- Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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6
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Färber G, Doenst T. Reply from authors: Why improve high-risk prediction if early surgery is low risk? JTCVS OPEN 2022; 11:91. [PMID: 36172454 PMCID: PMC9510882 DOI: 10.1016/j.xjon.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany
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7
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Singulane CC, Singh A, Addetia K, Yamat M, Lang RM. Developing Insights Regarding Tricuspid Valve Regurgitation: Morphology, Assessment of Severity, and the Need for a Novel Grading Scheme. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100026. [PMID: 37273466 PMCID: PMC10236825 DOI: 10.1016/j.shj.2022.100026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/17/2022] [Indexed: 06/06/2023]
Abstract
Current understanding that progressive tricuspid regurgitation (TR) is associated with worse outcomes has highlighted the clinical need for a more accurate assessment of TR morphology and severity. This need has been further emphasized owing to the development of a myriad of percutaneous right-sided interventions, which may offer successful treatment of TR in selected patients. Understanding the etiology and quantification of the severity of TR has important implications in the selection of novel therapeutic strategies, i.e., medical vs. percutaneous vs. surgical approaches. Newer grading schemas that better reflect the TR lesion severity have been recently proposed and may facilitate monitoring of the evolution of TR following percutaneous and/or surgical treatment. In this review, we summarize contemporary concepts regarding tricuspid valve morphology, TR etiology, and associated mechanisms and echocardiographic approaches to grade TR severity.
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Affiliation(s)
| | | | | | | | - Roberto Miguel Lang
- Address correspondence to: Roberto Miguel Lang, MD, FASE, FACC, The University of Chicago Medicine, 5758 S. Maryland Avenue, MR 9067, DCAM 5509, Chicago, IL 6063
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8
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Russo M, Di Mauro M, Saitto G, Lio A, Berretta P, Taramasso M, Scrofani R, Della Corte A, Sponga S, Greco E, Saccocci M, Calafiore A, Bianchi G, Leviner DB, Biondi A, Livi U, Sharoni E, De Vincentiis C, Di Eusanio M, Antona C, Troise G, Solinas M, Laufer G, Musumeci F, Andreas M. OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6572113. [PMID: 35448903 DOI: 10.1093/ejcts/ezac230] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/15/2022] [Accepted: 03/29/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Marco Russo
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Unit, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Guglielmo Saitto
- Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Mil.se, Italy
| | - Antonio Lio
- Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Maurizio Taramasso
- Cardiac Surgery Department, University Heart Center of Zurich, Zurich, Switzerland
| | - Roberto Scrofani
- Cardiac Surgery Unit, Ospedale Fatenefratelli Sacco, Milano, Italy
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Unit of Cardiac Surgery, V Monaldi Hospital, Naples, Italy
| | - Sandro Sponga
- Cardiac Surgery Unit, University Hospital of Udine, Udine, Italy
| | - Ernesto Greco
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological, and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Matteo Saccocci
- Cardiac Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | - Giacomo Bianchi
- Pasquinucci Heart Hospital, G. Monasterio Foundation, Massa, Italy
| | | | - Andrea Biondi
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Mil.se, Italy
| | - Ugolino Livi
- Cardiac Surgery Unit, University Hospital of Udine, Udine, Italy
| | | | - Carlo De Vincentiis
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Mil.se, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Carlo Antona
- Cardiac Surgery Unit, Ospedale Fatenefratelli Sacco, Milano, Italy
| | - Giovanni Troise
- Cardiac Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Marco Solinas
- Pasquinucci Heart Hospital, G. Monasterio Foundation, Massa, Italy
| | - Guenther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Francesco Musumeci
- Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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9
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Wang TKM, Desai MY. Improving evaluation and outcomes for isolated tricuspid valve surgery. J Card Surg 2021; 37:469. [PMID: 34751981 DOI: 10.1111/jocs.16132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Tom Kai Ming Wang
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Milind Y Desai
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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10
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Brescia AA, Bolling SF. Commentary: Early surgery should be pursued for all severe regurgitant lesions. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01401-X. [PMID: 34688488 DOI: 10.1016/j.jtcvs.2021.09.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 10/20/2022]
Affiliation(s)
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | -
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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11
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Di Tommaso E, Bruno VD. Commentary: Isolated tricuspid valve regurgitation: The worst is yet to come, so act now! J Thorac Cardiovasc Surg 2021:S0022-5223(21)01157-0. [PMID: 34482956 DOI: 10.1016/j.jtcvs.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 07/31/2021] [Accepted: 08/03/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Ettorino Di Tommaso
- Translational Health Science, University of Bristol Medical School, Bristol, United Kingdom
| | - Vito D Bruno
- Translational Health Science, University of Bristol Medical School, Bristol, United Kingdom.
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