Predictors of late outcomes after concomitant tricuspid valve repair with left-sided valve surgery

BACKGROUND

Concomitant tricuspid valve (TV) repair is a safe and effective procedure to protect against late moderate or greater tricuspid regurgitation (TR) after left-sided valve surgery, but studies regarding its late outcomes and recurrent TR are limited. This study aimed to reveal the late outcomes and explore the predictors of mortality and recurrent TR among patients who underwent concomitant TV repair with left-sided valve surgery.

METHODS AND RESULTS

This study included 645 patients (mean age, 69.7 years; 44% male) who underwent concomitant TV repair with left-sided valve surgery (mitral valve surgery in 594 cases, aortic valve surgery in 172 cases) from 2006-2020. Preoperative TR was grade 4, 3, and less than 2 in 85, 235, and 325 patients, respectively. The median follow-up period was 4.6 (IQR 1.7-7.8) years. The in-hospital or 30-day mortality was 1.7% (n = 11). Regarding long-term outcomes after TV repair, 90.3% and 80.8% achieved 5- and 10-year survival, respectively, while 96.1% and 88.8% achieved 5- and 10-year freedom from recurrent TR, respectively. The following were independent predictors of overall mortality on multivariate analysis in patients with preoperative TR grade ≥ 3: prior pacemaker implantation, preoperative renal dysfunction, diabetes mellitus and NYHA class ≥ 3. Also, suture annuloplasty and ring type of ring annuloplasty were not independent risk factors for recurrent TR, classified as grade ≥ 3.

CONCLUSIONS

Concomitant TV repair with left-sided valve surgery had acceptable outcomes in terms of survival and TR durability. In patients with preoperative TR grade ≥ 3, preoperative patient status had negative impacts on prognosis.

Outcomes of Concomitant Maze Procedure in Tricuspid Repair for Severe Tricuspid Regurgitation

BACKGROUND

We aimed to analyze the impact of concomitant Maze procedure on the clinical and rhythm outcomes, and echocardiographic parameters in tricuspid repair for patients with severe tricuspid regurgitation (TR) and persistent atrial fibrillation (AF).

METHODS

Patients who had severe TR and persistent AF and underwent tricuspid valve (TV) repair were included in the study. Both primary TR and secondary TR were included in the current study. The study population was stratified according to Maze procedure. The primary outcome was major adverse cardiovascular and cerebrovascular event (MACCE) at 15 years post-surgery. Propensity-score matching analyses was performed to adjust baseline differences.

RESULTS

Three hundred seventy-one patients who underwent tricuspid repair for severe TR and persistent AF from 1994 to 2021 were included, and 198 patients (53.4%) underwent concomitant Maze procedure. The maze group showed 10-year sinus rhythm (SR) restoration rate of 55%. In the matched cohort, the maze group showed a lower cumulative incidence of cardiac death (4.6% vs. 14.4%, P = 0.131), readmission for heart failure (8.1% vs. 22.2%, P = 0.073), and MACCE (21.1% vs. 42.1%, P = 0.029) at 15 years compared to the non-maze group. Left atrial (LA) diameter significantly decreased in the maze group at 5 years (53.3 vs. 59.6 mm, P < 0.001) after surgery compared to preoperative level, and there was a significant difference in the change of LA diameter over time between the two groups (P = 0.013).

CONCLUSION

The Maze procedure during TV repair in patients with severe TR and persistent AF showed acceptable SR rates and lower MACCE rates compared to those without the procedure, while also promoting LA reverse remodeling.

Percutaneous repair of tricuspid regurgitation

Tricuspid regurgitation (TR) is common both in patients with left side valvular heart disease and in patients with permanent atrial fibrillation and is associated with increased mortality, morbidity, and an increased risk of hospitalization. Surgery for isolated tricuspid repair is a viable option but burdened by a high-operative risk and a post-operative course characterized by high morbidity. Recently, percutaneous interventional techniques have emerged as a viable option in selected high-risk patients who may clinically benefit from tricuspid valve repair. The purpose of this article is to provide an overview of the current state of transcatheter restorative treatment of TR by providing an overview of new devices in clinical development.

Mid-term outcomes of right ventricular papillary muscle approximation for severe functional tricuspid regurgitation

OBJECTIVES

Recurrence of tricuspid regurgitation (TR) after tricuspid annuloplasty can occur in cases where a dilated right ventricle exists and subsequent leaflet tethering follows. We previously reported a new technique of the right ventricular papillary muscle approximation (RV-PMA) for functional TR associated with leaflet tethering. The objective of this study is to elucidate the mid-term outcomes and evaluate the durability of RV-PMA.

METHODS

Between January 2014 and March 2023, we applied RV-PMA in 20 patients of advanced functional TR with severe leaflet tethering. The indication of the technique was severe TR with leaflet tethering height >8 mm, and/or a right ventricular end-diastolic diameter >45 mm. The patients were followed up with echocardiography before discharge and at annual interval thereafter.

RESULTS

There was no perioperative mortality. In the echocardiography performed before discharge, TR was decreased to mild or less in 85%, and a significant improvement in right ventricular end-diastolic diameter and tethering height were achieved (53-45 mm and 11.1-4.4 mm, respectively). Furthermore, during the median 3-year follow-up period, TR was kept controlled mild or less in 80% of the cases.

CONCLUSIONS

RV-PMA is considered to be a safe, effective and durable technique as an additional approach for tricuspid annuloplasty.

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.

Guiding Interventions for Secondary Tricuspid Regurgitation: Follow the Intricate Interplay Between Form and Function

Secondary tricuspid regurgitation (TR) has long been considered a benign and well-tolerated valvular lesion that resolves after treatment of the underlying disease. This view has been challenged by data indicating that long-standing TR can be a progressive disorder, contributing to right ventricular failure and end-organ damage, despite adequate treatment of the underlying disease. Surgical correction is curative, but infrequently performed and historically associated with poor outcomes. This may be due to delayed diagnosis, lack of well-defined surgical indications, and, consequently, late intervention in patients in poor clinical condition with failing right ventricles. Because of limited evidence about timing and corresponding outcome of tricuspid valve surgery, current guideline recommendations are rather conservative and show several inconsistencies. Nevertheless, there has been a trend toward a more aggressive approach in the surgical treatment of TR with improved outcomes. Moreover, emerging transcatheter options claim to provide a lower-risk alternative for selected patients. This may facilitate earlier treatment and improve the attitude toward an early treatment strategy of secondary TR, yet is not reflected in the guidelines. Future research is needed for risk stratification to determine inclusion criteria and optimal timing for intervention.

Transcatheter and surgical treatment of tricuspid regurgitation: Predicting right ventricular decompensation and favorable responders

Isolated tricuspid regurgitation (TR) has gained increasing recognition in recent years both in the surgical and in the cardiological community. Left untreated, isolated TR significantly worsens survival. Despite being a strong predictor of negative prognosis, interventions to correct TR are rarely performed due to increased surgical risk and late patient presentation. Recently, the ultimate focus has been on patient selection, surgical or transcatheter indication, and correct timing. Furthermore, of paramount importance is the identification of predictors of outcome following treatment, in order to discriminate between favorable and unfavorable responders and guide the decision-making process of the most adequate treatment for every patient.

Observed versus predicted mortality after isolated tricuspid valve surgery

BACKGROUND

Aim of this study is to analyse the performances of Clinical Risk Score (CRS) and European System for Cardiac Operative Risk Evaluation (EuroSCORE)-II in isolated tricuspid surgery.

METHODS

Three hundred and eighty-three patients (54 ± 16 year; 54% female) were enrolled. Receiver operating characteristic analysis was performed to evaluate the relationship between the true positive fraction of test results and the false-positive fraction for a procedure.

RESULTS

Considering the 30-day mortality the area under the curve was 0.6 (95% confidence interval [CI] 0.50-0.72) for EuroSCORE II and 0.7 (95% CI 0.56-0.84) for CRS-score. The ratio of expected/observed mortality showed underestimation when considering EuroSCORE-II (min. 0.46-max. 0.6). At multivariate analysis, the CRS score (p = .005) was predictor of late cardiac death.

CONCLUSION

We suggest using both scores to obtain a range of expected mortality. CRS to speculate on late survival.

Outcomes of Tricuspid Valve Repair with Artificial Neochordae in Pediatric and Adult Patients

BACKGROUND

There is little data on outcomes following expanded polytetrafluoroethylene artificial neochordae (ePTFE-AN) for tricuspid valve (TV) repair. We evaluated outcomes after TV repair with ePTFE-AN in both pediatric and adult patients.

METHODS

We analyzed clinical data of 87 consecutive patients who underwent ePTFE-AN implantation at the time of TV repair from 1998 to 2020. Patients were categorized into pediatric and adult groups.

RESULTS

Twenty-nine (33.3%) were pediatric and 58 (66.7%) were adult patients. The most common etiology of tricuspid regurgitation (TR) was congenital (pediatrics: 86.2%, 25 of 29; adults: 39.7%, 23 of 59). Median number of pairs of ePTFE-AN implanted was 2 (interquartile range [IQR], 2-5) for pediatric and 3 (IQR, 2-4) for adult patients. There was no early death. Three adult patients (5.2%) required early TV reoperation; four (1 pediatric, 3 adults) underwent late TV reintervention. Etiology of TR was congenital in four of the six adults who required TV reintervention. Three-year cumulative risk of TV reintervention was 0.0% for pediatric and 7.3% (95% CI, 0.4-14.2%) for adult patients. There was significant improvement in TR grade after TV repair at dismissal and the latest echocardiographic follow-up in each group (P<.001). One pediatric and seven adult patients developed severe TR during follow-up, six of them underwent TV reoperation (1 pediatric, 5 adults).

CONCLUSIONS

ePTFE-AN implantation in the TV position can be performed safely and effectively with no early death. In adult patients with congenital TR, patient selection is critical to achieve durable outcome following TV repair.

Transcatheter Annular Approaches for Tricuspid Regurgitation (Cardioband and Others)

The tricuspid valve often is referred to as "the forgotten valve" because it frequently is managed conservatively due to poor prognostic outcomes with conventional surgical intervention, in particular, in high-risk patients. Nevertheless, a paradigm shift has occurred in recent years, due to a growing evidence base supporting the independent prognostic influence of severe tricuspid regurgitation (TR) on patient outcomes. Both transcatheter valve replacement and valve repair have emerged as feasible and efficacious interventions for TR correction. Novel transcatheter repair techniques that replicate surgical annuloplasty are evolving as potentially lower-risk alternatives.

Early surgery can improve the outcomes of patients with severe tricuspid regurgitation undergoing tricuspid replacement

Background

Tricuspid regurgitation (TR) usually remains asymptomatic for a long time, such that it is most often diagnosed at an advanced stage of right heart failure. The purpose of this study was to identify clinical characteristics and overall outcomes in patients with severe TR who received tricuspid valve replacement (TVR) at different clinical stages.

Methods

Between 1993 and 2018, 256 severe TR patients who received TVR alone or in combination with other procedures were assessed at Beijing Anzhen Hospital. Ninety-three patients underwent New York Heart Association (NYHA) class I/II operations (early surgery group), and the others underwent NYHA class III/IV operations. The primary outcome was in-hospital and long-term mortality. Clinical outcomes were evaluated by the Kaplan-Meier method and Cox regression models. Follow-up was conducted annually. Propensity score matching and overlap propensity score weighting were performed as sensitivity analyses.

Results

Postoperative complications, including low cardiac output (11.8% vs. 26.4%, P<0.001), renal failure (2.2% vs. 16.6%, P<0.001), and bleeding (3.2% vs. 11.7%, P=0.037), were significantly lower in the NYHA class I/II group than in the NYHA III/IV group. Patients in the NYHA class III/IV group had a significantly higher incidence of in-hospital mortality (18.4% vs. 5.4%, P<0.001) and long-term mortality (33.7% vs. 11.8%, P=0.006) after follow-up (median follow-up duration =63 months). The results indicated a consistently higher occurrence rate in the propensity score-matched cohort and overlap propensity score weighted analysis.

Conclusions

Consistent with the recent clinical trend to provide earlier and more aggressive TR intervention, our results indicate that surgery for severe TR patients should be considered before advanced heart failure develops, when patients are asymptomatic or mildly symptomatic (NYHA class I/II).

Prediction of mortality in isolated tricuspid surgery

BACKGROUND

Isolated tricuspid surgery is a rarely performed procedure considered at high risk for mortality. Preoperative risk estimation is still a s missing process and currently used risk score system are not validated for this procedures.

AIM

To discuss the external validation of the EuroSCORE II and STS-TVS score in the setting of isolated tricuspid valve surgery.

DISCUSSION

The stratification of the patient profile and risk estimation are still lacking in isolated tricuspid surgery. MELD Score, EuroSCORE II and STS-TVS score may help in the preoperative evaluation. Recently a dedicated score called TRI-SCORE has been introduced. We believe that the combination of these scores may determine a range of expected mortality rate and it could be an interesting approach to define the preoperative risk-profile of a patient planned for isolated tricuspid disease. Conclusion Further studies are needed to define the optimal risk stratification of patient affected by isolated tricuspid disease.

Transcatheter treatment of severe tricuspid regurgitation

PURPOSE OF REVIEW

Severe tricuspid regurgitation is a commonly prevalent valvular heart disease that is an independent adverse prognostic marker. However, the majority of patients with tricuspid regurgitation are managed medically; isolated tricuspid valve surgery is rarely performed, partly owing to high associated in-hospital mortality. Therefore, several transcatheter tricuspid valve interventions (TTVIs) that have been developed over the last few years to address this unmet clinical need.

RECENT FINDINGS

The early experience with TTVI has shown that most devices can be safely implanted with excellent rates of technical success and acceptable safety outcomes. Most TTVI recipients have significant improvement in tricuspid regurgitation severity, functional class, and quality of life. Recent retrospective data also suggest mortality benefit of TTVI compared with medical management. There are several issues that need to be addressed prior to widespread adoption of TTVI, including more effective tricuspid regurgitation reduction and need for longer term efficacy data.

SUMMARY

TTVI has emerged as an attractive treatment option for management of high-risk patients with tricuspid regurgitation. In this review, we will discuss the anatomical considerations specific to tricuspid valve, patient selection, preprocedure planning, and summarize the current evidence and future perspectives on TTVI.

Outcomes and Echocardiographic Follow-up After Surgical Management of Tricuspid Regurgitation in Patients With Transvenous Right Ventricular Leads

OBJECTIVE

To evaluate outcomes of elective surgical management of tricuspid regurgitation (TR) in patients with transvenous right ventricular leads, and compare results between non-lead-induced and lead-induced TR patients.

PATIENTS AND METHODS

We studied patients with right ventricular leads who underwent tricuspid valve surgery from January 1, 1993, through December 31, 2015, and categorized them as non-lead-induced and lead-induced TR. Propensity score (PS) for the tendency to have lead-induced TR was estimated from logistic regression and was used to adjust for group differences.

RESULTS

From the initial cohort of 470 patients, 444 were included in PS-adjustment analyses (174 non-lead-induced TRs [123 repairs, 51 replacements], 270 lead-induced TRs [129 repairs, 141 replacements]). In PS-adjusted multivariable analysis, lead-induced TR was not associated with mortality (P=.73), but tricuspid valve replacement was (hazard ratio, 1.59; 95% CI, 1.13 to 2.25; P=.008). Five-year freedom from tricuspid valve re-intervention was 100% for non-lead-induced TR and 92.3% for lead-induced TR; rates adjusted for PS differed between groups (P=.005). There was significant improvement in TR postoperatively in each group (P<.001). In patients having tricuspid valve repair, TR grades tended to worsen over time, but the difference in trends was not significantly different between groups.

CONCLUSION

Lead-induced TR did not affect long-term survival after elective tricuspid valve surgery. In patients with lead-induced TR, tricuspid valve re-intervention was more common. Improvement in TR was achieved in both groups after surgery; however, severity of TR tended to increase over follow-up after tricuspid valve repair.

Survival of Tricuspid Valve Replacement in Patients With Previous Tricuspid Valve Surgery

OBJECTIVES

This study was performed to investigate the short-term and long-term survival of patients who underwent reoperative tricuspid valve replacement (TVR).

METHODS

A retrospective analysis was performed of 273 patients who underwent TVRs while hospitalised in Beijing Anzhen Hospital from November 1993 to August 2018. Fifty-six (56) of them underwent reoperative TVR: 36 had previous tricuspid valve repair and 20 had previous TVR. Follow-up was 100% complete, with a mean follow-up of 8 years (range, 1-15 years).

RESULTS

The overall in-hospital mortality was 17.9% (n=10). In the univariate analysis, the overall in-hospital mortality and renal failure rate in the replacement group were lower than those in the repair group (5.0% vs 25%; p=0.046 and 27.8% vs 5%; p=0.040). However, in-hospital mortality was no longer statistically significant after multivariate adjustment (adjusted OR, 0.318; 95% CI, 0.030-3.338; p=0.340). There was no significant difference in survival between the patients with previous repair and those with previous replacement (log-rank test, p=0.839). Factors that correlated with long-term mortality on multivariate analysis were age >60 years (adjusted HR, 11.753; 95% CI, 1.686-81.915; p=0.013); cardiopulmonary bypass time (adjusted HR, 1.019; 95% CI, 1.005-1.034; p=0.009); intensive care unit time (adjusted HR, 1.024; 95% CI, 1.006-1.042; p=0.009); and ventilation time (adjusted HR, 0.982; 95% CI, 0.965-0.998; p=0.030).

CONCLUSIONS

Reoperative TVR was associated with high in-hospital mortality and morbidity. Overall in-hospital mortality was similar between the previous replacement group and the previous repair group. Previous tricuspid valve repair and replacement had similar long-term survival.

Beating vs Arrested Heart Isolated Tricuspid Valve Surgery: Long-term Outcomes

BACKGROUND

Isolated tricuspid valve (TV) surgery is a rare procedure generally considered at high risk of perioperative mortality and poor long-term outcomes. Surgical treatment can be performed with either an arrested heart (AH) or beating heart (BH) technique. Aim of this study is to compare the outcomes of isolated tricuspid surgery with two different approaches.

METHODS

The SUR-TRI study is a multicenter international retrospective study enrolling adult patients who underwent isolated tricuspid valve procedures (n=406, 56±16 years; 56% female) at 13 international sites. AH and BH strategies were performed in 253 and 153 cases, respectively. Propensity score-matched analysis was used to compare groups.

RESULTS

After matching, 129 pairs were obtained and analyzed. The 30-day mortality rate was 6.2 vs 5.0% in the AH and BH groups, respectively (p=0.9). The rates of acute renal failure requiring replacement therapy (3 vs 10%, p=0.02) and stroke (0 vs 1.8%, p=0.08) were numerically higher in the AH group. The 6-year survival rate was 67±6 vs 78±5% in the AH and BH groups, respectively (p=0.18), while freedom from cardiac death was 75±5 vs 84±4% (p=0.21). The six-year composite cardiac endpoint of cardiac death and reoperation rate was 60±9 vs 86±5% (p=0.024) comparing AH-TV replacement and BH-TV repair groups.

CONCLUSIONS

Isolated tricuspid valve surgery performed with a beating heart strategy is a safe option and resulted in a trend of increased long-term survival and freedom from reoperation when compared with the standard arrested heart technique. Patients undergoing beating heart valve repair had the best long-term outcome.

Ebstein's Anomaly of the Tricuspid Valve: an Overview of Pathology and Management

PURPOSE OF REVIEW

Ebstein's anomaly (EA) is a rare, but complex form of congenital heart disease consisting of a right ventricular myopathy and morphologic tricuspid valve disease leading to a high incidence of right ventricular dysfunction and arrhythmias. This review offers an updated overview of the current understanding and management of patients with EA with a focus on the adult population.

RECENT FINDINGS

Increased understanding of anatomic accessory atrioventricular pathways in EA has resulted in an improvement in ablation techniques and long-term freedom of atrial arrhythmia recurrence. Despite an improvement in understanding and recognition of EA, significant disease heterogeneity and complex treatment options continue to challenge providers, with the best outcomes achieved at expert congenital heart disease centers.

N-Terminal Pro-B-Type Natriuretic Peptide in Tricuspid Valve Replacement

The aim of the present study was to retrospectively investigate the prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in tricuspid valve replacement (TVR). A total of 73 TVR patients who had NT-proBNP measured on the first postoperative morning during a period of 10 years from February 2008 to December 2018 were included in the study. The endpoint was postsurgery all-cause in-hospital mortality. The outcome-based cut-point optimization was performed using X-tile software. NT-proBNP with the maximum χ² score and the minimum P value will be used as the optimal cut-point. Kaplan-Meier analysis and log-rank test were adopted to calculate and compare survival rates stratified by tertiles and the cut-point. Predictive capabilities of NT-proBNP were tested using univariable and multivariable Cox regression. Overall, 20 (27.3%) in-hospital deaths occurred. Postsurgery hospital stay was 21 days (interquartile range, 16-32 day). NT-proBNP were divided into low (<1262 pg/mL), medium (1262-4003 pg/mL), and high (≥4003 pg/mL) tertiles. The optimal cut-off point determined using X-tile was 3639 pg/mL. Kaplan-Meier analysis revealed a strong association between worse survival and elevated NT-proBNP expressed as tertiles (log-rank P = 0.002) and stratified by optimal cut point (log-rank P < 0.001). Multivariable Cox survival analysis demonstrated that NT-proBNP was a strong predictor of mortality (logNT-proBNP hazard ratio [HR], 2.11; 95% confidence interval [CI], 1.33-3.37; P = 0.002). In NT-proBNP tertiles model, multivariable Cox survival analysis showed that patients in the medium and high NT-proBNP tertiles had 6.32-fold (adjusted HR, 7.32; 95% CI, 0.76-70.69; P = 0.085) and 16.11-fold (adjusted HR, 17.11; 95% CI, 1.92-152.68, P = 0.011) increased risk for mortality, respectively, compared with patients in the low tertile. Elevated postoperative NT-proBNP level is a potential independent and strong in-hospital postsurgery mortality risk factor in TVR, thus may serve as a useful surrogate marker for risk-stratification.

Late Outcomes of Valve Repair Versus Replacement in Isolated and Concomitant Tricuspid Valve Surgery: A Nationwide Cohort Study

Background

Surgery for tricuspid valve (TV) diseases is associated with poor prognosis, but few studies have described the long‐term outcomes by comparing TV repair and replacement in isolated and concomitant TV surgeries separately.

Methods and Results

Between 2000 and 2013, adult patients who underwent TV repair or replacement surgeries were identified from the Taiwan National Health Insurance Research Database. Outcomes of interest included all‐cause mortality, composite outcome, and readmission attributable to any cause. Inverse probability of treatment weighting was used to reduce confounding effects. A total of 2644 patients with a mean follow‐up of 4.9 years were included. Of them, 12.6% and 87.4% underwent isolated and concomitant TV surgery, respectively. The in‐hospital mortality rates for isolated and concomitant TV surgery were 8.7% and 8.6%, respectively, whereas all‐cause mortality rates were 41.7% and 36.8%, respectively. Compared with TV replacement, TV repair demonstrated significantly lower risks of all‐cause mortality (concomitant: hazard ratio [HR], 0.76; 95% CI, 0.59–0.99), composite outcome (isolated: subdistribution HR, 0.55; 95% CI, 0.35–0.89; concomitant: subdistribution HR, 0.63; 95% CI, 0.46–0.86), and readmission (isolated: subdistribution HR, 0.64; 95% CI, 0.46–0.91; concomitant: subdistribution HR, 0.72; 95% CI, 0.60–0.86), except insignificant difference in all‐cause mortality in isolated surgery.

Conclusions

Compared with replacement, TV repair is associated with better short‐ and long‐term outcomes in both isolated and concomitant TV surgery. However, further prospective clinical trials are warranted.

Off-pump tricuspid valve repair by automated sutured tricuspid annular plication via transatrial cannulation: preclinical ex vivo and in vivo results

OBJECTIVES

Surgical repair is considered the gold standard treatment for severe symptomatic tricuspid valve (TV) regurgitation. However, patients undergoing isolated surgical tricuspid repair face a high perioperative mortality while long-term data on interventional treatment options are currently missing. We investigated a novel, minimally invasive approach for transatrial off-pump beating-heart tricuspid annular plication based on the surgical Hetzer repair.

METHODS

TV annular plication for the creation of a double-orifice valve using novel devices for automated annular suturing was performed in 10 human heart specimens in an ex vivo perfusion model under endoscopic guidance. Additionally, the technique was tested in an in vivo porcine model using the transatrial access under echocardiographic and fluoroscopic guidance.

RESULTS

Endoscopically guided conduction of the procedure was successful in all 10 human heart specimens in the ex vivo perfusion model with 1 observed suture pull-through of 60 sutures placed (1.7%). TV measurements yielded significant reductions of the TV septal-lateral diameter (50.9 ± 7.3 vs 42.6 ± 7.9 mm; P = 0.015) and the TV area (1208 ± 399 vs 193 ± 122 mm2; P < 0.0001). TV plication without direct vision using device-embedded intracardiac echocardiography, epicardial echocardiography and fluoroscopy was feasible in both acute animals with no observed device-related adverse events.

CONCLUSIONS

Successful plication was completed in 10 ex vivo human hearts, additionally proof-of-concept was conducted in 2 animals. We herein present encouraging early preclinical results of a novel minimally invasive technique for TV repair, which warrants further investigation.

Right ventricular failure in congenital heart disease

PURPOSE OF REVIEW

We aim to review select literature pertaining to congenital heart disease (CHD)-induced right ventricular (RV) function and failure.

RECENT FINDINGS

We review recent findings pertaining to children and adults with repaired tetralogy of Fallot (rTOF), systemic RV and hypoplastic left heart syndrome (HLHS). We emphasize pathophysiological mechanisms contributing to RV dysfunction in these conditions, the risk factors for adverse outcomes and the continuing challenges in treating these patients. We discuss how recent pathology findings, as well as developments in imaging and computer modeling have broadened our understanding of the pathophysiology of these conditions. We further review developments in the molecular and cellular basis of RV failure; and in particular, the RV molecular response to stress in repaired tetralogy of Fallot (rTOF). We highlight some of the genetic complexities in HLHS and how these may influence the long-term outcomes in these patients.

SUMMARY

Recent literature has led to new understandings in the pathology, pathophysiology, risk factors for adverse outcomes, molecular and genetic basis for RV dysfunction and failure in CHD. Although these findings provide new therapeutic targets, the treatment of RV failure at this time remains limited.