Long-term outcomes of concomitant tricuspid valve repair in patients undergoing mitral valve surgery

Sex-Based Differences in Concomitant Tricuspid Repair During Degenerative Mitral Surgery

BACKGROUND

Women with mitral valve disease have higher rates of tricuspid regurgitation (TR) than men. Although tricuspid valve repair (TVr) decreases the progression of TR, we hypothesize that there may be sex-based differences in concomitant TVr at the time of mitral valve operations.

METHODS

Adults undergoing mitral valve operation for degenerative disease with moderate or worse preoperative TR at a high-volume center from 2014 to 2023 were identified. Patients with a previous tricuspid intervention were excluded. A multivariable logistic regression identified predictors of concomitant TVr. To evaluate the clinical impact of not performing TVr, a competing risk model compared development of severe TR or valve-related reoperation by sex among patients without TVr.

RESULTS

Most included patients were women (55% [n = 214 of 388]), and the median age was 73 years (quartile 1-quartile 3, 65-79 years). There was no difference in the rate of severe TR by sex (female, 28%; male, 26%; P = .63). The unadjusted rate of concomitant TVr was 57% for women and 73% for men (P < .001). Overall, women had 52% lower adjusted odds of TVr (adjusted odds ratio, 0.48; 95% CI, 0.29-0.81; P = .006), including a lower adjusted rate for moderate TR (47% [95% CI, 45%-49%] vs 66% [95% CI, 64%-69%]) and for severe TR (83% [95% CI, 81%-86] vs 92% [95% CI, 90%-93%]) Among those without TVr, 12% of women and 0% of men had severe TR or required a valve-related reoperation at 4 years (P < .001).

CONCLUSIONS

Women with moderate or severe TR undergoing mitral valve operation for degenerative disease were less likely to receive concomitant TVr, severe TR was more likely to develop, or they would more likely need a valve-related reoperation. Evaluation of sex-based treatment differences is imperative to improve outcomes for women.

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.

Cost and Clinical Outcomes Evaluation Between the Endoaortic Balloon and External Aortic Clamp in Cardiac Surgery

OBJECTIVE

Endoaortic balloon occlusion facilitates cardioplegic arrest during minimally invasive surgery (MIS). Studies have shown endoclamping to be as safe as traditional aortic clamping. We compared outcomes and hospital costs of endoclamping versus external aortic occlusion in a large administrative database.

METHODS

There were 52,882 adults undergoing eligible cardiac surgery (October 2015 to March 2020) identified in the Premier Healthcare Database. Endoclamp procedures (n = 419) were 1:3 propensity score matched to similar procedures using external aortic occlusion (n = 1,244). Generalized linear modeling measured differences in in-hospital complications (major adverse renal and cardiac events, including mortality, new-onset atrial fibrillation, acute kidney injury [AKI], myocardial infarction [MI], postcardiotomy syndrome, stroke/transient ischemic attack [TIA], and aortic dissection) and length of stay (LOS).

RESULTS

The mean age was 63 years, and 53% were male (n = 882). The majority (93%, n = 1,543) were mitral valve procedures, and 17% of procedures (n = 285) were robot-assisted. Total hospitalization costs were not statistically significantly different between the 2 groups ($52,158 vs $49,839, P = 0.06). The median LOS was significantly shorter in the endoclamp group (incident rate ratio = 0.87, P < 0.001). Mortality, atrial fibrillation, AKI, and stroke/TIA were similar between the 2 groups. MI and postcardiotomy syndrome were lower in the endoclamp group (odds ratio [OR] = 0.14, P = 0.006, and OR = 0.27, P = 0.005). There were no aortic dissections in the endoclamp group.

CONCLUSIONS

Aortic endoclamping in MIS was associated with similar costs, shorter LOS, no dissections, and comparably low mortality and stroke rates when compared with external clamping in this hospital billing dataset. These results demonstrate the clinical safety and efficacy of endoaortic balloon clamping in a real-world setting. Further studies are warranted.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2022

This special article is the 15th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief Dr. Kaplan and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialties of cardiothoracic and vascular anesthesiology. The major themes selected for 2022 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights, in the specialties for 2022, begin with an update on COVID-19 therapies, with a focus on the temporal updates in a wide range of therapies, progressing from medical to the use of extracorporeal membrane oxygenation and, ultimately, with lung transplantation in this high-risk group. The second major theme is focused on medical cardiology, with the authors discussing new insights into the life cycle of coronary disease, heart failure treatments, and outcomes related to novel statin therapy. The third theme is focused on mechanical circulatory support, with discussions focusing on both right-sided and left-sided temporary support outcomes and the optimal timing of deployment. The fourth and final theme is an update on cardiac surgery, with a discussion of the diverse aspects of concomitant valvular surgery and the optimal approach to procedural treatment for coronary artery disease. The themes selected for this 15th special article are only a few of the diverse advances in the specialties during 2022. These highlights will inform the reader of key updates on a variety of topics, leading to the improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.

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.

Efficacy and Safety of Concomitant Tricuspid Repair in patients undergoing Mitral Valve Surgery: a systematic review and meta-analysis

BACKGROUND

Tricuspid valve surgery is recommended for both, classes I and IIb while being essential for class II patients undergoing MVS.

AIMS/OBJECTIVES

The meta-analysis aimed to evaluate the efficacy and safety of tricuspid valve repair in patients undergoing MVS.

METHODS

We systematically searched PubMed, Embase, and Google Scholar through January 2022, and studies comparing patients with tricuspid valve repair (TVR) and those without TVR were selected. The primary outcome was 30-day and all-cause mortality.

RESULTS

In this meta-analysis, 20 studies were included with a patient population of 72,422. 30-day mortality studies (RR: 1.14, 95% CI [0.69, 1.87]) and all-cause mortality studies (RR: 1.16, 95% CI [0.86, 1.57]) at follow-up both were insignificant. From the secondary outcomes, pacemaker insertion (RR: 2.62, 95% CI [2.24, 3.06]), new-onset TR or progression (RR: 0.32, 95% CI [0.16, 0.66]), stroke (RR: 1.22, 95% CI [1.05, 1.42]), cross-clamp time (WMD: 17.67, 95% CI [13.96, 21.37]), surgery time (WMD: 43.59, 95% CI [37.07, 50.10]), ICU time (WMD: 19.50, 95% CI [9.31, 29.67]), and ventilation time (WMD: 6.62, 95% CI [0.69, 12.55]) were significant. Whereas major bleeding events, atrial fibrillation, renal failure, heart failure hospitalization, postoperative MI, wound infection, early or prolonged morbidity, cardiopulmonary bypass time, and duration of hospital stay were non-significant.

CONCLUSION

No significant difference was observed between patients undergoing TVR with MVS in comparison to MVS group only for the primary outcomes, 30-day mortality and all-cause mortality, respectively.

Three dimensional modeling of atrioventricular valves provides predictive guides for optimal choice of prosthesis

Inaccuracies in intraoperative and preoperative measurements and estimations may lead to adverse outcomes such as patient-prosthesis mismatch. We aim to measure the relation between different dimensions of the atrioventricular valve complex in explanted porcine heart models. After a detailed physical morphology study, a cast of the explanted heart models was made using silicon-based materials. Digital models were obtained from three-dimensional scanning of the casts, showing the measured annulopapillary distance was 2.50 ± 0.18 cm, and 2.75 ± 0.36 cm for anterior and posterior papillary muscles of left ventricle, respectively. There was a significant linear association between the mitral annular circumference to anterior–posterior distance (p = 0.003, 95% CI 0.78–3.06), mitral annular circumference to interpapillary distance (p = 0.009, 95% CI 0.38–2.20), anterior–posterior distance to interpapillary distance (p = 0.02, 95% CI 0.10–0.78). Anterior–posterior distance appeared to be the most important predictor of mitral annular circumference compared to other measured distances. The mean length of the perpendicular distance of the tricuspid annulus, a, was 2.65 ± 0.54 cm; b was 1.77 ± 0.60 cm, and c was 3.06 ± 0.55 cm. Distance c was the most significant predictor for tricuspid annular circumference (p = 0.006, 95% CI 0.28–2.84). The anterior–posterior distance measured by three-dimensional scanning can safely be used to predict the annular circumference of the mitral valve. For the tricuspid valve, the strongest predictor for the circumference is the c-distance. Other measurements made from the positively correlated parameters may be extrapolated to their respective correlated parameters. They can aid surgeons in selecting the optimal prosthesis for the patients and improve procedural planning.

Surgical treatment of severe tricuspid regurgitation

PURPOSE OF REVIEW

Severe tricuspid regurgitation is associated with both significant symptoms as well as decreased survival. Surgical correction is possible in most cases but is markedly under used in this population. The purpose of this manuscript is to review the indications for treating severe tricuspid regurgitation and the surgical options available.

RECENT FINDINGS

Surgical correction of isolated severe tricuspid regurgitation has been associated with a high mortality in the surgical literature. This occurs generally from right heart failure associated with the late referral of isolated tricuspid regurgitation for correction. Recent outcomes are improving and tricuspid repair appears to be where mitral valve repair was 30 years ago.

SUMMARY

Severe tricuspid regurgitation is associated with severe symptoms as well as decreased survival. Tricuspid valve repair (TVr) for severe regurgitation is almost always technically possible. The high mortality thought to be associated with isolated TVr is likely due to late referral when right heart failure is already far advanced. Consideration for earlier referral for isolated severe tricuspid regurgitation should be considered.

Functional Tricuspid Regurgitation in Patients With Chronic Mitral Regurgitation: An Evidence-Based Narrative Review

Chronic mitral regurgitation leads to a series of downstream pathologic changes, including pulmonary hypertension, right ventricular dilation, tricuspid leaflet tethering, and tricuspid annular dilation, which can result in functional tricuspid regurgitation (FTR). The five-year survival rate for patients with severe FTR is reported to be as low as 34%. While FTR was often left uncorrected during left-heart valvular surgery, under the assumption that correction of the left-sided lesion would reverse the right-heart changes that cause FTR, recent data largely have supported concomitant tricuspid valve repair at the time of mitral surgery. In this review, the authors discuss the potentially irreversible nature of the changes leading to FTR, the likelihood of progression of FTR after mitral surgery, and the evidence for and against concomitant tricuspid valve repair at the time of mitral valve intervention. Lastly, this narrative review also examines advances in transcatheter therapies for the tricuspid valve and the evidence behind concomitant transcatheter tricuspid repair at the time of transcatheter mitral repair.