Indications for Surgery for Tricuspid Regurgitation

Five-year outcomes of tricuspid valve repair versus replacement; a propensity score-matched analysis

BACKGROUND

Tricuspid valve repair (TVr) is the recommended approach for managing tricuspid regurgitation; however, there is a concern about the long-term durability of the repair. Therefore, this study aimed to compare the long-term outcomes of TVr versus tricuspid valve replacement (TVR) in a matched cohort of patients.

METHODS

This study included 1161 patients who underwent tricuspid valve (TV) surgery from 2009 to 2020. Patients were grouped according to the procedure into two groups: patients who underwent TVr (n = 1020) and patients who underwent TVR (n = 159). The propensity score identified 135 matched pairs.

RESULTS

Renal replacement therapy and bleeding were significantly higher in the TVR group compared to the TVr group both before and after matching. Thirty-day mortality occurred in 38 (3.79%) patients in TVr group versus 3 (1.89%) in the TVR group (P ≤ 0.001) but was not significant after matching. After matching, TV reintervention (hazard ratio (HR): 21.44 (95% CI: 2.17-211.95); P  =  0.009) and heart failure rehospitalization (HR: 1.89 (95% CI: 1.13-3.16); P  =  0.015) were significantly higher in the TVR group. There was no difference in mortality in the matched cohort (HR: 1.63 (95% CI: 0.72-3.70); P  =  0.25).

CONCLUSIONS

TVr was associated with lower renal impairment, reintervention, and heart failure rehospitalization than replacement. TVr remains the preferred approach whenever feasible.

Tricuspid valve regurgitation: current diagnosis and treatment

Tricuspid regurgitation (TR) is present in 1.6 million individuals in the United States and 3.0 million people in Europe. Functional TR, the most common form of TR, is caused by cardiomyopathies, LV valve disease, or pulmonary disease. The five-year survival with severe TR and HFrEF is 34%. Echocardiography can assess the TR etiology/severity, measure RA and RV size and function, estimate pulmonary pressure, and characterize LV disease. Management includes diuretics, ACE inhibitors, and aldosterone antagonists. Surgical annuloplasty or valve replacement should be considered in patients with progressive RV dilatation without severe LV dysfunction and pulmonary hypertension. Transcatheter repair/replacement is possible in patients with a LVEF <40%, dilated annuli, and impaired RV function. The diagnosis and treatment of TR, including coaptation, annuloplasty devices and prosthetic valves, success rates, morbidity/mortality, and trials are discussed. Transcatheter tricuspid valve repair/replacement is an emerging therapy for high-risk patients with TR who would otherwise have a dismal clinical prognosis.

Tricuspid annulus cinching force under pulmonary hypertensive right ventricle conditions: An ex vivo study

This study investigates the force required to reduce or "cinch" the tricuspid annulus under elevated right ventricular pressures, commonly seen in patients with pulmonary hypertension. Tricuspid regurgitation affects 1.6 million Americans. Approximately 43% of patients who undergo tricuspid valve repair to correct tricuspid regurgitation will develop residual pulmonary hypertension, putting them at risk for developing increased right ventricle pressures. Previous studies have quantified the forces required to cinch the tricuspid annulus by only pressurizing the right ventricle, leaving out forces from the pressurized left ventricle and septal wall unaccounted for. This study pressurized both left and right ventricles of 10 porcine hearts to their normal physiological pressures of 110 mmHg and 30 mmHg respectively, then increased right ventricular pressures to mimic moderate and severe pulmonary hypertension. A suture was anchored around the free wall of the tricuspid annulus with the free end attached to a force transducer. The force transducer was mounted on a slider system which pulled the suture at regular intervals. The cinching force on the tricuspid annulus was quantified with each annular reduction by simulating peak systole condition in both ventricles. The data was compared with only the right ventricle pressurized as previous studies did. There were significant differences in required cinching forces with each increase in right ventricular pressure and between trials that pressurized both ventricles versus only the right ventricle, suggesting adoption of this physiologically improved protocol. We also found with increased cinching of the tricuspid annulus, notable changes occur in the mitral annulus.

Evaluation and Management of Primary Tricuspid Regurgitation

Tricuspid regurgitation (TR) is a highly prevalent echocardiographic finding in general population being present in almost 80% to 90% of them. However, TR is mild or functional rather than organic in majority of people. Significant TR was seen in 14.8% of adult men and 18.4% of adult women, respectively. Of all the significant TRs, approximately 8% to 10% are primary. Mild TR is benign but moderate-to-severe TR tends to progress and carries significant morbidity and mortality. Tricuspid valve disease is either primary or secondary (functional) in nature. Valve leaflets are predominantly diseased in primary TR, whereas annular dilatation is the main culprit in secondary TR. Of all the heart valves, tricuspid valve was the most neglected valve till a decade ago, though there was enough evidence to show that moderate to severe TR was not as benign as was assumed. With the availability of 2-dimensional echocardiography (2D echo) and transesophageal echocardiography, we are able to diagnose and determine the severity as well as etiology of TR. Although surgical therapy remains the gold standard for severe primary tricuspid valve disease, it continues to suffer from one of the highest morbidity and mortality rates among all cardiac valve-related surgeries even in the hands of experienced surgeons. For the same reason, majority of patients are not referred or subjected to surgical therapy. Therefore, there is an unmet need for less invasive and safer form of therapy to overcome this hurdle. So, several less-invasive and innovative technologies for treating patients with severe tricuspid valve disease at high surgical risk are being developed. Some of them have already been used for treatment of severe mitral regurgitation. They are being adopted for the treatment of severe TR. This review provides a comprehensive picture of newer guidelines and latest technologies and their impact on diagnosis and outcome of high-risk TV disease.

Pulmonary artery intravascular abscess: A rare complication of incomplete infective endocarditis treatment in the setting of injection drug use

Infective endocarditis (IE) is a serious complication of injection drug use. Right-sided IE encompasses 5–10% of all IE cases, with the majority involving the tricuspid valve (TV). The predominant causal organism is Staphylococcus aureus. Most cases of right-sided IE can be successfully treated with antimicrobials, but approximately 5–16% require eventual surgical intervention. We report the case of a 36-year-old female with active injection drug use who developed methicillin-sensitive Staphylococcus aureus IE of the tricuspid valve. Associated with poor adherence to medical therapy as a consequence of opioid addiction, she developed septic emboli to the lungs and an intravascular abscess in the left main pulmonary artery. These long-term potentially fatal, sequelae of incompletely treated IE require surgical intervention, as medical therapy is unlikely to be sufficient. Surgical management may involve TV replacement, pulmonary artery resection, and pneumonectomy. Prevention of these complications may have been achieved by concurrent opioid addiction therapy. An intravascular pulmonary artery abscess is a novel complication of advanced IE that has not been previously reported. This complication likely arose due to incomplete IE treatment as a consequence of opioid addiction, highlighting the need for concurrent addiction management. Intravenous antimicrobial therapy is likely not adequate, and surgical intervention, including pulmonary artery resection and pneumonectomy may be necessary.