Concomitant Tricuspid Valve Operations Affect Outcomes After Mitral Operations: A Multiinstitutional, Statewide Analysis

doi:10.1016/j.athoracsur.2012.03.020

The Annals of Thoracic Surgery

Volume 94, Issue 1, July 2012, Pages 52-58

Presented at the Fifty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 9–12, 2011.

https://doi.org/10.1016/j.athoracsur.2012.03.020 Get rights and content

Background

Mitral valve (MV) disease is often accompanied by concomitant tricuspid valve (TV) disease. This study determined the influence of performing TV procedures in the setting of MV operations within a multiinstitutional patient population.

Methods

From 2001 to 2008, 5,495 MV operations were performed at 17 different statewide centers. Of these, 5,062 patients (age, 63.4 ± 13.0 years) underwent an MV operation and 433 (age, 64.0 ± 14.2 years) underwent combined MV and TV (MV+TV) operations. The influence of concomitant TV procedures on operative death and the composite incidence of major complications was assessed by univariate and multivariate analyses.

Results

Patients undergoing MV+TV were more commonly women (62.7% vs 45.5%, p < 0.001), had higher rates of heart failure (73.7% vs 50.9%, p < 0.001), and more frequently underwent reoperations (17.1% vs 7.4%, p < 0.001) compared with MV patients. Other patient characteristics, including preoperative endocarditis (8.5% vs 8.2%, p = 0.78), were similar between groups. MV replacement (63.5%) was more common than repair (36.5%, p < 0.001) in MV+TV operations, and MV+TV operations incurred longer median cardiopulmonary bypass times (181 vs 149 minutes, p < 0.001). Unadjusted operative mortality (6.0% vs 10.4%, p = 0.001) and postoperative complications were higher after MV+TV compared with MV. More important, risk adjustment showed performance of concomitant TV procedures was an independent predictor of operative death (odds ratio, 1.50; p = 0.03) and major complications (odds ratio, 1.39; p = 0.004).

Conclusions

A concomitant TV operation is a proxy for more advanced valve disease. Compared with MV operations alone, simultaneous MV+TV operations are associated with elevated morbidity and death, even after risk adjustment. This elevated risk should be considered during preoperative patient risk stratification.

Section snippets

Patients and Methods

The University of Virginia Institutional Review Board exempted this study from formal review because it was a secondary analysis of the VCSQI data registry with the absence of Health Insurance Portability and Accountability Act patient identifiers and because the data were collected for quality analysis and purposes other than research.

Patient Characteristics and Operative Features for MV With or Without TV Operations

Table 1 reports patient characteristics and operative features for all patients stratified by MV and TV procedure type. Among those undergoing MV only, MV replacement (MVR) was performed in 2,262 patients (44.7%), and MV repair was performed in 2,800 (55.3%). MVR was more commonly performed in women. MVR patients had a higher prevalence of preoperative risk and longer aortic cross-clamp times than those undergoing MV repair. Among MV+TV operations, performance of TV repair (94.2%) was far more

Comment

The present study reports the influence of concomitant TV procedures during MV operations within a large, multiinstitutional cohort of patients undergoing cardiac operations. In this contemporary analysis, MV+TV operations were associated with increased unadjusted morbidity (38% vs 28%, p < 0.001) and mortality (10% vs 6%, p = 0.001) as well as with longer postoperative lengths of stay compared with MV operations alone. Patients undergoing MV+TV operations also encountered significantly higher

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Cited by (24)

Comparing Outcomes Between Surgical and Transcatheter Aortic Valve Replacement in Classical Low-Flow Low-Gradient Aortic Stenosis
2023, American Journal of Cardiology
Patients with classic low-flow low-gradient (cLFLG) aortic stenosis (AS) have a poor prognosis but still benefit from aortic valve replacement. There is a paucity of evidence to guide the choice between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). This study compared procedural and midterm outcomes in patients with cLFLG AS between TAVR and SAVR. Patients with cLFLG AS, defined as an aortic valve area ≤1 cm², mean gradient <40 mm Hg, and left ventricular ejection fraction <50%, were selected from a single center between 2015 and 2020. Inverse probability weighting and regression were used to adjust for differences in baseline characteristics, the nonrandom assignment of treatment modalities, and procedural differences. The primary end point was all-cause mortality. A total of 322 patients (220 TAVR and 102 SAVR) were included. At a follow-up of 4.4 ± 1.5 years, the adjusted hazard ratio (HR) for mortality after inverse probability weighting with SAVR was 0.66, 95% confidence interval (CI) 0.31 to 1.35; p = 0.24. Worse renal function at baseline (per 10 ml/min/m² increase HR 0.92, 95% CI 0.84 to 1.00, p = 0.04) and multiple valve interventions (HR 5.39, 95% CI 2.62 to 11.12, p <0.001) independently predicted mortality. There was no difference in stroke and permanent pacemaker implantation, but the rates of renal replacement therapy were higher among the SAVR cohort: 13.7% versus 0%; p <0.001. In conclusion, among patients with cLFLG AS, there was no difference in midterm mortality between TAVR and SAVR, supporting the use of either treatment. However, in patients with poor renal function or at risk of renal failure, TAVR may be the preferred option.
Efficacy and Safety of Concomitant Tricuspid Repair in Patients Undergoing Mitral Valve Surgery: a Systematic Review and Meta-Analysis
2022, Current Problems in Cardiology
Citation Excerpt :
A few studies suggest decreased mortality, while the rest report otherwise.36 A multi-institutional analysis demonstrated that TV surgery was an independent predictor of operative mortality and complications when patients with concomitant TV and MV surgery were compared to those with only MV surgery.37 On the other hand, a meta-analysis by Pagnesi et al demonstrated a reduction in cardiac-related mortality and a shift towards lower risk all-cause mortality in the study cohort when investigating patients undergoing left-sided (mitral and/or aortic) valve surgery with or without concomitant TV repair.9
Tricuspid valve repair (TVR) is recommended for patients with moderate primary tricuspid regurgitation (TR), those with moderate TR, and a history of heart failure without annular dilation, while being essential for patients with severe secondary TR undergoing MVS. The meta-analysis aimed to evaluate the efficacy and safety of tricuspid valve repair in patients undergoing MVS. We systematically searched PubMed, Embase, and Google Scholar through January 2022, and studies comparing patients with TVR and those without TVR were selected. The primary outcomes were 30-day, and all-cause mortality. In this meta-analysis, 20 studies were included with a patient population of 72,422. No significant differences were observed between patients undergoing TVR with MVS, in comparison to MVS group only for the primary outcomes i.e., 30-day mortality (RR: 1.14, 95% CI [0.69, 1.87], and all-cause mortality (RR: 1.16, 95% CI [0.86, 1.57]. 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. However, 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. Our meta-analysis has furthered the discussion for weighing the risks and benefits of pursuing TVR during MVS.
Impact of using the modified De Vega Annuloplasty using pericardial patch versus Ring Annuloplasty in Mitral valve replacement with severe functional tricuspid regurgitation
2022, Cirugia Cardiovascular
Citation Excerpt :
Without treatment, TR may worsen over time leading to worsening of symptoms, quality of life, heart failure and even death. Prior studies indicate an incidence of 7–16% for development of late, moderate to severe TR after MV operations.3 Consequently surgical correction of severe TR at the time of MV repair or replacement is recommended for the management of patients with valvular heart disease by the American College of Cardiology/American Heart Association Guidelines.3
Tricuspid regurgitation in patients with mitral valve disease is associated with poor outcome and predicts poor survival, heart failure, and reduced functional capacity. The objective was to access if modified De Vega Annuloplasty (mDA) using pericardial patch offered significant surgical, functional and economical benefits over RA done for Mitral valve replacement with severe functional tricuspid regurgitation in a predominant rheumatic population.
This retrospective study analyzed data from 50 patient who were eligible for this study and underwent mitral valve replacement surgery for severe mitral valve stenosis with functional tricuspid valve disease (30 AR and 20 mDA) between the period of January 2015 and December 2019 at Kem Hospital, Mumbai. Post-operatively all patients has routine TTE (transthoracic echocardiography) before discharge and subsequently at 6 months and 1 year. Severity of TR (Tricuspid Regurgitation), LVEF (Left Ventricular Ejection Fraction), TAPSE (Tricuspid Annular Plane Systolic Excursion) and PASP (Pulmonary Artery Systolic Pressure) were used for determining functional status of the patient.
There was no statistically significant difference in residual TR. There was significant improvement in NYHA (Newyork Heart Association) stage. Statistically significant difference was seen in the cost, with mDA demonstrating economic benefits for the patient.
Similar functional outcomes were seen with both techniques. Only incremental economic benefit was seen with mDA in the form of lower cost for the patient. However, this is just the early outcome and long term study is ongoing to ascertain outcome.
La regurgitación tricuspídea en pacientes con valvulopatía mitral se asocia a un mal resultado y predice una mala supervivencia, insuficiencia cardíaca y una menor capacidad funcional. El objetivo fue acceder a si la anuloplastia de De Vega modificada (mDA) mediante parche pericárdico ofrecía beneficios quirúrgicos, funcionales y económicos significativos sobre la RA realizada para la sustitución de la válvula mitral con regurgitación tricúspide funcional grave en una población predominantemente reumática.
Este estudio retrospectivo analizó datos de 50 pacientes que fueron elegibles para este estudio y se sometieron a cirugía de reemplazo de válvula mitral por estenosis severa de válvula mitral con enfermedad de válvula tricúspide funcional (30 AR y 20 mDA) entre el período comprendido entre enero del 2015 y diciembre del 2019 en el Hospital Kem, Bombay. Después de la operación, todos los pacientes tienen ETT (ecocardiografía transtorácica) de rutina antes del alta y posteriormente a los 6 meses y a un año. La gravedad de la TR (regurgitación tricuspídea), FEVI (fracción de eyección del ventrículo izquierdo), TAPSE(excursión sistólica del plano anular tricúspide y PASP (presión sistólica de la arteria pulmonar) se utilizaron para determinar el estado funcional del paciente.
No hubo diferencia estadísticamente significativa en la TR residual. Hubo una mejora significativa en el estadio de la NYHA (New York Heart Association). Se observó una diferencia estadísticamente significativa en el costo, demostrando la mDA beneficios económicos para el paciente.
Se observaron resultados funcionales similares con ambas técnicas. Sólo se observó un beneficio económico incremental con la mDA en forma de menor coste para el paciente. Sin embargo, este es solo el resultado inicial y se está llevando a cabo un estudio a largo plazo para determinar los resultados.
Tricuspid valve replacement: The old and the new
2022, Progress in Cardiovascular Diseases
Citation Excerpt :
Overall, TVR is performed in only 10–15% of patients as the majority of TV surgery are TVr (85–90%). Notably, during combined TV surgery, almost all patients have a repair (>90%).33 On the contrary, during isolated TV surgery, most patients have a TVR (approximately 60%), probably because of a later referral with more severe TV disease at the time of surgery.27,28,34
Tricuspid regurgitation is a frequent and serious condition but tricuspid valve (TV) surgery, that may be a valve replacement when a repair is not feasible, is rarely performed. Recent development of transcatheter TV interventions offers new options for those high-surgical risk patients, especially TV replacement for patients who are not eligible for transcatheter TV repair. In this review, we describe indications and outcome after surgical TV replacement, and devices available or in development for transcatheter TV replacement.
Impact of tricuspid regurgitation with and without repair during aortic valve replacement
2021, Journal of Thoracic and Cardiovascular Surgery
Long-term outcomes of aortic valve replacement (AVR) are worse in patients with tricuspid regurgitation (TR), but the impact of concomitant tricuspid valve intervention remains unclear. The purpose of this study was to determine the effect of tricuspid intervention in patients with TR undergoing AVR.
Patients undergoing AVR in a regional Society of Thoracic Surgeons database (2001-2017) were stratified by severity of TR and whether or not they underwent concomitant tricuspid intervention. Operative morbidity and mortality were compared between the 2 groups. Further analysis was performed using propensity score–matched pairs.
Among 17,483 patients undergoing AVR, 8984 (51%) had no TR, 7252 (41%) had mild TR, 1060 (6%) had moderate TR, and 187 (1%) had severe TR. Overall, more severe TR was associated with higher morbidity and mortality. Tricuspid intervention was performed in 104 patients (0.6%), including 0.2% of patients with mild TR, 2% of those with moderate TR, and 31% of those with severe TR. In the propensity score–matched analysis, there was not a statistically significant difference in operative mortality between the 2 groups (18% vs 9%; P = .16), but there was significantly higher composite major morbidity (51% vs 26%; P = .006) in the tricuspid intervention group compared with those without surgical TR correction.
Increasing severity of TR is associated with higher rates of morbidity and mortality after AVR. Correction of TR at the time of surgical AVR is not associated with increased operative mortality and has been shown to improve long-term outcomes.
Prevalence and Outcomes of Tricuspid Valve Disease in Patients Undergoing Mitral Valve Surgery (from the Nationwide Inpatient Sample Database)
2021, American Journal of Cardiology

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Original articleAdult cardiacConcomitant Tricuspid Valve Operations Affect Outcomes After Mitral Operations: A Multiinstitutional, Statewide Analysis

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Patient Characteristics and Operative Features for MV With or Without TV Operations

Comment

J Am Coll Cardiol

Ann Thorac Surg

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Conservative management of tricuspid regurgitation in patients undergoing mitral valve replacement

Circulation

Original article
Adult cardiac
Concomitant Tricuspid Valve Operations Affect Outcomes After Mitral Operations: A Multiinstitutional, Statewide Analysis