Outcomes of Tricuspid Valve Repair and Replacement: A Propensity Analysis

doi:10.1016/j.athoracsur.2008.10.003

The Annals of Thoracic Surgery

Volume 87, Issue 1, January 2009, Pages 83-89

Presented at the Fifty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 7–10, 2007.

https://doi.org/10.1016/j.athoracsur.2008.10.003 Get rights and content

Background

The purpose of this study was to compare operative mortality and long-term outcome of patients undergoing tricuspid valve replacement versus tricuspid valve repair.

Methods

From February 1986 to July 2006, 315 patients underwent tricuspid valve surgery including 93 replacements (72 biologic, 21 mechanical) and 222 repairs. To control for selection bias and varying comorbidities, a matched cohort of patients undergoing repair versus replacement was selected using propensity score analysis (68 patients in each group).

Results

In the propensity-matched cohorts, operative mortality was similar for tricuspid valve replacement (13% ± 4%) and repair (18% ± 5%; p = 0.64). Intensive care unit length of stay was similar between cohorts (replacement, 4 days; repair, 3 days; p = 0.45), but the replacements had a significantly longer hospital lengths of stay (9 days versus 6 days; p = 0.01). In the replacement cohort, survival was 85% at 1 year, 79% at 5 years, and 49% at 10 years. In the repair cohort, survival rates were similar with 80% at 1 year, 72% at 5 years, and 66% at 10 years (p = 0.66 versus replacement).

Conclusions

Surgical treatment of tricuspid valve disease, regardless of the operative approach, is associated with significant early and late mortality. However, there is no difference favoring tricuspid valve repair over replacement. Thus, we should not hesitate to consider tricuspid valve replacement for patients in whom we believe there is a reasonable chance for recurrence of regurgitation after repair.

Section snippets

Material and Methods

This retrospective review includes 315 consecutive patients who underwent tricuspid valve surgery between February 1986 and July 2006 at Washington University School of Medicine (Barnes-Jewish Hospital) by 19 different surgeons. The study was approved by the Washington University Institutional Review Board. There were 196 women (62%) and 119 men (38%) in the study with a mean age of 56.6 ± 16.5 years (range, 18 to 85). Of these patients, 222 underwent tricuspid valve repair and 93 underwent

Tricuspid valve repair

Operative mortality was 16% ± 3% (36 of 222) with tricuspid valve repair. At late follow-up, there were 60 deaths (27%), and mean follow-up was 5.5 ± 5.4 years. Survival was 82% at 1 year (175 patients at risk), 76% at 3 years (130 at risk), 74% at 5 years (89 at risk), and 69% at 10 years (47 patients at risk; Fig 1).

Tricuspid valve replacement

Operative mortality was 13% ± 4% (12 of 93) with tricuspid valve replacement. At late follow-up, there were 33 deaths (36%), and mean follow-up was 5.2 ± 5.3 years. Survival was

Comment

Clinically significant tricuspid valve disease requiring consideration for surgical intervention is uncommon, usually manifesting in patients with medically refractory congestive heart failure, endocarditis, or severe, irreversible pulmonary hypertension with secondary tricuspid regurgitation [9]. Presently, the optimal surgical approach, either tricuspid valve repair or replacement, remains controversial owing to the presence of multiple confounding preoperative comorbidities, the high

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Cited by (117)

Outcomes of minimally invasive isolated tricuspid valve repair and replacement through right mini-thoracotomy
2024, JTCVS Open
Isolated tricuspid valve surgery is uncommon and associated with high perioperative morbidity and mortality. We aimed to study the overall outcomes of patients who underwent minimally invasive right thoracotomy tricuspid valve surgery (Mini-TVS), consisting of either tricuspid valve repair (TVre) or replacement (TVR).
We performed a retrospective analysis of all Mini-TVS procedures (2017-2022), through which we identified isolated tricuspid valve surgeries. We examined in-hospital outcomes, survival analysis over a 4-year period, and competing risk analysis for reoperative surgery.
Among a total of 51 patients, the average age was 60 ± 16 years, and 67% (n = 34) were female. Severe tricuspid regurgitation was present in all cases. Infective endocarditis was noted in 7.8% (n = 4), and 24% (n = 12) had preexisting pacemakers. Mini-TVS included TVre in 18 patients (35%) and TVR in 33 patients (65%). The in-hospital and 30-day mortality rates were 4% (n = 2) and 6% (n = 3), respectively. At 4 years, the overall TVS survival was 76% (confidence interval, 62-93%), with no significant difference between TVre and TVR (91% vs 69%, P = .16). At follow-up, 3 patients required repeat surgery for recurrent regurgitation after 2.6, 3.3, and 11 months, with a reoperation rate of 7.3% (confidence interval, 2.4-22%) at 2 years. Factors associated with worse overall survival included nonelective surgery, right ventricular dysfunction, serum creatinine >2 g/dL, and concomitant left-sided valve disease.
A nonsternotomy minimally invasive approach is a feasible option for high-risk patients. Midterm outcomes were similar in repair or replacement. Patients with right ventricular dysfunction and left-sided disease had worse outcomes.
De Vega annuloplasty. Fifty years since the beginning of selective, adjustable and permanent valve repair
2023, Cirugia Cardiovascular
La anuloplastia de De Vega consiste en una doble sutura apoyada en parches de teflón en sus extremos y anudada de tal forma que corrige la regurgitación en la válvula tricúspide. Tras 50 años desde su publicación, se repasan sus antecedentes históricos, la técnica original y las sucesivas modificaciones que han ido surgiendo bajo el mismo concepto fisiopatológico. La anuloplastia de De Vega ha sido empleada extensamente en todo el mundo para corregir la insuficiencia tricúspide, especialmente aquella regurgitación secundaria funcional de forma concomitante a la cirugía de la válvula mitral. También se ha empleado en lesiones traumáticas, trasplante cardiaco o población infantil. En comparación con la anuloplastia con anillo rígido o semirrígido parece conferir menor estabilidad en el tiempo, sin que ello se haya traducido en un aumento de la morbimortalidad o la tasa de reintervenciones. Es una técnica rápida, sencilla, reproducible, económica, segura y que ofrece excelentes resultados clínicos en pacientes seleccionados. Tras 50 años sigue vigente especialmente como tratamiento de la insuficiencia tricúspide funcional no severa en el contexto de una cirugía valvular izquierda sin dilatación significativa del ventrículo derecho.
De Vega annuloplasty consists of a double suture supported by Teflon patches at its ends and tied in such a way as to correct regurgitation in the tricuspid valve. After 50 years since its publication, its historical background, the original technique and the successive modifications that have emerged under the same pathophysiological concept are reviewed. De Vega annuloplasty has been used extensively throughout the world to correct tricuspid insufficiency, especially secondary functional regurgitation concomitantly with mitral valve surgery. It has also been used in traumatic injuries, heart transplantation or the child population. Compared with annuloplasty with a rigid or semirigid ring, it seems to confer less stability over time, without this having translated into an increase in morbidity and mortality or in the rate of reinterventions. It is a fast, simple, reproducible, economical, safe technique that offers excellent clinical results in selected patients, and that after 50 years is still valid, especially as a treatment for non-severe functional tricuspid regurgitation in the context of left valve surgery without significant dilatation of the right ventricle.
Outcomes and risk analysis after tricuspid valve surgery for non-Ebstein 2-ventricle congenital tricuspid valve diseases
2022, JTCVS Open
Tricuspid valve (TV) surgery remains understudied and little data exist describing the surgical indications, outcomes, and prognostic factors for pediatric patients with non-Ebstein 2-ventricle congenital TV lesions. This study aims to describe early and late outcomes of pediatric patients with non-Ebstein congenital TV lesions undergoing isolated TV procedures at a single institution.
All patients who underwent TV surgery for non-Ebstein congenital TV disease between 2006 and 2018 were included. Patients who had missing preoperative data, patients with single-ventricle physiology, congenitally corrected transposition of the great arteries, and patients undergoing TV intervention as part of repair of an atrioventricular canal defect were excluded. The primary end point was the occurrence of TV reintervention or TV regurgitation (TR) ≥ moderate.
A total of 85 patients were included. The tricuspid lesion was isolated TR in 80 (94.1%), isolated tricuspid stenosis in 3 (3.5%) and mixed disease in 2 (2.4%) patients. Median age at surgery was 33 years (interquartile range, 12-53 years). TV repair and TV replacement were performed in 66 (77.6%) and 19 (22.4%) patients, respectively. One (1.2%) patient underwent TV reoperation during the same admission. There was no in-hospital mortality. Median follow-up was 3.3 years (interquartile range, 0.1-4.7 years). The overall cumulative incidence of TV reintervention or TR deemed moderate or greater at 1, 3, and 5 years was 3% ± 2%, 11% ± 4%, and 20% ± 8%. In multivariable analysis, age younger than 12 years (P = .04) and mitral valve regurgitation deemed moderate or greater (P = .01) were independent risk factors for TV reintervention or recurrent TR deemed to be moderate or greater at last follow-up.
TV surgery in patients with non-Ebstein congenital TV disease can be performed with good outcomes. TV reintervention or TR deemed moderate or greater occurred in 20% of patients on midterm follow-up. Patients younger than age 12 years are at higher risk for recurrent TR or TV reintervention, whereas preoperative MR deemed moderate or greater increases this risk, especially in patients older than age 12 years. There was no difference in outcomes between TV replacement and repair.
Tricuspid Valve Replacement: The Road Less Traveled
2022, Annals of Thoracic Surgery
Long-term Outcomes of Adults With Tricuspid Regurgitation Following Transcatheter Atrial Septal Defect Closure
2022, Canadian Journal of Cardiology
Citation Excerpt :
Longitudinal prospective studies with serial clinical and imaging follow-up are needed to assess the extent of right heart remodelling following ASD closure and to establish and validate a predictive model of persistent TR. With significant early and late mortality associated with open-heart tricuspid valve repair/replacement,21 it would be of interest to study the proportion and clinical outcomes of patients with persistent TR who go on to receive percutaneous tricuspid interventions after ASD closure. This study showed that compared with patients with < moderate TR, patients with ≥ moderate TR had poorer long-term outcomes after isolated transcatheter ASD closure.
Functional tricuspid regurgitation (TR) is a common pathophysiologic condition in adults with ostium secundum atrial septal defect (ASD). The aim of this study was to evaluate long-term outcomes following transcatheter ASD closure, which have not been well studied among patients with significant TR.
We reviewed consecutive adult patients who underwent transcatheter ASD closure at Toronto General Hospital, Ontario, Canada, from 1998 to 2016. We linked our hospital registry with Ontario population-based health administrative databases to collect longitudinal data on inpatient and outpatient health care utilisation and vital status.
In this cohort study of 949 patients, 199 (22%) had moderate to severe TR before transcatheter ASD closure. A significant proportion of patients (61%) showed improvement in TR severity to at least mild TR after ASD intervention. At a median follow-up of 10.9 years, patients with baseline mild or no TR, compared with those with greater than moderate TR, had significantly lower rates of all-cause mortality (6.8 vs 22.5 per 1000 person-years [PY]; P < 0.001), composite hospitalisation for atrial fibrillation (AF) or heart failure (HF) (22.3 vs 49.1 per 1000 PY; P < 0.001), and new onset of AF (10.4 vs 20.2 per 1000 PY; P = 0.002) and HF (5.0 vs 9.2 per 1000 PY; P = 0.039). Preprocedural TR was independently associated with higher all-cause mortality (adjusted hazard ratio 1.69, 95% confidence interval 1.08-2.62).
TR severity was independently associated with a higher risk of mortality and morbidity. Further investigation of earlier device closure or concomitant tricuspid valve intervention may be of interest.
La régurgitation tricuspide (RT) fonctionnelle est un trouble pathophysiologique courant chez les adultes qui présentent une communication interauriculaire (CIA) de type ostium secundum. Cette étude visait à évaluer l’issue à long terme de la fermeture d’une CIA par cathéter, qui n’a pas été étudiée de manière approfondie chez les patients atteints d’une RT importante.
Nous avons examiné les cas de patients adultes consécutifs qui ont subi une fermeture de CIA par cathéter au Toronto General Hospital, Ontario, Canada, entre 1998 et 2016. Nous avons relié notre registre hospitalier aux bases de données administratives sur les soins de santé en population générale de l’Ontario afin de recueillir des données longitudinales sur l’utilisation des soins de santé et le statut vital chez les patients hospitalisés et les patients ambulatoires.
Dans la cohorte composée de 949 patients, 199 (22 %) présentaient une RT modérée ou grave avant la fermeture de leur CIA par cathéter. Chez une proportion importante de patients (61 %), on a observé une atténuation de la gravité de la RT, celle-ci devenant au plus d’intensité légère à la suite de l’intervention percutanée. Après un suivi d’une durée médiane de 10,9 ans, les patients ayant au départ une RT légère ou n’en ayant pas présentaient, par rapport aux patients atteints d’une RT d’intensité supérieure à une intensité modérée, des taux plus faibles de mortalité toutes causes confondues (6,8 vs 22,5 par 1000 années-personnes [A-P], p ≤ 0,001), d’hospitalisation pour cause de fibrillation auriculaire (FA) ou d’insuffisance cardiaque (IC) (22,3 vs 49,1 par 1000 A-P, p < 0,001), d’un premier épisode de FA (10,4 vs 20,2 par 1000 A-P, p = 0,002) et d’IC (5,0 vs 9,2 par 1000 A-P, p = 0,039). La RT telle qu’elle était avant l’intervention a été associée de façon indépendante à une mortalité toutes causes confondues plus élevée (rapport des risques instantanés : 1,69; intervalle de confiance à 95 % : 1,08-2,62).
La gravité de la RT a été associée de façon indépendante à un risque plus élevé de mortalité et de morbidité. Il serait intéressant d’évaluer la fermeture plus précoce ou une intervention concomitante sur la valve tricuspide.
Mechanical Versus Bioprosthetic Valve Replacement in the Tricuspid Valve Position: A Systematic Review and Meta-Analysis
2021, Heart Lung and Circulation
The ideal prosthesis for tricuspid valve replacement (TVR) continues to be debated. There are few published data comparing mechanical and bioprosthetic valves, and all are retrospective studies with relatively small sample sizes.
This study was conducted to compare mechanical and bioprosthetic valves for TVR.
A literature search of six databases (PubMed, EMBASE, Ovid, ScienceDirect, JSTOR, and Wiley Blackwell's online library) was performed with the keywords “tricuspid valve disease, tricuspid valve replacement and (bioprosthetic or mechanical)”. Primary outcomes were hospital mortality, long-term survival, tricuspid valve reoperation, valve failure, thrombosis, and thrombo-embolism. Risk ratio (RR) was used to compare dichotomous parameters and time-to-event outcomes. “Survival and re-interventions” were pooled using a meta-analysis of hazard ratios (HR). Publication bias was accessed using a funnel plot.
A total of 23 retrospective studies involving 945 mechanical and 1,332 biological tricuspid prostheses were included. The studies were published between January 2002 and September 2019. Hospital mortality (30-day mortality) did not differ between groups (RR, 0.83; 95% confidence interval [CI], 0.66–1.05; p=0.12). Long-term survival was evaluated in 15 studies, and it was not significantly different between patients with mechanical compared with those with bioprosthetic valves (pooled HR, 0.97; 95% CI, 0.61–1.54; p=0.88). Freedom from tricuspid valve reoperation was assessed in eight studies, and no difference was found between the groups (pooled HR, 1.03; 95% CI, 0.63–1.69; p=0.89). Valve failure in the 5-year postoperative period was evaluated by seven studies, and there was no statistically significant difference between the two groups (pooled RR, 1.33; 95% CI, 0.42–4.27; p=0.63).
The results of this meta-analysis suggest an equal risk of 30-day and late mortality, reoperation, and 5-year valve failure in patients with mechanical versus biological TVR. The choice of the prosthesis in the tricuspid position should depend mainly on the patient's risk factors and no superiority of one prosthesis over the other in this position.

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Original articleAdult cardiacOutcomes of Tricuspid Valve Repair and Replacement: A Propensity Analysis

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Tricuspid valve repair

Tricuspid valve replacement

Comment

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Original article
Adult cardiac
Outcomes of Tricuspid Valve Repair and Replacement: A Propensity Analysis