Optimising Surgical Treatments of Tricuspid Regurgitation

Abstract

Tricuspid regurgitation(TR) affects 65-85% of the population with tricuspid valve disease and can be treated with tricuspid valve surgery(TVS). However, TR remains undertreated in terms of the timing of earlier referral for surgery. TVS is associated with poorer outcomes that may be associated with factors such as technique, right ventricular dysfunction(RVD) and pre-operative atrial fibrillation(AF). To investigate the risk factors for outcomes after TVS for TR, we present two studies.

The first study examines the survival outcomes of TVS for TR in a quaternary centre. A retrospective analysis of prospectively collected data from 214 patients who had TVS from 2009-2020 was performed. Patients were characterised into 3 groups according to the severity of their TR and the nature of their right ventricular function. The main findings are that patients with severe TR and RVD had a 1.5 times higher risk of death(HR 1.46(0.74-2.88);p=0.566) compared to those without RVD. Pre-operative AF was an independent risk factor for post-operative permanent pacemaker(PPM) insertion(p=0.014). TV replacement posed twice the risk for PPM insertions than repair(p=0.05). Other risk factors for death include pre-op creatinine>150(p=0.003), peripheral vascular disease(p=0.059), New York Heart Association (NYHA) class 3-4 (p=0.006), diabetes(p=0.016) and undergoing urgent surgery(p=0.022).

The second study was a systematic review and meta-analysis comparing outcomes of patients who had beating heart(BH) vs. arrested heart(AH) for isolated TVS(iTVS). Seven studies and 7306 patients who had iTVS were included. BH had higher 30-day mortality(p < 0.001) and higher rates of post-operative PPM implantation(p=0.002). BH had higher rates of freedom from long-term mortality(p=0.0002), lower rates of post-operative stroke(p=0.04) and re-operation for bleeding(p= 0.003).

Therefore, we encourage surgeons to consider earlier intervention for patients with severe TR and to perform BH surgery for iTVS.