Mid-term outcomes of isolated tricuspid valve surgery according to preoperative clinical and functional staging

Abstract

OBJECTIVES This study aimed at assessing mid-term outcomes of patients undergoing isolated tricuspid valve (TV) surgery based on a preoperative baseline clinical and functional classification. METHODS All patients treated with isolated TV repair or replacement from March 1997 to May 2020 at a single institution were retrospectively reviewed and assessed for mid-term postoperative outcome according to a novel classification [stages 1–5 related to the absence or presence and extent of right heart failure (RHF)]. Kaplan–Meier survival curves were used to estimate mid-term survival. Competing risk analysis for time to cardiac death and hospitalizations for RHF were also carried out. RESULTS Among the 172 patients included, 129 (75%) underwent TV replacement and 43 (25%) TV repair. At follow-up (median 4.2 years [2.1–7.5]), there were 23 late deaths. At 5 years, overall survival was 100% in stage 2, 88 ± 4% in stage 3 and 60 ± 8% in stages 4–5 (P = 0.298 and P = 0.001, respectively). Cumulative incidence function of cardiac death at 5 years was 0%, 8.6 ± 3.76% and 13.2 ± 5% for stages 2, 3 and 4 and 5, respectively. At follow-up, cumulative incidence function of re-hospitalizations for RHF was 0% for stage 2, 20 ± 5% for stage 3 and 20 ± 6.7% for stages 4 and 5 (P = 0.118 and P = 0.039, respectively). CONCLUSIONS Both short- and mid-term outcomes support early referral for surgery in isolated TV disease, with excellent survival at 5 years and no further hospitalizations for RHF.

Transcatheter and surgical treatment of tricuspid regurgitation: Predicting right ventricular decompensation and favorable responders

“…These results were further confirmed by a single-center retrospective study published by our group ( 26 , 27 ). The 172 patients analyzed were divided according to a new classification based not only on TR grade, but also symptoms, RV remodeling and function, RHF episodes and medical therapy ( 30 ), ranging from Stage 1 (less than moderate TR, no symptoms) to Stage 5 (severe TR, RHF episodes despite maximal medical therapy, organ damage, severe RV dysfunction).…”

“…Furthermore, these studies reported a trend toward increasing patient complexity over time, and a significant impact on outcomes of factors associated with disease duration and late clinical presentation ( 17 , 19 ). Recent data has underlined how early referral for surgical correction results in excellent both short and long-term outcomes ( 23 – 27 ). These findings support the message that the cardiac surgery community has recently tried to deliver regarding “early referral and treatment” in TR.…”

“…The cardiac surgery community has stressed the idea of early referral following recent data published in the literature. Early referral and early treatment, before the development of overt symptomatology, right heart dysfunction and failure and end-organ damage, are associated to excellent in-hospital outcomes, with a higher rate of TV repair vs. replacement, and good long-term outcomes, with low-to-none mortality at 5 years and significant improvement in symptomatology ( 24 , 26 , 27 ). To better define early referral and therefore aid in the stratification of surgical risk, the TRI-SCORE was recently developed ( 32 ).…”

Epidemiology, pathophysiology, diagnosis and management of chronic right‐sided heart failure and tricuspid regurgitation. A clinical consensus statement of the Heart Failure Association (HFA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC

“…In a large single centre retrospective study, operative mortality for isolated TR was 0% in patients at early stages of the disease and 16% at the late stages, once more confirming the importance of timely intervention and correct risk stratification 117 . Recently, a dedicated risk model, the TRI‐SCORE, was proposed to estimate in‐hospital mortality in patients undergoing isolated TR surgery.…”

“…10,11 In a large single centre retrospective study, operative mortality for isolated TR was 0% in patients at early stages of the disease and 16% at the late stages, once more confirming the importance of timely intervention and correct risk stratification. 117 Recently, a dedicated risk model, the TRI-SCORE, was proposed to estimate in-hospital mortality in patients undergoing isolated TR surgery. Notably, most of the variables included in this model (age ≥70 years, NYHA functional class III-IV, right-sided HF signs, daily dose of furosemide ≥125 mg, glomerular filtration rate <30 ml/min, elevated total bilirubin, LVEF <60%, moderate/severe RVD) are HF-and congestion-related confirming the prognostic importance of HF stage and presentation.…”