Outcomes after tricuspid valve surgery concomitant with left ventricular assist device implantation in the EUROMACS registry: a propensity score matched analysis

Abstract

OBJECTIVES Tricuspid regurgitation (TR) is common in patients receiving a left ventricular assist device (LVAD). Controversy exists as to whether concomitant tricuspid valve surgery (TVS) is beneficial in currently treated patients. Therefore, our goal was to investigate the effect of TVS concomitant with a LVAD implant. METHODS The European Registry for Patients with Mechanical Circulatory Support was used to identify adult patients. Matched patients with and without concomitant TVS were compared using a propensity score matching strategy. RESULTS In total, 3323 patients underwent LVAD implantation of which 299 (9%) had TVS. After matching, 258 patients without TVS were matched to 258 patients with TVS. In the matched population, hospital deaths, days on inotropic support, temporary right ventricular assist device implants and hospital stay were comparable, whereas stay in the intensive care unit was higher in the TVS cohort (11 vs 15 days; P = 0.026). Late deaths (P = 0.17), cumulative incidence of unexpected hospital readmission (P = 0.15) and right heart failure (P = 0.55) were comparable between patients with and without concomitant TVS. In the matched population, probability of moderate-to-severe TR immediately after surgery was lower in patients with concomitant TVS compared to patients without TVS (33% vs 70%; P = 0.001). Nevertheless, the probability of moderate-to-severe TR decreased more quickly in patients without TVS (P = 0.030), resulting in comparable probabilities of moderate-to-severe TR within 1.5 years of follow-up. CONCLUSIONS In matched patients, TVS concomitant with LVAD implant does not seem to be associated with better clinical outcomes. Concomitant TVS reduced TR significantly early after LVAD implant; however, differences in probability of TR disappeared during the follow-up period.

Concomitant cardiac surgery procedures during left ventricular assist device implantation: single-centre experience

“…The main finding was that tricuspid valve procedure in patients for whom, tricuspid repair may be considered per current ISHLT recommendation, was associated with increased mortality (10). Veen and colleagues presented data from the EUROMACS registry, showing comparable survival rates for patients with or without concomitant tricuspid valve procedure at thirty days (13% vs. 10%), in-hospital (20% vs. 17%), and one year, but diverging survival curves after two years of follow up (76% in isolated LVADs vs. 63% in patients with concomitant procedures) (7). The effect of tricuspid repair seemed to be unsustainable, resulting in comparable risks for a recurrence of moderate to severe regurgitation after one-year.…”

“…It was suggested that patients in need of valve repair are their own entity of LVAD recipients. Such patients are less acute with a longer history of heart failure and fewer ischemic etiologies (7). Valvular insufficiencies, especially of the tricuspid valve, are probably-in the absence of structural defects-more an expression of secondary longterm effects of dilatation and pulmonary hypertension on the RV function in chronic heart failure rather than a symptom to treat per se.…”

“…It remains controversial whether issues other than more than mild aortic valve regurgitation or intracardiac shunts [both Class I indications for concomitant surgery according to the International Society of Heart and Lung Transplantation (ISHLT) guidelines (6)] should be addressed at the time of LVAD implantation. Multiple studies have shown contrary results with both adverse effects and improvement of outcomes in terms of right ventricular (RV) function, length of intensive care unit and hospital stay, catecholamine dependency, mortality and more, after LVAD and concomitant cardiac surgery (7)(8)(9)(10)(11)(12).…”

Development of tricuspid regurgitation and right ventricular performance after implantation of centrifugal left ventricular assist devices

“…Some single-center studies showed a reduction in post-operative RHF or readmission rates in patients undergoing concomitant TVR while others could not confirm these findings (10)(11)(12)(13). In retrospective multicenter registries, TVR at the time of LVAD implantation was not associated with improved survival (4,14).…”

“…It has been shown that LVAD implantation decreases pulmonary arterial pressure, central venous pressure and TR (15,16). However, about 10% of patients present with moderate-to-severe TR one year after LVAD implantation, regardless of whether they underwent TVR or not (14).…”