Outcomes of patients with severe tricuspid regurgitation and congestive heart failure

Abstract

<jats:sec><jats:title>Objectives</jats:title><jats:p>A substantial number of patients with severe tricuspid regurgitation (TR) and congestive heart failure (CHF) are medically managed without undergoing corrective surgery. We sought to assess the characteristics and outcomes of CHF patients who underwent tricuspid valve surgery (TVS), compared with those who did not.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>Retrospective observational study involving 2556 consecutive patients with severe TR from the Cleveland Clinic Echocardiographic Database. Cardiac transplant patients or those without CHF were excluded. Survival difference between patients who were medically managed versus those who underwent TVS was compared using Kaplan-Meier survival curves. Multivariate analysis was performed to identify variables associated with poor outcomes.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Among a total of 534 patients with severe TR and CHF, only 55 (10.3%) patients underwent TVS. Among the non-surgical patients (n=479), 30% (n=143) had an identifiable indication for TVS. At 38 months, patients who underwent TVS had better survival than those who were medically managed (62% vs 35%; p&lt;0.001). On multivariate analysis, advancing age (HR: 1.23; 95% CI 1.12 to 1.35 per 10-year increase in age), moderate (HR: 1.39; 95% CI 1.01 to 1.90) and severe (HR: 2; 95% CI 1.40 to 2.80) right ventricular dysfunction were associated with higher mortality. TVS was associated with lower mortality (HR: 0.44; 95% CI 0.27 to 0.71).</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>Although corrective TVS is associated with better outcomes in patients with severe TR and CHF, a substantial number of them continue to be medically managed. However, since the reasons for patients not being referred to surgery could not be ascertained, further randomised studies are needed to validate our findings before clinicians can consider surgical referral for these patients.</jats:p></jats:sec>

The advantages, pitfalls and limitations of guideline‐directed medical therapy in patients with valvular heart disease

“…Despite poor prognosis, TR is undertreated. In a study of 534 patients with severe TR and congestive heart failure, only 10% underwent surgery (despite at least one indication for intervention in 30%) with demonstrable survival benefit (HR 0.44, 95% CI 0.27–0.71) 84 . Whilst management of pulmonary hypertension and loop diuretics may reduce volume overload and improve symptoms, no medical treatment strategies have proven efficacy in preventing the development of right heart failure.…”

Commentary: Isolated tricuspid valve surgery time has changed: From futile to a must

“…Nevertheless, some results are not surprising; for example, that functional tricuspid regurgitation is followed by a worse long-term outcome than structural valve pathologies. [6][7][8] Nevertheless, early outcome was similar for both indications. With regard to this observation, it would have been interesting to insist on the fact that either tricuspid valve repair or replacement can usually be performed on a beating heart, which considerably limits the perioperative burden.…”

Transcatheter treatment for tricuspid valve disease

“…Furthermore, relatively high mortality rates (8.8%-9.7%) have been reported after conventional surgery for isolated TR, usually as a result of late referral [45][46][47][48] . However, according to single-centre studies including younger and less sick patients compared to the TTVI cohorts, tricuspid surgery may be safe and effective when performed in experienced centres 49,50 .…”