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Vol. 72. Issue 2.
Pages 178-180 (February 2019)
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Vol. 72. Issue 2.
Pages 178-180 (February 2019)
Scientific letter
DOI: 10.1016/j.rec.2017.12.017
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Outcomes After Surgical Treatment of Severe Tricuspid Regurgitation in a Contemporary Series
Resultados del tratamiento quirúrgico de la insuficiencia tricuspídea grave en una serie contemporánea
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Víctor Manuel Becerra-Muñoza,
Corresponding author
vmbecerram@gmail.com

Corresponding author:
, Jorge Rodríguez-Capitánb, Gemma Sánchez-Espína, Miguel Such-Martíneza, Juan José Gómez-Doblasa, Eduardo de Teresa-Galvána
a Unidad de Gestión Clínica del Corazón, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), CIBERCV Enfermedades Cardiovasculares, Málaga, Spain
b Servicio de Medicina Interna, Hospital de Antequera, Área Sanitaria Norte de Málaga, Antequera, Málaga, Spain
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Table. Baseline and Surgical Characteristics of the Patients, Surgical Complications, and Perioperative Mortality
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To the Editor,

Tricuspid regurgitation (TR) has received little attention from clinicians and researchers, and in Spain few centers have published their experience with this process.1 In 2013, our group reported the outcomes of surgical treatment of severe TR in a series of 119 consecutive patients who underwent surgery between April 1996 and February 2010, and high perioperative and long-term mortality was found.2 Today, this series should be considered historic, and the outcomes cannot serve as a guide for predicting those that would currently be obtained after surgery for TR. The objective of the present study was to analyze the clinical and echocardiographic outcomes of a recent sample of patients with severe TR who underwent surgery.

This retrospective study included 87 consecutive patients with severe TR who underwent tricuspid surgery in our hospital between March 2010 and December 2013. The indication for tricuspid surgery was established by the presence of a symptomatic and severe tricuspid lesion according to the echocardiographic definition described in our previous study.2 Treatment was decided by consensus among cardiologists, cardiac surgeons, and the patient. Repair was always the preferred option if technically feasible, essentially in cases with absence of significant organ damage. As an exception, valve replacement was considered, according to the judgement of the surgeon, in cases with functional damage and prior cardiac surgery. Perioperative and long-term morbidity and mortality were analyzed, as well as onset of new severe TR. Predictive factors were studied.

In the period analyzed, ring-free annuloplasty according to the De Vega technique was performed in 4 patients while ring annuloplasty was done in 60; 23 patients received biologic prostheses while none received mechanical prostheses. The Table summarizes the patients’ baseline characteristics, complications after surgery, and perioperative mortality. Overall, 74.7% of the patients were women (mean age, 64.64 [10.08] years). The etiology was organic in 60.9% of tricuspid replacements and functional in 85.9% of repairs. In the group with repaired valves, the patients were older (40.6% vs 17.4% > 70 years; P = .044), had higher preoperative pulmonary pressures (pulmonary artery systolic pressure, 55.67 [14.85] vs 39.65 [14.06] mmHg; P<.001), and a lower proportion of tricuspid surgery alone (7.8% vs 52.2%; P<.001). In 47.1% of the patients, a complication arose during the postoperative period, and perioperative mortality was 8%.

Table.

Baseline and Surgical Characteristics of the Patients, Surgical Complications, and Perioperative Mortality

  Total number of patients (n = 87)  Triscuspid repair (n = 64; 73.6%)  Triscuspid replacement (n = 23; 26.4%)  P 
Age, y  64.64 ± 10.08  65.64 ± 9.95  61.87 ± 10.11  .124 
Age > 70 y  34.5 (30/87)  40.6 (26/64)  17.4 (4/23)  .044 
Female sex  74.7 (65/87)  73.4 (47/64)  78.3 (18/23)  .648 
Renal failure  10.3 (9/87)  10.9 (7/64)  8.7 (2/23)  .762 
COPD  16.1 (14/87)  20.3 (13/64)  4.3 (1/23)  .074 
Previous CVA  2.3% (2/87)  0% (0/64)  8.7 (2/23)  .017 
Charlson comorbidity index  4.36 ± 1.54  4.31 ± 1.31  4.53 ± 2.08  .548 
Prior surgery  32.2 (28/87)  26.6 (17/64)  47.8 (11/23)  .061 
Sinus rhythm  82.8 (72/87)  15.6 (10/64)  21.7 (5/23)  .506 
Organic etiology  26.4 (23/87)  14.1 (9/64)  60.9 (14/23)  < .001 
Functional etiology  73.6 (64/87)  85.9 (55/64)  39.1 (9/23)  < .001 
LVEF, %  61.79 ± 9.08  62.48 ± 9.19  59.87 ± 8.64  .238 
LVEF< 45%  6.9 (6/87)  6.2 (4/64)  8.7 (4/64)  .691 
PASP, mmHg  51.44 ± 16.21  55.67 ± 14.85  39.65 ± 14.06  < .001 
Presurgical PASP > 35 mmHg  85.1 (74/87)  95.3 (61/64)  56.5 (13/23)  < .001 
Presurgical PSAP > 70 mmHg  17.2 (15/87)  21.9 (14/64)  4.3 (1/23)  .056 
Tricuspid surgery alone  19.5 (17/87)  7.8 (5/64)  52.2 (12/23)  < .001 
Mitral prostheses  55.2 (48/87)  64.1 (41/64)  30.4 (7/23)  .005 
Aortic prosthesis  23 (20/87)  26.6 (17/64)  13 (3/23)  .186 
Mitral and aortic prostheses  19.5 (17/87)  23.4 (15/64)  8.7 (2/23)  .126 
Mitral repair  17.2 (15/87)  21.9 (14/64)  4.3 (1/23)  .056 
Coronary surgery  6.9 (6/87)  6.2 (4/64)  8.7 (2/23)  .691 
Logistic EuroSCORE  10.68 ± 9.68  11.22 ± 10.32  9.41 ± 8.05  .456 
Duration of ECC, min  117.43 ± 48.72  118.98 ± 44.28  112.78 ± 61.40  .643 
Low postsurgical cardiac output  21.8 (19/87)  23.4 (15/64)  17.4 (4/23)  .547 
Postsurgical complications
Infectious  8 (7/87)  10.9 (7/64)  0% (0/23)  .098 
Neurologic  4.6 (4/87)  4.7 (3/64)  4.3% (1/23)  .947 
Respiratory  20.7 (18/87)  21.9 (14/64)  17.4 (4/23)  .649 
Renal  13.8 (12/87)  14.1 (9/64)  13 (3/23)  .903 
Reoperation due to bleeding  5.7 (5/87)  3.1 (2/64)  13 (3/23)  .080 
Any complication  47.1 (41/87)  50 (32/64)  39.1 (9/23)  .370 
Mortality  8 (7/87)  7.8 (5/64)  8.7% (2/23)  .894 

CVA, cerebrovascular accident; ECC, extracorporeal circulation; LVEF, left ventricular ejection fraction; PASP, pulmonary artery systolic pressure.

Data expressed as No. (%) or mean ± SD.

A multivariate analysis was performed to identify predictors of perioperative mortality. The analysis included left ventricular ejection fraction < 45%, the only variable significantly associated with the event in the univariate analysis (Table of the supplementary material), as well as the variables identified as predictors in our previous study (age, duration of extracorporeal circulation).2 The only predictor of perioperative mortality was left ventricular ejection fraction < 45% (odds ratio, 10.531; 95% confidence interval [CI], 1.262-87.905; P = .030).

After discharge following the operation, changes in TR were assessed in 66 of the 80 survivors (82.5%) in echocardiographic follow-up (median, 30 [interquartile range, 20-44] months). Severe TR occurred in 4 patients, all belonging to the group of ring-free annuloplasty (7.1% of patients with follow-up in this group). Predictors of the onset of severe TR during follow-up were not assessed, given its low incidence.

Mortality was assessed after a follow-up that included all survivors of the perioperative period (median, 38 [30.25-48] months).

Mortality during overall follow-up was 18.8% among patients alive on discharge from hospital and the overall mortality (perioperative and during overall follow-up) was 25.3%. A univariate analysis of overall mortality was performed (Table, Supplementary material) and multivariate analysis of the variables with a significant association was performed. The only predictor of overall mortality was the duration of extracorporeal circulation (hazard ratio, 1.012; 95% CI, 1.003-1.021; P=.009). The Figure shows the survival curve during follow-up of the cohort of patients in the study.

Figure.

Kaplan-Meier survival curves.

(0.06MB).

In the present study, perioperative mortality was 8%, comparable to that found in other extensive studies in Spain,3 but somewhat lower than 18.5%, the mortality rate obtained in our previous study.2 The reasons for the improved perioperative mortality in our study cannot be inferred from this study because of its design. One possibility would be that the indication for surgery is increasingly made in earlier stages of the disease, in line with studies that have shown higher mortality in patients with more advanced symptoms at the time of surgery.4 In addition, clinical and anesthetic experience acquired over time has probably also had a positive impact on outcomes. It is foreseen that these outcomes may be improved through use of different percutaneous treatments already developed for the treatment of severe TR, with a low periprocedural morbidity and mortality.5

In our study, the duration of extracorporeal circulation was a predictor of overall mortality, as in our previous series.2 A long duration of extracorporeal circulation reflects greater valve comorbidity, which supports the prognostic value of this variable for follow-up.

In addition to the impossibility of identifying determinants of improved clinical outcomes, other limitations of this study are due to its retrospective and single-center nature, and the absence of data with prognostic value such as right ventricular volume and function.

In conclusion, in our series of patients with severe TR who underwent surgery, short- and long-term clinical outcomes bore little relation to the suboptimal findings of our previous series. Left ventricular ejection fraction < 45% was identified as a predictor of perioperative mortality, while duration of extracorporeal circulation was a predictor of long-term mortality.

References
[1]
J.M. González-Santos, M.E. Arnáiz-García.
Correcting tricuspid regurgitation: an unresolved issue.
Rev Esp Cardiol., 66 (2013), pp. 609-612
[2]
J. Rodríguez-Capitán, J.J. Gómez-Doblas, L. Fernández-López, et al.
Short- and long-term outcomes of surgery for severe tricuspid regurgitation.
Rev Esp Cardiol., 66 (2013), pp. 629-635
[3]
J.M. Bernal, A. Pontón, B. Díaz, et al.
Surgery for rheumatic tricuspid valve disease: a 30-year experience.
J Thorac Cardiovasc Surg., 136 (2008), pp. 476-481
[4]
Y. Topilsky, A.D. Khanna, J.K. Oh, et al.
Preoperative factors associated with adverse outcome after tricuspid valve replacement.
Circulation., 123 (2011), pp. 1929-1939
[5]
F. Campelo-Parada, O. Lairez, D. Carrié.
Percutaneous treatment of the tricuspid valve disease: new hope for the “forgotten” valve.
Rev Esp Cardiol., 70 (2017), pp. 856-866
Copyright © 2018. Sociedad Española de Cardiología
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