This study evaluated contemporary practices and outcomes of isolated tricuspid valve surgeries at the population level, using the STS Adult Cardiac Surgery Database.
After excluding patients with certain conditions (endocarditis, tricuspid stenosis, emergency surgeries, prior heart transplant), 6,507 patients were analyzed. Endpoints included intraoperative mortality and major postoperative complications.
The results indicated an increase in isolated tricuspid valve operations, from 983 cases in 2012 to 2,155 cases in 2019. The median annual volume per center was 2 cases, and 40% of patients had New York Heart Association (NYHA) class III/IV heart failure (HF). Intraoperative mortality was 7.3%, and the rate of new permanent pacemaker implantation was 10.8%. Factors associated with perioperative mortality included NYHA class III/IV HF, non-elective surgeries, tricuspid replacement, annual volume of 5 or fewer cases per center, and higher scores on the Model for End-Stage Liver Disease (MELD). Beating heart surgery was associated with a lower adjusted risk of pacemaker implantation, renal failure, and blood transfusions compared to arrested heart surgery with cardioplegia.
In conclusion, this study found that isolated tricuspid valve repair was associated with lower adjusted mortality and complication rates compared to tricuspid valve replacement. Beating heart surgery was associated with fewer major complications.
COMMENTARY:
The tricuspid valve has often been referred to as the “forgotten valve.” However, its prevalence is increasing with the aging population, and its study is gaining attention in the medical community. Surgical treatment is more commonly performed in conjunction with left-sided valve operations, while isolated tricuspid valve replacement is performed in only 14% to 20% of cases.
Current European clinical practice guidelines for isolated tricuspid valve surgery recommend surgery at a level I, with level C evidence, for symptomatic patients with severe tricuspid stenosis. Regarding tricuspid regurgitation, surgery is recommended at a level I and level C evidence for cases of severe symptomatic tricuspid regurgitation without right ventricular dysfunction. Surgery is also recommended at a level IIa and level C evidence for asymptomatic or mildly symptomatic patients with primary tricuspid regurgitation and right ventricular dilation. For secondary tricuspid regurgitation, a level IIa recommendation with level B evidence suggests considering surgery for symptomatic patients or those with right ventricular dilation in the absence of severe left or right ventricular dysfunction and severe pulmonary hypertension.
These recommendations are primarily based on level C evidence, that is, expert consensus or retrospective studies or studies with small sample sizes. Therefore, this STS registry provides valuable insights into the outcomes of tricuspid surgery that may assist decision-making for a relatively uncommon procedure (in the United States, an average of 2 cases per center per year).
It was observed that markers indicating worsening valvular disease severity, such as NYHA class III/IV functional class, non-elective surgeries, advanced age, and a high MELD score for liver disease, were associated with higher mortality. Identifying these risk factors may assist the medical team in decision-making for cases where an interventional alternative may be considered. In symptomatic cases with some of these characteristics and specific anatomical particularities, percutaneous tricuspid valve intervention is a viable option, as discussed in a recent publication on this blog.
Regarding differences between repair and replacement, prosthesis implantation was preferred for patients with more comorbidities. After statistical adjustment, replacement was associated with higher mortality and complications, including an increased rate of permanent pacemaker implantations and renal failure. However, these results should be interpreted cautiously. In cases where valve replacement was performed, a biological prosthesis was chosen in over 90% of cases, following the trend of avoiding mechanical prostheses in the right chambers, which could be associated with a higher risk of thrombosis.
Finally, another technical aspect considered in the registry was performing the surgery with a beating heart or cardiac arrest using cardioplegia. Better outcomes were observed for surgeries performed with a beating heart, with no differences in mortality and a lower rate of major complications. However, the authors acknowledge that this should be a decision based on surgeon preference.
The STS registry provides extensive knowledge about a rare surgery, as it is a prospective study that includes a large sample size. However, it lacks variables analyzing right ventricular function in operated patients. Additionally, there is a need for variables and elements that could provide evidence-based guidance on decisions for patients with pacemakers who receive prostheses in the tricuspid position, as well as long-term follow-up outcomes for isolated tricuspid surgery.
REFERENCE:
Chen Q, Bowdish ME, Malas J, Roach A, Gill G, Rowe G, et al. Isolated Tricuspid Operations: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis. Ann Thorac Surg. 2023 May;115(5):1162-1170. doi: 10.1016/j.athoracsur.2022.12.041.
