A new risk-score model to predict in-hospital mortality after isolated tricuspid valve surgery for severe tricuspid regurgitation

Abstract Aims Isolated tricuspid valve surgery (ITVS) is considered to be a high-risk procedure, but in-hospital mortality is markedly variable. This study sought to develop a dedicated risk score model to predict the outcome of patients after ITVS for severe tricuspid regurgitation (TR). Methods and results All consecutive adult patients who underwent ITVS for severe non-congenital TR at 12 French centres between 2007 and 2017 were included. We identified 466 patients (60 ± 16 years, 49% female, functional TR in 49%). In-hospital mortality rate was 10%. We derived and internally validated a scoring system to predict in-hospital mortality using multivariable logistic regression and bootstrapping with 1000 re-samples. The final risk score ranged from 0 to 12 points and included eight parameters: age ≥70 years, New York Heart Association Class III–IV, right-sided heart failure signs, daily dose of furosemide ≥125 mg, glomerular filtration rate <30 mL/min, elevated bilirubin, left ventricular ejection fraction <60%, and moderate/severe right ventricular dysfunction. Tricuspid regurgitation mechanism was not an independent predictor of outcome. Observed and predicted in-hospital mortality rates increased from 0% to 60% and from 1% to 65%, respectively, as the score increased from 0 up to ≥9 points. Apparent and bias-corrected areas under the receiver operating characteristic curves were 0.81 and 0.75, respectively, much higher than the logistic EuroSCORE (0.67) or EuroSCORE II (0.63). Conclusion We propose TRI-SCORE as a dedicated risk score model based on eight easy to ascertain parameters to inform patients and physicians regarding the risk of ITVS and guide the clinical decision-making process of patients with severe TR, especially as transcatheter therapies are emerging (www.tri-score.com).

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Outcomes of Isolated Tricuspid Valve Surgery

The Heart Surgery Forum ◽

10.1532/hsf.3093 ◽

2020 ◽

Vol 23 (6) ◽

pp. E763-E769

Author(s):

Gemma Sánchez-Espín ◽

Jorge Rodríguez-Capitán ◽

Juan José Otero Forero ◽

Víctor Manuel Becerra Muñoz ◽

Emiliano Andrés Rodríguez Caulo ◽

...

Keyword(s):

Tricuspid Valve ◽

Tricuspid Regurgitation ◽

Functional Class ◽

Valve Surgery ◽

Perioperative Mortality ◽

Severe Tricuspid Regurgitation ◽

Tricuspid Valve Surgery ◽

Long Term Mortality

Background: Isolated tricuspid valve surgery is a rarely performed procedure and traditionally is associated with a bad prognosis, although its clinical outcomes still are little known. The aim of this study was to assess the short- and long-term clinical outcomes obtained at our center after isolated tricuspid valve surgery as treatment for severe tricuspid regurgitation. Methods: This retrospective study included 71 consecutive patients with severe tricuspid regurgitation who underwent isolated tricuspid valve surgery between December 1996 and December 2017. Perioperative and long-term mortality, tricuspid valve reoperation, and functional class were analyzed after follow up. Results: Regarding surgery, 7% of patients received a De Vega annuloplasty, 14.1% an annuloplasty ring, 11.3% a mechanical prosthesis, and 67.6% a biological prosthesis. Perioperative mortality was 12.7% and no variable was shown to be predictive of this event. After a median follow up of 45.5 months, long-term mortality was 36.6%, and the multivariate analysis identified atrial fibrillation as the only predictor (Hazard Ratio 3.014, 95% confidence interval 1.06-8.566; P = 0.038). At the end of follow up, 63.6% of survivors had functional class I. Conclusions: Isolated tricuspid valve surgery was infrequent in our center. Perioperative mortality was high, as was long-term mortality. However, a high percentage of survivors were barely symptomatic after follow up.

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P288 Prognostic role of hemoglobin levels in patients with severe tricuspid regurgitation

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.142 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

A Garcia Martin ◽

R Hinojar ◽

A Gonzalez Gomez ◽

M Plaza Martin ◽

M Pascual Izco ◽

...

Keyword(s):

Heart Failure ◽

Iron Deficiency ◽

Ejection Fraction ◽

Tricuspid Valve ◽

Tricuspid Regurgitation ◽

Valve Surgery ◽

Therapeutic Options ◽

Severe Tricuspid Regurgitation ◽

End Point ◽

Tricuspid Valve Surgery

Abstract Background Patients with severe tricuspid regurgitation (TR) frequently develop heart failure (HF) and their surgical therapeutic options are limited because of very high or prohibitive risk. According to the 2016 ESC guidelines for HF, anaemia and iron deficiency are associated with worse prognosis and intravenous iron therapy should be considered in symptomatic patients with HF reduced ejection fraction (HFrEF) in order to alleviate symptoms, improve exercise capacity and quality of life. The effect of treating iron deficiency in HF preserved ejection fraction (HFpEF) is unknown. The purpose of this study was to analyze the correlation between levels of hemoglobin (Hb) and the prognosis in patients with severe TR and preserve EF. Methods Consecutive patients with significant TR (moderate to severe or severe by echocardiography) evaluated in the Heart Valve Clinic between 2015-2018 were included. End-point included cardiovascular mortality, tricuspid valve surgery or heart failure. Results A total of 70 patients were included (mean age was 74± 8 years, 71% females). According to aetiology, 94% were functional TR (60% due to left valve disease, 27% due to tricuspid annulus dilatation, 13% others). Mean left ventricular ejection fraction was 56,5% ±6,7%. During a median follow up of 18 months [IQR: 4-28], 35% of the patients reached the combined end-point (n = 16 developed right HF, n = 17 underwent tricuspid valve surgery, and n = 3 died). Patients with events showed lower Hb values (p = 0.04). The level of anaemia was a prognostic factor of the combined endpoint (per gr/dl, HR 0.77 [0-61-0.98], p = 0.036). Conclusion Hemoglobin is predictive of poor outcomes in patients with significant TR. According to these preliminary results, iron deficiency could be a therapeutic target in this subgroup of patients with limited therapeutic options.

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Faculty Opinions recommendation of TRI-SCORE: a new risk score for in-hospital mortality prediction after isolated tricuspid valve surgery.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.740896218.793589354 ◽

2021 ◽

Author(s):

Michele De Bonis ◽

Davide Carino

Keyword(s):

Hospital Mortality ◽

Tricuspid Valve ◽

Risk Score ◽

Mortality Prediction ◽

Valve Surgery ◽

Tricuspid Valve Surgery

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Tricuspid valve surgery for severe tricuspid regurgitation: Table 1

Heart ◽

10.1136/heartjnl-2012-303063 ◽

2012 ◽

Vol 99 (3) ◽

pp. 149-150 ◽

Cited By ~ 6

Author(s):

Ottavio Alfieri ◽

Michele De Bonis

Keyword(s):

Tricuspid Valve ◽

Tricuspid Regurgitation ◽

Valve Surgery ◽

Severe Tricuspid Regurgitation ◽

Tricuspid Valve Surgery

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Haemodynamic determinants of improved aerobic capacity after tricuspid valve surgery in Ebstein anomaly

Heart ◽

10.1136/heartjnl-2020-317756 ◽

2020 ◽

pp. heartjnl-2020-317756

Author(s):

Alexander Egbe ◽

William Miranda ◽

Heidi Connolly ◽

Joseph Dearani

Keyword(s):

Relative Risk ◽

Tricuspid Valve ◽

Aerobic Capacity ◽

Tricuspid Regurgitation ◽

Valve Surgery ◽

Ebstein Anomaly ◽

Severe Tricuspid Regurgitation ◽

Tricuspid Valve Surgery ◽

Postoperative Improvement

BackgroundAlthough tricuspid valve surgery improves functional capacity in patients with Ebstein anomaly, it is not always associated with improvement in aerobic capacity. The purpose of this study was to identify the determinants of improved aerobic capacity after tricuspid valve surgery in adults with Ebstein anomaly with severe tricuspid regurgitation.MethodsRetrospective study of patients with severe tricuspid regurgitation due to Ebstein anomaly that had tricuspid valve surgery at Mayo Clinic Rochester (2000–2019) and had preoperative and postoperative cardiopulmonary exercise tests and echocardiograms. The patients were divided into aerobic capacity(+) and aerobic capacity(-) groups depending on whether they had postoperative improvement in %-predicted peak oxygen consumption (VO2).ResultsOf 76 patients with severe tricuspid regurgitation due to Ebstein anomaly, 28 (37%) and 48 (63%) were in aerobic capacity(+) and aerobic capacity(-) groups, respectively. The average improvement in peak VO2 was 2.1±1.4 mL/kg/min and −0.9±0.4 mL/kg/min in the in aerobic capacity(+) and aerobic capacity(-) groups, respectively. Although both groups had similar severity of residual tricuspid regurgitation, the aerobic capacity(+) group had more postoperative improvement in right atrial (RA) function, left atrial (LA) function and left ventricular preload and stroke volume. Of the preoperative variables analysed, RA reservoir strain (relative risk 1.12; 95% CI 1.06 to 1.18); LA reservoir strain (relative risk 1.09; 95% CI 1.04 to 1.14) and LV stroke volume index (OR 1.04; 95% CI 1.01 to 1.07) were predictors of postoperative improvement in peak VO2.ConclusionsOne-third of patients with severe tricuspid regurgitation due to Ebstein anomaly had postoperative improvement in aerobic capacity, and atrial function indices were the best predictors of postoperative improvement in aerobic capacity. These data provide new insight into the haemodynamic determinants of exercise capacity and lay the foundation for further studies to determine whether postoperative improvement in aerobic capacity translates to improved long-term survival, and whether timing of tricuspid valve surgery based on these echocardiographic indices will improve long-term outcomes.

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Recent advances in managing tricuspid regurgitation

F1000Research ◽

10.12688/f1000research.13328.1 ◽

2018 ◽

Vol 7 ◽

pp. 355 ◽

Cited By ~ 4

Author(s):

Benedetto Del Forno ◽

Elisabetta Lapenna ◽

Malcom Dalrymple-Hay ◽

Maurizio Taramasso ◽

Alessandro Castiglioni ◽

...

Keyword(s):

Clinical Experience ◽

Tricuspid Valve ◽

Tricuspid Regurgitation ◽

Treatment Options ◽

Valve Surgery ◽

Attractive Alternative ◽

High Morbidity ◽

Severe Tricuspid Regurgitation ◽

Tricuspid Valve Surgery ◽

Very High

Isolated tricuspid valve surgery is usually carried out with very high morbidity and mortality given the complexity of the affected patients. In light of this, trans-catheter tricuspid valve interventions have been emerging as an attractive alternative to surgery over the last few years. Although feasibility has been shown with a number of devices, clinical experience remains preliminary and associated with significant clinical and technical challenges. Here we describe currently available trans-catheter treatment options for severe tricuspid regurgitation implanted in different locations.

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Isolated tricuspid valve surgery: impact of aetiology and clinical presentation on outcomes

European Heart Journal ◽

10.1093/eurheartj/ehaa643 ◽

2020 ◽

Vol 41 (45) ◽

pp. 4304-4317 ◽

Cited By ~ 2

Author(s):

Julien Dreyfus ◽

Michele Flagiello ◽

Baptiste Bazire ◽

Florian Eggenspieler ◽

Florence Viau ◽

...

Keyword(s):

Hospital Mortality ◽

Tricuspid Valve ◽

Tricuspid Regurgitation ◽

Clinical Presentation ◽

Statistical Significance ◽

Nyha Class ◽

Valve Surgery ◽

Administrative Database ◽

Tricuspid Valve Surgery ◽

The Impact

Abstract Aims The aim of this study was to identify determinants of in-hospital and mid-term outcomes after isolated tricuspid valve surgery (ITVS) and more specifically the impact of tricuspid regurgitation (TR) mechanism and clinical presentation. Methods and results Among 5661 consecutive adult patients who underwent a tricuspid valve (TV) surgery at 12 French tertiary centres in 2007–2017 collected from a mandatory administrative database, we identified 466 patients (8% of all tricuspid surgeries) who underwent an ITVS. Most patients presented with advanced disease [47% in New York Heart Association (NYHA) III/IV, 57% with right-sided heart failure (HF) signs]. Tricuspid regurgitation was functional in 49% (22% with prior left-sided heart valve surgery and 27% isolated) and organic in 51% (infective endocarditis in 31% and other causes in 20%). In-hospital mortality and major complications rates were 10% and 31%, respectively. Rates of survival and survival free of HF readmission were 75% and 62% at 5 years. Patients with functional TR incurred a worse in-hospital mortality than those with organic TR (14% vs. 6%, P = 0.004), but presentation was more severe. Independent determinants of outcomes were NYHA Class III/IV [odd ratios (OR) = 2.7 (1.2–6.1), P = 0.01], moderate/severe right ventricular dysfunction [OR = 2.6 (1.2–5.8), P = 0.02], lower prothrombin time [OR = 0.98 (0.96–0.99), P = 0.008], and with borderline statistical significance, right-sided HF signs [OR = 2.4 (0.9–6.5), P = 0.06] while TR mechanism was not [OR = 0.7 (0.3–1.8), P = 0.88]. Conclusion Isolated TV surgery was associated with high mortality and morbidity, both in hospital and during follow-up, predicted by the severity of the presentation but not by TR mechanism. Our results suggest that TV intervention should be performed earlier in the course of the disease.

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Prevalence of moderate-to-severe TR suitable for percutaneous intervention in TTE patients

Echo Research and Practice ◽

10.1530/erp-18-0018 ◽

2018 ◽

pp. 149-153

Author(s):

Z H Teoh ◽

J Roy ◽

J Reiken ◽

M Papitsas ◽

J Byrne ◽

...

Keyword(s):

Tricuspid Valve ◽

Tricuspid Regurgitation ◽

Transthoracic Echocardiography ◽

Operative Mortality ◽

Percutaneous Intervention ◽

Valve Surgery ◽

Severe Tricuspid Regurgitation ◽

Mortality And Morbidity ◽

Tricuspid Valve Surgery ◽

Tertiary Center

Moderate-to-severe tricuspid regurgitation is associated with higher mortality and morbidity yet remains significantly undertreated. The reasons for this are complex but include a higher operative mortality for patients undergoing isolated tricuspid valve surgery. This study sought to determine the prevalence of patients with moderate-to-severe tricuspid regurgitation and identify those who could be potentially suitable for percutaneous tricuspid valve intervention by screening patients referred for transthoracic echocardiography (ECHO) at a tertiary center. Our results showed that the prevalence of moderate-to-severe tricuspid regurgitation in our total ECHO patient population was 2.8%. Of these, approximately one in eight patients with moderate-to-severe tricuspid regurgitation would be potentially suitable for percutaneous intervention and suggests a large, unmet clinical need in this population.

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