Our study of more than 20,000 patients demonstrates that grade of TR is associated with increased risk of mortality after cardiac surgery. In addition, all patients who underwent TV surgery had a statistically significantly increased likelihood of survival compared with those with the same degree of TR who did not undergo TV surgery.
Background
The association between long-term mortality and aortic atheroma in
cardiac surgical patients has not been comprehensively investigated. In this
study we determine the relationship between grade of atheroma and the risk
of long-term mortality in a retrospective cohort of over 20,000 patients
undergoing cardiac surgery over a 20 - year period.
Methods
We included 22,304 consecutive intraoperative transesophageal and
epiaortic ultrasound examinations performed at Brigham and Women’s
Hospital between 1995 and 2014, with long-term follow-up. The extent of
atheromatous disease recorded in each examination was used for analysis.
Mortality data was obtained from our institution’s data registry.
Mortality analyses were done using Cox proportional hazard regression models
with follow-up as a time scale. We repeated the analysis in a subgroup of
14,728 patients with more detailed demographics, including postoperative
stroke, queried from the institutional Society of Thoracic Surgeons
database.
Results
A total of 7,722 mortality events and 872 stroke events occurred.
Patients with atheromatous disease demonstrated a significant increase in
mortality across all grades of severity, both for the ascending and
descending aorta. This relationship remained unchanged after adjusting for
additional covariates. Adjustments for postoperative stroke resulted in only
minimal attenuation in the risk of postoperative mortality related to aortic
atheroma.
Conclusions
Aortic atheromatous disease of any grade in the ascending and
descending aorta is a significant long-term risk of long-term, all-cause
mortality in cardiac surgery patients. This association remains independent
of other conventional risk factors, and is not related to postoperative
cerebrovascular accidents.
The tricuspid valve (TV), although occasionally considered "neglected" is the subject of renewed and increasing interest. Factors include an awareness that tricuspid value dysfunction is influential in patient outcomes, an improving understanding of valve anatomy and function and evolving techniques available to address tricuspid regurgitation. Tricuspid regurgitation (TR) can be classified as being due to primary diseases of the valve or functional in nature, with the majority being functional. Whilst it was previously believed that such functional TR, resulting from left sided disease, would resolve after correction of the underlying pathology this is now known not to be true. In fact, annular dilatation, TR and right ventricular dysfunction may all continue to progress after successful surgery on the aortic or mitral valve. Although there are many modalities with which to image the TV, this lecture will focus on echocardiography, primarily transesophageal echocardiography (TEE). In every patient undergoing cardiac surgery with TEE, a thorough and systematic examination of the TV structure and function should be performed, utilizing quantitative and qualitative measures with both 2D and 3D echocardiography. As the appearance of TR can be significantly influenced by hemodynamic factors, it is essential that echocardiography to investigate TR also be performed in the resting conscious state. Ideally, deciding whether the TV warrants operative attention at the time of planned cardiac surgery should be determined preoperatively based on a high quality transthoracic echocardiography (TTE) and relevant patient and surgical factors. This lecture aims to give an overview of the echocardiographic assessment of the TV, parameters available to grade the severity of TR, and how these may be utilized to assist the surgeon considering intervention. Whilst the surgical management at the extremes of TR (mild or severe) is relatively clear, the ideal intervention in intermediate grades, especially during concurrent left sided surgery remains uncertain and is the subject of ongoing research.
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