Isolated Tricuspid Valve Repair Versus Replacement: Predictors of Mortality on the National Level

Abstract

Objective: Isolated tricuspid valve surgery (TVR) is rarely performed, and literature reports are confined to small sample sizes and old studies. Thus, the advantage of repair over replacement could not be determined. We aimed to evaluate repair and replacement outcomes along with predictors of mortality for TVR on a national level. Methods: All adult patients (18+ years old) who underwent TVR from 2011 to 2020 were identified using the National Inpatient Sample dataset. The primary outcome was in-hospital mortality. Secondary outcomes included complications, length of stay (LOS), hospitalization cost, and discharge disposition. Results: Over a 10-year period, 37,931 patients had TVR and predominantly underwent repair ( n = 25,027, 66.0%). In comparison with patients who underwent tricuspid replacement, more patients with a history of liver disease and pulmonary hypertension presented for repair surgery, and fewer patients had endocarditis and rheumatic valve disease ( P < 0.001). The repair group had less mortality, less stroke, shorter LOS, and reduced cost, while the replacement group had fewer myocardial infarctions ( P < 0.05). However, the outcomes were not different for cardiac arrest, wound complications, or bleeding. After excluding congenital TV disease and adjusting for relevant factors, TV repair was associated with a reduced in-hospital mortality by 28% (adjusted odds ratio [aOR] = 0.72, P = 0.011). Older age increased mortality risk by 3-fold, prior stroke by 2-fold, and liver diseases by 5-fold ( P < 0.001). Patients undergoing TVR in recent years had a better chance of survival (aOR = 0.92, P < 0.001). Conclusions: TV repair has better outcomes than replacement does. Patient comorbidities and late presentation play an independently significant role in determining outcomes.

Outcomes of minimally invasive isolated tricuspid valve repair and replacement through right mini-thoracotomy

“…The urgent nature of the surgery, as well as age >50 years, functional etiology, and hepatic dysfunction were described as predictors in previous studies. 15 , 38 , 40 , 41 Due to the severity of TV regurgitation in our patients, the estimated pulmonary artery pressure by preoperative echocardiogram could be misleading. Although most patients underwent elective surgeries in our series, nonelective surgery was performed in 12% of patients (n = 6) and strongly associated with decreased overall survival, therefore suggesting the need for earlier surgical referral.…”

“…The current study adds important midterm outcomes data that demonstrate no increase in mortality between TVR and TVre over time following ITV surgery. 15 …”

“…We used bioprosthetic valves for TVR as the primary prosthesis of choice, consistent with patient preference and most other published series, 24 , 25 , 26 , 27 including our national ITV study (75% bioprosthetic [n = 6262] vs 25% mechanic valves [n = 2051] in secondary TV disease [supplementary material]). 15 However, within TVR surgery recommendations, the debate between mechanical versus bioprosthetic prostheses is still ongoing. Said and colleagues 28 found that ITV with a mechanical prosthesis is associated with increased early mortality.…”

“…Our national ITV study estimated an increased risk of in-hospital mortality due to late presentation—patients admitted nonelectively, with heart failure, and liver disease—of more than 2-fold. 15 Most Mini-TVS procedures involved a beating-assisted approach (59%) in order to optimize myocardial protection and limit dissection in these high-risk comorbid patients, especially in redo scenarios. However, beating-heart surgery showed no significant association with overall survival, perhaps due to a small sample size.…”

Impact of Bariatric Surgery on Mortality of Mitral Valve Surgery: A National Analysis

“…Consideration for class imbalance was made. Thus, following an earlier example from this journal, 11 we performed a sensitivity analysis between weighting our final model and unweighted (using random oversampling) before presenting the final results (Supplemental Table 2). Significance was determined using α = 0.05, and P values <0.05 were considered statistically significant.…”