STS 2023, SAN DIEGO — The best practices for tricuspid valve surgery gained definition Sunday at STS 2023 as experts took the first steps to end the tricuspid’s undeserved reputation as the “forgotten valve.”
Qiudong (Kevin) Chen, MD, MS, research resident at Cedars-Sinai Medical Center Smidt Heart Institute in Los Angeles, California, presented the Richard E. Clark Memorial Paper, which demonstrated that:
· For non-endocarditis-related tricuspid regurgitation (TR), isolated tricuspid valve repair is associated with a lower risk of operative mortality (in-hospital or 30-days post-operative) than valve replacement.
· In the same population, beating heart surgery (repair or replacement) is associated with a lower risk of pacemaker implant, renal failure, and post-operative blood transfusions than surgery under cardioplegic arrest. However, no mortality benefit was identified.
· Higher pre-operative Model for End-Stage Liver Disease (MELD) scores were associated with higher operative mortality, especially for patients with MELD scores 20 or above.
Increased levels of tricuspid valve regurgitation are associated with worse survival rates, and operative mortality can be up to 11% in patients undergoing isolated surgery. Both these factors contributed to the need for this analysis on a larger population level in order to start uncovering optimal surgical strategies.
Dr. Chen and his surgeon colleagues conducted their review using the STS National Database™, which he called a “powerful, comprehensive tool” that allowed his team to review procedural trends and volumes from 2012 to 2019 across the US. He noted several limitations in the analysis, including lack of long-term outcomes and incomplete etiology.
From the Adult Cardiac Surgery Database, physician-scientists initially identified 14,704 patients who underwent isolated tricuspid valve surgery and further narrowed this to 6,507 patients with non-endocarditis-related tricuspid regurgitation, who were assessed in the study.
Although tricuspid regurgitation is common, the study confirmed that this disorder is extremely undertreated. Tricuspid repair and replacement remain rare surgeries nationwide: the investigators found that 93% of US medical centers performed five or fewer of these procedures annually. A majority of procedures were conducted with patients under cardiac arrest, followed by surgeries on patients with beating hearts and a small minority performed on patients with fibrillating hearts.
“I believe these findings suggest that in this patient population, tricuspid repair may be a safer option when feasible,” Dr. Chen said.
He was joined by senior co-authors Michael E. Bowdish, MD, MS, Jad Malas, MD, and Amy Roach, MD, all also from Cedars-Sinai, in this study.
“Surgical outcomes for isolated TR are poor, and we can do better by generating additional clinical evidence by identifying those patients with TR and operating on them early,” added James Gammie, MD, professor of surgery at Johns Hopkins Medicine, who served as discussant.
Putting tricuspid regurgitation in perspective, Dr. Gammie noted that about 1.6 million people in the US have significant TR, making the disease almost as prevalent as aortic stenosis.