Predictive value of acute kidney injury for major adverse cardiovascular events following tricuspid annuloplasty: A comparison of three consensus criteria.

BACKGROUND: Tricuspid annuloplasty (TA) is increasingly being performed, but the clinical outcome is unsatisfactory. Acute kidney injury (AKI) is a common complication following cardiac surgery and predicts outcome. Nonetheless the occurrence rate and prognostic value of AKI after TA are unclear. METHODS: This study reviewed 339 consecutive patients (age 65±11 years; male 42%) who underwent TA. The incidence of AKI was defined according to risk/injury/failure/loss/end stage (RIFLE), acute kidney injury network (AKIN), and kidney disease improving global outcomes (KDIGO) criteria, respectively. Major adverse cardiovascular events (MACE) was defined as death, heart failure, stroke, and myocardial infarction (MI). The influence of AKI on MACE was evaluated as a short-term outcome and outcome beyond 30 days. RESULTS: The incidence of AKI, defined according to RIFLE, AKIN, and KDIGO was 57%, 52%, and 53%, respectively. MACE occurred in 94 cases (21 deaths, 63 heart failure requiring hospitalization, 7 stroke, and 3 MI). For short-term outcome, AKI defined by all three scoring systems was independently associated with MACE and death (p<0.01 for both), but not heart failure, stroke, or MI. For outcome beyond 30 days, AKI by all three criteria was associated with MACE and heart failure. Only AKI by AKIN and KDIGO, but not RIFLE, was independently associated with death. CONCLUSION: Our data suggest AKI affects over half of all patients who undergo TA, and has a major and long-lasting impact on survival, MACE, and heart failure. Use of AKIN and KDIGO is more useful than the RIFLE criteria when determining the prognostic value of AKI for mortality beyond 30 days.

Prevalence, Predictors and Clinical Outcome of Residual Pulmonary Hypertension Following Tricuspid Annuloplasty.

BACKGROUND: Tricuspid annuloplasty is increasingly performed during left heart valve surgery, but the long-term clinical outcome postoperatively is not satisfactory. The aim of this study was to determine whether residual pulmonary hypertension (PHT) contributes to the adverse outcome. METHODS AND RESULTS: One-hundred thirty-seven patients (age 61±11 years; men, 30%) who underwent tricuspid annuloplasty during left-side valve surgery were enrolled. The mean pulmonary artery systolic pressure before surgery was 49±13 mm Hg and 32±15 mm Hg following surgery. Patients were divided into 3 groups according to postoperative pulmonary artery systolic pressure: no residual PHT (n=78, 57%), mild residual PHT (n=43, 31%), or significant residual PHT (n=16, 12%). A preoperative larger right ventricular (RV) geometry and tricuspid valve tethering area were associated with mild or significant residual PHT. A total of 24 adverse events (20 heart failures and 4 cardiovascular deaths) occurred during a median follow-up of 25 months. Kaplan-Meier survival curve demonstrated that patients with significant residual PHT had the highest percentage of adverse events followed by those with mild residual PHT. Patients with no residual PHT had a very low risk of adverse events. Multivariable Cox regression analysis revealed that both mild (hazard ratio=4.94; 95% CI =1.34-18.16; P=0.02) and significant residual PHT (hazard ratio=8.67; 95% CI =2.43-30.98; P<0.01) were independent factors associated with adverse events. CONCLUSIONS: The present study demonstrated that 43% of patients who underwent tricuspid annuloplasty had residual PHT. The presence of mild or significant residual PHT was associated with adverse events in these patients.

Prognostic value of preoperative right ventricular geometry and tricuspid valve tethering area in patients undergoing tricuspid annuloplasty.

BACKGROUND: Patients who undergo tricuspid annuloplasty during left-side heart valve surgery have a poor postoperative clinical outcome. However, preoperative right ventricular (RV) echocardiography parameters that predict adverse events in these patients are poorly understood. METHODS AND RESULTS: We studied 74 patients (age, 58±10 years; men, 27%) with significant tricuspid regurgitation who consequently underwent tricuspid annuloplasty during left-side heart valve surgery. A total of 26 adverse events (22 heart failures and 4 cardiovascular deaths) occurred during a median follow-up of 26 months. RV midcavity diameter (hazard ratio=2.44; 95% confidence interval=1.48-4.02; P<0.01), RV longitudinal dimension (hazard ratio=1.64; 95% confidence interval=1.10-2.45; P=0.02), and tricuspid valve tethering area (hazard ratio=3.25; 95% confidence interval=1.71-6.19; P<0.01) were independently associated with adverse events after adjustment for age and New York Heart Association class III/IV. Receiver-operator characteristic curve analysis demonstrated that RV midcavity diameter (area under the curve=0.74; P<0.01) and tricuspid valve tethering area (area under the curve=0.70; P=0.04) were most associated with adverse events at the 1-year follow-up. The presence of either a large RV midcavity diameter or tricuspid valve tethering area was predictive of adverse outcome at 1 year after tricuspid annuloplasty. CONCLUSIONS: The present study demonstrates that RV geometry dimensions, namely RV midcavity diameter and tricuspid valve tethering area, are important preoperative measures associated with adverse events in patients undergoing tricuspid annuloplasty.