20 Years of Triple-Valve Surgery in the United Kingdom: Demographic and Outcome Trends.

OBJECTIVES: To describe evolving demographic trends and early outcomes in patients undergoing triple-valve surgery in the UK, between 2000-2019. METHODS: We planned a retrospective analysis of national registry data including patients undergoing triple valve surgery for all aetiologies of disease. We excluded patients in a critical preoperative state and those with missing admission dates. The study cohort was split into 5 consecutive 4-year cohorts (groups A, B, C, D and E). The primary outcome was in-hospital mortality, and secondary outcomes included prolonged admission, re-exploration for bleeding, postoperative stroke and postoperative dialysis. Binary logistic regression models were used to establish independent predictors of mortality, stroke, postoperative dialysis and re-exploration for bleeding in this high-risk cohort. RESULTS: We identified 1,750 patients undergoing triple-valve surgery in the UK between 2000-2019. Triple valve surgery represents 3.1% of all patients in the dataset. Overall mean age of patients was 68.5 years ±12, having increased from 63 years ±12 in group A to 69 years ±12 in group E (p < 0.001). Overall in-hospital mortality rate was 9%, dropping from 21% in group A to 7% in group E (p < 0.001). Overall rates of re-exploration for bleeding (11%, p = 0.308) and postoperative dialysis (11%, p = 0.066) remained high across the observed time period. Triple valve replacement, redo sternotomy and poor preoperative left ventricular ejection fraction emerged as strong independent predictors of mortality. CONCLUSIONS: Triple valve surgery remains rare in the UK. Early postoperative outcomes for triple valve surgery have improved over time. Redo sternotomy is a significant predictor of mortality. Attempts should be made to repair the mitral and/or tricuspid valves where technically possible.

The Right Coronary Anatomy and Operative Topography of the Tricuspid Valve Annulus.

BACKGROUND: The region of the tricuspid valve is an important area for various cardiac interventions. In particular, the spatial relationships between the right coronary artery and the annulus of the tricuspid valve should be considered during surgical interventions. The aim of this study was to provide an accurate description of the clinical anatomy and topography of this region. METHODS: We analyzed 107 computed tomography scans (44% female, age 62.1 ± 9.4 years) of the tricuspid valve region. The circumference of the free wall of the tricuspid valve annulus was divided into 13 annular points and measurements were taken at each point. The prevalence of danger zones (distance between artery and annulus less than 2 mm) was also investigated. RESULTS: Danger zones were found in 20.56% of the cases studied. The highest prevalence of danger zones and the smallest distances were found at the annular points of the tricuspid valve located at the posterior insertion of the leaflets, without observed sex-specific differences. CONCLUSION: The highest risk of iatrogenic damage to the right coronary artery is in the posterior part of the tricuspid valve annulus.

Surgical repair for primary tricuspid regurgitation related to trauma.

We report a case of a 45-year-old man presenting with tachycardia and palpitation. Echocardiography indicated severe tricuspid regurgitation. We suspected traumatic tricuspid damage due to high energy trauma in a motor vehicle accident 17 years earlier. He underwent a sternotomy, and his tricuspid valve was repaired with chordal reconstruction, indentation closure, and ring annuloplasty. The postoperative period was uneventful, and he was discharged 10 days after the operation. This report highlights the value of echocardiography for diagnosis of primary tricuspid regurgitation related to trauma, and the importance of early diagnosis to allow surgical intervention before irreversible damage occurs. Learning objective: Traumatic tricuspid regurgitation is a rare cardiovascular complication of blunt chest trauma. The mechanism of the tricuspid valve injury is thought to be secondary to sudden impact causing an anteroposterior compression of the right ventricle by the sternum in end-diastole. This injury is often incidentally identified or can be missed until the patient experiences symptoms of right heart failure resulting from severe tricuspid regurgitation.

Tricuspid valve repair and replacement for infective endocarditis.

Infective endocarditis represents a challenging and life-threatening clinical condition affecting native and prosthetic heart valves, endocardium, and implanted cardiac devices. Right-sided infective endocarditis account for approximately 5-10% of all infective endocarditis and are often associated with intravenous drug use, intracardiac devices, central venous catheters, and congenital heart disease. The tricuspid valve is involved in 90% of right-side infective endocarditis. The primary treatment of tricuspid valve infective endocarditis is based on long-term intravenous antibiotics. When surgery is required, different interventions have been proposed, ranging from valvectomy to various types of valve repair to complete replacement of the valve. Percutaneous removal of vegetations using the AngioVac system has also been proposed in these patients. The aim of this narrative review is to provide an overview of the current surgical options and to discuss the results of the different surgical strategies in patients with tricuspid valve infective endocarditis. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01650-0.

Concomitant tricuspid valve regurgitation repair in patients with minimally invasive mitral valve surgery: a single-centre experience in Vietnam.

Background: This study aims to present the early and mid-term outcomes of combining minimally invasive mitral valve surgery (MIMVS) with tricuspid valve repair (TVR) at the authors' centre. Methods: From January 2017 to March 2022, our centre treated a total of 67 patients with both MIMVS and TVR. Among these patients, 41 were women (61.2%), and 26 were men (38.8%). The average Euro SCORE II was 2.67±1.54%, and the patients had an average follow-up period of 25.45±16.2 months. Results: Pre-discharge echocardiography revealed no or mild TR in 82.8% of cases. The overall 30-day mortality rate was 4.5%, with 3 deaths. Five-year survival was 94.5%±3.2%. In patients with mild or moderate preoperative tricuspid regurgitation (TR), the 5-year survival rate was 95.7%±4.3%, while for those with severe TR, it was 93.7%±4.5% (P=0.947). Conclusions: The authors' 5-year experience demonstrates that the combination of MIMVS and TVR can be routinely performed with favourable perioperative and postoperative outcomes in patients undergoing non-high-risk surgery. Additionally, there is no significant difference in five-year survival between the severe TR and mild to moderate TR groups preoperatively.

A Large Tricuspid Subvalvular Apparatus Infective Endocarditis Undetected by Transthoracic Echocardiography.

A 39-year-old male with a history of intravenous drug use (IVDU) and no significant cardiovascular disease was admitted to the ICU for management of septic shock and acute hypoxic respiratory failure secondary to septic pulmonary emboli. Due to a high clinical suspicion for right-sided infective endocarditis (IE), he received a transthoracic echocardiogram (TTE), which did not reveal any vegetations. However, a transesophageal echocardiogram (TEE) was subsequently performed; this showed a large 2.4 cm vegetation in the septal aspect of the tricuspid valve (TV) subvalvular apparatus. He urgently underwent surgical removal of the vegetation and repair of the TV. Postoperatively, he clinically recovered with appropriate antibiotic therapy. TEE is the ideal imaging modality in evaluation for IE, but a minimally invasive TTE is often performed first. This case highlights a highly unusual anatomic location of IE, which harbored a large vegetation undetected by TTE. In patients without cardiac devices or non-native valves, an urgent TEE remains diagnostically essential if there is a high clinical suspicion for right-sided IE, even if a TTE shows no evidence of IE.

Personalized Guidance of Edge-to-Edge Transcatheter Tricuspid Valve Repair by Multimodality Imaging.

Background: Transcatheter edge-to-edge tricuspid valve repair (T-TEER) for tricuspid regurgitation (TR) is always guided by transesophageal echocardiography (TEE). As each patient has unique anatomy and acoustic window, adding transthoracic echocardiography (TTE) and cardiac CT could improve procedural planning and guidance. Objectives: We aimed to assess T-TEER success and outcomes of a personalized guidance approach, based on multimodality imaging (MMI) of patient-tailored four right-sided chamber views (four-right-ch), as depicted by CT, TTE, TEE and fluoroscopy. Methods: Patients were assigned to MMI or classical TEE guidance, depending on TTE acoustic window. In MMI patients, planning included cardiac CT, which determined the fluoroscopic angulations of the specific four-right-ch, while guidance relied heavily on TTE, with minimal intermittent TEE for leaflet grasping and result confirmation. Both TTE and TEE were matched to respective CT and fluoroscopy four-right-ch. TR severity and quality of life (QoL) parameters were assessed from baseline to 12 months. Results: A total of 40 T-TEER patients were included, with 17 procedures guided by MMI and 23 solely by TEE. Baseline characteristics were similar between groups, e.g., age (83.1 ± 4.1 vs. 81 ± 5.3, p = 0.182) or STS-Score (11.1 ± 7.4% vs. 10.6 ± 5.9%, p = 0.813). The primary efficacy endpoint of ≥one-grade TR reduction at 30 days was 94% (16/17) in MMI vs. 91% (21/23) in TEE patients, with two or more TR grade reduction in 65% vs. 52% (p = 0.793). Device success was overall 100%, with no device-related complications, but three TEE-associated cases of gastrointestinal bleeding in the TEE-only group. By 12 months, all 15 MMI and 19 TEE survivors improved NYHA functional class and QoL, e.g., Kansas City Cardiomyopathy Questionnaire Score Δ29.6 ± 6.7 vs. 21.9 ± 5.8 (p = 0.441) pts., 6-min walk distance Δ101.5 ± 36.4 vs. 85.7 ± 32.1 (p = 0.541) meters. Conclusions: In a subset of patients with good TTE acoustic window, MMI guidance of T-TEER is effective and seems to avoid gastroesophageal injuries caused by TEE probe manipulation. TR reduction, irrespective of guidance method, impacts long-term QoL.

Simultaneous Tricuspid Valve Repair at the Time of Mitral Valve Surgery: Determinants of Postoperative Pacemaker Implantation.

OBJECTIVE: Guidelines recommend tricuspid valve (TV) repair for patients with severe tricuspid valve regurgitation (TR) undergoing surgery for degenerative mitral valve (MV) disease, but management of ≤ moderate TR is controversial. This study examines the incidence and causes of bradyarrhythmias leading to PPM implantation. METHODS: Review of patients undergoing simultaneous TV repair and MV surgery for degenerative MV disease from 2001 to 2022 (N=404). Primary endpoint was the incidence of postoperative PPM implantation. Secondary endpoints included the incidence of high-degree AV block and overall survival. RESULTS: All patients underwent TV repair at the time of MV surgery; 332 (82%) underwent MV repair and 72 (18%) MV replacement. Tricuspid valve repair techniques included flexible band (n=258, 63.8%), DeVega annuloplasty (n=78, 19.3%), complete flexible ring (n=49, 12.1%), and incomplete rigid ring (n=19, 4.7%). The 30-day mortality was 0.5% (n=2). A total of 35 (8.7%) patients had a PPM implanted postoperatively, 26 (6.4%) for high-degree AV block. On multivariable analysis, only older age was associated with PPM implantation. Patients who received a PPM due to high-degree AV block had reduced overall survival (Figure, p=0.01). CONCLUSIONS: Need for permanent pacing following TV repair at the time of MV surgery is not uncommon, but there are few modifiable factors that might reduce this risk. Careful selection of patients with less-than-severe TR and surgical techniques may reduce PPM-related risks and complications.

Effect of concomitant tricuspid annuloplasty on postoperative wound complications in heart failure patients undergoing mitral valve repair.

Tricuspid valve repair (TVR) combined with mitral valve surgery (MVS) has been a controversial issue. It is not clear whether the combined surgery has any influence on the occurrence of postoperative complications. The aim of this study was to compare the occurrence of complications including wound infection, wound bleeding, and mortality after MVS combined with or without TVR. By meta-analysis, a total of 1576 papers were collected from 3 databases, and 7 of them were included. We provided the necessary data of 7 included studies such as the authors, publication date, country, surgical approach and case number, patient age, and so on. Statistical analysis was carried out with RevMan 5.3 software. We found that patients with heart failure accepting MVS combined with or without TVR, performed no statistically significant difference in postoperative wound infection (OR: 0.88; 95% CI: 0.29, 2.62; P = 0.81), wound bleeding (OR: 0.74; 95% CI: 0.3, 1.48; P = 0.39), and mortality (OR: 1.05; 95% CI: 0.42, 2.61; P = 0.92). In conclusion, current evidence indicated that the combined surgery had no additional risk of postoperative complications, and might be an effective alternative surgical approach to mitral valve diseases accompany with tricuspid regurgitation. However, for the limited case size, it was required to support the findings with a large number of cases in further studies.

Current management of tricuspid regurgitation: a focus on the spiral suspension approach.

The indication for surgery for tricuspid regurgitation (TR) has reached a major turning point. It has become clear that the presence of moderate or severe TR alone worsens the prognosis of life, and the previous guidelines of Japanese Circulation Society, in which the indication for surgery was recommended at the timing of "right heart failure difficult to treat medically," now recommends surgery with a trigger of "repeated right heart failure" in the 2020 edition. In addition, a new repair technique targeting at subvalvular structure has been developed for end-stage TR to overcome a high TR recurrence rate that is associated with severe right ventricular enlargement and leaflet tethering. This review focuses on the spiral suspension technique, in which the papillary muscles are spirally suspended towards the septal leaflet annulus to correct tethering and enhances the understanding of its application in the context of TR management.

Congestion patterns in severe tricuspid regurgitation and transcatheter treatment: Insights from a multicentre registry.

AIMS: While invasively determined congestion holds mechanistic and prognostic significance in acute heart failure (HF), its role in patients with tricuspid regurgitation (TR)-related right- heart failure (HF) undergoing transcatheter tricuspid valve intervention (TTVI) is less well established. A comprehensive understanding of congestion patterns might aid in procedural planning, risk stratification, and the identification of patients who may benefit from adjunctive therapies before undergoing TTVI. The aim of this study was to investigate the role of congestion patterns in patients with severe TR and its implications for TTVI. METHODS AND RESULTS: Within a multicentre, international TTVI registry, 813 patients underwent right heart catheterization (RHC) prior to TTVI and were followed up to 24 months. The median age was 80 (interquartile range 76-83) years and 54% were women. Both mean right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP) were associated with 2-year mortality on Cox regression analyses with Youden index-derived cut-offs of 17 mmHg and 19 mmHg, respectively (p < 0.01 for all). However, RAP emerged as an independent predictor of outcomes following multivariable adjustments. Pre-interventionally, 42% of patients were classified as euvolaemic (RAP <17 mmHg, PCWP <19 mmHg), 23% as having left-sided congestion (RAP <17 mmHg, PCWP ≥19 mmHg), 8% as right-sided congestion (RAP ≥17 mmHg, PCWP <19 mmHg), and 27% as bilateral congestion (RAP ≥17 mmHg, PCWP ≥19 mmHg). Patients with right-sided or bilateral congestion had the lowest procedural success rates and shortest survival times. Congestion patterns allowed for discerning specific patient's physiology and specifying prognostic implications of right ventricular to pulmonary artery coupling surrogates. CONCLUSION: In this large cohort of invasively characterized patients undergoing TTVI, congestion patterns involving right-sided congestion were associated with low procedural success and higher mortality rates after TTVI. Whether pre-interventional reduction of right-sided congestion can improve outcomes after TTVI should be established in dedicated studies.

Transcatheter tricuspid valve interventions: Current devices and clinical evidence.

The tricuspid valve is known as "the forgotten valve". Tricuspid regurgitation (TR) is a highly prevalent valvular heart disease. TR is often late in the course of the disease when it becomes symptomatic, often being a marker of late-stage chronic heart failure with a poor prognosis and high mortality rate at long-term follow-up. Despite the clear correlation between TR and mortality, most TR patients are under-treated. Neither pharmacologic nor surgical treatment demonstrates a significant survival benefit. Isolated tricuspid valve surgery has the highest mortality rate of all valve surgeries. Therefore, there is an urgent clinical need for minimally invasive therapies to meet the needs of patients with TR. In recent years, a variety of transcatheter tricuspid valve interventions representing less invasive alternatives to surgery have shown promising results, which bring hope to patients with severe TR. The purpose of this review is to provide a complete and updated overview on current transcatheter tricuspid valve interventions and clinical evidence.

Role of preexisting right ventricular remodeling in symptoms and prognosis after transcatheter tricuspid valve repair.

BACKGROUND: Severe tricuspid regurgitation (TR) is associated with chronic volume overload and right ventricular remodeling (RVR). Transcatheter tricuspid valve repair (TTVr) reduces TR and can improve quality of life (QoL), but the role of preprocedural RVR on TTVr outcomes remains unclear. AIMS: To investigate the role of RVR on outcomes after TTVr for severe TR. METHODS: Consecutive patients undergoing TTVr (61% edge-to-edge vs. 39% direct annuloplasty) for severe TR were retrospectively compared by preexisting RVR which was defined as dilation of RV mid-level diameter (> 35 mm) according to guidelines. QoL was evaluated using NYHA class, Minnesota Living with Heart Failure Questionnaire (MLHFQ), 36-Item Short Form Health Survey (SF-36), and 6-min walking distance (6MWD) 1-month after TTVr. Mid-term mortality and heart failure (HF) hospitalization were assessed through 1 year. RESULTS: RVR was present in 137 of 223 patients (61%). Symptoms and QoL improved equally in both groups: ≥ 1 NYHA class (57% vs. 65% of patients with vs. without RVR, respectively), 6MWD (36% vs. 34%), MLHFQ (81% vs. 69%), and SF-36 (68% vs. 65%) improvement. One-year mortality and HF hospitalization were significantly higher in patients with RVR (24% and 30%, respectively) than in patients without (8% and 13%, both p < 0.05). In multivariable analysis, RVR was independently associated with mortality (HR 2.3, 95%CI (1.0-5.0), p = 0.04) and the combined endpoint of mortality or rehospitalization (HR 2.0, 95%CI (1.1-3.8), p = 0.03). CONCLUSIONS: TTVr was associated with significant QoL improvement after 1 month, irrespective of RVR. Despite increased mortality and rehospitalization for heart failure, TTVr in the presence of RVR still provides substantial symptomatic benefit for patients with severe TR.

Changes in right ventricular function and clinical outcomes following tricuspid transcatheter edge-to-edge repair.

AIMS: Prognostic impact of post-procedural changes in right ventricular (RV) function after tricuspid transcatheter edge-to-edge repair (T-TEER) is still unclear. We investigated association of RV function and its post-procedural changes with clinical outcomes in patients undergoing T-TEER. METHODS AND RESULTS: We retrospectively analysed 204 patients who underwent T-TEER and echocardiographic follow-up at 3 months after T-TEER. RV function was assessed by RV fractional area change (RVFAC), and RV dysfunction was defined as RVFAC <35%. Patients with an increase in RVFAC from baseline to the follow-up were considered as RV responders. Patients were divided into four groups according to baseline RVFAC and the RV responder. The primary outcome was a composite of mortality and hospitalization due to heart failure within 1 year. Forty-five of 204 patients (22.1%) had RVFAC <35% at baseline, and 71 (34.8%) were RV responders. The association between the RV responder and the composite outcome had a significant interaction with RVFAC at baseline. Among patients with baseline RVFAC <35%, RV responders had a lower risk of the composite outcome than RV non-responders, while this association was not significant in those with baseline RVFAC ≥35%. Among patients with baseline RVFAC <35%, a smaller RV diameter and a greater reduction of tricuspid regurgitation were predictors for the RV responder. CONCLUSION: Post-procedural increase in RVFAC after T-TEER is associated with improved outcomes in patients with RV dysfunction. The factors related to the increase in RVFAC may support patient selection for T-TEER in patients with RV dysfunction.

Tricuspid repair: short and long-term results of suture annuloplasty techniques and rigid and flexible ring annuloplasty techniques.

BACKGROUND: Functional tricuspid regurgitation may arise from left heart valve diseases or other factors. If not addressed concurrently with primary surgical intervention, it may contribute to increased morbidity and mortality rates during the postoperative period. This study investigates the impact of various repair techniques on crucial factors such as systolic pulmonary artery pressure (SPAP), tricuspid valve regurgitation, and New York Heart Association (NYHA) functional capacity class in the postoperative period. MATERIALS AND METHODS: From April 2007 to June 2013, 379 adults underwent open-heart surgery for functional tricuspid regurgitation. Patients were categorized into four groups: Group 1 (156) with De Vega suture annuloplasty, Group 2 (60) with Kay suture annuloplasty, Group 3 (122) with Flexible Duran ring annuloplasty, and Group 4 (41) with Semi-Rigid Carpentier-Edwards ring annuloplasty. Demographic, clinical, operative, and postoperative data were recorded over a mean follow-up of 35.6 ± 19.1 months. Postoperative SPAP values, tricuspid regurgitation grades, and NYHA functional capacity classes were compared among the groups. RESULTS: No statistically significant differences were observed among the groups regarding age, gender, preoperative disease diagnoses, history of previous cardiac operations, or echocardiographic characteristics such as preoperative ejection fraction, SPAP, and tricuspid regurgitation. Hospital and intensive care unit length of stay and postoperative complications also showed no significant differences. However, patients in Group 3 exhibited longer Cardio-Pulmonary Bypass duration, cross-clamp duration, and higher positive inotrope requirements. While the mortality rate within the first 30 days was higher in Group 1 compared to the other groups (p: 0.011), overall mortality rates did not significantly differ among the groups. Significant regression in functional tricuspid regurgitation and a notable decrease in SPAP values were observed in patients from Group 3 and Group 4 (p: 0.001). Additionally, patients in Group 3 and Group 4 showed a more significant reduction in NYHA functional capacity classification during the postoperative period (p: 0.001). CONCLUSION: Among the repair techniques, ring annuloplasty demonstrated superiority in reducing SPAP, regressing tricuspid regurgitation, and improving NYHA functional capacity in functional tricuspid regurgitation repairs.

Implications of tricuspid regurgitation and right ventricular volume overload in patients with heart failure with preserved ejection fraction.

AIMS: The aim of this study was to assess the pathophysiological implications of severe tricuspid regurgitation (TR) in patients with heart failure with preserved ejection fraction (HFpEF) by using tricuspid transcatheter edge-to-edge repair (T-TEER) as a model of right ventricular (RV) volume overload relief. METHODS AND RESULTS: This prospective interventional single arm trial (NCT04782908) included patients with invasively diagnosed HFpEF. The following parameters were prospectively assessed before and after T-TEER: left ventricular (LV) diastolic properties by invasive pressure-volume loop recordings; biventricular time-volume curves and function as well as septal curvature by cardiac magnetic resonance imaging; strain analyses for timing of septal motion. Overall, 20 patients (median age 78, interquartile range [IQR] 72-83 years, 65% female) were included. T-TEER reduced TR by a median of 2 (of 5) grades (IQR 2-1). T-TEER increased LV stroke volume and LV end-diastolic volume (LVEDV) (p < 0.001), without increasing LV end-diastolic pressure (LVEDP) (p = 0.094), consequently diastolic function improved with a reduction in LVEDP/LVEDV (p = 0.001) and a rightward shift of the end-diastolic pressure-volume relationship. The increase in LVEDV correlated with a decrease in RV end-diastolic volume (p < 0.001) and LV transmural pressure increased (p = 0.028). Secondary to a decrease in early RV filling, improvements in early LV filling were observed, correlating with an alleviation of leftwards bowing of the septum (p < 0.01, respectively). CONCLUSION: Diastolic LV properties in patients with HFpEF and severe TR are importantly determined by ventricular interaction in the setting of RV volume overload. T-TEER reduces RV volume overload and improves biventricular interaction and physiology.

Multimodality Imaging Approach for Planning and Guiding Direct Transcatheter Tricuspid Valve Annuloplasty.

Interest in transcatheter treatment of tricuspid regurgitation (TR) has grown significantly in recent years due to increasing evidence correlating TR severity with mortality and to limited availability of surgical options often considered high-risk in these patients. Although edge-to-edge repair is currently the main transcatheter therapeutic strategy, tricuspid valve direct annuloplasty can also be performed safely and effectively to reduce TR and improve heart failure symptoms and quality of life. In the annuloplasty procedure, an adjustable band is implanted around the tricuspid annulus to reduce valvular size and improve TR. Patient selection and careful preoperative imaging, including transthoracic echocardiography, transesophageal echocardiography, and computed tomography, are critical for procedural success and proper device implantation. Compared to edge-to-edge repair, perioperative imaging with transesophageal echocardiography and fluoroscopy is particularly challenging. Alignment and insertion of the anchors are demanding but essential to achieve good results and avoid damaging the surrounding structures. The presence of shadowing artifacts due to cardiac devices makes the acquisition of good-quality images even more challenging. In this review, we discuss the current role of multimodality imaging in planning direct transcatheter tricuspid valve annuloplasty and describe all procedural steps focusing on echocardiographic monitoring.

Totally endoscopic, robotic-assisted tricuspid valve repair and biatrial CryoMAZE.

We describe in detail our technique for totally endoscopic, robotic-assisted tricuspid valve repair for iatrogenic tricuspid regurgitation and biatrial cryoMAZE.