Prognostic implications of staging right heart failure in patients with significant tricuspid regurgitation undergoing tricuspid valve surgery. (14th October 2021)

• Record Type: Journal Article
• Authors: Galloo, X; Stassen, J; Butcher, S C; Meucci, M C; Dietz, M F; Mertens, B J A; Prihadi, E A; Van Der Bijl, P; Ajmone Marsan, N; Bax, J J; Delgado, V
• Is Part Of: European heart journal. Volume 42(2021)Supplement 1
• Publication Date: 2021-10-14
• Subjects: Valves; Cardiology -- Periodicals; Heart -- Diseases -- Periodicals; 616.12005
• DOI: 10.1093/eurheartj/ehab724.2254
• Languages: English
• ISSNs: 0195-668X

Abstract

Abstract: Introduction: Mortality of tricuspid valve (TV) surgery for severe secondary tricuspid regurgitation (TR) remains relatively high. Current guidelines advise surgery in patients with symptomatic severe TR as a concomitant procedure to left-sided valve surgery. Right ventricular (RV) dysfunction is an important prognostic marker and may appear late in the natural history of TR. How a staging algorithm of right heart failure (RHF) may impact on TV surgery outcomes has not been evaluated. Purpose: To evaluate the impact of staging RHF on survival of patients with significant TR undergoing TV surgery. Methods: Patients diagnosed with significant (moderate and severe) TR who subsequently underwent TV surgery, were staged into 4 groups of progressive disease according to the diagnosis of RV dysfunction and the presence of RHF: stage 1, at risk for RHF; stage 2, RV dysfunction without clinical symptoms of RHF; stage 3, RV dysfunction with symptoms of RHF, and stage 4, RV dysfunction with refractory symptoms of RHF (Figure 1). The study endpoint was all-cause mortality. Results: A total of 279 patients (mean age 64±12 years, 49% male), were included in the analysis, of which 20 patients (7%) were in stage 1, 14 patients (5%) were in stage 2, 141 patients (51%) were in stage 3 and 104 patients (37%) were in stage 4. The majority of the patients (266 patients, 95%) underwent TV annuloplasty. Most patients had TV surgery concomitant to left-sided valve surgery or coronary artery bypass grafting (254 patients, 91%). In per-group analysis, patients in stage 4 had significantly larger left ventricular (LV) and RV dimensions, lower LV ejection fraction and more severe diastolic dysfunction than patients in other RHF stages. During a median follow-up of 65 [15 - 106] months after TV surgery, 145 deaths (52%) occurred. The cumulative survival rates were 88%, 77% and 60% at 1 month, 1 year and 5 years, respectively. The Kaplan-Meier curves for overall survival according to RHF stage are shown in Figure 2. Survival rates at 5 years were significantly worse in more advanced stages of RHF: 71% (stage 1 and 2), 66% (stage 3) and 49% (stage 4); log-rank chi-square: 11.302; p=0.004. Right heart failure stage was independently associated with all-cause mortality following adjustment for age, gender, LV ejection fraction, kidney function, TV annulus diameter, concomitant mitral valve surgery and time delay from diagnosis until surgery (p=0.021). Conclusion: Patients diagnosed with significant TR may benefit from earlier referral for surgical intervention, before presenting with RV dysfunction and before the onset of symptoms of RHF. Funding Acknowledgement: Type of funding sources: None.