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Right Heart Failure and Patient Selection for Isolated Tricuspid Valve Surgery

Published:November 24, 2021DOI:https://doi.org/10.1016/j.jtcvs.2021.10.059
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      ABSTRACT

      Objective

      To characterize patients with right heart failure undergoing isolated tricuspid valve surgery, focusing on right heart morphology and function.

      Methods

      From 1/2007 to 1/2014, 62 patients underwent isolated tricuspid valve surgery. Forty-five patients (73%) had undergone prior heart operations. Right heart morphology and function variables were measured de novo from stored echocardiographic images, and clinical and hemodynamic data were extracted from patient registries and records. Cluster analysis was performed and outcomes assessed.

      Results

      On average, the right ventricle was dilated (diastolic area 32 cm2), but its function was preserved (free-wall strain -17%±5.8%) and right heart failure manifestations moderate with 40 (65%) having congested neck veins, 35 (56%) lower limb edema, and 15 (24%) ascites. Average MELD-Na score was 11±4.4, but individual values varied widely. Tricuspid valve variables split patients into 2 equal clusters: those with functional tricuspid regurgitation (TR) and those with structural TR. These groups had similar right ventricular function but the functional TR group had worse right ventricular morphology and more severe manifestations of right heart failure, including higher MELD-Na scores (12±44 vs. 9.1±3.9; P=.008). Both groups survived operation with low morbidity, but patients with functional TR had worse long-term survival, 48% versus 73% at 10 years after surgery.

      Conclusions

      The cluster analysis of patients with right heart failure undergoing isolated tricuspid valve surgery separated functional and structural tricuspid valve disease. Good early outcomes suggest expanding criteria for tricuspid valve surgery and earlier intervention for functional TR with right heart failure.

      Graphical abstract

      Keywords

      Abbreviations and acronyms:

      INR (International normalized ratio), MELD (model for end-stage liver disease), MELD-Na (model for end-stage liver disease with sodium), RV S’ (right ventricular systolic excursion velocity), TAPSE (tricuspid anular plane systolic excursion), TR (tricuspid regurgitation)
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