Performing Concomitant Tricuspid Valve Repair at the Time of Mitral Valve Operations Is Not Associated With Increased Operative Mortality

摘要

Background The performance of concomitant tricuspid valve repair (TVr) at the time of mitral valve repair or replacement (MVRR) has previously been associated with elevated short-term risk. Outcomes were assessed at incremental grades of tricuspid regurgitation (TR) to quantify the contemporary risk of concomitant TVr.;Methods Between July 2011 and June 2014, 88,473 patients undergoing MVRR were examined using The Society of Thoracic Surgeons database. Outcomes with or without TVr, after isolated MVRR (n?= 62,118) and MVRR with coronary artery bypass graft surgery (CABG [n?= 26,355]), were independently analyzed at three levels of TR: none-mild, moderate, and severe. Risk-adjusted morbidity and mortality associated with the performance of concomitant TVr were evaluated using multivariable logistic regression.;Results The TR was graded as none-mild in 74.3% of patients (65,769 of 88,473), moderate in 17.2% (15,222 of 88,473), and severe in 8.5% (7,482 of 88,473). The rate of?TVr by TR grade was 3.5% (2,308 of 65,769) for none-mild, 30.6% (4,661 of 15,222) for moderate, and 75.6% (5,654 of 7,482) for severe. Overall risk-adjusted occurrence of any morbidity associated with performance of TVr was increased in both groups (MVRR odds ratio [OR] 1.36, 95% confidence interval [CI]: 1.24 to 1.48; and MVRR plus CABG OR 1.33, 95% CI: 1.19 to 1.49). However, at all grades of TR, TVr was not associated with increased risk-adjusted mortality (MVRR OR 0.99, 95% CI: 0.84 to 1.17; and MVRR plus CABG OR 1.04, 95% CI: 0.85 to 1.27).;Conclusions In contemporary patients, concomitant TVr is not associated with a risk-adjusted increase in mortality, regardless of TR severity. A more liberal approach to TVr at the time of MVRR may be justified when long-term benefits are thought to outweigh incremental short-term morbidity risk. Further investigation of longitudinal TVr outcomes is warranted.;;Dr Gammie discloses a financial relationship with Edwards Lifesciences.;Jump to SectionMaterial and MethodsPatient PopulationStudy DesignStatistical AnalysisResultsCommentStudy LimitationsConclusionReferences;Between July 1, 2011, and June 30, 2014, 89,008 patients underwent MVRR operations with or without concomitant TVr, surgical ablation of atrial fibrillation (AF), closure of an atrial septal defect, or concomitant coronary artery bypass graft surgery (CABG) in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD). Patients from institutions outside of North America, those with missing age or sex data, patients with prior MitraClip procedures, or those undergoing any concomitant operations other than previously noted, were excluded. This resulted in a final study population of 88,473 patients.;The entire cohort was analyzed for baseline demographics and all STS comorbid risk variables. To mitigate the influence of concomitant CABG on the outcomes and endpoints of concomitant TVr, MVRR plus CABG patients were independently analyzed. Therefore, the final study population was categorized into those undergoing isolated MVRR (n?= 62,118), and those having MVRR plus CABG (n?= 26,355).;Separate risk-adjusted multivariable regression analyses were performed for MVRR and MVRR plus CABG populations for the endpoints of mortality and major morbidity. Mortality was defined as inhospital or 30-day operative mortality. Major morbidity was defined as the occurrence of any of the following: prolonged ventilation more than 24 hours, deep sternal wound infection, stroke, renal failure, or reoperation. Logistic regression models adjusted for baseline characteristics as established by existing STS cardiac surgery risk models [21, 22]. The covariates in the current model included preoperative atrial fibrillation, age, race, body surface area, congestive heart failure, chronic lung disease, creatinine, cardiovascular disease, cerebrovascular accident, diabetes mellitus plus control methods, number of diseased vessels, left main, ejection fraction, intraa