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Surgical Treatment of Tricuspid Valve Insufficiency Promotes Early Reverse Remodeling in Patients With Axial-Flow Left Ventricular Assist Devices
Study Questions:
Is concomitant tricuspid valve intervention safe and effective in reducing tricuspid regurgitation or right ventricular (RV) dysfunction in patients undergoing left ventricular assist device (LVAD) implant?
Methods:
This was a single-center nonrandomized study of tricuspid valve (TV) annuloplasty/replacement versus no valve intervention in patients with advanced heart failure undergoing LVAD implant. Echocardiograms were obtained at baseline and within 1 month of LVAD surgery (mean 17 days). Tricuspid regurgitation (TR) severity and RV function were compared based on the presence or absence of an operative TV intervention.
Results:
Of the 83 patients undergoing HeartMate II LVAD implant, 34 (41%) had a TV intervention (28 repairs and 6 replacements). Patients undergoing TV intervention were of similar age (mean 63 ± 12 years), had similar heart failure etiologies (34% nonischemic) and preoperative inotrope requirements (74%) as controls, but TV intervention patients had higher right atrial pressures (17 ± 7 vs. 15 ± 5 mm Hg, p = 0.03) and were more likely to require preoperative intra-aortic balloon placement (44% vs. 27%, p = 0.03). On preoperative echocardiogram, intervention patients had worse preoperative TR (vena contracta 5.6 ± 2.1 mm vs. 2.9 ± 2.0 mm, p < 0.001) and greater RV areas but similar RV-index of myocardial performance, TV annular velocities, and visual estimates of RV systolic function. Following surgery, intervention patients had a 50% reduction in TR vena contracta width and a 34% reduction in RV area, while controls had an increase in TR vena contracta width by 19% (between group p < 0.005) and a smaller reduction in RV area (by 30%, between group p = 0.03). Postoperative requirements for RVAD support, inotropes, and incidences of hepatic and renal dysfunction were similar between the groups (all p > 0.05). Thirty-day mortality tended to be higher in TV intervention patients (18%) compared with controls (10%, p = 0.07).
Conclusions:
Patients undergoing concomitant TV intervention for severe TR display early RV remodeling following LVAD.
Perspective:
The development of RV failure after LVAD is associated with increased morbidity and mortality. Many centers perform TV interventions in the setting of severe TR to reduce post-LVAD RV failure burdens, but the impact of such an intervention is not well known. The study by Maltais and colleagues was not a true case-control study because controls did not have severe TR prior to surgery. TV intervention (broadly defined) appeared to improve TR severity, which may lead to an improvement in RV morphology, as assessed by improvements in filling pressures and RV area. The long-term impact of TV intervention on reducing RV failure and RV failure’s comorbidities (renal dysfunction, heart failure rehospitalization) is not known. The severity of TR that needs to be present on preoperative echocardiogram to warrant TV is not known. Importantly, there was a strong trend toward increased mortality in TV intervention patients. While this is likely due to the fact that TV intervention patients were higher risk preoperatively, data are lacking to properly assess cause and effect.
Keywords: Ventricular Function, Right, Heart Atria, Societies, Medical, Tricuspid Valve Insufficiency, Heart-Assist Devices, Comorbidity, Systole, Ventricular Dysfunction, Right, Heart Transplantation, Incidence, Case-Control Studies, Atrial Pressure, Heart Failure, Stroke Volume, Mitral Valve, Echocardiography
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