Tricuspid Valve Repair Outcomes in LVAD Patients

Jan 02, 2020
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Authors:
Barac YD, Nicoara A, Bishawi M, et al.
Citation:
Durability and Efficacy of Tricuspid Valve Repair in Patients Undergoing Left Ventricular Assist Device Implantation. JACC Heart Fail 2019;Dec 11:[Epub ahead of print].
Summary By:
David S. Bach, MD, FACC

Study Questions:

What is the durability of tricuspid valve repair (TVr) performed concurrently with left ventricular assist device (LVAD) implantation, and is there an association between TVr and the development of late right-sided heart failure (RHF)?

Methods:

In a retrospective, single-center study, medical records were reviewed for consecutive adult patients who underwent durable LVAD implantation and concurrent TVr between 2009 and 2017. Late RHF was defined as readmission for HF requiring inotropic or diuretic therapy. TVr failure was defined as moderate or severe tricuspid regurgitation (TR) at any follow-up echocardiographic examination after LVAD implantation.

Results:

Of 813 patients who underwent durable LVAD implantation during the study period, 156 patients underwent concurrent TVr. For those patients, the mean duration of echocardiographic follow-up was 23 ± 22 months. Out of 156 patients who underwent LVAD implantation with concomitant TVr, 59 (37.8%) had a failed TVr. Out of the 146 patients who were discharged after the index hospitalization, 53 patients (36.3%) developed late RHF. Multivariable Cox proportional hazard analysis demonstrated that TVr failure was an independent predictor of late RHF development (hazard ratio, 2.62; 95% confidence interval, 1.38-4.96; p = 0.003).

Conclusions:

Failure of TVr among patients who underwent durable LVAD implantation occurred at a significant rate, and was an independent risk factor for development of late RHF. The authors concluded that future studies should investigate strategies to reduce the recurrence of significant TR.

Perspective:

This single-center, retrospective study suggests that over one in three patients has persistent or recurrent moderate or severe TR following concomitant TVr at the time of durable LVAD implantation, and that failed TVr is associated with an increased risk of hospitalization for RHF. A cohort of five patients who underwent tricuspid valve replacement was not analyzed due to the small sample size, and the risk for RHF hospitalization was not compared between patients who underwent TVr (with or without recurrent TR) and those who underwent no tricuspid valve intervention at the time of LVAD implantation. It is possible that TVr failure was a manifestation of underlying right ventricular failure; and that TR was a sign of, rather than the primary cause of, RHF. Additional evaluation is needed in order to sort out the respective roles of the right ventricle and the tricuspid valve in RHF following LVAD implantation.

Keywords: Cardiac Surgical Procedures, Diagnostic Imaging, Diuretics, Echocardiography, Heart Failure, Heart Valve Diseases, Heart-Assist Devices, Patient Discharge, Patient Readmission, Risk Factors, Tricuspid Valve Insufficiency, Ventricular Dysfunction, Right


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