When not to perform isolated tricuspid valve surgery? Our long-term experience in tricuspid valve replacement in highly symptomatic patients

When not to perform isolated tricuspid valve surgery? Our long-term experience in tricuspid valve... Letters to the Editor / European Journal of Cardio-Thoracic Surgery 893 bioprosthetic valves: a consensus statement from the European Association REFERENCES of Percutaneous Interventions (EAPCI) endorsed by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery [1] Antunes MJ, Rodr ıguez-Palomares J, Prendergast B, Bonis MD, Rosenhek R, (EACTS). Eur J Cardiothorac Surg 2017;52:408–17. Al-Attar N et al. Management of tricuspid valve regurgitation. Eur J Cardiothoracic Surg 2017; doi:10.1093/ejcts/ezx279. [2] Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA *Corresponding author. Department of Cardiothoracic, Transplant and et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for Vascular Surgery, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 the management of patients with valvular heart disease: a report of the Hannover, Germany. Tel: +49-511-5324290; fax: +49-511-5328280; e-mail: American College of Cardiology/American Heart Association Task Force on ius.r@libero.it (F. Ius). Clinical Practice Guidelines. Circulation 2017;135:e1159–95. [3] Badhwar V, Rankin JS, He M, Jacobs JP, Furnary AP, Fazzalari FL et al. doi:10.1093/ejcts/ezx404 Performing concomitant tricuspid valve repair at the time of mitral valve Advance Access publication 17 November 2017 operations is not associated with increased operative mortality. Ann Thorac Surg 2017;103:587–93. [4] Buzzatti N, Iaci G, Taramasso M, Nisi T, Lapenna E, De Bonis M et al. Long- term outcomes of tricuspid valve replacement after previous left-side heart surgery. Eur J Cardiothorac Surg 2014;46:713–9; discussion 719. [5] Jeganathan R, Armstrong S, Al-Alao B, David T. The risk and outcomes of When not to perform isolated tricuspid valve reoperative tricuspid valve surgery. Ann Thorac Surg 2013;95:119. surgery? Our long-term experience in tricus- [6] Redondo Palacios A, Lopez  Mene ´ ndez J, Miguelena Hycka J, Mart ın Garc ıa M, Varela Barca L, Ferreiro Marzal A et al. Which type of valve should we pid valve replacement in highly symptomatic use in tricuspid position? Long-term comparison between mechanical and biological valves. J Cardiovasc Surg (Torino) 2017;58:739–46. patients Ana Redondo*, Jose Lopez-Menendez, Javier Miguelena and Laura Varela *Corresponding author. Department of Cardiovascular Surgery, Hospital Department of Cardiovascular Surgery, Hospital Ramon y Cajal, Madrid, Spain Ramon y Cajal, Carretera Colmenar Viejo, km 9, 100, 28034 Madrid, Spain. Tel: +34-91-3368651; e-mail: a.redondopalacios@gmail.com (A. Redondo). Received 3 November 2017; accepted 18 November 2017 doi:10.1093/ejcts/ezx444 Keywords: Tricuspid valve replacement � Risk factors � Prognosis Advance Access publication 12 December 2017 Tricuspid regurgitation and its management remain a controversial issue in cardiology and cardiovascular surgery. As reflected in the article [1], moderate tricuspid regurgitation should be addressed early, in the setting of left valve cardiac surgery. Although the latest guideline recommendations [2] insist on the fact that neither right ventricular function nor tricuspid regurgitation Reply to Redondo et al. might improve after left heart valve surgery, and annuloplasty is highly recom- mended even in asymptomatic patients [3], the scenario of isolated tricuspid Manuel J. Antunes* valve surgery is still an issue that remains to be resolved. Department of Cardiothoracic Surgery, University Hospital and Faculty of Right ventricular function and pulmonary hypertension are directly related Medicine, Coimbra, Portugal to prognosis of these patients. According to the European Society of Cardiology (ESC) Working Groups of Cardiovascular Surgery and Valvular Received 15 November 2017; accepted 18 November 2017 Heart Disease recommendations, both parameters should be adequately and closely monitored on a routine basis in a patient with tricuspid valve disease. Keywords: Tricuspid valve � Guidelines If tricuspid surgery is performed once the damage is done and the right ven- tricle is too enlarged, or the pulmonary pressure is too high, surgery may not In a Letter to the Editor published in this issue of the journal, with a provoca- provide any kind of clinical or survival benefit [4]. tive title of ‘When not to perform isolated tricuspid valve surgery?’, Redondo Not only can these measures affect the prognosis of a patient with tricuspid et al. [1] are in agreement with our recommendations about the management valve disease, highly symptomatic patients may also not be offered any relief of tricuspid valve regurgitation (TR) published in the Position Paper of the of their symptoms if surgery is done too late [5], especially when the right ven- European Society of Cardiology (ESC) Working Groups of Cardiovascular tricle and the morphology of the tricuspid valve are too disrupted to perform Surgery and of Valvular Heart Disease [2]. The indication and timing of sur- a valve repair and tricuspid valve replacement (TVR) is the only option (exces- gery for treatment of isolated TR after successful left-side valve surgery, sive annular dilatation, distortion of the right ventricle and advanced rheum- whether primary or late, are at stake. This pathology was deemed so import- atic heart disease). ant that isolated TR was mentioned 12 times in the text of the position paper. Indeed, we conducted a retrospective, observational and descriptive study In the position paper, we endorsed the recommendations of both the with all patients receiving a tricuspid valve prosthesis between 2000 and 2015 European and the American Guidelines that ‘isolated tricuspid valve surgery is in our department [6]. Among the isolated TVR group (40 patients), the factors indicated in symptomatic patients with severe primary TR (Class I) and should associated with a poor survival were: (i) logistic EuroSCORE I [hazard ratio be considered in asymptomatic or mildly symptomatic patients with right (HR) 1.06, 95% confidence interval (CI) 1.02–1.09; P = 0.001]; (ii) low preopera- ventricle (RV) enlargement or deteriorating function (Class IIa)’. It was further tive haemoglobin levels (HR 0.66, 95% CI 0.49–0.89; P = 0.007); (iii) renal failure stated that ‘delayed surgery is likely to result in irreversible RV damage, organ (HR 3.09, 95% CI 1.09–8.80; P = 0.0035) and (iv) surgery performed in patients failure and poor results of the surgical intervention’, that is, the earlier the who were in New York Heart Association (NYHA) Class IV (HR 4.12, 95% intervention the better the outcome. On the other hand, with increasing ex- CI 1.46–12.19; P = 0.008). In fact, patients who were in NYHA Class IV had a perience, surgery in selected patients is now possible with acceptable risk. poor 1-year survival (only 12.5%). Naturally, the results vary widely, depending on several parameters related We also analysed the functional class of all the patients during the follow- not only to the condition of the patient but also to the function of the right up. Only 1 patient undergoing isolated TVR remained in NYHA Class IV, while ventricle and the degree of pulmonary hypertension. Redondo et al. con- most of them, who were preoperatively in NYHA Class II–III, were in Class II in firmed this fact in a retrospective analysis of 40 patients who had isolated tri- the follow-up, therefore, they experienced no significant relief in their clinical cuspid valve replacement in whom renal failure and New York Heart status after undergoing isolated TVR. Association (NYHA) Class IV were the strongest predictors of poorer results What we would like to highlight is the fact that surgery in a NYHA Class IV after surgery. In fact, only 12.5% of their patients who were in NYHA Class IV situation may not provide any benefit in terms of clinical improvement and survived longer than 1 year. mortality. Therefore, and according to what our colleagues stated, tricuspid We are, therefore, in full agreement with Redondo et al. on the following valve disease must be addressed early, before right ventricular and clinical de- recommendation: ‘isolated tricuspid valve disease must be addressed early, terioration, either surgically or with any other percutaneous techniques. Downloaded from https://academic.oup.com/ejcts/article-abstract/53/4/893/4734975 by Ed 'DeepDyve' Gillespie user on 16 March 2018 LETTERS TO THE EDITOR http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

When not to perform isolated tricuspid valve surgery? Our long-term experience in tricuspid valve replacement in highly symptomatic patients

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Abstract

Letters to the Editor / European Journal of Cardio-Thoracic Surgery 893 bioprosthetic valves: a consensus statement from the European Association REFERENCES of Percutaneous Interventions (EAPCI) endorsed by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery [1] Antunes MJ, Rodr ıguez-Palomares J, Prendergast B, Bonis MD, Rosenhek R, (EACTS). Eur J Cardiothorac Surg 2017;52:408–17. Al-Attar N et al. Management of tricuspid valve regurgitation. Eur J Cardiothoracic Surg 2017; doi:10.1093/ejcts/ezx279. [2] Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA *Corresponding author. Department of Cardiothoracic, Transplant and et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for Vascular Surgery, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 the management of patients with valvular heart disease: a report of the Hannover, Germany. Tel: +49-511-5324290; fax: +49-511-5328280; e-mail: American College of Cardiology/American Heart Association Task Force on ius.r@libero.it (F. Ius). Clinical Practice Guidelines. Circulation 2017;135:e1159–95. [3] Badhwar V, Rankin JS, He M, Jacobs JP, Furnary AP, Fazzalari FL et al. doi:10.1093/ejcts/ezx404 Performing concomitant tricuspid valve repair at the time of mitral valve Advance Access publication 17 November 2017 operations is not associated with increased operative mortality. Ann Thorac Surg 2017;103:587–93. [4] Buzzatti N, Iaci G, Taramasso M, Nisi T, Lapenna E, De Bonis M et al. Long- term outcomes of tricuspid valve replacement after previous left-side heart surgery. Eur J Cardiothorac Surg 2014;46:713–9; discussion 719. [5] Jeganathan R, Armstrong S, Al-Alao B, David T. The risk and outcomes of When not to perform isolated tricuspid valve reoperative tricuspid valve surgery. Ann Thorac Surg 2013;95:119. surgery? Our long-term experience in tricus- [6] Redondo Palacios A, Lopez  Mene ´ ndez J, Miguelena Hycka J, Mart ın Garc ıa M, Varela Barca L, Ferreiro Marzal A et al. Which type of valve should we pid valve replacement in highly symptomatic use in tricuspid position? Long-term comparison between mechanical and biological valves. J Cardiovasc Surg (Torino) 2017;58:739–46. patients Ana Redondo*, Jose Lopez-Menendez, Javier Miguelena and Laura Varela *Corresponding author. Department of Cardiovascular Surgery, Hospital Department of Cardiovascular Surgery, Hospital Ramon y Cajal, Madrid, Spain Ramon y Cajal, Carretera Colmenar Viejo, km 9, 100, 28034 Madrid, Spain. Tel: +34-91-3368651; e-mail: a.redondopalacios@gmail.com (A. Redondo). Received 3 November 2017; accepted 18 November 2017 doi:10.1093/ejcts/ezx444 Keywords: Tricuspid valve replacement � Risk factors � Prognosis Advance Access publication 12 December 2017 Tricuspid regurgitation and its management remain a controversial issue in cardiology and cardiovascular surgery. As reflected in the article [1], moderate tricuspid regurgitation should be addressed early, in the setting of left valve cardiac surgery. Although the latest guideline recommendations [2] insist on the fact that neither right ventricular function nor tricuspid regurgitation Reply to Redondo et al. might improve after left heart valve surgery, and annuloplasty is highly recom- mended even in asymptomatic patients [3], the scenario of isolated tricuspid Manuel J. Antunes* valve surgery is still an issue that remains to be resolved. Department of Cardiothoracic Surgery, University Hospital and Faculty of Right ventricular function and pulmonary hypertension are directly related Medicine, Coimbra, Portugal to prognosis of these patients. According to the European Society of Cardiology (ESC) Working Groups of Cardiovascular Surgery and Valvular Received 15 November 2017; accepted 18 November 2017 Heart Disease recommendations, both parameters should be adequately and closely monitored on a routine basis in a patient with tricuspid valve disease. Keywords: Tricuspid valve � Guidelines If tricuspid surgery is performed once the damage is done and the right ven- tricle is too enlarged, or the pulmonary pressure is too high, surgery may not In a Letter to the Editor published in this issue of the journal, with a provoca- provide any kind of clinical or survival benefit [4]. tive title of ‘When not to perform isolated tricuspid valve surgery?’, Redondo Not only can these measures affect the prognosis of a patient with tricuspid et al. [1] are in agreement with our recommendations about the management valve disease, highly symptomatic patients may also not be offered any relief of tricuspid valve regurgitation (TR) published in the Position Paper of the of their symptoms if surgery is done too late [5], especially when the right ven- European Society of Cardiology (ESC) Working Groups of Cardiovascular tricle and the morphology of the tricuspid valve are too disrupted to perform Surgery and of Valvular Heart Disease [2]. The indication and timing of sur- a valve repair and tricuspid valve replacement (TVR) is the only option (exces- gery for treatment of isolated TR after successful left-side valve surgery, sive annular dilatation, distortion of the right ventricle and advanced rheum- whether primary or late, are at stake. This pathology was deemed so import- atic heart disease). ant that isolated TR was mentioned 12 times in the text of the position paper. Indeed, we conducted a retrospective, observational and descriptive study In the position paper, we endorsed the recommendations of both the with all patients receiving a tricuspid valve prosthesis between 2000 and 2015 European and the American Guidelines that ‘isolated tricuspid valve surgery is in our department [6]. Among the isolated TVR group (40 patients), the factors indicated in symptomatic patients with severe primary TR (Class I) and should associated with a poor survival were: (i) logistic EuroSCORE I [hazard ratio be considered in asymptomatic or mildly symptomatic patients with right (HR) 1.06, 95% confidence interval (CI) 1.02–1.09; P = 0.001]; (ii) low preopera- ventricle (RV) enlargement or deteriorating function (Class IIa)’. It was further tive haemoglobin levels (HR 0.66, 95% CI 0.49–0.89; P = 0.007); (iii) renal failure stated that ‘delayed surgery is likely to result in irreversible RV damage, organ (HR 3.09, 95% CI 1.09–8.80; P = 0.0035) and (iv) surgery performed in patients failure and poor results of the surgical intervention’, that is, the earlier the who were in New York Heart Association (NYHA) Class IV (HR 4.12, 95% intervention the better the outcome. On the other hand, with increasing ex- CI 1.46–12.19; P = 0.008). In fact, patients who were in NYHA Class IV had a perience, surgery in selected patients is now possible with acceptable risk. poor 1-year survival (only 12.5%). Naturally, the results vary widely, depending on several parameters related We also analysed the functional class of all the patients during the follow- not only to the condition of the patient but also to the function of the right up. Only 1 patient undergoing isolated TVR remained in NYHA Class IV, while ventricle and the degree of pulmonary hypertension. Redondo et al. con- most of them, who were preoperatively in NYHA Class II–III, were in Class II in firmed this fact in a retrospective analysis of 40 patients who had isolated tri- the follow-up, therefore, they experienced no significant relief in their clinical cuspid valve replacement in whom renal failure and New York Heart status after undergoing isolated TVR. Association (NYHA) Class IV were the strongest predictors of poorer results What we would like to highlight is the fact that surgery in a NYHA Class IV after surgery. In fact, only 12.5% of their patients who were in NYHA Class IV situation may not provide any benefit in terms of clinical improvement and survived longer than 1 year. mortality. Therefore, and according to what our colleagues stated, tricuspid We are, therefore, in full agreement with Redondo et al. on the following valve disease must be addressed early, before right ventricular and clinical de- recommendation: ‘isolated tricuspid valve disease must be addressed early, terioration, either surgically or with any other percutaneous techniques. Downloaded from https://academic.oup.com/ejcts/article-abstract/53/4/893/4734975 by Ed 'DeepDyve' Gillespie user on 16 March 2018 LETTERS TO THE EDITOR

Journal

European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Apr 1, 2018

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