Early and mid-term outcomes of tricuspid valve replacement: A retrospective study in a single center_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHANG Xunli , JING Tong , AIZERETIAILI Maimaiti , ZHANG Le , LIU Shengchen ,  HUANG Fuhua

Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing, 210006, P. R. China;

Corresponding?author：

HUANG Fuhua, Email: huangfuhua@sina.cn

Keywords：

Tricuspid valve replacement; isolated tricuspid valve replacement; concomitant tricuspid valve replacement; perioperative mortality; European System for Cardiac Operative Risk EvaluationⅡ; survival analysis

DOI：

10.7507/1007-4848.202601054

Video：

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Objective To evaluate the early and mid-term mortality rates of isolated tricuspid valve replacement (iTVR) and concomitant tricuspid valve replacement (cTVR), and to assess associated risk factors. Methods Patients with tricuspid regurgitation who underwent TVR at Nanjing First Hospital between June 2012 and May 2021 were retrospectively enrolled. Early and mid-term outcomes were compared between iTVR and cTVR patients. The predictive performance of the European System for Cardiac Operative Risk EvaluationⅡ (EuroSCOREⅡ) for perioperative mortality was also evaluated. Results A total of 67 patients were included, comprising 23 (34%) males with a mean age of (52±13) years. Atrial fibrillation was the most common comorbidity (35/67, 52%). Among these patients, 40 underwent iTVR and 27 underwent cTVR. The perioperative mortality rate was 18%, with causes including low cardiac output syndrome (LCOS), bleeding, multiple organ failure, and severe sepsis. Compared to survivors, non-survivors were older, had worse cardiac function, larger left atrial diameters, higher EuroSCOREⅡ values, longer cardiopulmonary bypass (CPB) time and ICU stays, and higher complication rates (P<0.05). EuroSCOREⅡ was significantly associated with perioperative mortality [OR=1.274, 95%CI (1.065, 1.740), P=0.049]. The median follow-up duration was 32.9 (18.9, 73.2) months, during which 5 patients died. The survival rates at 6 months, 1 year, 3 years, and 5 years postoperatively were 98.1%, 97.4%, 82.6%, and 77.8%, respectively. Compared to cTVR, iTVR demonstrated shorter CPB and aortic cross-clamp time, lower perioperative mortality, and reduced incidence of LCOS. EuroSCOREⅡ showed good predictive performance for perioperative mortality in both iTVR and cTVR (area under the receiver operating characteristic curve: 0.982 vs. 0.684). During follow-up, there was no statistical difference in survival rates between iTVR and cTVR patients (P=0.489). Conclusion Compared to cTVR, iTVR is associated with lower perioperative mortality and LCOS incidence, while mid-term survival rates are similar. EuroSCOREⅡ effectively predicts perioperative mortality risk for TVR, with superior predictive performance observed in iTVR.

1.	Wang N, Fulcher J, Abeysuriya N, et al. Tricuspid regurgitation is associated with increased mortality independent of pulmonary pressures and right heart failure: a systematic review and meta-analysis. Eur Heart J, 2019, 40(5): 476-484.
2.	Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary. J Am Coll Cardiol, 2014, 63(22): 2438-2488.
3.	Zack CJ, Fender EA, Chandrashekar P, et al. National trends and outcomes in isolated tricuspid valve surgery. J Am Coll Cardiol, 2017, 70(24): 2953-2960.
4.	Wong W, Chen S, Chou A, et al. Late outcomes of valve repair versus replacement in isolated and concomitant tricuspid valve surgery: a nationwide cohort study. J Am Heart Assoc, 2020, 9(8): e015637.
5.	Ian Munro A, Eric Jamieson WR, Frank G, et al. Tricuspid valve replacement: porcine bioprostheses and mechanical prostheses. Ann Thorac Surg, 1995, 60: S470-S474.
6.	Chen J, Abudupataer M, Hu K, et al. Risk factors associated with perioperative morbidity and mortality following isolated tricuspid valve replacement. J Surg Res, 2018, 221: 224-231.
7.	Buzzatti N, Iaci G, Taramasso M, et al. Long-term outcomes of tricuspid valve replacement after previous left-side heart surgery. Eur J Cardiothorac Surg, 2014, 46(4): 713-719.
8.	Viganò G, Guidotti A, Taramasso M, et al. Clinical mid-term results after tricuspid valve replacement. Interact Cardiovasc Thorac Surg, 2010, 10(5): 709-713.
9.	Leviner DB, Friedman T, Zafrir B, et al. Midterm results of isolated tricuspid valve replacement: implications for clinical decision making. Ann Thorac Surg, 2022, 113(3): 793-799.
10.	Topilsky Y, Khanna AD, Oh JK, et al. Preoperative factors associated with adverse outcome after tricuspid valve replacement. Circulation, 2011, 123(18): 1929-1939.
11.	Nashef SAM, Roques F, Sharples LD, et al. EuroSCOREⅡ. Eur J Cardiothorac Surg, 2012, 41(4): 734-745.
12.	Chalmers J, Pullan M, Fabri B, et al. Validation of EuroSCOREⅡ in a modern cohort of patients undergoing cardiac surgery. Eur J Cardiothorac Surg, 2013, 43(4): 688-694.
13.	Dreyfus J, Flagiello M, Bazire B, et al. Isolated tricuspid valve surgery: impact of aetiology and clinical presentation on outcomes. Eur Heart J, 2020, 41(45): 4304-4317.
14.	Hua K, Zhao R, Peng Z, et al. Early surgery can improve the outcomes of patients with severe tricuspid regurgitation undergoing tricuspid replacement. Cardiovasc Diagn Ther, 2021, 11(5): 1058-1066.
15.	Pan Y, Liu L, Zhou X, et al. Isolated and concomitant tricuspid valve replacement: long-term survival and predictors of mortality in a 25-year cohort. Rev Cardiovasc Med, 2025, 26(11): 38102.
16.	Lim K, Au ACC, Hui MMH, et al. Cluster analysis of Model for End-stage Liver Disease and European System for Cardiac Operative Risk Evaluation for predicting operative mortality after concomitant tricuspid valve surgery. JTCVS Struct Endovasc, 2024, 1-2: 100017.
17.	趙若瑾, 廉虹, 王欣, 等. 二尖瓣手術同期修復中度及以下三尖瓣關閉不全對三尖瓣及右心功能早中期預后的影響. 中國胸心血管外科臨床雜志, 2023, 30(3): 389-395.Zhao RJ, Lian H, Wang X, et al. Concomitant repair of moderate or less tricuspid regurgitation during mitral valve surgery improves early and mid-term prognosis of tricuspid valve and right heart function. Chin J Clin Thorac Cardiovasc Surg, 2023, 30(3): 389-395.
18.	楊亮, 楊燕晨, 顏倩, 等. 608例三尖瓣置換術患者長期隨訪結果的傾向性評分匹配分析. 中國胸心血管外科臨床雜志, 2021, 28(7): 777-787.Yang L, Yang YC, Yan Q, et al. Long-term results of tricuspid valve replacement in 608 patients: A propensity scorematching analysis. Chin J Clin Thorac Cardiovasc Surg, 2021, 28(7): 777-787.
19.	劉小希, 吳子寧, 宋民, 等. 合并三尖瓣反流的中度缺血性二尖瓣關閉不全患者的外科處理策略. 心肺血管病雜志, 2022, 41(4): 384-390.Liu XX, Wu ZN, Song M, et al. Surgical management strategy for patients with moderate ischemic mitral regurgitation complicated with tricuspid regurgitation. J Cardiovasc Pulm Dis, 2022, 41(4): 384-390.
20.	Mastroiacovo G, Bonomi A, Ludergnani M, et al. Is EuroSCOREⅡ still a reliable predictor for cardiac surgery mortality in 2022? A retrospective study. Eur J Cardiothorac Surg, 2022, 64(3): ezad294.

1. Wang N, Fulcher J, Abeysuriya N, et al. Tricuspid regurgitation is associated with increased mortality independent of pulmonary pressures and right heart failure: a systematic review and meta-analysis. Eur Heart J, 2019, 40(5): 476-484.
2. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary. J Am Coll Cardiol, 2014, 63(22): 2438-2488.
3. Zack CJ, Fender EA, Chandrashekar P, et al. National trends and outcomes in isolated tricuspid valve surgery. J Am Coll Cardiol, 2017, 70(24): 2953-2960.
4. Wong W, Chen S, Chou A, et al. Late outcomes of valve repair versus replacement in isolated and concomitant tricuspid valve surgery: a nationwide cohort study. J Am Heart Assoc, 2020, 9(8): e015637.
5. Ian Munro A, Eric Jamieson WR, Frank G, et al. Tricuspid valve replacement: porcine bioprostheses and mechanical prostheses. Ann Thorac Surg, 1995, 60: S470-S474.
6. Chen J, Abudupataer M, Hu K, et al. Risk factors associated with perioperative morbidity and mortality following isolated tricuspid valve replacement. J Surg Res, 2018, 221: 224-231.
7. Buzzatti N, Iaci G, Taramasso M, et al. Long-term outcomes of tricuspid valve replacement after previous left-side heart surgery. Eur J Cardiothorac Surg, 2014, 46(4): 713-719.
8. Viganò G, Guidotti A, Taramasso M, et al. Clinical mid-term results after tricuspid valve replacement. Interact Cardiovasc Thorac Surg, 2010, 10(5): 709-713.
9. Leviner DB, Friedman T, Zafrir B, et al. Midterm results of isolated tricuspid valve replacement: implications for clinical decision making. Ann Thorac Surg, 2022, 113(3): 793-799.
10. Topilsky Y, Khanna AD, Oh JK, et al. Preoperative factors associated with adverse outcome after tricuspid valve replacement. Circulation, 2011, 123(18): 1929-1939.
11. Nashef SAM, Roques F, Sharples LD, et al. EuroSCOREⅡ. Eur J Cardiothorac Surg, 2012, 41(4): 734-745.
12. Chalmers J, Pullan M, Fabri B, et al. Validation of EuroSCOREⅡ in a modern cohort of patients undergoing cardiac surgery. Eur J Cardiothorac Surg, 2013, 43(4): 688-694.
13. Dreyfus J, Flagiello M, Bazire B, et al. Isolated tricuspid valve surgery: impact of aetiology and clinical presentation on outcomes. Eur Heart J, 2020, 41(45): 4304-4317.
14. Hua K, Zhao R, Peng Z, et al. Early surgery can improve the outcomes of patients with severe tricuspid regurgitation undergoing tricuspid replacement. Cardiovasc Diagn Ther, 2021, 11(5): 1058-1066.
15. Pan Y, Liu L, Zhou X, et al. Isolated and concomitant tricuspid valve replacement: long-term survival and predictors of mortality in a 25-year cohort. Rev Cardiovasc Med, 2025, 26(11): 38102.
16. Lim K, Au ACC, Hui MMH, et al. Cluster analysis of Model for End-stage Liver Disease and European System for Cardiac Operative Risk Evaluation for predicting operative mortality after concomitant tricuspid valve surgery. JTCVS Struct Endovasc, 2024, 1-2: 100017.
17. 趙若瑾, 廉虹, 王欣, 等. 二尖瓣手術同期修復中度及以下三尖瓣關閉不全對三尖瓣及右心功能早中期預后的影響. 中國胸心血管外科臨床雜志, 2023, 30(3): 389-395.Zhao RJ, Lian H, Wang X, et al. Concomitant repair of moderate or less tricuspid regurgitation during mitral valve surgery improves early and mid-term prognosis of tricuspid valve and right heart function. Chin J Clin Thorac Cardiovasc Surg, 2023, 30(3): 389-395.
18. 楊亮, 楊燕晨, 顏倩, 等. 608例三尖瓣置換術患者長期隨訪結果的傾向性評分匹配分析. 中國胸心血管外科臨床雜志, 2021, 28(7): 777-787.Yang L, Yang YC, Yan Q, et al. Long-term results of tricuspid valve replacement in 608 patients: A propensity scorematching analysis. Chin J Clin Thorac Cardiovasc Surg, 2021, 28(7): 777-787.
19. 劉小希, 吳子寧, 宋民, 等. 合并三尖瓣反流的中度缺血性二尖瓣關閉不全患者的外科處理策略. 心肺血管病雜志, 2022, 41(4): 384-390.Liu XX, Wu ZN, Song M, et al. Surgical management strategy for patients with moderate ischemic mitral regurgitation complicated with tricuspid regurgitation. J Cardiovasc Pulm Dis, 2022, 41(4): 384-390.
20. Mastroiacovo G, Bonomi A, Ludergnani M, et al. Is EuroSCOREⅡ still a reliable predictor for cardiac surgery mortality in 2022? A retrospective study. Eur J Cardiothorac Surg, 2022, 64(3): ezad294.

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