Concomitant tricuspid valve surgery during implantation of continuous-flow left ventricular assist devices: a Society of Thoracic Surgeons database analysis

Jason O Robertson, Maria V Grau-Sepulveda, Shoichi Okada, Sean M O'Brien, J Matthew Brennan, Ashish S Shah, Akinobu Itoh, Ralph J Damiano, Sunil Prasad, Scott C Silvestry
Journal of Heart and Lung Transplantation 2014, 33 (6): 609-17

BACKGROUND: Performing concomitant tricuspid valve procedures (TVPs) in left ventricular assist device (LVAD) patients with significant pre-operative tricuspid regurgitation (TR) is controversial, and no studies have been large enough to definitively guide therapy.

METHODS: Between January 2006 and September 2012, 2,196 patients with moderate to severe pre-operative TR from 115 institutions underwent implantation of a continuous-flow left ventricular assist device (LVAD) as reported by The Society of Thoracic Surgeons National Database. Of these, 588 (27%) underwent a concomitant TVP. Inverse probability weighting based on propensity score was used to adjust for differences between the LVAD alone and LVAD+TVP groups, and outcomes were compared.

RESULTS: Most patients in the LVAD+TVP group underwent an annuloplasty alone (81.1%). Concomitant TVP did not affect risk of post-operative right VAD insertion (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.49-1.36; p = 0.4310) or death (RR, 0.95; 95% CI, 0.68-1.33; p = 0.7658). However, TVP was associated with an increased risk for post-operative renal failure (RR, 1.53; 95% CI, 1.13-2.08; p = 0.0061), dialysis (RR, 1.49; 95% CI, 1.03-2.15; p = 0.0339), reoperation (RR, 1.24; 95% CI, 1.07-1.45; p = 0.0056), greater total transfusion requirement (RR, 1.03; 95% CI, 1.01-1.05; p = 0.0013), and hospital length of stay > 21 days (RR, 1.29; 95% CI, 1.16-1.43; p < 0.0001). Time on the ventilator and intensive care unit length of stay were also significantly prolonged for the LVAD+TVP group.

CONCLUSIONS: Performing a concomitant TVP for continuous-flow LVAD patients with moderate to severe TR did not reduce early death or right VAD requirement and was associated with worse early post-operative outcomes. These data caution against routine concomitant TVP based solely on degree of pre-operative TR and suggest that additional selection criteria are needed to identify those patients in whom concomitant TVP may prevent post-operative right ventricular failure.

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