Key result
Concomitant tricuspid valve intervention during pulmonary valve replacement was associated with a greater reduction in tricuspid regurgitation grade (OR 0.44; 95% CI 0.25-0.77) without increasing early adverse events.
Why the study?
Tricuspid regurgitation is common among adults with corrected TOF or PS referred for PVR, but combined valve surgery remains controversial.
Does concomitant tricuspid valve intervention improve post-operative TR and clinical outcomes compared to isolated pulmonary valve replacement in adults with TOF or PS and mild to severe TR?
Cohort (n=542)
Yes
Does concomitant tricuspid valve intervention improve post-operative TR and clinical outcomes compared to isolated pulmonary valve replacement in adults with TOF or PS and mild to severe TR?
Odds Ratio: 0.44 (95% CI 0.25–0.77)
Concomitant tricuspid valve intervention during pulmonary valve replacement safely improves early tricuspid valve competence in adults with congenital heart disease.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Tricuspid valve disease is grotesquely undertreated, both in the cardiac surgical arena and in the cardiology arena. And I think it is really ripe for percutaneous intervention. For years, he said the valve was largely ignored because it was assumed that treating the mitral valve would indirectly improve tricuspid regurgitation.”
“For decades, tricuspid regurgitation was largely overlooked, often addressed only during surgeries for other heart valves. Today, advances in minimally invasive treatments like transcatheter edge-to-edge repair (TEER) and transcatheter tricuspid valve replacement (TTVR) are providing new hope. These innovative procedures offer safe and effective options for high-risk patients who previously had limited or no treatment alternatives, focusing on enhancing quality of life.”
“Studies have shown excellent safety profiles for both platforms, with durable reductions in tricuspid regurgitation and improved quality of life for patients. We have seen impressive results in our patients who had no alternative surgical treatment option and hope to offer the procedure to more patients who are in a similar situation and may benefit.”
May inform decisions on tricuspid intervention with PVR; leaves open need for randomized confirmation.
BACKGROUND Tricuspid regurgitation (TR) is common among adults with corrected tetralogy of Fallot (TOF) or pulmonary stenosis (PS) referred for pulmonary valve replacement (PVR). Yet, combined valve surgery remains controversial. OBJECTIVES This study sought to evaluate the impact of concomitant tricuspid valve intervention (TVI) on post-operative TR, length of hospital stay, and on a composite endpoint consisting of 7 early adverse events (death, reintervention, cardiac electronic device implantation, infection, thromboembolic event, hemodialysis, and readmission). METHODS The national Canadian cohort enrolled 542 patients with TOF or PS and mild to severe TR who underwent isolated PVR (66.8%) or PVR+TVI (33.2%). Outcomes were abstracted from charts and compared between groups using multivariable logistic and negative binomial regression. RESULTS Median age at reintervention was 35.3 years. Regardless of surgery type, TR decreased by at least 1 echocardiographic grade in 35.4%, 66.9%, and 92.8% of patients with pre-operative mild, moderate, and severe insufficiency. In multivariable analyses, PVR+TVI was associated with an additional 2.3-fold reduction in TR grade (odds ratio [OR]: 0.44; 95% confidence interval [CI]: 0.25 to 0.77) without an increase in early adverse events (OR: 0.85; 95% CI: 0.46 to 1.57) or hospitalization time (incidence rate ratio: 1.17; 95% CI: 0.93 to 1.46). Pre-operative TR severity and presence of transvalvular leads independently predicted post-operative TR. In contrast, early adverse events were strongly associated with atrial tachyarrhythmia, extracardiac arteriopathy, and a high body mass index. CONCLUSIONS In patients with TOF or PS and significant TR, concomitant TVI is safe and results in better early tricuspid valve competence than isolated PVR.
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Deshaies et al. (2020) conducted a cohort in Corrected tetralogy of Fallot or pulmonary stenosis with tricuspid regurgitation (n=542). Concomitant tricuspid valve intervention (PVR+TVI) vs. Isolated pulmonary valve replacement (PVR) was evaluated on Reduction in tricuspid regurgitation grade (OR 0.44, 95% CI 0.25 to 0.77). Concomitant tricuspid valve intervention during pulmonary valve replacement was associated with a greater reduction in tricuspid regurgitation grade (OR 0.44; 95% CI 0.25-0.77) without increasing early adverse events.
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