National trends and in-hospital outcomes of tricuspid valve surgery in Germany from 2011 to 2023

Background Severe tricuspid regurgitation was long considered a benign or secondary condition and was therefore often left untreated. This dogma has been abandoned in recent years. Tricuspid valve disease is now recognised as an independent predictor of morbidity and mortality and has become a field of extensive research activity, particularly in transcatheter therapies. Yet surgical tricuspid valve interventions, historically associated with high perioperative mortality, continue to play a crucial role in the treatment of tricuspid valve disease. Contemporary nationwide data on surgical practice and outcomes in the era of transcatheter therapies remain limited. Purpose The aim of this study was to evaluate national trends in comorbidities, surgical management and in-hospital outcomes of patients undergoing tricuspid valve surgery in Germany from 2011 to 2023. Methods This study is based on data from the German Diagnosis-Related Groups database. All inpatient cases undergoing tricuspid valve surgery between 2011 and 2023 were identified. Using ICD-10-GM and OPS codes, data on procedures, comorbidities and outcomes were obtained and statistically analysed. Results Between 2011 and 2023, 47,297 patients (46% female; median age 71 years) underwent tricuspid valve surgery in Germany. Annual surgical volumes remained stable over the study period (p=0.10). Over time, the mean age declined significantly (p<0.001). Most patients had severe comorbidities, particularly cardiovascular conditions (65.5% hypertension, 65.6% congestive heart failure, 73.2% atrial fibrillation or flutter). The prevalence of chronic kidney disease (28.9%) and liver disease (2.3%), both markers of end-organ damage, decreased significantly over time (p<0.001). The most common documented aetiology was non-rheumatic tricuspid regurgitation (58.5%). Rheumatic tricuspid regurgitation was less frequent (13.7%) but significantly increasing over time (p=0.004). Infective endocarditis accounted for 2.8% of cases. The predominant procedure was tricuspid valve annuloplasty (83%). Valve replacement was performed in 8% of patients. Overall, in-hospital mortality was 12%. Mortality and major adverse cardiac and cerebrovascular events declined significantly over time. Mortality in complex procedures including tricuspid valve surgery, left-sided valve surgery and coronary artery bypass grafting was significantly higher (20%) than in isolated tricuspid valve surgery (6%). Conclusions In Germany, surgical tricuspid valve volumes remained stable from 2011 to 2023 despite the rapid expansion of transcatheter therapies. Most patients present with severe comorbidities. The prevalence of infective endocarditis was substantially lower than previously reported. Although perioperative outcomes improved, in-hospital mortality remains considerable, particularly in complex combined procedures. These findings highlight the need for careful timing, patient selection and risk stratification.