Impact of preoperative assessment of right heart echocardiography in patients with severe tricuspid valve regurgitation undergoing valve surgery

Andreas Joachim Rieth (Bad Nauheim)1, C. Hellner (Bad Nauheim)1, M. Schönburg (Bad Nauheim)2, S. Kriechbaum (Bad Nauheim)1, T. Keller (Bad Nauheim)3, J. Sperzel (Bad Nauheim)1, U. Fischer-Rasokat (Frankfurt am Main)4, S. T. Sossalla (Gießen)5

1Kerckhoff Klinik GmbH Abteilung für Kardiologie Bad Nauheim, Deutschland; 2Kerckhoff Klinik GmbH Herzchirurgie Bad Nauheim, Deutschland; 3Justus-Liebig-Universität Giessen Franz-Groedel-Institut (FGI) Bad Nauheim, Deutschland; 4Kardiologie-am-Main Privatpraxis für Kardiologie Frankfurt am Main, Deutschland; 5Universitätsklinikum Gießen und Marburg GmbH Medizinische Klinik I - Kardiologie und Angiologie Gießen, Deutschland


Background: Tricuspid valve surgery (TVS) is considered to be a high-risk procedure in patients with severe tricuspid valve regurgitation (TR). Risk factors for postoperative right heart failure and mortality include severe right ventricular (RV) dysfunction determined by echocardiography; however, there is no commonly accepted definition of this condition. The primary objective of the present study was to investigate associations between preoperative RV echo parameters, RV failure, and mortality after TVS.

Methods: Between July 2010 and May 2018, 56 patients with symptomatic severe TR underwent RV echocardiography before TVS. Postoperative RV failure was the primary outcome, and the secondary outcome was 12-month mortality.

Results: Patients had a median age of 74 years (IQR 69-76), 54% of the patients were female, and 73% presented with symptoms of heart failure according to NYHA class III. Mean tricuspid annular systolic excursion (TAPSE) was 16 mm, mean RV end-diastolic diameter (RVEDD) was 47 mm, and median LV ejection fraction was 58%. The median NT-proBNP serum level was 1590 pg/ml (IQR 831-3924), and echocardiography revealed that 100% of the cohort had severe TR (grade III of III). TR was judged as primary in 11 patients. Isolated TVS was performed in 36 patients, whereas 20 underwent combined surgery.

The primary outcome of postoperative RV failure was met by 10 patients (17.9%), which was significantly associated with overall mortality (HR 4.68, 95%CI 1.65-11.76; p=0.002). Two RV echo parameters were significantly associated with RV failure: RV free wall strain (RVFWS, OR 0.86, 95%CI 0.75-0.98; p=0.03; AUC 0.74) and RV fractional area change (RVFAC, OR 0.89, 95%CI 0.81-0.97; p=0.01; AUC 0.74). Both were also associated with 12-month mortality (RVFWS: OR 0.86, 95%CI 0.75-0.97; p=0.02; AUC 0.74 and RVFAC: OR 0.90, 95%CI 0.82-0.90; p=0.01; AUC 0.72).

Conclusions: In our cohort of patients with severe TR undergoing TVS, the echocardiographic parameters of contractile RV function RVFWS and RVFAC were significantly associated with postoperative RV failure and 12-month mortality. These parameters may be used to identify patients with a particularly high risk of RV failure and death after TVS.

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