Durability and clinical impact of tricuspid valve procedures in patients receiving a continuous-flow left ventricular assist device.

Patients evaluated for a continuous-flow left ventricular assist device frequently present with severe right ventricular dysfunction with tricuspid regurgitation. Long-term outcomes of concurrent tricuspid valve procedures in continuous-flow left ventricular assist device implantation are unclear. From May 2004 to December 2013, 336 patients received continuous-flow left ventricular assist devices. Among these, 8 patients with prior tricuspid valve procedures were excluded. At continuous-flow left ventricular assist device implantation, 76 patients underwent tricuspid valve procedures (group A), including 68 repairs and 8 replacements. The remaining 252 patients did not receive concurrent tricuspid valve procedures (group B). Preoperatively, group A had higher central venous pressure/pulmonary capillary wedge pressure (P = .032), total bilirubin (P = .009), and percentage of moderate or greater tricuspid regurgitation (98.7% vs 18.8%; P < .001). In group A, cardiopulmonary bypass time (136 ± 52.0 minutes vs 83.9 ± 38.8 minutes; P < .001), intraoperative platelet use (13.6 ± 6.70 units vs 11.7 ± 5.92 units; P = .042), and bleeding requiring reoperation (27.5% vs 16.7%; P = .046) were significantly increased. In-hospital mortality was similar (10.5% vs 6.4%; P = .22). On-device 2-year survival was 73.9% in group A and 74.2% in group B (P = .24). At 2 years, mean cumulative readmissions for right heart failure was 0.21 in group A and 0.27 in group B (P = .95). A generalized linear mixed-effects model showed that tricuspid valve procedures are protective for developing future significant tricuspid regurgitation (odds ratio, 0.38; 95% confidence interval, 0.19-0.76; P = .006). Concomitant tricuspid valve procedures at continuous-flow left ventricular assist device implantation can be performed safely and are protective against worsening tricuspid regurgitation during the first 2 years of support.

Han J ，Takeda K ，Takayama H ，Kurlansky PA ，Mauro CM ，Colombo PC ，Yuzefpolskaya M ，Fukuhara S ，Truby LK ，Topkara VK ，Garan AR ，Mancini DM ，Naka Y ... -  《-》

Utility of concomitant tricuspid valve procedures for patients undergoing implantation of a continuous-flow left ventricular device.

Patients referred for implantable continuous-flow left ventricular assist devices (cfLVAD) frequently have preoperative right heart failure and tricuspid regurgitation (TR). The objective of this report is to examine early clinical benefits of concomitant tricuspid surgery for these patients. Sixty-one of 200 consecutive cfLVAD patients at our institution displayed preimplant right heart dysfunction and significant TR. Thirty-three underwent cfLVAD plus a tricuspid valve procedure (TVP), and 28 had cfLVAD alone. Preimplant characteristics and clinical outcomes were retrospectively studied. As previously described, post-LVAD right ventricular failure was defined as need for right ventricular assist device (RVAD) support or greater than 14 days of intravenous inotropic support. Preimplant characteristics were similar between the 2 groups. Cardiopulmonary bypass time was increased for the group that received concomitant TVPs. The most common TVP consisted of an undersizing ring annuloplasty. The cfLVAD-alone group had greater TR after implant relative to the cfLVAD+TVP group. The cfLVAD-alone group experienced greater postprocedure right ventricular failure relative to cfLVAD+TVP (46.4% vs 18.2%; P < .05). Furthermore, prolonged hospitalization was increased for the cfLVAD-alone group versus the cfLVAD+TVP. Survival was similar between the 2 groups. Concomitant TVP appears to reduce postprocedure right ventricular failure for patients with significant TR undergoing cfLVAD implantation.

Piacentino V 3rd ，Ganapathi AM ，Stafford-Smith M ，Hsieh MK ，Patel CB ，Simeone AA ，Rogers JG ，Milano CA ... -  《-》

Surgical treatment of tricuspid valve insufficiency promotes early reverse remodeling in patients with axial-flow left ventricular assist devices.

The HeartMate II (Thoratec Corp, Pleasanton, Calif) continuous-flow left ventricular assist device has emerged as the standard of care for patients with advanced heart failure. The objective of this study was to assess the safety and early effectiveness of concomitant tricuspid valve procedures in patients undergoing implantation of a HeartMate II device. From February 2007 to April 2010, 83 patients underwent HeartMate II left ventricular assist device implantation. Of these, 37 patients had concomitant tricuspid valve procedures (32 repairs, 5 replacements) for severe tricuspid regurgitation. The effects of a tricuspid valve procedure on tricuspid regurgitation and right ventricular remodeling were assessed comparing echocardiographic findings at baseline and 30 days after left ventricular assist device implantation. Overall survival was also compared. Patients undergoing a concomitant tricuspid valve procedure had more tricuspid regurgitation (vena contracta, 5.6 ± 2.1 mm vs 2.9 ± 2.0 mm; P < .001), worse right ventricular dysfunction (right ventricular end-diastolic area, 33.6 ± 6.2 mm vs 31.6 ± 8.5 mm; P = .05), higher mean right atrial pressure (17.4 ± 7.1 mm Hg vs 14.9 ± 5.1 mm Hg; P = .03), and a higher Kormos score (2.6 ± 2.1 vs 1.2 ± 1.4; P = .0008) preoperatively. One month after surgery, tricuspid regurgitation was worse in patients who underwent left ventricular assist device implantation alone (+18.6%), whereas it improved significantly in patients undergoing a concomitant tricuspid valve procedure (-50.2%) (P = .005). A corresponding significant reduction in right ventricular end-diastolic area (33.6% ± 6.2% vs 30.1% ± 9.7%; P = .03) and a trend toward better right ventricular function (55.5% ± 79.7% vs 35.7% ± 60.5%; P = .28) were noted in patients undergoing a concomitant tricuspid valve procedure. Survival was comparable between the 2 groups. In patients with severe tricuspid regurgitation undergoing left ventricular assist device implantation, a concomitant tricuspid valve procedure effectively reduces tricuspid regurgitation and promotes reverse remodeling of the right ventricle.

Maltais S ，Topilsky Y ，Tchantchaleishvili V ，McKellar SH ，Durham LA ，Joyce LD ，Daly RC ，Park SJ ... -  《-》

Relationship of tricuspid repair at the time of left ventricular assist device implantation and survival.

Brewer RJ ，Cabrera R ，El-Atrache M ，Zafar A ，Hrobowski TN ，Nemeh HM ，Selektor Y ，Paone G ，Williams CT ，Velez M ，Tita C ，Morgan JA ，Lanfear DE ... -  《-》

Impact of concomitant cardiac procedures performed during implantation of long-term left ventricular assist devices.

There is a paucity of data evaluating the effect of performing a concomitant cardiac procedure (CCP) on peri-operative survival in patients undergoing implantation of long-term left ventricular assist devices (LVADs). The objective of this study was to review our single-institutional experience with patients who underwent a CCP during implantation of a long-term continuous-flow LVAD. From March 2006 through June 2012, 130 patients underwent implantation of a LVAD. Of these, 76 (58.5%) were implanted as bridge-to-transplant and 54 (41.5%) as destination therapy. The LVAD implantation was isolated in 95 patients and with CCP in 35. This included 19 tricuspid valve repairs, 14 aortic valve repair/replacements, and 2 patent foramen ovale closures. The LVAD only and LVAD+CCP groups were compared regarding pre-operative demographics, peri-operative and midterm survival, and the incidence of post-operative complications. Pre-operative central venous pressure (p = 0.047), moderate to severe tricuspid regurgitation (p = 0.011), cardiopulmonary bypass time (p < 0.0001), cross-clamp time (p < 0.0001), and right ventricular end diastolic diameter (p = 0.039) were higher in the CCP group. Body mass index (p = 0.01) and body surface area (p = 0.037) were higher in the LVAD-only group. Peri-operative and midterm survival at 30 days, 6 months, 1 year, and 2 years was 94%, 87%, 80%, and 73%, respectively, for isolated LVAD implants vs. 97%, 90%, 86%, and 86%, respectively, for LVAD+CCP (p = NS). Survival was similar for LVAD patients with tricuspid valve repairs, with aortic valve repair, and with patent foramen ovale repair (p = NS). Cox proportional hazard models showed a CCP was not an independent predictor of outcome (p = NS). CCPs performed during implantation of a long-term continuous-flow LVADs does not increase peri-operative or mid-term mortality. In addition, unlike previous reports, there was no additive procedural risk for patients undergoing concomitant aortic valve repair or replacement.

Morgan JA ，Tsiouris A ，Nemeh HW ，Hodari A ，Karam J ，Brewer RJ ，Paone G ... -  《-》