The Heart Valve Society

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Prevalence, In-hospital Outcomes, and Prognostic Determinants of Triple Valve Surgery in the United States: The Role of Valve Repair in the Current Era.
Christopher Lau, Mario Gaudino, Luke Kim, Lucas Ohmes, Monica Munjal, Dmitry Feldman, Leonard Girardi.
Weill Cornell Medicine, New York, NY, USA.

Background: Triple valve surgery (3VS) remains a challenging procedure. We aimed at evaluating the prevalence, in-hospital outcomes, and prognostic determinants of 3VS in the United States in the current era.
Methods: We reviewed the 2003-2012 Nationwide Inpatient Sample database and included all patients who underwent aortic valve replacement (AVR) combined with mitral valve replacement (MVR) or repair (MVPL) and tricuspid valve replacement (TVR) or repair (TVPL). Logistic regression analysis was used to identify independent predictors of in-hospital mortality and propensity matching was adopted to compare groups receiving different operations.
Results: Overall, 5234 patients were included (733 AVR+MVR+TVR, 2667 AVR+MVR+TVPL, 1745 AVR+MVPL+TVPL and 89 AVR+MVPL+TVR). In-hospital mortality was 13.9%. Major adverse events occurred in 42.9% of the cases (44.9%, 40.3%, 44.4% and 74.2% in the AVR+MVR+TVR, AVR+MVR+TVPL, AVR+MVPL+TVPL and AVR+MVPL+TVR respectively, p<0.05 for all intergroup comparisons). The incidence of perioperative respiratory insufficiency requiring tracheostomy, need for dialysis, stroke, myocardial infarction and need for intra-aortic balloon was 6.9%, 8.6%, 2.8%, 3.5% and 12.2% respectively (see table). In-hospital mortality in the AVR+MVR+TVR, AVR+MVR+TVPL, AVR+MVPL+TVPL and AVR+MVPL+TVR groups was 19.9%, 13.3%, 12.9% and 0% respectively (p<0.05 for all intergroup comparisons). At regression analysis age, reoperation and urgent/emergent operation were independent predictors of in-hospital mortality (see table). Patients submitted to tricuspid valve repair and mitral and tricuspid repair had a 62% and 63% mortality risk reduction (OR 0.380, CI 0.191-0.758 p= 0.006 and OR 0.37, CI 0.18-0.78 p= 0.009 respectively). In the propensity matched comparisons, in-hospital mortality was statistically similar between groups, even though a trend toward better outcome with valve repair was noted (p = 0.08 for the AVR+MVR+TVR vs. AVR+MVR+TVPL comparison and p= 0.06 for the AVR+MVR+TVR vs. AVR+MVPL+TVPL comparison).
Conclusions: Even in the current era 3VS is associated with significant in-hospital mortality and morbidity. The use of valve repair strategies for the mitral and tricuspid valves has the potential to positively impact postoperative outcomes.

Overall
n=5234
Group 1
AVR,MVR,TVR
n=733
Group 2
AVR,MVR,TVPL
n=2667
Group 3
AVR,MVPL,TVPL
n=1745
Group 4
AVR,MVPL,TVR
n=89
Postoperative Outcomes In Unmatched Groups
Death before discharge acdef728 (13.9)146 (19.9)355 (13.3)225 (12.9)0 (0)
Major adverse events abdef2245 (42.9)329 (44.9)1074 (40.3)775 (44.4)66 (74.2)
Percutaneous Cardiopulmonary bypass52 (1.0)10 (1.4)19 (0.7)21 (1.2)0 (0)
Postop Intra-aortic Balloon Pumpac638 (12.2)115 (15.7)312 (11.7)202 (11.6)9 (10.1)
Postop Ventricular Assist Device a16 (0.3)5 (0.7)5 (0.2)5 (0.3)0 (0)
Acute myocardial infarction183 (3.5)19 (2.6)93 (3.5)65 (3.7)5 (5.6)
Acute Stroke ac147 (2.8)32 (4.4)64 (2.4)49 (2.8)5 (5.6)
Acute Renal failure bdef1517 (29.0)218 (29.7)709 (26.6)550 (31.5)42 (47.2)
Acute Pulmonary Heart Disease abcdef79 (1.5)19 (2.6)13 (0.5)24 (1.4)20 (22.5)
Tracheostomy ac361 (6.9)82 (11.2)176 (6.6)99 (5.7)5 (5.6)
Hemodialysis450 (8.6)62 (8.5)213 (8.1)162 (9.3)10 (11.2)
ap<.05 for Group1 vs Group2, bp<.05 for Group2 vs Group3, cp<.05 for Group1 vs Group3, dp<.05 for Group1 vs Group4
ep<.05 for Group2 vs Group4, fp<.05 for Group3 vs Group4
OR (95% CI)P Value
Independent Predictors of In-Hospital Death
Age1.042 (1.020-1.065)<0.001
Reoperation2.827 (1.352-5.911)0.006
Urgent/Emergent operation1.813 (1.025-3.208)0.041
Groups
AVR, MVR, TVRreference group1.00
AVR, MVR, TVPL0.380 (0.191-0.758)0.006
AVR, MVPL, TVPL0.377 (0.182-0.780)0.009


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