Tricuspid valve interventions increasing—but mortality rate remains high

Procedures to replace or repair patients’ tricuspid valves (TVs) remain rare but have increased in recent years, according to a study in the Journal of the American College of Cardiology. But despite this increased volume, in-hospital mortality has remained steady at 8.8 percent.

Using the National Inpatient Sample, which includes roughly 20 percent of the hospital admissions in the United States, Mayo Clinic researchers estimated 5,005 operations for isolated TV repair or replacement were performed from 2004 to 2013. Patients with congenital heart disease were excluded.

Operations per year increased from 290 in 2004 to 780 in 2013. However, those increasing numbers still lag behind the expected numbers given 1.6 million Americans are estimated to have moderate to severe tricuspid regurgitation, and guidelines recommend intervention in those patients, the authors wrote.

“The rarity of TV surgery may be driven by a high perceived operative mortality, as high as 24 percent in previous reports; we observed the mortality to still be high: 8.8 percent in this contemporary national sample,” wrote lead author Chad J. Zack, MD, and colleagues. “Despite increased utilization of isolated TV surgery and improvement in operative techniques, operative mortality did not decrease over the study period. … Given the increasing prevalence of isolated TV disease in the population, research into optimal surgical timing and patient selection is critical.”

Zack et al. noted in-hospital mortality occurred in 5.9 percent of patients treated with TV repair, 9.1 percent of patients treated with a bioprosthetic valve, and 13.6 percent treated with a mechanical replacement. Risk-adjusted in-hospital mortality for tricuspid valve replacement was nearly double that of valve repair.

“The higher mortality with valve replacement may represent a selection bias, as some surgeons would place a prosthesis in those sicker patients with end-stage annular dilatation and severe noncoaptation of the valve leaflets with poorer RV (right ventricular) function to avoid reoperation,” Zack and colleagues wrote. “However, as with valve repair in the aortic and mitral position, the valve repair itself may result in better outcome than replacement due to better maintenance of RV function with preservation of tricuspid continuity and fewer prosthetic valve–related complications.”

The authors noted more research is needed to determine whether new percutaneous TV devices can reduce the mortality risk for these patients. Also, their study was missing important data on right ventricular size and function and pulmonary arterial pressures, variables that could have played a role in the increased mortality seen in people undergoing valve replacements.

“Because we have such poor measures of RV function available to us, the decision of when to undergo TV repair/replacement has always been and continues to remain a clinical challenge. It often comes down to a judgment call,” Thomas M. Bashore, MD, and John D. Serfas, MD, both with Duke University Medical Center, wrote in an accompanying editorial.