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Background: The efficacy of different cardioplegia solutions on outcomes of complex cardiac operations such as triple valve surgery (TVS) is scarce. Here we compared the outcomes in TVS patients receiving either crystalloid (Bretschneider) or blood (Calafiore) cardioplegia. Methods: Screening of our institutional database with prospectively entered data identified 471 consecutive patients (mean age 70.3 ± 9.2 years; 50.9% male), who underwent TVS (replacement or repair of aortic, mitral and tricuspid valve) between December 1994 and January 2013. In 277 patients, cardiac arrest was induced with HTK-Bretschneider solution (HTK, n = 277, 58.8%), whereas 194 received cold blood cardioplegia (BCP) according to Calafiore (n = 194, 41.2%). Comparisons of perioperative and follow up outcomes were made between cardioplegia groups. Results: Preoperative patient characteristics and comorbidities were equally balanced between groups. 30-days mortality was similar between groups (HTK: 16.2%; BCP: 18.2%; p = 0.619). Incidence of the cumulative endpoint (30days mortality, myocardial infarction (MI), arrhythmia, low cardiac output syndrome or need for permanent pacemaker implantation) was also comparable (HTK: 47.6%; BCP: 54.8%, p = 0.149). In patients with reduced left ventricular ejection fraction (LVEF <40%), 30days mortality was higher in the HTK group (HTK 18/71 22.5%; BCP 5/50 10%; p = 0.037). Five-year survival was similar between groups (52 ± 6% for HTK and 55 ± 5% for BCP patients). In-Hospital mortality was best predicted by length of surgery and reperfusion ratio. Decreased age, shorter bypass time, preserved LVEF and concomitant surgical procedures have been found to be protective from long-term mortality. Conclusions: Myocardial protection with HTK shows equivalent outcomes compared to BCP during TVS. Patients with reduced left ventricular function may benefit from BCP during TVS. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES To describe evolving demographic trends and early outcomes in patients undergoing triple-valve surgery in the UK between 2000 and 2019. METHODS We planned a retrospective analysis of national registry data including patients undergoing triple-valve surgery for all aetiologies of disease. We excluded patients in a critical preoperative state and those with missing admission dates. The study cohort was split into 5 consecutive 4-year cohorts (groups A, B, C, D and E). The primary outcome was in-hospital mortality, and secondary outcomes included prolonged admission, re-exploration for bleeding, postoperative stroke and postoperative dialysis. Binary logistic regression models were used to establish independent predictors of mortality, stroke, postoperative dialysis and re-exploration for bleeding in this high-risk cohort. RESULTS We identified 1750 patients undergoing triple-valve surgery in the UK between 2000 and 2019. Triple valve surgery represents 3.1% of all patients in the dataset. Overall mean age of patients was 68.5 ± 12 years, having increased from 63 ±12 years in group A to 69 ± 12 years in group E (P  < 0.001). Overall in-hospital mortality rate was 9%, dropping from 21% in group A to 7% in group E (P  < 0.001). Overall rates of re-exploration for bleeding (11%, P  = 0.308) and postoperative dialysis (11%, P  = 0.066) remained high across the observed time period. Triple valve replacement, redo sternotomy and poor preoperative left ventricular ejection fraction emerged as strong independent predictors of mortality. CONCLUSIONS Triple-valve surgery remains rare in the UK. Early postoperative outcomes for triple valve surgery have improved over time. Redo sternotomy is a significant predictor of mortality. Attempts should be made to repair the mitral and/or tricuspid valves where technically possible. [ABSTRACT FROM AUTHOR]

Context: Triple valve surgery (TVS) is a relatively higher in-hospital mortality rate than any isolated valve surgery. In advanced-stage valvular heart disease, maladaptation may occur, creating RV-PA uncoupling. Aims To evaluate whether RV-PA coupling is associated with the in-hospital outcome of patients after TVS. Settings and Design: From the medical records, clinical and echocardiography data were collected and compared between the survived and patients with in-hospital mortality groups. Methods and Material: Patients with the rheumatic multivalvular disease who underwent triple valve surgery were included in the study. Statistical and analysis used Uni and bivariate analysis assessed any association between the RV-PA coupling using TAPSE/PASP and other clinical variables with the in-hospital mortality post TVS. Result: From 269 patients, the in-hospital mortality rate was 10 %. The median value of TAPSE/PASP ratio in all group is 0.41 (0.02-5.79). Impaired RV-PA coupling which value < 0.36 occurs in 38.3 % population. By multivariate analysis, independent predictors of in-hospital mortality were TAPSE/PASP < 0.36 (OR 3.46, 95 % CI 1.21 – 9.89; P 0.02), age (OR 1.04, 95 % CI 1.003-1.094; P 0.035), CPB duration, (OR 1.01, 95 % CI 1.003-1.017; P 0.005). Conclusion: RV-PA uncoupling assessed by TAPSE / PASP ratio < 0.36 is associated with the in-hospital mortality in patients post triple valve surgery. Other factors associated with the outcome were older age and longer CPB machine duration. [ABSTRACT FROM AUTHOR]

Background: Despite significant advancements in operative techniques and myocardial protection, triple valve surgery (TVS) remains a formidable operation with a relatively high in‐hospital mortality. We evaluated the prognostic value of Model for End‐stage Liver Disease score including sodium (MELD‐Na) for mortality after TVS and its predictive value when incorporated in the EuroSCORE risk model. Methods: We performed a retrospective cohort study of 61 consecutive patients who underwent TVS from November 2005 to June 2016. Demographics, clinical, biochemical, and operative data were collected and analyzed. Results: Median follow‐up duration was 8.0 years. The majority (70.5%) of patients suffered from rheumatic heart disease and underwent mechanical double valve replacement with tricuspid valve repair. There were six operative deaths (9.84%), with the most common cause of death being multiorgan failure (83.3%). In 26.2% of the cohort, the MELD‐Na score was moderately elevated at 9 to 15. A small fraction (4.9%) had a severely elevated MELD‐Na greater than 15. Patients with a MELD‐Na greater than 9 had a higher unadjusted rate of operative mortality, prolonged ventilation, need for dialysis and acute liver failure after TVS. Hierarchical logistic regression was performed using logistic EuroSCORE as the base model. After risk adjustment, each point of MELD‐Na score increase was associated with 1.405 times increase in odds of operative mortality. The regression analysis was repeated by incorporating individual components of the MELD‐Na score, including bilirubin, sodium, and albumin. All three biochemical parameters were significantly associated with operative mortality Conclusion: MELD‐Na score as a quantifier of hepatorenal dysfunction is sensitive and specific for operative mortality after triple valve surgery. [ABSTRACT FROM AUTHOR]

There is limited clinical evidence on when to address tricuspid regurgitation in patients with aortic and mitral valve disease requiring surgical intervention. In this study, we aimed to investigate the potential added value of performing a tricuspid valve repair concomitantly in patients requiring double valve surgery (DVS) of the aortic and mitral valves. We reviewed 223 cases of multivalve surgery from 2011 to 2016. In this single-institution series, 190 underwent DVS in aortic and mitral positions and 33 had triple valve surgery in aortic, mitral, and tricuspid positions. Preoperative and postoperative echocardiograms were evaluated to determine changes in valve function. A logistic regression model was performed to assess relationship of patient comorbidities and type of valve operations to perioperative adverse events. Mid-term survival was similar between the 2 groups (P = 0.541). Compared to DVS, TVS was not associated with an increased risk of perioperative adverse events, including need for pacemaker or mortality on multivariable analysis. Within the DVS subgroup, 19.8% of patients experienced improvement in tricuspid valve function with decrease in the degree of tricuspid regurgitation within a 6-month postoperative follow-up. Our study indicates that repairing the tricuspid valve while addressing the aortic and mitral valves does not pose significant additional risk. The observed improvement of the degree of tricuspid regurgitation without tricuspid operation suggests the need to further define subpopulations of patients with multivalvular disease. [ABSTRACT FROM AUTHOR]

Objective: Minimally invasive surgery is a widely accepted surgical treatment for valve disease, however triple valve surgery (TVS) is a complex and challenging procedure. The objective of this study was to describe the morbidity and mortality related to minimally invasive TVS at our institution. Methods: This was a retrospective review of all minimally invasive TVS performed between 2012 and 2019. Baseline and perioperative characteristics were reviewed, as were postoperative outcomes. Results: Eighteen patients underwent TVS; 12 patients underwent additional procedures at the time of TVS. Median time to initial extubation was 11.5 hours (interquartile range [IQR] 9.8‐13.3). Intensive care unit and total length of stay were 1.22 (IQR, 1.16‐1.31) and 9 (IQR, 6‐17) days, respectively. No hospital deaths occurred; 30‐, 90‐, and 365‐day mortality were 0%. Two postoperative neurologic complications occurred, two patients had acute kidney injuries. The most common complication was rhythm disturbance with five patients requiring permanent pacemaker implantation. Mean follow‐up was 39.9 months (252‐2642 days). Conclusions: Our findings demonstrate that minimally invasive TVS utilizing femoral cannulation results in an acceptable risk of complication. Short and intermediate term survival were excellent. [ABSTRACT FROM AUTHOR]

Female gender is a risk factor in several cardiac surgery risk stratification systems. This study explored the differences in the outcomes following triple heart valve surgery in men vs women. The study included 250 patients (males n = 101; females n = 149) who underwent triple valve surgery from 2009 to 2020. BMI (body mass index) was higher in females (29.6 vs 26.5 kg/m2, P < .001), and diabetes was more common in males (44 vs 42%, P = .012). The ejection fraction was higher in females (55 vs 50%, P < .001). The severity of mitral valve stenosis and tricuspid valve regurgitation was significantly greater in females (33.11 vs 27.72%, P = .003 and 44.30 vs 19.8%, P < .001, respectively). Mitral valve replacement was more common in females (P < .001), and they had lower concomitant coronary artery bypass grafting (P = .001). Bleeding and renal failure were lower in females (P = .021 and <0.001, respectively). Hospital mortality, readmission, and reintervention were not significantly different between genders. By multivariable analysis, male gender was a risk factor for lower survival [HR (hazard ratio): 2.18; P = .024]. Triple valve surgery can be performed safely in both genders, with better long-term survival in females. Female gender was not a risk factor in patients undergoing triple valve surgery. [ABSTRACT FROM AUTHOR]

Background: Triple valve surgery (TVS) remains a challenging procedure with limited existing literature. We aim to evaluate the prevalence, in-hospital outcomes, and prognostic determinants of TVS in the current era.Materials and Methods: We reviewed the Nationwide Inpatient Sample database from 2003 to 2012 and included all patients who underwent aortic valve replacement (AVR) combined with mitral valve replacement (MVR) or repair (MVRep) and tricuspid valve replacement (TVR) or repair (TVRep). Logistic regression analysis was used to identify independent predictors of in-hospital mortality and propensity score matching was adopted to compare groups receiving different operations.Results: Overall, 5234 patients were included. 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 + TVRep, AVR + MVRep + TVRep and AVR + MVRep + TVR groups respectively, p < 0.05 for all intergroup comparisons). In-hospital mortality in the AVR + MVR + TVR, AVR + MVR + TVRep, AVR + MVRep + TVRep and AVR + MVRep + 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. Patients submitted to tricuspid valve repair and mitral and tricuspid repair had a 62% and 63% mortality risk reduction (OR:0.380, CI:0.19-0.76 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 (p = 0.08 for AVR + MVR + TVR vs. AVR + MVR + TVRep comparison and p = 0.06 for AVR + MVR + TVR vs. AVR + MVRep + TVRep comparison).Conclusions: TVS is associated with significant in-hospital mortality and morbidity. The use of valve repair strategies for the mitral and tricuspid valves can positively impact postoperative outcomes. [ABSTRACT FROM AUTHOR]

Background: Triple valve surgery (TVS) is associated with an elevated risk for operative mortality and thus remains a surgical challenge. We report our experience and results of TVS procedures, especially with respect to identification of preoperative risk factors, to improve patient selection. Methods: Between December 1994 and January 2013, 487 consecutive patients (240 male, 247 female) underwent TVS at the Heart Center Leipzig, University of Leipzig. The data were prospectively collected and retrospectively analyzed. Univariate and multivariable regression analyses were performed to identify risk factors. Results: The 30-day mortality was 16.1% and the long-term survival at 1 year and 5 years was 71.8% and 54.6%, respectively. Multivariable logistic regression analysis identified previous myocardial infarction to be the only significant predictor for early mortality. Age, New York Heart Association functional class IV, previous myocardial infarction, dialysis, and liver dysfunction were identified as preoperative predictors for late mortality. Furthermore, an increase of operative risk, given for each year, was observed during the study period. In contrast, 30-day mortality decreased during the observation time. Conclusion: TVS is associated with a high surgical risk. Long-termsurvival is decreased, but acceptable for these high-risk patients. The series demonstrates that increasing surgical risk, age, and comorbidities are the future challenges in TVS. [ABSTRACT FROM AUTHOR]

A 63-year-old woman was referred to our institution for surgical treatment of triple valve (aortic, mitral, and tricuspid) insufficiency and underwent a robot-assisted endoscopic procedure. Three intercostal ports were placed in the right lateral chest for robotic instruments and a retrograde cardioplegic cannula, and a 5 cm thoracotomy was made for the procedure, which was a mitral valve repair with neochords and ring annuloplasty, an aortic valve replacement with bioprosthetic valve, and a ring tricuspid annuloplasty. Surgery was successfully achieved without blood transfusion or any complications.

Abstract: Background: Triple valve surgery (TVS) is still of choice for advanced rheumatic heart disease (RHD), which has been associated with reported poor early and late outcomes. We describe the short- and long-term results after TVS in last two decades in Mainland China. Methods: From January 1985 to January 2005, a total of 871 patients (217 men, 654 women), with mean age of 42±11 years, underwent primary TVS for isolated advanced RHD. All patients received replacement procedures in mitral and aortic position (845 mechanical, 26 bioprosthetic), and 840 patients received repair procedures and the other 31 received replacement procedures in tricuspid position (9 mechanical, 22 bioprosthetic). Preoperative, perioperative, and postoperative data were retrospectively analyzed and risk factors affecting early and late survival were evaluated. Results: The 30-day hospital mortality was 8% (n =71). Presence of ascites, New York Heart Association (NYHA) class IV and lower left ventricular ejection fraction (LVEF) were identified as independent risk factors for hospital mortality. Overall long-term survival rate was 71%±3% at 5 years, and 59%±5% at 10 years. The cardiac survival rate was 75%±3% at 5 years and 63%±4% at 10 years. The event-free survival rate at 5 years and 10 years was 61%±6% and 41%±13%, respectively. Multivariate analysis revealed advanced age, NYHA class IV and lower LVEF were associated with increased late mortality. The freedom from thromboembolism and anticoagulation-related hemorrhage at 10 years was 90%±4% and 81%±5%, respectively. Of the 508 patients still alive, 376 (74%) were in NYHA class I and II. Conclusions: Primary TVS for advanced RHD appears to offer satisfactory short- and long-term results with excellent symptomatic improvement. Cardiac-related late mortality following TVS may be improved by early surgical treatment before NYHA class IV or deterioration of LVEF occurs. [Copyright &y& Elsevier]

Between 1968 and 1984, 78 patients (mean age 43, range 14 to 65 years) underwent combined aortic, mitral and tricuspid surgery (22 triple valve replacements, 56 aortic valve replacements with tricuspid conservative surgery and mitral valve replacement (N=48), or commissuroplasty (N=8). Pre-operative consequences of valvular disease (mainly mixed valve disease) were severe as assessed by functional class (72 pts in III or IV NYHA), cardiomegaly (CTR: 62±6%), increase of mean pulmonary arterial and wedge pressures (respectively 30±12 and 19±6mmHg) decrease in cardiac index (2.1±0.5 lmin m), LV dilatation (LVend diastolic volume: 184±86ml m) and impairment of LV systolic function (LV ejection fraction: 50±12%). Operative mortality rate was 11.5%. The 69 survivors were all followed up, for a mean of 56 months (2 to 207). 16 late deaths occurred. Actuarial survival rate at 10 years was 58.4%, and greatly influenced by pre-operative NYHA class. Linearized rates of thromboembolic events, valve thrombosis and haemorrhage were respectively 6.4, 1.5 and 1.2% pt yr. Those of infective endocarditis, periprosthetic leak, reoperation and valve failure were 0.6, 3.3 and 4.9% pt yr respectively. At 9 years, 42% of the patients were in NYHA class I or II and free from complications [ABSTRACT FROM PUBLISHER]

Objectives: Triple valve surgery (TVS) is still a challenge for surgeons because of prolonged cardiopulmonary bypass (CPB) and myocardial ischaemic times. The reported operative mortality rate for TVS ranges between 2.5 and 25%; long-term survival is also diminished, with reported survival rates at 5 and 10 years of 75-82 and 61-75%, respectively. The objective of our study is to define early and late clinical outcomes, reporting the initial experience in the treatment of triple valve disease through a minimally invasive approach., Methods: A retrospective, observational, cohort study was undertaken of prospectively collected data on 106 patients who underwent TVS at our institution between October 2001 and June 2013. A total of 101 procedures were done through the standard median sternotomy; however, in 5 patients, the surgical procedure was carried out through a right minithoracotomy. Univariate analysis was performed to identify predictors of early and late survival., Results: The in-hospital mortality rate was 5.6% (6 of 107 patients). Predictors of early mortality were: previous cardiac surgery [odds ratio (OR) 4, 95% confidence interval (CI) 1.08-5.2, P = 0.04], preoperative left ventricular ejection fraction (LVEF) (OR 0.9, 95% CI 0.8-1.1, P = 0.003), prolonged CPB time (OR 1.02, 95% CI 1.01-1.04, P = 0.01) and postoperative pulmonary complications (OR 8, 95% CI 5.8-41, P = 0.0001). Five- and 10-year survival rates were 85 ± 3 and 65 ± 9%, respectively. In univariate analysis, diabetes [hazard ratio (HR) 2.5, 95% CI 1-6.2, P = 0.045], preoperative dialysis (HR 3, 95% CI 2-4.7, P = 0.001), unstable angina (HR 4.8, 95% CI 1-18, P = 0.03), preoperative LVEF (HR 0.9, 95% CI 0.8-1.1, P = 0.02), concomitant coronary artery bypass grafting (CABG) (HR 2.5, 95% CI 1.5-5.7, P = 0.006), prolonged CPB time (HR 1.02, 95% CI 1.01-1.13, P = 0.006), postoperative pacemaker (PMK) implantation (HR 6.2, 95% CI 1.3-18, P = 0.01) and postoperative pulmonary complications (HR 3.3, 95% CI 2.1-7.3, P = 0.002) were found to be significant predictors of late mortality following TVS. The freedom rates from valve-related complications and reoperation at 10 years were 95 ± 2 and 97 ± 2%, respectively. The 10-year freedom rates from thromboembolism and anticoagulation-related haemorrhage were 88 ± 5 and 88 ± 4%, respectively., Conclusions: TVS offers encouraging short-term and long-term patient survival; these good results after TVS in patients with advanced valvular heart disease justify aggressive surgical therapy in these patients. TVS with a minimally invasive approach is feasible and could be another treatment option., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Triple valve surgery is usually complex and carries a reported operative mortality of 13% and 10-yr survival of 61%. We examined surgical results based on our hospital's experience. A total of 160 consecutive patients underwent triple valve surgery from 1990 to 2006. The most common aortic and mitral valve disease was rheumatic disease (82%). The most common tricuspid valve disease was functional regurgitation (80%). Seventy-four percent of the patients were in New York Heart Association (NYHA) class III and IV. Univariate and multivariable analyses were performed to identify predictors of early and late survival. Operative mortality was 6.9% (n=11). Univariate factors associated with mortality included old age, preoperative renal failure, postoperative renal failure, pulmonary complications, and stroke. Of them, postoperative renal failure and stroke were associated with mortality on multivariable analysis. Otherwise, neither tricuspid valve replacement nor reoperation were statistically associated with late mortality. Survival at 5 and 10 yr was 87% and 84%, respectively. Ninety-two percent of the patients were in NYHA class I and II at their most recent follow-up. Ten-year freedom from prosthetic valve endocarditis was 97%; from anticoagulation-related hemorrhage, 82%; from thromboembolism, 89%; and from reoperation, 84%. Postoperative renal failure and stroke were significantly related with operative mortality. Triple valve surgery, regardless of reoperation and tricuspid valve replacement, results in acceptable long-term survival.