This study described the early clinical outcomes in patients with reduced RV function undergoing reoperative TVR via total thoracoscopic surgery and full sternotomy approach at a single institution.
Severe functional TR, which is often associated with severe RV dysfunction, has been reported in 27% of patients who underwent previous left-sided valve surgery.[9] Previous studies identified RV dysfunction as a predictor of poor outcome after reoperative TVR. Current guidelines recommend surgery only in patients with severe TR after left-sided surgery and without severe RV dysfunction.[10][11] Therefore, the decision to perform reoperative TVR in patients with reduced RV function is challenging. We concentrated on this subgroup of patients since we believe this is a high-risk surgical population with poorer clinical condition and had severe comorbidities resulting from systemic venous congestion due to exacerbation of preexisting RV dysfunction.
This group of patients tend to experience more postoperative complications that lead to prolonged intensive care unit (ICU) and total hospital stay, which leads to higher short and long-term mortality. The patients in our study had severe RV dysfunction on admission and immediate surgical intervention was generally inappropriate. We recommend optimizing preoperative drug therapy, particularly strengthening diuresis, to reduce RV volume overload until symptoms of RV dysfunction such as edema, are alleviated
Our experience in this series of patients with severe RV dysfunction suggests that patients undergoing total thoracoscopic reoperation have better early outcomes, including shorter hospital stays and ICU stays, which are in agreement with of the literature. Previous studies have shown that isolated tricuspid valve surgery is associated with high mortality, particularly in the presence of reoperation and RV dysfunction. In-hospital mortality for the entire cohort in our study was 13.6%, similar to the range of 13–26% reported by other studies,[12] and appears to be quite encouraging when in-hospital mortality in the T-TVR group was 8.0%.
In line with other series involving minimally invasive TV surgery, this study showed that T-TVR seems to have a tremendous advantage over C-TVR in terms of the reducing operative time, drainage amounts, and transfusion requirement.[13] According to Stoppe et al., shorter CPB time would likely lead to shorter ICU and hospital stay durations and faster postoperative recovery.[14] Moreover, less postoperative bleeding and a decreased requirement for transfusion probably indicated more stable hemodynamics, facilitating early removal of the tracheal intubation.[15] The T-TVR group had a shorter operative time and extracorporeal circulation time, which reduced the impact of surgery on postoperative recovery. Patients with relatively intact chest and reduced pain after thoracoscopic surgery avoided sternal infection, and sternal instability, and were able to perform respiratory function exercises and resume daily life activities earlier. It should be emphasized that low postoperative blood loss was also responsible for this difference. Aikebaier et al. reported 49 cases of isolated tricuspid redo procedure, with a median re-sternotomy in 23 patients and a right anterolateral thoracotomy in 26 patients. The results showed that the total drainage amount was lower in the right anterolateral mini-thoracotomy group (P = .012).[16] Gavin et al. determined that blood product transfusion in patients undergoing cardiac surgery is strongly associated with hospital stay, increased early and late mortality, and hospital costs. Minimally invasive thoracoscopic technique can reduce bleeding by avoiding sternal injury and extensive fibrous adhesion separation. In the T-TVR group, it was also observed that there was less postoperative mediastinal drainage and therefore less need for transfusion of blood products, lead to shorter stays in the ICU, and reduced postoperative hospitalization time.
Studies on RV functional recovery in patients undergoing isolated reoperative TVR are scarce. It is important for surgeons to assess the status of RV functional recovery because RV dysfunction is a major independent predictor of all-cause mortality in this subgroup of patients. Assessment of right ventricular functional recovery improves risk stratification in this high-risk group and provides long-term prognostic data. We found a significantly faster recovery of RV function with significant improvement in TAPSE and RVFAC in the T-TVR group. We speculate that this may be related to the shorter operative time, shorter CPB time, and higher possibility of on-pump beating heart surgery in the T-TVR group, which allows for better protection of the RV myocardium during the procedure and facilitates recovery of cardiac function after surgery. Another reason is the reduced risk of potential damage to the heart tissue, especially the right ventricle, from thoracoscopic surgery. In this setting of severe functional TR secondary to left heart surgery, RV dysfunction may be reversible and could recover to a certain extent in the early postoperative period after TVR, which is therefore an advantage; however, determining whether it can lead to full recovery and achieve consistent stability requires further long-term observation.
An increasing number of alternative therapies have been introduced for structural heart diseases. Transcatheter tricuspid valve implantation (TTVI) has also begun to play an important role in tricuspid stenosis and insufficiency. However, TTVI is a new treatment alternative that is still in its infancy, and it is less cost-effective compared to thoracoscopic surgery.
Most surgeons refer to the recommendations for functional tricuspid valve disease in the European Society of Cardiology (ESC)/ European Association for Cardio-Thoracic Surgery (EACTS) guidelines on the management of valvular heart disease (version 2017) guidelines and the American College of Cardiology (ACC)/American Heart Association (AMA) guidelines (version 2006), and choose tricuspid valve repair as the preferred treatment.[17] [18] Reubendra et al. reported that repair of the tricuspid valve is feasible in the majority of patients with functional tricuspid valve disease.[19] However, in another study, Guillaume et al. presented that replacement is more effective in early and late corrections of regurgitation after TV surgery,[20] However, in another study, McCarthy et al. concluded in their research that follow-up echocardiography demonstrated recurrent moderate-to-severe regurgitation in 20% of patients undergoing repair in the long term after surgery.[21] Recurrent TR is a significant problem that may affect the survival and quality of life after tricuspid valve repair. The choice of replacement or repair should be based on the overall state of the patient and personal experience. In our opinion, for patients with severe right ventricular dysfunction, timely and reasonable TVR may be the first choice, which can prevent the occurrence of severe right ventricular dysfunction or irreversible right heart failure, and avoid further intervention for the recurrence of TR.
The present analysis has some limitations. First, this is a single-center retrospective study with a small sample size. Our results may not be generalized to subgroups of patients treated in other institutions. Patients with more severe and advanced right ventricular dysfunction may not benefit from T-TVR. Further research is needed to confirm these findings and better determine the most suitable candidates for T-TVR. Second, TAPSE and RVFAC are older echocardiographic measures for assessing right ventricular structure and function, suggesting its utility in identifying patients at risk for right ventricular dysfunction. Newer echocardiographic techniques, including 3-dimensional evaluation and global longitudinal strain, may improve the ability to evaluate RV function and can be used for further research in the future. Third, our research was restricted to short-term consequences. Another point of contention in this patient population is whether surgery may enhance long-term results in this population, which requires more investigation.
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