The impact of minimally invasive technique on the outcomes of isolated tricuspid valve surgery

This commentary refers to ‘Isolated tricuspid valve surgery: impact of aetiology and clinical presentation on outcomes’, by J. Dreyfus et al., doi: 10.1093/eurheartj/ehaa643.

Dreyfus et al.¹ conducted a relatively large cohort of isolated tricuspid valve surgery (ITVS) from a mandatory administrative database including 12 French tertiary centres. They concluded that the high mortality and morbidity of ITVS were mainly associated with the advanced disease stage, which was consistent with our findings.² The timing of referral to surgeons in these patients was often too late probably due to the historically high operative mortality rate.³

Patients referred for ITVS were a heterogeneous population. Functional tricuspid regurgitation (TR) usually presented more severe right heart dysfunction than organic TR. Especially, the patients with a previous history of left-sided valve surgery suffered the highest incidences of in-hospital death and major post-operative complications in their study, which were up to 15.8% and 47.5%, respectively. For these high-risk vulnerable patients, post-operative bleeding due to surgical trauma was correlated with in-hospital mortality and acute kidney failure according to our findings.⁴ Thus, the impact of the surgical technique on the outcomes of ITVS should not be ignored. We believe that the minimally invasive surgical techniques also play an important and beneficial role in improving the survival rate of these high-risk patients.⁴ The modified techniques at our centre for late severe TR after left-sided valve surgery include endoscopy-assisted right mini-thoracotomy, vacuum-assisted single femoral venous drainage, direct right atriotomy through the pericardium and the beating-heart technique⁵. This modified protocol enables us to reach the tricuspid valve with minimal trauma, avoids unnecessary dissection or snare of the vena cava, simplifies the operation and promotes the preservation of right heart function and post-operative recovery. As a result, the in-hospital mortality dramatically decreased to around 4% and the major post-operative complications were also remarkably reduced, especially in terms of post-operative bleeding and acute kidney failure. However, the detailed information about surgical technique was unexplained in their article. These data are welcome for us to identify the potential impact of surgical technique on the outcomes of ITVS.

We believe that both timely referral and minimally invasive technique would contribute to the better prognosis of ITVS. In recent years, transcatheter tricuspid valve repair and replacement are also emerging. These minimally invasive operations including surgical and transcatheter therapies will significantly change the treatment paradigm of ITVS in the near future.

Funding

This work was sponsored by the Shanghai Sailing Program (No. 20YF1405400) and the fellowship of China Postdoctoral Science Foundation (No. 2020M671001).

Conflict of interest: none declared.

References