title: Determinants of short- and long-term outcomes following triple valve surgery.
abstract: OBJECTIVE
  Triple valve surgery (3VS) is required in some cardiac disorders that simultaneously involve the aortic valve (AV), mitral valve (MV), and tricuspid valve (TCV). Herein are reported details of the authors' experience with 3VS, and their attempts to identify those factors associated with a poor clinical outcome.
  
  
  METHODS
  The medical records of patients who underwent 3VS between 1985 and 2005 were reviewed. A competing-risks methodology was used to determine the time-related prevalence and associated factors for three mutually exclusive end states after 3VS, namely death, valve reoperation, and survival without subsequent valve reoperation.
  
  
  RESULTS
  A total of 206 consecutive patients (124 females, 82 males; median age 34 years; range: 12-82 years) underwent 3VS. The most common underlying pathology for all valves was rheumatic, followed by repair failure and prosthesis dysfunction for AV and MV, and functional regurgitation for TCV. In total, 72 patients (35.0%) had undergone prior valve surgery. At 3VS, the MV and AV were usually replaced (> 70%), whereas the TCV was usually repaired (91%). The operative mortality (prior to hospital discharge) was 11%, and 15-year survival 68%. At 15 years after 3VS, 21% of the patients had died, without subsequent valve reoperation, 50% had undergone valve reoperation, and 30% remained alive without valve reoperation. Baseline factors associated with early mortality after 3VS were older age at operation, TCV replacement, and the use of a mechanical MV during 3VS. A late risk of mortality was associated with poor left ventricular function and renal impairment at the time of the initial 3VS, and MV prosthesis prior to the initial 3VS. Younger age at 3VS and MV repair during the index 3VS were associated with a higher constant risk of valve reoperation, while female gender, MV prosthesis prior to index 3VS, MV replacement with a bioprosthesis during 3VS, and rheumatic TCV disease were associated with an increased late risk of valve reoperation.
  
  
  CONCLUSIONS
  Both, primary and reoperative 3VS can be performed with acceptable operative mortality and long-term survival. However, patients continue to be at risk of valve reoperation, which steadily increases over time.
authors.affiliation: King Faisal Heart Institute, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
authors.forename: Bahaa M
authors.initials: BM
authors.lastname: Fadel
authors.forename: Bahaaldin
authors.initials: B
authors.lastname: Alsoufi
authors.forename: Cedric
authors.initials: C
authors.lastname: Manlhiot
authors.forename: Brian W
authors.initials: BW
authors.lastname: McCrindle
authors.forename: Ghassan
authors.initials: G
authors.lastname: Siblini
authors.forename: Zohair
authors.initials: Z
authors.lastname: Al-Halees
authors.forename: Aly
authors.initials: A
authors.lastname: Al Sanei
authors.forename: Charles C
authors.initials: CC
authors.lastname: Canver
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D002648:Child; D005260:Female; D006349:Heart Valve Diseases / Q000401:mortality / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012529:Saudi Arabia; D013997:Time Factors; D016896:Treatment Outcome; D014261:Tricuspid Valve / Q000601:surgery*; D055815:Young Adult