title: Triple-valve surgery: clinical results of a three-decade experience.
abstract: OBJECTIVE
  Triple-valve disease is a challenge that surgeons face periodically, yet the clinical benefits of triple-valve surgery, in relation to the high operative risk, are not well known. The study aims were to describe the early and late mortality associated with triple-valve surgery, to assess the risk factors, and describe the long-term outcomes.
  
  
  METHODS
  A retrospective analysis of 178 consecutive triple-valve surgeries performed at the Montreal Heart Institute between 1977 and 2008 was performed. The median follow up was 5.0 years (inter-quartile range: 1.6 to 9.4 years).
  
  
  RESULTS
  Among 170 patients (122 females, 48 males; mean age 60 +/- 11 years), the preoperative NYHA functional class was > or = III/IV in 93% of cases; 61% of the patients had undergone previous cardiac surgery. The operative mortality was 12% between 1999 and 2008, and 25% between 1977 and 1998 (p = 0.033). Independent risk factors between 1999 and 2008 period included tricuspid regurgitation severity (OR = 13.71; p = 0.03) and the presence of a right intraventricular pacemaker lead (OR = 11.25; p = 0.039). Survival rates at five and 10 years were 61 +/- 4% and 38 +/- 5%, respectively. A lower left ventricular ejection fraction at discharge was associated with a poor late survival, independent of patient age and gender (OR = 0.95; p = 0.035). Twenty-three patients (18%) required reoperation during the follow up period, at which time the NYHA functional class was improved compared to baseline (p < 0.001).
  
  
  CONCLUSIONS
  Although triple-valve surgery is associated with substantial operative mortality, this situation has improved significantly over the years. Currently, survivors experience a significant improvement in their cardiac functional capacity, justifying the continued use of triple-valve procedures, though preferably earlier during the course of the disease.
authors.affiliation: Department of Surgery, Montreal Heart Institute and University of Montreal, Montreal, Canada. Guillaume.Marquis.Gravel@umontreal.ca
authors.forename: Guillaume Marquis
authors.initials: GM
authors.lastname: Gravel
authors.forename: Denis
authors.initials: D
authors.lastname: Bouchard
authors.forename: Louis P
authors.initials: LP
authors.lastname: Perrault
authors.forename: Pierre
authors.initials: P
authors.lastname: Pagé
authors.forename: Michel
authors.initials: M
authors.lastname: Carrier
authors.forename: Raymond
authors.initials: R
authors.lastname: Cartier
authors.forename: Hugues
authors.initials: H
authors.lastname: Jeanmart
authors.forename: Michel
authors.initials: M
authors.lastname: Pellerin
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D002170:Canada; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D016009:Chi-Square Distribution; D005260:Female; D006349:Heart Valve Diseases / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000503:physiopathology / Q000601:surgery*; D016017:Odds Ratio; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D014261:Tricuspid Valve / Q000503:physiopathology / Q000601:surgery*