title: Concomitant tricuspid valve surgery during implantation of continuous-flow left ventricular assist devices: a Society of Thoracic Surgeons database analysis.
abstract: BACKGROUND
  Performing concomitant tricuspid valve procedures (TVPs) in left ventricular assist device (LVAD) patients with significant pre-operative tricuspid regurgitation (TR) is controversial, and no studies have been large enough to definitively guide therapy.
  
  
  METHODS
  Between January 2006 and September 2012, 2,196 patients with moderate to severe pre-operative TR from 115 institutions underwent implantation of a continuous-flow left ventricular assist device (LVAD) as reported by The Society of Thoracic Surgeons National Database. Of these, 588 (27%) underwent a concomitant TVP. Inverse probability weighting based on propensity score was used to adjust for differences between the LVAD alone and LVAD+TVP groups, and outcomes were compared.
  
  
  RESULTS
  Most patients in the LVAD+TVP group underwent an annuloplasty alone (81.1%). Concomitant TVP did not affect risk of post-operative right VAD insertion (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.49-1.36; p = 0.4310) or death (RR, 0.95; 95% CI, 0.68-1.33; p = 0.7658). However, TVP was associated with an increased risk for post-operative renal failure (RR, 1.53; 95% CI, 1.13-2.08; p = 0.0061), dialysis (RR, 1.49; 95% CI, 1.03-2.15; p = 0.0339), reoperation (RR, 1.24; 95% CI, 1.07-1.45; p = 0.0056), greater total transfusion requirement (RR, 1.03; 95% CI, 1.01-1.05; p = 0.0013), and hospital length of stay > 21 days (RR, 1.29; 95% CI, 1.16-1.43; p < 0.0001). Time on the ventilator and intensive care unit length of stay were also significantly prolonged for the LVAD+TVP group.
  
  
  CONCLUSIONS
  Performing a concomitant TVP for continuous-flow LVAD patients with moderate to severe TR did not reduce early death or right VAD requirement and was associated with worse early post-operative outcomes. These data caution against routine concomitant TVP based solely on degree of pre-operative TR and suggest that additional selection criteria are needed to identify those patients in whom concomitant TVP may prevent post-operative right ventricular failure.
authors.affiliation: Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Jason O
authors.initials: JO
authors.lastname: Robertson
authors.affiliation: Duke Clinical Research Institute, Duke University, Durham, North Carolina.
authors.forename: Maria V
authors.initials: MV
authors.lastname: Grau-Sepulveda
authors.affiliation: Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Shoichi
authors.initials: S
authors.lastname: Okada
authors.affiliation: Duke Clinical Research Institute, Duke University, Durham, North Carolina.
authors.forename: Sean M
authors.initials: SM
authors.lastname: O'Brien
authors.affiliation: Duke Clinical Research Institute, Duke University, Durham, North Carolina.
authors.forename: J
authors.initials: J
authors.lastname: Matthew Brennan
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Ashish S
authors.initials: AS
authors.lastname: Shah
authors.affiliation: Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Akinobu
authors.initials: A
authors.lastname: Itoh
authors.affiliation: Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Ralph J
authors.initials: RJ
authors.lastname: Damiano
authors.affiliation: Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Sunil
authors.initials: S
authors.lastname: Prasad
authors.affiliation: Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri. Electronic address: silvestrys@wudosis.wustl.edu.
authors.forename: Scott C
authors.initials: SC
authors.lastname: Silvestry
mesh_terms: D000328:Adult; D000368:Aged; D058385:Cardiac Valve Annuloplasty; D016208:Databases, Factual; D005260:Female; D006333:Heart Failure / Q000150:complications* / Q000401:mortality / Q000601:surgery*; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D057216:Propensity Score; D012189:Retrospective Studies; D016896:Treatment Outcome; D014262:Tricuspid Valve Insufficiency / Q000150:complications* / Q000401:mortality / Q000601:surgery*
keywords: Left ventricular assist device; tricuspid; tricuspid regurgitation