title: Triple valve surgery in the modern era: short- and long-term results from a single centre.
abstract: OBJECTIVE
  Triple valve surgery (TVS) is still a challenge for surgeons because of prolonged cardiopulmonary bypass (CPB) and myocardial ischaemic times. The reported operative mortality rate for TVS ranges between 2.5 and 25%; long-term survival is also diminished, with reported survival rates at 5 and 10 years of 75-82 and 61-75%, respectively. The objective of our study is to define early and late clinical outcomes, reporting the initial experience in the treatment of triple valve disease through a minimally invasive approach.
  
  
  METHODS
  A retrospective, observational, cohort study was undertaken of prospectively collected data on 106 patients who underwent TVS at our institution between October 2001 and June 2013. A total of 101 procedures were done through the standard median sternotomy; however, in 5 patients, the surgical procedure was carried out through a right minithoracotomy. Univariate analysis was performed to identify predictors of early and late survival.
  
  
  RESULTS
  The in-hospital mortality rate was 5.6% (6 of 107 patients). Predictors of early mortality were: previous cardiac surgery [odds ratio (OR) 4, 95% confidence interval (CI) 1.08-5.2, P = 0.04], preoperative left ventricular ejection fraction (LVEF) (OR 0.9, 95% CI 0.8-1.1, P = 0.003), prolonged CPB time (OR 1.02, 95% CI 1.01-1.04, P = 0.01) and postoperative pulmonary complications (OR 8, 95% CI 5.8-41, P = 0.0001). Five- and 10-year survival rates were 85 ± 3 and 65 ± 9%, respectively. In univariate analysis, diabetes [hazard ratio (HR) 2.5, 95% CI 1-6.2, P = 0.045], preoperative dialysis (HR 3, 95% CI 2-4.7, P = 0.001), unstable angina (HR 4.8, 95% CI 1-18, P = 0.03), preoperative LVEF (HR 0.9, 95% CI 0.8-1.1, P = 0.02), concomitant coronary artery bypass grafting (CABG) (HR 2.5, 95% CI 1.5-5.7, P = 0.006), prolonged CPB time (HR 1.02, 95% CI 1.01-1.13, P = 0.006), postoperative pacemaker (PMK) implantation (HR 6.2, 95% CI 1.3-18, P = 0.01) and postoperative pulmonary complications (HR 3.3, 95% CI 2.1-7.3, P = 0.002) were found to be significant predictors of late mortality following TVS. The freedom rates from valve-related complications and reoperation at 10 years were 95 ± 2 and 97 ± 2%, respectively. The 10-year freedom rates from thromboembolism and anticoagulation-related haemorrhage were 88 ± 5 and 88 ± 4%, respectively.
  
  
  CONCLUSIONS
  TVS offers encouraging short-term and long-term patient survival; these good results after TVS in patients with advanced valvular heart disease justify aggressive surgical therapy in these patients. TVS with a minimally invasive approach is feasible and could be another treatment option.
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy Humanitas Clinical and Research Center, Rozzano, MI, Italy antoniolio@hotmail.it.
authors.forename: Antonio
authors.initials: A
authors.lastname: Lio
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Murzi
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy Humanitas Clinical and Research Center, Rozzano, MI, Italy.
authors.forename: Gioia
authors.initials: G
authors.lastname: Di Stefano
authors.affiliation: Humanitas Clinical and Research Center, Rozzano, MI, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Miceli
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Enkel
authors.initials: E
authors.lastname: Kallushi
authors.affiliation: Humanitas Clinical and Research Center, Rozzano, MI, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Ferrarini
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Solinas
authors.affiliation: Humanitas Clinical and Research Center, Rozzano, MI, Italy.
authors.forename: Mattia
authors.initials: M
authors.lastname: Glauber
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D058385:Cardiac Valve Annuloplasty / Q000009:adverse effects / Q000379:methods / Q000401:mortality; D002315:Cardiopulmonary Bypass; D018572:Disease-Free Survival; D005240:Feasibility Studies; D005260:Female; D006349:Heart Valve Diseases / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods / Q000401:mortality; D006439:Hemodynamics; D017052:Hospital Mortality; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000503:physiopathology / Q000601:surgery*; D058386:Mitral Valve Annuloplasty; D016017:Odds Ratio; D061646:Operative Time; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D056346:Sternotomy; D013908:Thoracotomy; D013997:Time Factors; D016896:Treatment Outcome; D014261:Tricuspid Valve / Q000503:physiopathology / Q000601:surgery*
keywords: Minimally invasive; Right minithoracotomy; Triple valve surgery