Risk Factors Analysis Of Re-operation In Patients With Severe Tricuspid Valve Regurgition After Left-sided Valve Replacement

Objective Analyse the risk factors affecting perioperative mortality and long-term survival of re-operation for severe tricuspid regurgitation after left-sided valve replacement, and discuss the appropriate timing of re-operation.Methods Clinical data was collected from 111 patients who were recorded with severe tricuspid regurgitation after receiving left-sided valve replacement at our hospital from January, 2001 to December, 2015 and consequently received another tricuspid valve surgery. Patients who survived postoperative were followed up with. An analysis was performed on the risk factors that influence patients’ perioperative mortality and long-term survival.Results (1) 11 cases (9.9%) received Tricuspid valve plasty and 100 cases (90.1%)underwent Tricuspid valve replacement, including 45 cases of mechanical valve replacement and 55 cases of biological valve replacement. 11 mortalities occurred perioperative deaths,a mortality rate of 9.9%. The cause of death are respiratory function failure (2 cases),kidney failure(1 case) ,heart failure(3 case) and multiple organ failure(5 cases).Univariate analysis showed that preoperative stubborn right ventricular disfunction(P=0.015), New York Heart Association ( NYHA ) functional classification IV(P=0.002), Pulmonary arterial hypertension(P=0.008), left ventricular ejection fraction(P=0.016) ,serum creatinine(P<0.001),total bilirubin(P=0.042) and albumin(P=0.020)are related with perioperative death. Multivariate Logistic regression analysis showed preoperative stubborn right ventricular disfunction(OR:44.075, 95%CI : 2.602-74 6.60 2,P=0.009), Pulmonary arterial hypertension(OR:79.886,95%CI:2.709- 2355.405,P=0.011),LVEF less than 0.5(OR:29.278,95%CI:1.413-606.765,P=0.029),albumin less than 35g/L(OR: 21.757, 95%CI: 1.246-379.886,P=0.035) are the independent risk factors affecting perioperative mortality.(2)There were 100 perioperative survivors with the follow-up rate of 95%. The follow-up time ranged from 8 months to 186 months and the mean follow-up time was 59.2±39.5 months. 10 deaths were recorded during the follow-up period.(6 patients dead of heart failure, one dead of endocarditis, one dead of hematencephalon, one dead of stroke,one was sudden death). The 1-year, 5-year, 10-year cumulative postoperative survival rates were 98.0%, 88.0% and 73.3%, respectively. Univariate analysis showed that preoperative stubborn right ventricular disfunction(Log-rank P<0.001), NYHA functional classification Ⅳ(Log-rank P=0.026), LVEF<0.5 (Log-rank P=0.020), serum creatinine>110μmol/L (Log-rank P=0.017) and albumin < 35g/L(Log-rank P=0.037) are statistically significant to the postoperative survival time. And multivariate Cox regression analysis showed preoperative stubborn right ventricular disfunction as the independent risk factor of the postoperative survival time (HR:7.451,95%CI:2.204-25.190,P=0.001).(3 ) The 1-year, 5-year, 10-year cumulative postoperative survival rates freedom from Major Adverse Cadiac Event were 98.0%, 79.9% and 63.7%, respectively. Univariate analysis showed that preoperative stubborn right ventricular disfuction(Log-rank P<0.001),NYHA functional classification Ⅳ (Log-rank P=0.021),LVEF<0.5(Log-rank P=0.032),serum creatinine>110umol/L(Log-rank P=0.013) and albumin < 35g/L(Log-rank P=0.034)are statistically significant to the postoperative survival rates freedom from MACE. And multivariate Cox regression analysis showed preoperative stubborn right ventricular disfunction (HR:4.705,95%CI:2.193-10.093,P<0.001) , and serum creatinine>110μmol/L(HR:3.422,95%CI:1.044-11.219,P=0.042 ) are the independent risk factors of the postoperative survival rates freedom from MACE.(4 ) For the 90 survived patients who accept TVR surgery , The cumulative postoperative survival rates of the mechanical valve replacement group(41 case) and the biological valve replacement group(49 case) showed no statistical difference ( Log-rank P=0.754 ) . And the cumulative postoperative survival rates freedom from MACE of the two groups also showed no statistical difference( Log-rank P=0.726).Conclusion ( 1 ) Preoperative stubborn right ventricular disfunction, Pulmonary arterial hypertension, LVEF less than 0.5, albumin less than 35g/L are the independent risk factors affecting perioperative mortality.(2 ) Preoperative stubborn right ventricular disfunction is the independent risk factor of the postoperative survival rate(3 ) Preoperative stubborn right ventricular disfunction and serum creatinine>110μmol/L are the independent risk factors of the postoperative survival rate freedom from MACE.(4) For patients found with severe tricuspid regurgitation after left-sided valve replacement operations, for optimized clinical outcomes, surgical intervention is recommended before the development of irreversible damage in patients’ right ventricular function and noticeable hepatic and renal function abnormality.