Does Concomitant Tricuspid Valve Repair Elevate the Operative Risk Due to Prolonged Time of Surgery in Patients with Minimally Invasive Mitral Valve Repair?

Objective: Some surgeons argument against concomitant tricuspid valve (TV) surgery in minimally invasive mitral valve (MV) repair due to prolonged time of surgery with presumably elevated operative risk. Aim of this retrospective study was to investigate the cross-clamp and bypass-times, the length of surgery and the 30-day mortality of patients without and with concomitant TV repair.

Patients and methods: Between 15 years (1999–2014), a total of 3,962 patients with MV regurgitation underwent minimally-invasive MV repair ± MAZE-procedure and without (n = 3463; 87.4%; group A) or with (n = 499; 12.6%; group B) concomitant TV repair. The preoperative parameters between both groups were significantly different. In group B were more women included (51.7 vs. 35.5%, p < 0.001), more patients with atrial fibrillation (65.1 vs. 26.7%, p < 0.001), with permanent pacemaker (12.2 vs. 3.9%, p < 0.001), diabetes mellitus (18.2 vs. 9.1%, p < 0.001) and pulmonary hypertonus >60 mg (37.3 vs. 14.2%, p < 0.001). The latter patients were significantly older (69.0 ± 9.6 vs. 59.1 ± 13.0 years, p < 0.001) with a higher log EuroScore (4.3 ± 5.2 vs. 7.6 ± 6.7%, p < 0.001) and a lower left ventricular ejection fraction (55.2 ± 13.3 vs. 60.4 ± 12.3%, p = 0.003).

Results: The mean cross-clamp-time, bypass-time, and the length of surgery were 73.8 ± 31.7 min, 125.5 ± 55.8 min and 173.1 ± 46.6 min in group A and 91.7 ± 28.5 min, 162.0 ± 58.0 min and 213.4 ± 42.7 min in group B (p < 001). That means a difference of 18min in the mean cross-clamp time, 37min in the mean bypass-time and 51min in the mean length of surgery. The rate of additional MAZE-procedure was also significantly higher in group B in regard to group A (58.1 vs. 23.7%, p < 0.001). Overall 30-day mortality was significantly different with 1.2% in group A and 4.0% in group B (p < 0.001). Risk factors for early mortality were identified with the binary regression analysis: age ≥ 70 years (OR: 4.1, 95% CI: 2.5–6.8, p < 0.001) and LVEF ≤30% (OR: 6.3, 95% CI: 3.0–13.2, p < 0.001).

Conclusion: Concomitant TV surgery in patients with minimally invasive MV repair leads to moderate prolonged cross-clamp- and bypass-times, and to a moderate elevation of the time of procedure. The elevated early mortality in patients with concomitant TV-repair seems to be more a result of preoperative patient conditions than a result of the prolonged time of surgery. Concomitant TV-repair in minimally invasive MV surgery is a safe procedure.