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Risk stratification for isolated tricuspid valve surgery: Still on the way

Open AccessPublished:June 07, 2022DOI:https://doi.org/10.1016/j.xjon.2022.06.002
      To the Editor:
      The authors reported no conflicts of interest.
      The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
      We read with interest the recent study by Färber and colleagues,
      • Färber G.
      • Marx J.
      • Scherag A.
      • Saqer I.
      • Diab M.
      • Sponholz C.
      • et al.
      Risk stratification for isolated tricuspid valve surgery assisted using the Model for End-Stage Liver Disease score.
      which found that classic surgical risk stratification with the Society of Thoracic Surgeons or European System for Cardiac Operative Risk Evaluation II scores failed to predict perioperative mortality for isolated tricuspid valve surgery if there was evidence of severe liver dysfunction and the Model for End-Stage Liver Disease (MELD) scoring system might be useful to assist in risk stratification for these patients.
      As we know, patient selection is very critical for favorable outcomes after tricuspid valve surgery or intervention. The historical high mortality of isolated tricuspid valve surgery was partly due to late referral to surgery, resulting in right heart failure and end-organ damages such as liver and renal dysfunction. Thus, accurate risk stratification is useful to identify the high-risk subgroup. However, the paucity and heterogeneity of isolated tricuspid valve surgery led to difficulty in establishing a special risk stratification system.
      The MELD scoring system initially was developed for patients undergoing transjugular intrahepatic portosystemic shunt procedures
      • Malinchoc M.
      • Kamath P.S.
      • Gordon F.D.
      • Peine C.J.
      • Rank J.
      • ter Borg P.C.
      A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts.
      and further for patients with end-stage liver disease.
      • Kamath P.S.
      • Wiesner R.H.
      • Malinchoc M.
      • Kremers W.
      • Therneau T.M.
      • Kosberg C.L.
      • et al.
      A model to predict survival in patients with end-stage liver disease.
      ,
      • Wiesner R.
      • Edwards E.
      • Freeman R.
      • Harper A.
      • Kim R.
      • Kamath P.
      • et al.
      Model for end-stage liver disease (MELD) and allocation of donor livers.
      Subsequently, Suman and colleagues
      • Suman A.
      • Barnes D.S.
      • Zein N.N.
      • Levinthal G.N.
      • Connor J.T.
      • Carey W.D.
      Predicting outcome after cardiac surgery in patients with cirrhosis: a comparison of Child-Pugh and MELD scores.
      found that MELD score was significantly associated with hepatic decompensation and mortality after cardiac surgery using cardiopulmonary bypass in patients with cirrhosis. Ailawadi and colleagues
      • Ailawadi G.
      • Lapar D.J.
      • Swenson B.R.
      • Siefert S.A.
      • Lau C.
      • Kern J.A.
      • et al.
      Model for end-stage liver disease predicts mortality for tricuspid valve surgery.
      used the MELD score to predict mortality for tricuspid valve surgery, although 85.7% of the patients in their study had various concomitant surgeries.
      Färber and colleagues
      • Färber G.
      • Marx J.
      • Scherag A.
      • Saqer I.
      • Diab M.
      • Sponholz C.
      • et al.
      Risk stratification for isolated tricuspid valve surgery assisted using the Model for End-Stage Liver Disease score.
      first used the MELD score for isolated tricuspid valve surgery in a relatively large cohort. However, both their and our studies suggested that the etiology of isolated tricuspid valve surgery was highly heterogenous.
      • Färber G.
      • Marx J.
      • Scherag A.
      • Saqer I.
      • Diab M.
      • Sponholz C.
      • et al.
      Risk stratification for isolated tricuspid valve surgery assisted using the Model for End-Stage Liver Disease score.
      ,
      • Chen J.
      • Abudupataer M.
      • Hu K.
      • Maimaiti A.
      • Lu S.
      • Wei L.
      • et al.
      Risk factors associated with perioperative morbidity and mortality following isolated tricuspid valve replacement.
      Notably, 1 parameter of the MELD score is international normalized ration (INR).
      • Kamath P.S.
      • Wiesner R.H.
      • Malinchoc M.
      • Kremers W.
      • Therneau T.M.
      • Kosberg C.L.
      • et al.
      A model to predict survival in patients with end-stage liver disease.
      We speculated that part of patients in their study may receive warfarin for left-sided mechanic valve replacement or chronic atrial fibrillation.
      • Chen J.
      • Hu K.
      • Ma W.
      • Lv M.
      • Shi Y.
      • Liu J.
      • et al.
      Isolated reoperation for tricuspid regurgitation after left-sided valve surgery: technique evolution.
      ,
      • Chen J.
      • Ma W.
      • Ming Y.
      • Wang W.
      • Liu S.
      • Yang Y.
      • et al.
      Minimally invasive valve replacement for late tricuspid regurgitation after left-sided valve surgery.
      Would this increased INR due to warfarin administration influence the MELD score and further influence the accuracy of risk prediction for this subgroup? Actually, the simplified MELD score has been reported by Tsuda and colleagues.
      • Tsuda K.
      • Koide M.
      • Kunii Y.
      • Watanabe K.
      • Miyairi S.
      • Ohashi Y.
      • et al.
      Simplified model for end-stage liver disease score predicts mortality for tricuspid valve surgery.
      They suggested to remove the INR parameter from the formula to predict mortality for tricuspid valve surgery, although 93.6% of patients in their study also had various concomitant surgery. In our previous study, we found that higher simplified MELD score was an independent risk factor for composite adverse outcomes rather than mortality.
      • Chen J.
      • Hu K.
      • Ma W.
      • Lv M.
      • Shi Y.
      • Liu J.
      • et al.
      Isolated reoperation for tricuspid regurgitation after left-sided valve surgery: technique evolution.
      Thus, the simplified MELD score has also not been widely validated for predicting mortality of isolated tricuspid valve surgery.
      The ideal risk stratification for isolated tricuspid valve surgery is still on the way. Many efforts have been made in this field. A simple clinical risk score based on the Society of Thoracic Surgeons database was established to predict mortality and major morbidity after isolated tricuspid valve surgery.
      • LaPar D.J.
      • Likosky D.S.
      • Zhang M.
      • Theurer P.
      • Edwin Fonner C.
      • Kern J.A.
      • et al.
      Development of a risk prediction model and clinical risk score for isolated tricuspid valve surgery.
      That clinical risk score enrolled 9 parameters, including age, sex, stroke, hemodialysis, chronic lung disease, ejection fraction, New York Heart Association functional class, reoperation, and status. Recently, the TRI-SCORE was reported as a new risk score for in-hospital mortality prediction after isolated tricuspid valve surgery.
      • Dreyfus J.
      • Audureau E.
      • Bohbot Y.
      • Coisne A.
      • Lavie-Badie Y.
      • Bouchery M.
      • et al.
      TRI-SCORE: a new risk score for in-hospital mortality prediction after isolated tricuspid valve surgery.
      It ranged from 0 to 12 points and included 8 parameters: age ≥70 years, New York Heart Association functional class III or IV, right-sided heart failure signs, daily dosage of furosemide ≥125 mg, glomerular filtration rate <30 mL/min, elevated bilirubin, left ventricular ejection fraction <60%, and moderate/severe right ventricular dysfunction. However, these scoring systems were somewhat complex and some parameters were subjective. With the development of transcatheter tricuspid valve repair or replacement, more hemodynamic data of isolated tricuspid regurgitation and right heart failure were obtained by right heart catheterization.
      • Unterhuber M.
      • Kresoja K.P.
      • Besler C.
      • Rommel K.-P.
      • Orban M.
      • von Roeder M.
      • et al.
      Cardiac output states in patients with severe functional tricuspid regurgitation: impact on treatment success and prognosis.
      ,
      • Stocker T.J.
      • Hertell H.
      • Orban M.
      • Braun D.
      • Rommel K.-P.
      • Ruf T.
      • et al.
      Cardiopulmonary hemodynamic profile predicts mortality after transcatheter tricuspid valve repair in chronic heart failure.
      Some effects were also made to investigate special molecular mechanism of right ventricular failure.
      • Tzimas C.
      • Rau C.D.
      • Buergisser P.E.
      • Jean-Louis Jr., G.
      • Lee K.
      • Chukwuneke J.
      • et al.
      WIPI1 is a conserved mediator of right ventricular failure.
      In the future, the risk scoring system may integrate multidimensional parameters, including symptomatic, echocardiographic, hemodynamic, and molecular variables, to accurately predict the risk of isolated tricuspid valve surgery and intervention.

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      Linked Article

      • Risk stratification for isolated tricuspid valve surgery assisted using the Model for End-Stage Liver Disease score
        The Journal of Thoracic and Cardiovascular Surgery
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          Isolated tricuspid valve surgery is perceived as high-risk. This perception is nurtured by patients who often present with substantial liver dysfunction, which is inappropriately reflected in current surgical risk scores (eg, the Society of Thoracic Surgeons [STS] score has no specific tricuspid model). The Model for End-Stage Liver Disease (MELD) has was developed as a measure for the severity of liver dysfunction. We report scores and outcomes for our patient population.
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      • Reply from authors: Why improve high-risk prediction if early surgery is low risk?
        JTCVS OpenVol. 11
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          We wish to thank Chen and colleauges1 for their appreciative comment regarding our recent manuscript on the model for end-stage liver disease (MELD) score in isolated tricuspid surgery. We fully agree with the general notion that we need better and simpler scores to assess preoperative risk, such as the TRI-SCORE or the simple clinical risk score. While these 2 scores seem to have been assessed in parallel to our investigation, they are still more complex (requiring echocardiographic parameters for the right heart, which are still controversial, TRI-SCORE) or do not include any liver-related parameters (clinical risk score).
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