Faerber Gloria, Berretta Paolo, Nguyen Tom C, Wilbring Manuel, Lamelas Joseph, Stefano Pierluigi, Kempfert Jörg, Rinaldi Mauro, Pacini Davide, Pitsis Antonios, Gerdisch Marc, Dinh Nguyen Hoang, Van Praet Frank, Salvador Loris, Yan Tristan, Bonaros Nikolaos, Fiore Antonio, Doenst Torsten, Di Eusanio Marco
Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany.
Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy.
JTCVS Open. 2023 Nov 19;17:64-71. doi: 10.1016/j.xjon.2023.10.036. eCollection 2024 Feb.
Randomized evidence suggests a high risk of pacemaker implantation for patients undergoing mitral valve (MV) surgery with concomitant tricuspid valve repair (cTVR). We investigated the impact of cTVR on outcomes in the Mini-Mitral International Registry.
From 2015 to 2021, 7513 patients underwent minimally invasive MV with or without cTVR in 17 international centers (MV: n = 5609, cTVR: n = 1113). Propensity matching generated 1110 well-balanced pairs. Multivariable analysis was applied.
Patients with cTVR were older and had more comorbidities. Propensity matching eliminated most differences except for more TR in patients who underwent cTVR (77.2% vs 22.1% MV, < .001). Mean matched age was 71 years, and 45% were male. European System for Cardiac Operative Risk Evaluation II was still 2.68% (interquartile range [IQR], 0.80-2.63) vs 1.9% (IQR, 1.12-3.9) in matched MV ( < .001). MV replacement (30%) and atrial fibrillation surgery (32%) were similar in both groups. Cardiopulmonary bypass (161 minutes [IQR, 133-203] vs MV: 130 minutes [IQR, 103-166]; < .001) and crossclamp times (93 minutes [IQR, 66-123] vs MV: 83 minutes [IQR, 64-107]; < .001) were longer with cTVR. Although in-hospital mortality was similar (cTVR: 3.3% vs MV: 2.2%; = .5), postoperative pacemaker implantations (9% vs MV: 5.8%; = .02), low cardiac output syndrome (7.7% vs MV: 4.4%; = .02), and acute kidney injury (13.8% vs MV: 10%; = .01) were more frequent with cTVR. cTVR eliminated relevant TR in most patients (greater-than-moderate TR: 6.8%). Multivariable analysis identified MV replacement, atrial fibrillation, and cTVR as risk factors of postoperative pacemaker implantation.
cTVR in minimally invasive MV surgery is an independent risk factor for pacemaker implantation in this international registry. It is also associated with more bleeding, low output syndrome, and acute kidney injury. It remains unclear whether technical or patient factors (or both) explain these differences.
随机对照证据表明，接受二尖瓣（MV）手术并同期进行三尖瓣修复（cTVR）的患者植入起搏器的风险较高。我们在Mini-Mitral国际注册研究中调查了cTVR对手术结局的影响。
2015年至2021年，17个国际中心的7513例患者接受了微创MV手术，其中部分患者同期进行了cTVR（MV组：n = 5609，cTVR组：n = 1113）。倾向评分匹配产生了1110对均衡良好的配对。应用多变量分析。
cTVR组患者年龄更大，合并症更多。倾向评分匹配消除了大多数差异，但cTVR组患者的三尖瓣反流更多（77.2% vs MV组22.1%，P <.001）。匹配后的平均年龄为71岁，45%为男性。欧洲心脏手术风险评估系统II级在匹配的MV组中仍为2.68%（四分位间距[IQR]，0.80 - 2.63），而在cTVR组中为1.9%（IQR，1.12 - 3.9）（P <.001）。两组的MV置换术（30%）和房颤手术（32%）相似。cTVR组的体外循环时间（161分钟[IQR，133 - 203] vs MV组：130分钟[IQR，103 - 166]；P <.001）和主动脉阻断时间（93分钟[IQR，66 - 123] vs MV组：83分钟[IQR，64 - 107]；P <.001）更长。尽管住院死亡率相似（cTVR组：3.3% vs MV组：2.2%；P =. = 0.5），但cTVR组术后起搏器植入率（9% vs MV组：5.8%；P =. = 0.02）、低心排血量综合征（7.7% vs MV组：4.4%；P =. = 0.02）和急性肾损伤（13.8% vs MV组：10%；P =. = 0.01）更常见。cTVR使大多数患者的三尖瓣反流得到改善（中重度以上三尖瓣反流：6.8%）。多变量分析确定MV置换术、房颤和cTVR为术后起搏器植入的危险因素。
在这个国际注册研究中，微创MV手术中的cTVR是起搏器植入的独立危险因素。它还与更多出血、低心排血量综合征和急性肾损伤相关。尚不清楚是技术因素还是患者因素（或两者）导致了这些差异。
