Trends in Utilization and Outcomes of Isolated and Concomitant Tricuspid Valve Operations in the United States

A. P. Ng¹, T. Coaston², S. Mallick³, Y. Sanaiha¹, J. E. Hadaya¹, K. Ali¹, P. Benharash^4
1David Geffen School of Medicine at UCLA, Los Angeles, California ²David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California ³UCLA, Los Angeles, California ⁴UCLA Division of Cardiac Surgery, Los Angeles, California

Purpose: Despite the increasing prevalence of tricuspid valve (TV) disease and advances in valve technology, surgical interventions remain low.1 While postoperative mortality has previously been reported to be as high as 10%, contemporary data are lacking.2 We examined trends in utilization and outcomes among patients undergoing isolated and concomitant TV operations.

Methods: This was a cross-sectional study of all adults (≥ 18 years) in the 2016-2021 National Inpatient Sample undergoing TV replacement or repair. International Classification of Diseases 10th Revision procedure codes were used to identify and stratify the study cohort based on isolated vs concomitant TV surgery (TV-Mitral valve, TV-Aortic valve, TV-CABG). Patients undergoing heart transplantation, ventricular assist device placement, or with history of endocarditis were excluded. Hospitals were stratified into low-, medium-, and high-volume tertiles based on annual institutional case volume of heart valve operations. Multivariable logistic regression models were developed to evaluate patient, operative and hospital characteristics associated with type of TV surgery and outcomes of interest, including in-hospital mortality, perioperative complications, hospitalization costs and length of stay (LOS). An interaction term between year of admission and TV surgery type was used to analyze differences in risk-adjusted mortality rates over time.

Results: Of 51,655 patients, 9,905 (19.2%) underwent Isolated TV, 24,350 (47.1%) TV-Mitral, 7,550 (14.6%) TV-Aortic, and 9,850 (19.1%) TV-CABG. Over the 6-year study period, the number of Isolated TV cases significantly increased, while the volume of concomitant operations remained stable (Figure 1A). Concomitant TV-CABG and TV-Aortic patients experienced higher mortality rates of 10.4% and 8.1%, respectively, while TV-Mitral patients experienced lower mortality of 3.6% compared to 4.7% among Isolated TV (p < 0.001). Of note, mortality rates did not vary over time regardless of operative type (Figure 1B). Furthermore, TV-CABG and TV-Aortic experienced significantly greater composite complications (75.0% vs 67.0% vs 57.9% vs 57.0%, p< 0.001), costs ($76,800 vs $77,800 vs $60,700 vs $59,700, p< 0.001), and LOS (12 vs 11 vs 9 vs 9 days, p< 0.001). Following adjustment, TV-Mitral was associated with significantly decreased odds of mortality compared to Isolated TV (AOR 0.58, 95% CI 0.44-0.76, Table 1). Additionally, patients with concomitant mitral operations demonstrated a -$10,200 decrement in costs (95% CI -15,100, -5,300) and -1.9-day decrement in LOS (95% CI -2.5, -1.2) relative to Isolated TV. Compared to low-volume, high-volume hospitals demonstrated significantly decreased odds of mortality (AOR 0.63, 95% CI 0.49-0.80). Adjusted mortality rates remained stable among TV operative types over time.

Conclusion: While the majority of TV operations are performed concomitantly, utilization of isolated surgery has increased over the last decade. Compared to isolated TV, concomitant mitral operations demonstrated significantly lower mortality and resource use. Given the persistent disparity in mortality over time, concomitant TV-mitral surgery when appropriate should not be deferred.

Identify the source of the funding for this research project: No source of funding applicable.