Influence of hepatic dysfunction in patients who underwent tricuspid valve surgery

Abstract

Background: Hepatic dysfunction (HD) is frequently associated with chronic tricuspid regurgitation (TR), and is a risk factor for TR surgery. Late referral of patients with TR is associated with the progression of TR and HD, as well as an increase in surgical morbidity and mortality. Many patients with severe TR suffer from HD; however, their clinical impact is not well documented.

Methods: This retrospective review was conducted between October 2008 and July 2017. In total, 159 consecutive patients underwent surgery for TR; 101 with moderate to severe TR were included. We divided patients into N (normal liver function; n=56) and HD (HD; n=45) groups. HD was defined as clinically or radiologically diagnosed liver cirrhosis, or a preoperative Model for End-Stage Liver Disease (MELD)-XI score ≥13. Perioperative data were compared between groups, and changes in the MELD score following TR surgery were estimated in the HD group. Long-term survival rates were analyzed, and analyses were performed to obtain the assessment tool and cutoff value to determine the degree of HD affecting late mortality.

Results: The preoperative demographics of both groups were similar, excluding the presence of HD. The EuroSCORE II, MELD score, and prothrombin time international normalization ratio were significantly higher in the HD group, and although early mortality was comparable between groups [N group: 0%, HD group: 2.2% (n=1); P=0.446], intensive care unit and hospital stays were significantly longer in the HD group. The MELD score in the HD group temporarily increased immediately after surgery, and then decreased. The long-term survival rates were significantly lower in the HD group. The most suitable tool for predicting late mortality was the MELD-XI score, with a cutoff value of 13 points.

Conclusions: Surgery for patients with severe TR can be performed with relatively low morbidity and operative mortality, regardless of associated HD. MELD scores significantly improved after TR surgery in patients with HD. Even with favorable early outcomes, compromised long-term survival with HD suggests the need to develop an assessment tool that can evaluate the appropriate timing for TR surgery.

Keywords: Hepatic dysfunction; MELD score; tricuspid regurgitation; tricuspid valve surgery.

Figure 1

Patient selection. A retrospective review of a prospectively collected database was performed of patients with diagnosed moderate to severe tricuspid regurgitation before surgery. A-fib, atrial fibrillation; LC, liver cirrhosis; MELD_XI, the model for end-stage liver disease excluding international normalized ratio; TV, tricuspid valve; TR, tricuspid regurgitation.

Figure 2

Receiver operating characteristic curves to determine the perioperative risk assessment tool of patients undergoing cardiac surgery associated with mortality 1 year after cardiac surgery. The symbol × indicates an optimal cutpoint maximizing the Youden-Index based on sensitivity and specificity. MELD score; Model for End-stage Liver Disease score; MELD-albumin, Model for End-stage Liver Disease with albumin replacing internal normalized ratio; MELD-XI, Model for End-stage Liver Disease excluding international normalized ratio; AUC, area under the curve.

Figure 3

Comparison of 6- and 12-month postoperative MELD score, MELD-XI score, and MELD-albumin score with preoperative data. Data are shown as mean ± SD. MELD score; Model for End-stage Liver Disease score; MELD-albumin, Model for End-stage Liver Disease with albumin replacing internal normalized ratio; MELD-XI, Model for End-stage Liver Disease excluding international normalized ratio.

Figure 4

Kaplan-Meier curve. The rates of mid-term mortality were higher in the hepatic dysfunction group. HD, hepatic dysfunction; N, normal.

Figure 5

Kaplan-Meier curve. The rates of long-term mortality were higher in the hepatic dysfunction group. HD, hepatic dysfunction; N, normal.