Impact of tricuspid valve annulus dilation on mid-term survival after implantation of a left ventricular assist device.

Background: After left ventricular assist device (LVAD) implantation, right ventricular (RV) failure is a major cause of post-operative morbidity and mortality. Recently, in patients with similar hemodynamic challenge, but less severe RV impairment, who were undergoing surgery for mitral valve repair, concomitant tricuspid valve repair improved post-operative RV re-remodeling in patients with severely dilated tricuspid annuli without tricuspid regurgitation (TR).

Methods: Pre-operative transesophageal echocardiography and clinical data were prospectively collected from 122 patients without severe TR, who were selected for LVAD implantation. Patients were assigned to one of two groups according to pre-operative tricuspid annulus diameter <43 mm or >43 mm. Groups were compared for parameters that may impact survival after LVAD implantation. Kaplan-Meier survival curves were evaluated for the impact of tricuspid annulus size and right-to-left ventricular diameter ratio (R/L ratio) on 36-month survival. Multivariate analysis was used to identify the pre-operative parameters that independently affected survival.

Results: Patients with tricuspid annulus >43 mm presented with higher R/L ratio (0.73 ± 0.21 vs 0.56 ± 0.13; p < 0.00001) and higher proBNP plasma concentration (12,872 ± 13,084 vs 8,988 ± 13,018 pg/ml; p = 0.018). Both R/L ratio >0.72 and tricuspid annulus >43 mm adversely affected survival (p = 0.003 and 0.007, respectively). In the multivariate analysis only tricuspid annulus diameter >43 mm (hazard ratio 2.16, CI 1.21 to 3.84, p = 0.009) and age (hazard ratio 1.03, CI 1.00 to 1.06, p = 0.04) were independent predictors of survival after LVAD.

Conclusions: Tricuspid dilation, even without severe regurgitation, adversely affects survival after LVAD implantation. Further studies are required to determine whether concomitant tricuspid valve repair may improve survival in these patients.