Establishment and Validation of a Predictive Model for Long-Term Severe Functional Tricuspid Regurgitation after Mitral Valve Replacement
DOI:
https://doi.org/10.1532/hsf.4425Keywords:
Nomogram, Prediction model, Mitral valve replacement, Functional tricuspid regurgitationAbstract
Background: The objective was to develop and validate an individualized nomogram to predict severe functional tricuspid regurgitation (S-FTR) after mitral valve replacement (MVR) via retrospective analysis of rheumatic heart disease (RHD) patients’ pre-clinical characteristics.
Methods: Between 2001-2015, 442 MVR patients of RHD were examined. Transthoracic echocardiography detected S-FTR, and logistic regression model analyzed its independent predictors. R software established a nomogram prediction model, and Bootstrap determined its theoretical probability, which subsequently was compared with the actual patient probability to calculate the area under the curve (AUC) and calibration plots. Decision curve analysis (DCA) identified its clinical utility.
Results: Ninety-six patients developed S-FTR during the follow-up period. Both uni- and multivariate analyses found significant correlations between S-FTR occurrence with gender, age, atrial fibrillation (AF), pulmonary arterial hypertension (PH), left atrial diameter (LAD), and tricuspid regurgitation area (TRA). The individualized nomogram model had the AUC of 0.99 in internal verification. Calibration test indicated high agreement of predicted and actual S-FTR onset. DCA also showed that utilization of those six aforementioned factors was clinically useful.
Conclusion: The nomogram for the patient characteristics of age, gender, AF, PH, LAD, and TRA found that they were highly predictive for future S-FTR onset within 5 years. This predictive ability therefore allows clinicians to optimize postoperative patient care and avoid unnecessary tricuspid valve surgeries.
References
Asmarats L, Taramasso M, Rodés-Cabau J. 2019. Tricuspid valve disease: diagnosis, prognosis, and management of a rapidly evolving field. Nat Rev Cardiol. 16:538-54.
Beckhoff F, Alushi B, Jung C, et al. 2018. Tricuspid regurgitation-medical management and evolving interventional concepts. Front Cardiovasc Med. 5:1-9.
Bertrand PB, Overbey JR, Zeng X, et al. 2021. Cardiothoracic surgical trials network (CTSN). Progression of tricuspid regurgitation after surgery for ischemic mitral regurgitation. J Am Coll Cardiol. 77:713-24.
Choi JW, Kim KH, Chang HW, et al. 2018. Long-term results of annuloplasty in trivial-to-mild functional tricuspid regurgitation during mitral valve replacement: should we perform annuloplasty on the tricuspid valve or leave it alone? Eur J Cardiothorac Surg. 53:756-63.
Collins GS, Reitsma JB, Altman DG, Moons KGM. 2015. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement. BMJ. 7:350.
David TE, David CM, Manlhiot C. 2018. Tricuspid annulus diameter does not predict the development of tricuspid regurgitation after mitral valve repair for mitral regurgitation due to degenerative diseases. J Thorac Cardiovasc Surg. 155:2429-36.
Desai RR, Vargas Abello LM, Klein AL, et al. 2013. Tricuspid regurgitation and right ventricular function after mitral valve surgery with or without concomitant tricuspid valve procedure. J Thorac Cardiovasc Surg. 146:1126-32.
Dreyfus J, Ghanem N, Garbarz E, et al. 2018. Timing of referral of patients with severe isolated tricuspid valve regurgitation to surgeons (from a French Nationwide Database). Am J Cardiol. 122:323-6.
Gao Y, Li S, Zhuang X, et al. 2020. Comparison of mitral valve repair versus replacement for the progression of functional tricuspid regurgitation. Ann Thorac Cardiovasc Surg. 26:72-8.
Guta AC, Badano LP, Tomaselli M, et al. 2021. The pathophysiological link between right atrial remodeling and functional tricuspid regurgitation in patients with atrial fibrillation: a three-dimensional echocardiography study. J Am Soc Echocardiogr. 34:585-94.
Hamadi M, George TJ, Smith RL, Mack MJ. 2019. Current outcomes of tricuspid valve surgery. Prog Cardiovasc Dis. 62:463-6.
Izumi C. 2020. Isolated functional tricuspid regurgitation: when should we go to surgical treatment? J Cardiol. 75:339-43.
Kusajima K, Fujita T, Hata H, et al. 2016. Long-term echocardiographic follow-up of untreated 2+ functional tricuspid regurgitation in patients undergoing mitral valve surgery. Interact Cardiovasc Thorac Surg. 23:96-103.
Lang RM, Badano LP, Mor-Avi V, et al. 2015. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 28:1-39.
Muntané-Carol G, Alperi A, Faroux L, et al. 2021. Transcatheter interventions for tricuspid valve disease: what to do and who to do it on. Can J Cardiol. 37:953-67.
Mutlak D, Khalil J, Lessick J, et al. 2020. Risk factors for the development of functional tricuspid regurgitation and their population-attributable fractions. JACC: Cardiovascular Imaging. 13:1643-51.
Mutlak D, Khoury E, Lessick J, et al. 2019. Lack of increased cardiovascular risk due to functional tricuspid regurgitation in patients with left-sided heart disease. J Am Soc Echocardiogr. 32:1538-46.
Otto CM, Nishimura RA, Bonow RO, et al. 2021. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circ. 143:e35-e71.
Pozzoli A, Buzzatti N, Vicentini L, DE Bonis M, Alfieri O. 2017. Results of tricuspid valve surgery for functional tricuspid regurgitation: acute and long-term outcomes and predictors of failure. Minerva Cardioangiol. 65:491-9.
Sordelli C, Lancellotti P, Carlomagno G, et al. 2016. Tricuspid annular size and regurgitation progression after surgical repair for degenerative mitral regurgitation. Am J Cardiol. 118: 424-31.
Steyerberg EW, Vergouwe Y. 2014. Towards better clinical prediction models: seven steps for development and an ABCD for validation. Eur Heart J. 35:1925-31.
Topolsky Y, Maltais S, Medina Inojosa J, et al. 2019. Burden of tricuspid regurgitation in patients diagnosed in the community setting. JACC Cardiovasc Imaging. 12:433-42.
Vachiéry JL, Tedford RJ, Rosenkranz S, et al. 2019. Pulmonary hypertension due to left heart disease. Eur Respir J. 53:1801897.
Vassileva CM, Li S, Thourani VH, et al. 2014. Outcome characteristics of multiple-valve surgery: comparison with single-valve procedures. Innovations (Phila). 9:27-32.
Vaturi M, Kotler T, Shapira Y, et al. 2016. Prevalence of late functional tricuspid regurgitation in degenerative mitral regurgitation surgery. J Heart Valve Dis. 25:157-61.
Wang N, Fulcher J, Abeysuriya N, et al. 2019. Tricuspid regurgitation is associated with increased mortality independent of pulmonary pressures and right heart failure: a systematic review and meta-analysis. Eur Heart J. 40:476-84.
Yang M, Tao L, An H, et al. 2020. A novel nomogram to predict all- cause readmission or death risk in Chinese elderly patients with heart failure. ESC Heart Failure. 3:1015-24.
Zoghbi WA, Adams D, Bonow RO, et al. 2017. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 30:303-371.
