Long-term benefit of surgical treatment of severe tricuspid regurgitation according to TRI-SCORE

Introduction

Severe tricuspid regurgitation (TR) is a major public health issue due to its prevalence which increases with age(1) and the mortality and morbidity associated with it. Surgical curative treatment is rarely performed despite recommendations(2).
The TRI-SCORE (3), based on 8 clinical, biological and ultrasound parameters, allows a good assessment of the progressive stage of the disease and the impact of IT. It allows the prediction of post-operative intra-hospital mortality after isolated tricuspid valve surgery, and the prediction of medium-term mortality in populations treated medically, surgically and percutaneously (4). However, the long-term benefit and the impact of the type of surgery (valve repair or replacement) are not clearly established.
The aim of the study is to compare the long-term survival of surgical treatment of isolated severe functional IT versus medical treatment, depending on the progressive stage of the disease assessed by the TRI-SCORE, as well as the impact of the type of surgery (valve repair or replacement).

Methodology

• This is an international, multicenter registry study, including more than 30 centers in 10 countries.
• Included patients had severe functional IT on native valve without other significant valvulopathy
• The intervention studied was isolated surgical treatment of IT, with a distinction between management by tricuspid valve repair or replacement, compared with medical treatment alone.
• The population was divided into 3 TRI-SCORE categories: low (≤ 3), intermediate (4-5) or high (≥ 6)
• The primary outcome measure was 10-year survival.

Results

• A total of 1768 patients were included in the analysis, 1217 receiving medical treatment and 551 receiving surgical treatment. Patients receiving percutaneous tricuspid intervention were excluded.
• Regarding the primary endpoint of 10-year mortality in the overall population, no significant difference was found between surgical treatment and medical treatment (HR = 0.97 [IC95% 0.88-1.08]p = 0.57)
• The distribution of the population into subgroups according to the risk assessed by the TRI-SCORE highlights a benefit of surgical treatment (whether valve repair or replacement) in patients with a low TRI-SCORE (HR = 0.27 [IC95% 0.20-0.37]p Figure 1)
• In the intermediate-risk group, repair treatment is associated with a survival benefit compared with medical treatment (10-year survival of 59% vs 37%, p Figure 2)

Figure 1 : Comparison of surgical treatment and conservative treatment according to risk groups

Figure 2 : central illustration of the study

Conclusion

In this large international multicenter registry study, surgical curative treatment of severe functional IT compared with medical treatment:

• significantly improves 10-year survival of patients with low TRI-SCORE (≤ 3)
• improves survival in patients with intermediate TRI-SCORE (4-5) only in patients for whom valve repair is feasible and not in those who require valve replacement.
• does not provide any benefit on 10-year survival in the case of a high TRI-SCORE (≥ 6).

This study highlights the importance of delay in the surgical management of severe functional IT, emphasizing the need for early management before the onset of irreversible organ damage.

References

1. Topilsky Y, Maltais S, Medina Inojosa J, Oguz D, Michelena H, Maalouf J, et al. Burden of Tricuspid Regurgitation in Patients Diagnosed in the Community Setting. JACC Cardiovasc Imaging. mars 2019;12(3):433‑42.
2. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal. 14 févr 2022;43(7):561‑632.
3. Dreyfus J, Audureau E, Bohbot Y, Coisne A, Lavie-Badie Y, Bouchery M, et al. TRI-SCORE: a new risk score for in-hospital mortality prediction after isolated tricuspid valve surgery. Eur Heart J. 12 févr 2022;43(7):654‑62.
4. Dreyfus J, Galloo X, Taramasso M, Heitzinger G, Benfari G, Kresoja KP, et al. TRI-SCORE and benefit of intervention in patients with severe tricuspid regurgitation. Eur Heart J. 21 févr 2024;45(8):586‑97.