Effect of venoarterial extracorporeal membrane oxygenation initiation timing on tricuspid valve surgery outcomes

Amy Hembree; Matthew Lawlor; Samantha Nemeth; Sivagowry Rasalingam Mørk; Yuji Kaku; Jessica Spellman; Andrea Miltiades; Paul Kurlansky; Koji Takeda; Isaac George

doi:10.1016/j.xjon.2023.02.012

Effect of venoarterial extracorporeal membrane oxygenation initiation timing on tricuspid valve surgery outcomes

JTCVS Open. 2023 Mar 1:14:171-181. doi: 10.1016/j.xjon.2023.02.012. eCollection 2023 Jun.

Authors

Affiliations

¹ Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital-Columbia University Irving Medical Center, New York, NY.
² Division of Cardiology, New York Presbyterian Hospital-Columbia University Irving Medical Center, New York, NY.
³ Department of Surgery, Center for Innovation and Outcome Research, New York Presbyterian Hospital-Columbia University Irving Medical Center, New York, NY.
⁴ Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
⁵ Department of Anesthesiology, New York Presbyterian Hospital-Columbia University Irving Medical Center, New York, NY.

Abstract

Objectives: Tricuspid valve surgery is associated with high rates of shock and in-hospital mortality. Early initiation of venoarterial extracorporeal membrane oxygenation after surgery may provide right ventricular support and improve survival. We evaluated mortality in patients undergoing tricuspid valve surgery based on the timing of venoarterial extracorporeal membrane oxygenation.

Methods: All consecutive adult patients undergoing isolated or combined surgical tricuspid valve repair or replacement from 2010 to 2022 requiring venoarterial extracorporeal membrane oxygenation use were stratified by initiation in the operating room (Early) versus outside of the operating room (Late). Variables associated with in-hospital mortality were explored using logistic regression.

Results: There were 47 patients who required venoarterial extracorporeal membrane oxygenation: 31 Early and 16 Late. Mean age was 55.6 years (standard deviation, 16.8), 25 (54.3%) were in New York Heart Association class III/IV, 30 (60.8%) had left-sided valve disease, and 11 (23.4%) had undergone prior cardiac surgery. Median left ventricular ejection fraction was 60.0% (interquartile range, 45-65), right ventricular size was moderately to severely increased in 26 patients (60.5%), and right ventricular function was moderately to severely reduced in 24 patients (51.1%). Concomitant left-sided valve surgery was performed in 25 patients (53.2%). There were no differences in baseline characteristics or invasive measurements immediately before surgery between the Early and Late groups. Venoarterial extracorporeal membrane oxygenation was initiated 194 (23.0-840.0) minutes after cardiopulmonary bypass in the Late venoarterial extracorporeal membrane oxygenation group. In-hospital mortality was 35.5% (n = 11) in the Early group versus 68.8% (n = 11) in the Late group (P = .037). Late venoarterial extracorporeal membrane oxygenation was associated with in-hospital mortality (odds ratio, 4.00; 1.10-14.50; P = .035).

Conclusions: Early postoperative initiation of venoarterial extracorporeal membrane oxygenation after tricuspid valve surgery in high-risk patients may be associated with improvement in postoperative hemodynamics and in-hospital mortality.

Keywords: VA-ECMO; heart failure; tricuspid valve regurgitation.