Tricuspid Annuloplasty Prevents Right Ventricular Dilatation and Progression of Tricuspid Regurgitation in Patients With Tricuspid Annular Dilatation Undergoing Mitral Valve Repair

Study Questions:

Among patients with tricuspid annular dilatation undergoing mitral valve repair, does concomitant tricuspid annuloplasty prevent progression of tricuspid regurgitation (TR) and right ventricular (RV) remodeling?

Methods:

In 2002, 80 patients underwent mitral valve repair. Concomitant tricuspid annuloplasty was performed in 13 patients with grade 3+ or 4+ TR. In 2004, 102 patients underwent mitral valve repair. Concomitant tricuspid annuloplasty was performed in 21 patients with grade 3+ or 4+ TR and in 43 patients with an echocardiographically determined tricuspid annular diameter ≥40 mm. Patients underwent transthoracic echocardiographic analysis preoperatively and at 2-year follow-up.

Results:

In the 2002 cohort, RV dimensions did not decrease (RV long axis 69 ± 7 vs. 70 ± 8 mm; RV short axis 29 ± 7 vs. 30 ± 7 mm); TR grade and trans-tricuspid gradient remained unchanged. In the 2004 cohort, RV reverse remodeling was observed (RV long axis 71 ± 6 vs. 69 ± 9 mm; RV short axis 29 ± 5 vs. 27 ± 5 mm; p < 0.0001); TR diminished (1.6 ± 1.0 vs. 0.9 ± 0.6, p < 0.0001), and trans-tricuspid gradient decreased (28 ± 13 vs. 23 ± 15 mm Hg, p = 0.02). Subanalysis of the 2002 cohort showed that in 23 patients with baseline tricuspid annular dilatation but no more than grade 2+ TR, the degree of TR was worse at the 2-year follow-up, with associated RV dilatation. Subanalysis of the 2004 cohort demonstrated reverse RV remodeling and decreased TR in 43 patients with preoperative tricuspid annular dilatation who underwent tricuspid annuloplasty.

Conclusions:

Based on findings of improved echocardiographic outcomes, concomitant tricuspid annuloplasty during mitral valve repair should be considered in patients with tricuspid annular dilatation, despite the absence of important TR at baseline.

Perspective:

Observational data suggest that TR can progress or even first develop after surgery for left-sided heart valve disease. Based on these observations, many mitral valve surgeons now promote both a more aggressive stance in addressing existing TR at the time of mitral valve surgery, and ‘prophylactic’ concomitant tricuspid annuloplasty in any patient with a dilated tricuspid annulus. Although the present report does not include clinical outcomes such as hospitalizations for right heart failure, it provides echocardiographic data that support a more aggressive approach to the tricuspid valve. In the absence of data reflecting clinical outcomes, the decision of whether or not to intervene on the tricuspid valve at the time of mitral valve surgery probably should be based on estimates of procedural success and risks associated with concomitant tricuspid annuloplasty in the hands of the operating surgeon.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Valvular Heart Disease, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Follow-Up Studies, Tricuspid Valve Insufficiency, Heart Failure, Heart Valve Diseases, Dilatation, Mitral Valve, Echocardiography


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