Mild-to-Moderate Functional Tricuspid Regurgitation in Patients Undergoing Valve Replacement for Rheumatic Mitral Disease: The Influence of Tricuspid Valve Repair on Clinical and Echocardiographic Outcomes

Study Questions:

Should concomitant tricuspid valve repair be performed among patients with mild-to-moderate functional tricuspid regurgitation (TR) undergoing mitral valve surgery?

Methods:

To minimize heterogeneity in the patient population, evaluation was limited to patients with TR undergoing isolated mechanical mitral valve replacement (MVR) for rheumatic disease. Between 1997 and 2009, 236 patients with mild-to-moderate functional TR underwent first-time isolated mechanical MVR for rheumatic mitral disease. Of these, 123 underwent concomitant tricuspid valve repair (repair group) and 113 did not (nonrepair group). Survival, valve-related complications, and tricuspid valve function in the two groups were compared after adjustment for baseline characteristics using inverse-probability-of-treatment weighting.

Results:

Follow-up was complete in 225 patients (95.3%), with a median follow-up of 48.7 months (interquartile range, 20.2-89.5 months). During that time, 991 echocardiographic assessments were done. Freedom from moderate-to-severe TR at 5 years was 92.9 ± 2.9% in the repair group and 60.8 ± 6.9% in the nonrepair group (p < 0.001 and 0.048 in crude and adjusted analyses, respectively). After adjustment, both groups had similar risks of death (hazard ratio [HR], 0.57; p = 0.43), tricuspid reoperation (HR, 0.10; p = 0.080), and congestive heart failure (HR, 1.12; p = 0.87). Postoperative moderate-to-severe TR was an independent predictor of poorer event-free survival (HR, 2.90; p = 0.038).

Conclusions:

The authors concluded that the findings support a strategy of correcting mild-to-moderate functional TR at the time of MVR to maintain tricuspid valve function and improve clinical outcomes.

Perspective:

The decision to repair mild-to-moderate functional TR during left-sided heart valve surgery remains controversial. Data suggest that TR increases after otherwise successful left-sided valve surgery if it is present preoperatively or if there is evidence of tricuspid annular dilation even without preoperative TR. For these reasons, some surgeons advocate intervention (with tricuspid annuloplasty) if TR is present, and prophylactic intervention if the systolic tricuspid annulus diameter exceeds 40 mm. This study does a nice job of showing that patients who underwent mechanical MVR had less TR on follow-up if concomitant tricuspid annuloplasty was performed. However, measured clinical endpoints did not appear to differ between groups, and it remains something of an act of faith that tricuspid annuloplasty results in less postoperative right-sided heart failure after otherwise successful MV surgery.

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

Keywords: Rheumatic Heart Disease, Tricuspid Valve Insufficiency, Heart Failure, Mitral Valve, Echocardiography


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