Tricuspid Annuloplasty After Repair of Mitral Valve Prolapse | Journal Scan

Study Questions:

Does routine tricuspid annuloplasty affect outcomes among patients with either moderate tricuspid regurgitation (TR) or tricuspid annular dilation, who are undergoing mitral valve repair for degenerative mitral regurgitation (MR)?

Methods:

Of 645 consecutive patients (mean age 57 ± 13 years) undergoing primary repair of degenerative MR between 2003 and 2011 by a single surgeon at a single institution, 419 (65%) underwent concomitant tricuspid annuloplasty for moderate TR and/or tricuspid annular dilation (diastolic annular diameter >40 mm on echocardiography, or mismatch between leaflets and annulus on direct surgical inspection). Tricuspid ring size was 28 mm or smaller in 83% of patients treated. Patients were retrospectively analyzed with longitudinal echocardiographic follow-up.

Results:

Patients undergoing tricuspid valve repair were older (median age 59.2 ± 12.3 years vs. 52.3 ± 13.5 years, p < 0.001), had worse left ventricular function (ejection fraction 60.2 ± 7.7 vs. 61.5 ± 6.9, p = 0.03), a higher prevalence of right ventricular (RV) dysfunction (20.0% vs. 9.3 %, p < 0.001), a higher pulmonary artery systolic pressure (Doppler PASP 38 ± 14 vs. 32 ± 14 mm Hg, p < 0.001), and were more likely to have had atrial fibrillation (23% vs. 12%, p < 0.001) than patients undergoing isolated mitral valve repair. No significant differences were found between treatment groups in 30-day mortality, morbidity, or permanent pacemaker requirement. There was a trend toward greater freedom from moderate TR at 7 years (97 ± 2% vs. 91 ± 3%, p = 0.07); among patients with mild TR, freedom from moderate TR at 7 years was higher among patients who underwent concomitant tricuspid annuloplasty (97 ± 3% vs. 83 ± 7%, p = 0.004). Multivariate analysis showed that tricuspid annuloplasty was independently associated with freedom from late moderate TR (hazard ratio [HR] 0.26; 95% confidence interval [CI], 0.07-0.94; p = 0.04), and was an independent predictor of late recovery of preoperative RV dysfunction (HR, 1.4; 95% CI, 1.06-1.96; p = 0.02).

Conclusions:

In patients with moderate TR or tricuspid annular dilation who underwent mitral repair for degenerative MR, concomitant tricuspid annuloplasty was safe, effective, and associated with improved long-term right-sided remodeling. The authors concluded that moderate TR or tricuspid annular dilation should be routinely treated at the time of degenerative mitral valve repair.

Perspective:

There is growing appreciation of the morbidity associated with TR complicating left-sided heart valve disease. The current American Heart Association/American College of Cardiology valvular heart disease guideline includes a Class I (Level of Evidence C) recommendation for tricuspid valve surgery among patients with severe TR undergoing left-sided valve surgery, and a Class IIa (Level of Evidence B) recommendation for tricuspid valve repair at the time of left-sided valve surgery among patients with at least mild TR and either tricuspid annular dilation or prior evidence of right-sided heart failure. The present study provides additional data to support a more aggressive approach in concomitant tricuspid repair at the time of surgical intervention for mitral valve disease.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Mitral Regurgitation

Keywords: Atrial Fibrillation, Blood Pressure, Cardiac Surgical Procedures, Diastole, Echocardiography, Heart Failure, Heart Valve Diseases, Mitral Valve, Mitral Valve Annuloplasty, Mitral Valve Insufficiency, Mitral Valve Prolapse, Multivariate Analysis, Prevalence, Pulmonary Artery, Retrospective Studies, Tricuspid Valve, Tricuspid Valve Insufficiency, Ventricular Function, Left


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