CTCR-MVS: Concomitant Tricuspid Repair in Patients With MR

Concomitant tricuspid annuloplasty in patients undergoing mitral valve (MV) surgery was associated with less progression to severe tricuspid regurgitation (TR) over two years, compared with MV surgery alone, according to results from the CTCR-MVS trial presented Nov. 13 during AHA 2021 and simultaneously published in the New England Journal of Medicine.

James S. Gammie, MD, FACC, and colleagues randomly assigned 401 patients scheduled to undergo MV surgery for degenerative mitral regurgitation (MR) to receive a procedure with or without concomitant tricuspid annuloplasty. Eligible participants had moderate TR or had none/trace or mild TR with tricuspid annular dilation.

At two years of follow-up, those who underwent the combined procedure were less likely to meet the primary endpoint of a composite of reoperation for TR, progression of TR (by two grades from baseline or the presence of severe TR) or death. Primary endpoint events rates were 3.9% for MV surgery plus tricuspid annuloplasty and 10.2% for MV surgery alone (relative risk [RR], 0.37; 95% confidence interval [CI], 0.16-0.86; p=0.02).

This difference was primarily driven by a lower prevalence of progression of TR in the surgery plus tricuspid annuloplasty arm. Only 0.6% of the participants in the MV plus tricuspid annuloplasty group had progressed to severe TR after two years, compared with 5.6% of those in the mitral valve only surgery group (RR, 0.10; 95% CI, 0.01-0.77). The difference in TR in the two groups had no impact on survival, heart function, symptoms or quality of life.

Two-year mortality did not differ between groups (3.2% for MV surgery plus tricuspid annuloplasty and 4.5% for surgery alone; RR, 0.69; 95% CI, 0.25-1.88), nor did the occurrence of major adverse cardiac and cerebrovascular events, functional status or quality of life. Permanent pacemaker implantation was noted in 14.5% of the MV surgery plus tricuspid annuloplasty arm compared with 2.5% of the MV surgery alone arm (rate ratio, 5.75; 95% CI, 2.27-14.60).

"This trial highlights the safety of modern mitral valve surgery. The mortality rate for people in this study was less than 1%, and two years later more than 96% of patients had survived," said Gammie.

"While the differences in tricuspid regurgitation and pacemaker implantation were of great interest, they didn't seem to have an impact on survival, quality of life or cardiac function. We clearly need to better understand the risk factors for needing a permanent pacemaker implanted after tricuspid valve repair, and how to best mitigate this risk. That may entail technique modifications and/or changing post-operative management strategies."

Gammie presented two-year data, but patients will be followed for up to five years.

In a related editorial comment, Joanna Chikwe, MD, FACC, and Mario Gaudino, MD, PhD, FACC, note, "Gammie and colleagues provide evidence that supports the repair of moderate tricuspid regurgitation during mitral-valve surgery while employing techniques that minimize pacemaker placement. The most appropriate strategy for the treatment of milder tricuspid regurgitation may emerge from longer follow-up."

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Cardiac Surgery and CHD and Pediatrics, Congenital Heart Disease, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, Interventions and Imaging, Interventions and Structural Heart Disease

Keywords: AHA Annual Scientific Sessions, American Heart Association, AHA21, Mitral Valve, Cardiac Surgical Procedures, Tricuspid Valve Insufficiency, Heart Defects, Congenital, Diagnostic Imaging

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