Concomitant Tricuspid Repair in Patients with Degenerative Mitral Regurgitation

Abstract

Background: Tricuspid regurgitation is common in patients with severe degenerative mitral regurgitation. However, the evidence base is insufficient to inform a decision about whether to perform tricuspid-valve repair during mitral-valve surgery in patients who have moderate tricuspid regurgitation or less-than-moderate regurgitation with annular dilatation. Methods: We randomly assigned 401 patients who were undergoing mitral-valve surgery for degenerative mitral regurgitation to receive a procedure with or without tricuspid annuloplasty (TA). The primary 2-year end point was a composite of reoperation for tricuspid regurgitation, progression of tricuspid regurgitation by two grades from baseline or the presence of severe tricuspid regurgitation, or death. Results: Patients who underwent mitral-valve surgery plus TA had fewer primary-end-point events than those who underwent mitral-valve surgery alone (3.9% vs. 10.2%) (relative risk, 0.37; 95% confidence interval [CI], 0.16 to 0.86; P = 0.02). Two-year mortality was 3.2% in the surgery-plus-TA group and 4.5% in the surgery-alone group (relative risk, 0.69; 95% CI, 0.25 to 1.88). The 2-year prevalence of progression of tricuspid regurgitation was lower in the surgery-plus-TA group than in the surgery-alone group (0.6% vs. 6.1%; relative risk, 0.09; 95% CI, 0.01 to 0.69). The frequencies of major adverse cardiac and cerebrovascular events, functional status, and quality of life were similar in the two groups at 2 years, although the incidence of permanent pacemaker implantation was higher in the surgery-plus-TA group than in the surgery-alone group (14.1% vs. 2.5%; rate ratio, 5.75; 95% CI, 2.27 to 14.60). Conclusions: Among patients undergoing mitral-valve surgery, those who also received TA had a lower incidence of a primary-end-point event than those who underwent mitral-valve surgery alone at 2 years, a reduction that was driven by less frequent progression to severe tricuspid regurgitation. Tricuspid repair resulted in more frequent permanent pacemaker implantation. Whether reduced progression of tricuspid regurgitation results in long-term clinical benefit can be determined only with longer follow-up. (Funded by the National Heart, Lung, and Blood Institute and the German Center for Cardiovascular Research; ClinicalTrials.gov number, NCT02675244.).

Prevalence and Prognostic Importance of Massive Tricuspid Regurgitation in Patients Undergoing Tricuspid Annuloplasty With Concomitant Left-Sided Valve Surgery: A Study on Rheumatic Valvular Heart Disease

“…According to the current guidelines, TA should be performed during concomitant left-sided valve surgery in patients with TR or dilated tricuspid annulus (6,7). Recent research further showed that the inclusion of TA at the time of mitral valve surgery resulted in a lower risk of a primary-end-point event at 2 years than those who underwent mitral-valve surgery alone (25). Nonetheless the severity of TR, in particular massive TR, is not one of the indications for surgical correction.…”

Long-Term Impact of Preventive Tricuspid Valve Annuloplasty on Right Ventricular Remodeling

“…The occurrence of major adverse events and the overall survival were similar in the groups with and without TV annuloplasty. 23 The present study is a retrospective cohort study from a single tertiary center with limitations inherent to its design. Due to the strict inclusion criteria, the sample size was relatively small.…”

Balancing the Benefits of Tricuspid Annuloplasty

“…In a similar study by Farooq and colleagues on TA plus mitral valve replacement there was no progression of TR reported at three years (11). Recently reported randomized controlled trial by Gammie and colleagues showed much lesser progression of moderate TR at two years (0.6% vs. 6.1% control group, relative risk, 0.09; 95% CI, 0.01 to 0.69) (3). Bernal and colleagues reported progression of TR during their 15,8 years mean follow up in 23,5% of the RHD population caused by recurrent rheumatic disease (12).…”

“…It is reported that 65-85% of the population present with trivial to moderate TR which remain asymptomatic until it is discovered in an echocardiogram for preoperative cardiac evaluation or routine cardiovascular checkup (3). Moderate to severe TR occurs in patients with rightand left-sided congenital and acquired diseases and may be associated to bi-ventricular failure, increased risk for associated morbidity such as pulmonary arterial hypertension (PAH), hepatorenal syndrome and mortality (1,4,(7)(8)(9).…”