Effect of Concomitant Tricuspid Annuloplasty on Early Outcomes of Mitral Valve Replacement: A Study on Rheumatic Heart Disease Patients

Abstract

Introduction Mitral valve abnormalities in rheumatic heart disease commonly lead to functional tricuspid regurgitation. Tricuspid annuloplasty (TA) is often performed in these cases along with mitral valve replacement (MVR). Our aim was to compare the perioperative morbidity and mortality among those patients that underwent mitral valve replacement with tricuspid annuloplasty versus those that underwent isolated mitral valve replacement. Methods A retrospective analysis of 158 patients that underwent mitral valve replacement, with or without tricuspid annuloplasty, secondary to rheumatic heart disease between January 2017 and August 2020. Patients who underwent additional cardiothoracic surgical procedures (aortic valve replacement and coronary artery bypass grafting) were excluded to reduce confounders. Results The study group consisted of 158 patients (mean age 41; 73 male, 85 female) that underwent MVR with TA (n=22; 13.9%) or without TA (n=136; 86.1%). Both groups had similar comorbidity frequencies and medication history. Preoperative echocardiography showed a comparable degree of pulmonary hypertension and ejection fraction between the two groups. The TA+MVR group had similar intraoperative (81.8% vs 66.9%; p=0.161) and postoperative (45.5% vs 45.6%; p=0.991) blood products usage compared to the MVR only group. Concurrent TA resulted in similar in-hospital mortality (4.5% vs 4.4%; p=0.977) as well as early postoperative complications, namely, prolonged ICU stay (13.6% vs 10.3%; p=0.639), prolonged ventilation (0 vs 2.2%; p=0.482), re-intubation (9.1% vs 2.9%; p= 0.161), and reopening for bleeding tamponade (0 vs 5.1%; p=0.276).

Balancing the Benefits of Tricuspid Annuloplasty

“…The cumulative incidence of death in Arafat et al series at 7 years was 4.8% (10). Similar studies were conducted by Farooq and Bernal and their colleagues in younger patients at a mean age of 41-46 years, the 30-day mortality was 4.5 -5.9% (11,12). The Kaplan-Meier survival probability in the series of Bernal and colleagues was 74.4% at 10 years and age >65 years was the only predictor of late mortality (12).…”

“…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).…”

“…The authors should be congratulated for their laudable clinical studies and for sharing the results with the global cardiovascular community. Although it is a single centre observational trial like others, which they admit, their data provide valuable information that stimulates discussions in the clinical practice, which encourages early aggressive approach for concomitant tricuspid annuloplasty (TA) plus mitral valve surgery (MVS) in rheumatic populations (11,12 ). A multi-centre randomized controlled trial to provide predictive power of the resultant data is required for developing a surgical strategy for TA and MVS in rheumatic patients (10)(11)(12).…”

“…Although it is a single centre observational trial like others, which they admit, their data provide valuable information that stimulates discussions in the clinical practice, which encourages early aggressive approach for concomitant tricuspid annuloplasty (TA) plus mitral valve surgery (MVS) in rheumatic populations (11,12 ). A multi-centre randomized controlled trial to provide predictive power of the resultant data is required for developing a surgical strategy for TA and MVS in rheumatic patients (10)(11)(12). Pacemaker implantation was not an issue in their series as well as Farooq and Bernal and their colleagues, but it is a global concern as indicated by a recent multicenter trial that TA carries an additional risk of pacemaker (PM) implantation at a rate of up to 14% as compared to 2.5% for mitral valve surgery alone (rate ratio, 5.75; 95% CI, 2.27 -14.60) (3,11,12).…”

“…A multi-centre randomized controlled trial to provide predictive power of the resultant data is required for developing a surgical strategy for TA and MVS in rheumatic patients (10)(11)(12). Pacemaker implantation was not an issue in their series as well as Farooq and Bernal and their colleagues, but it is a global concern as indicated by a recent multicenter trial that TA carries an additional risk of pacemaker (PM) implantation at a rate of up to 14% as compared to 2.5% for mitral valve surgery alone (rate ratio, 5.75; 95% CI, 2.27 -14.60) (3,11,12). The risk for procedural related PM implantation needs to be addressed (4)(5)(6)(7)(8)(9)(10)(11)(12)(13).…”