Management of Moderate Functional Tricuspid Valve Regurgitation at the Time of Pulmonary Valve Replacement: Is Concomitant Tricuspid Valve Repair Necessary?

Abstract

Congenital heart defects with a component of pulmonary stenosis are often palliated in childhood by disrupting the pulmonary valve. Patients often undergo subsequent pulmonary valve replacement (PVR) to protect the heart from the consequences of pulmonary regurgitation. In the presence of associated moderate functional tricuspid valve (TV) regurgitation, it is unclear what factors contribute to persistent TV regurgitation following PVR. In particular, it is unknown whether PVR alone will reduce the right ventricular (RV) size and restore TV function or whether concomitant TV annuloplasty is required as well. Thirty-five patients were analyzed. Each patient underwent initial palliation of congenital pulmonary stenosis or tetralogy of Fallot, underwent subsequent PVR between 2002 and 2008, and had at least moderate TV regurgitation at the time of valve replacement. Serial echocardiograms were analyzed. Pulmonary and TV regurgitation, along with RV dilation and dysfunction, were scored (0, none; 1, mild; 2, moderate; 3, severe). RV volume and area were also calculated. Potential risk factors for persistent postoperative TV regurgitation were evaluated. One month following PVR, there was a significant reduction in pulmonary valve regurgitation (mean, 3 vs. 0.39; P < 0.0001) and TV regurgitation (mean, 2.33 vs. 1.3; P < 0.0001). There were also significant reductions in RV dilation, volume, and area. There were no significant further improvements in any of the parameters at 1 and 3 years. There was no difference in the degree of TV regurgitation postoperatively between those patients who underwent PVR alone and those who underwent concomitant tricuspid annuloplasty (mean, 1.29 vs. 1.31; P = 0.81). We conclude that following PVR, improvement in TV regurgitation and RV size occurs primarily in the first postoperative month. TV function improved to a similar degree with or without annuloplasty.

Congenital Heart Disease in the Older Adult

“…Judicious use of tricuspid valve annuloplasty, valve repair, and right atrial reduction plasty is indicated when there is evidence of more than mild valvular incompetence to prevent further deterioration and perhaps the onset of atrial arrhythmia. 130,389,[413][414][415][416][417] Some authors also recommend that prophylactic cryoablation be performed in patients with severe tricuspid valve regurgitation and right atrial enlargement to decrease the risk of late arrhythmia.…”

Leaving Moderate Tricuspid Valve Regurgitation Alone at the Time of Pulmonary Valve Replacement: A Worthwhile Approach

“…A stated before, closure of the ventricular septal defect may also affect tricuspid valve function but did not appear to be a risk factor for tricuspid valve regurgitation in our initial study [3]. Unfortunately, risk may be incurred by adding concomitant tricuspid annuloplasty to pulmonary valve replacement.…”

“…Upon reviewing the 1-month postoperative echocardiograms after pulmonary valve replacement, we found that moderate and severe tricuspid valve regurgitation improved to a similar degree regardless of whether a concomitant tricuspid valve annuloplasty was performed [3]. We contended that most of the improvement in tricuspid valve function relates to the volume unloading that occurs with pulmonary valve replacement and that concomitant annuloplasty adds very little.…”

“…In addition, the multivariate analysis from the initial study showed a diagnosis of tetralogy of Fallot was not a risk factor for increased 1-month postoperative tricuspid regurgitation. Therefore, we continued to evaluate these patients together in the present study [3].…”

“…In 2010 we evaluated the same patient cohort, patients with tetralogy of Fallot or congenital pulmonary stenosis, who had undergone prior pulmonary valve disruption and closure of a ventricular septal defect when present [3]. Upon reviewing the 1-month postoperative echocardiograms after pulmonary valve replacement, we found that moderate and severe tricuspid valve regurgitation improved to a similar degree regardless of whether a concomitant tricuspid valve annuloplasty was performed [3].…”