Outcomes of Guideline-Directed Concomitant Annuloplasty for Functional Tricuspid Regurgitation

Brescia, Alexander A.; Ward, Sarah; Watt, Tessa M.F.; Rosenbloom, Liza M; Baker, Megan; Khan, Shazli; Ziese, Emilie; Romano, Matthew A.; Bolling, Steven F.

doi:10.1016/j.athoracsur.2019.07.035

Cited by 48 publications

(31 citation statements)

References 25 publications

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“…Despite an increasing body of evidence and guidelines recommending that TR be addressed at the time of left‐sided valve surgery, the adoption of concomitant TVr has been delayed 3,7 . One consideration is that transient improvements in TR may be observed following left‐sided valve operations 13 .…”

Section: Discussionmentioning

confidence: 99%

“…In addition, risks for increased rates of heart block with double valve procedures as well as concern regarding the longitudinal freedom from postoperative TR may lead to resistance towards performing concomitant TVr. Brescia et al 3 evaluated concomitant TVr in 171 patients with moderate‐or‐greater TR undergoing left‐sided valve surgery and found acceptable pacemaker rates (4.1%) as well as acceptable freedom from TR at 3‐years (89%).…”

Section: Discussionmentioning

confidence: 99%

“…Functional TR has many causes including annular dilation and leaflet tethering from right ventricular dysfunction induced by pulmonary hypertension associated with left‐sided valvular dysfunction. Historically, a conservative approach has been applied to tricuspid valve (TV) interventions at the time of mitral or aortic valve surgery, since significant increases in mortality were attributed to concomitant TV surgery and observational studies had suggested improvements in TR following left‐sided valve surgery 2‐4 . In the modern era, however, several studies have suggested that neglecting the TV at the time of left‐sided valve surgery may not be as benign as previously thought and instead incurs increases in longitudinal mortality due to progressive heart failure 5,6 .…”

Section: Introductionmentioning

confidence: 99%

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Concomitant tricuspid valve surgery is beneficial at the time of left‐sided valve surgery

et al. 2021

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Background This study evaluates the impact of secondary functional tricuspid regurgitation (TR) and concomitant tricuspid valve repair (TVr) at the time of left‐sided valve operations. Methods Adults undergoing left‐sided valve operations between 2010 and 2019 at a multihospital academic institution were included. Patients were stratified into three groups: less‐than‐moderate TR without TVr (Group 1), moderate‐or‐greater TR without TVr (Group 2), and moderate‐or‐greater TR with TVr (Group 3). Primary outcomes included survival and hospital readmissions. Secondary outcomes included major postoperative morbidities. Multivariable logistic regression evaluated risk‐adjusted mortality and readmission. Results About 3444 patients were included in the analysis and were stratified into Group 1 (n = 2612, 75.8%), Group 2 (n = 563, 16.3%), and Group 3 (n = 269, 7.8%). Patients with moderate or greater TR (Groups 2 and 3) had higher rates of mortality, hospital readmissions and major postoperative complications including reoperations, renal failure requiring dialysis, blood transfusions, and prolonged ventilation (all, p < .05). When assessed individually, the Group 3 had substantially higher rates of renal failure requiring dialysis, prolonged ventilation, and reoperations, although the Group 2 had higher rates of 30‐day mortality (all, p < .05). These findings persisted in risk‐adjusted analysis with the highest hazards for mortality (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.7–2.2) and readmission (HR 1.3, 95% CI 1.2–1.5) appreciated in the Group 2. Conclusions In this analysis of 3444 patients, those with moderate‐to‐severe TR who did not undergo a TVr at the time of their left‐sided valve operation had substantially higher risks of mortality and hospital readmissions compared with those who did undergo TV surgery.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Concomitant tricuspid valve surgery is beneficial at the time of left‐sided valve surgery

et al. 2021

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“…Sakata et al [ 5 ] have also supported that concomitant tricuspid annuloplasty during left heart valve surgery benefits right ventricular geometry. So, tricuspid annuloplasty is recommended urgently and aggressively as excellent surgical strategy against FTR [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

Risk factors for postoperative recurrent tricuspid regurgitation after concomitant tricuspid annuloplasty during left heart surgery and the association between tricuspid annular circumference and secondary tricuspid regurgitation

Han

Zhang

et al. 2021

BMC Cardiovasc Disord

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Background To identify the association between tricuspid annular circumference and secondary tricuspid regurgitation and analyze the risk factors of recurrent tricuspid regurgitation after concomitant tricuspid annuloplasty during left heart surgery. Methods From October 2018 to June 2019, a total of 117 patients receiving concomitant tricuspid annuloplasty within left heart surgery were enrolled. Severity of tricuspid regurgitation was classified as 4 subtypes: normal, mild, moderate and severe. Perioperative data and mid-term outcome were collected. Tricuspid annular circumference (TAC) was measured under cardiac arrest during surgery procedure by cardioplegia. Optimal TAC and TAC index (TAC/body surface area, BSA) cutoffs of significant tricuspid annulus dilatation (moderate and severe) were obtained. Univariable and multivariable logistic regression analyses were performed to identify the risk factors of postoperative recurrent tricuspid regurgitation. The follow up period is 13–19 months (mean 15.5 ± 3.2 months). Results There was 1 patient was excluded who died after surgery. A total of 116 patients receiving tricuspid annuloplasty were included. Optimal cutoffs of significant tricuspid annulus dilatation were recommended (TAC 11.45 cm, Sensitivity 82.89%, Specificity 73.68%, AUC 0.915; TAC index 7.09 cm/m2, Sensitivity 73.68%, Specificity 85%, AUC 0.825, respectively). Based on findings of multivariable logistic regression, it has been showed that TAC index and postoperative atrial fibrillation were the independent risk factors of recurrent regurgitation after surgery. Optimal TAC index cutoff to predict recurrent tricuspid regurgitation was 7.86 cm/m2 Conclusions The severity of secondary tricuspid regurgitation is associated with the tricuspid annular circumference. The cut-offs of significant tricuspid regurgitation (more than moderate) were TAC 11.45 cm and TAC index 7.09 cm/m2, respectively. Clinically, concomitant tricuspid annuloplasty is relative safe and effective. TAC index ≥ 7.86 cm/m2 and postoperative atrial fibrillation are the risk factors of recurrent significant tricuspid regurgitation after concomitant tricuspid annuloplasty during left heart surgery.

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“…Tricuspid regurgitation is not a benign lesion, and even moderate degrees have been associated with reduced survival. Tricuspid regurgitation is highly 37 Yilmaz et al 17 David et al 19 Class IIb: "May be considered"…”

Section: Discussionmentioning

confidence: 99%

Rationale and surgical strategy for concomitant tricuspid repair

Chikwe

Megna

2020

JTCVS Open

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The tricuspid has oft been the forgotten valve. When it comes to intervention for secondary tricuspid regurgitation (TR), the approach has historically been conservative, with the expectation that TR would reverse with correction of mitral regurgitation. Growing evidence has shown that late symptomatic heart failure can develop secondary to residual TR after isolated mitral valve surgery for degenerative disease and that late TR is prevalent in these patients upon long-term followup. Recently, a more aggressive stance toward concomitant repair of the tricuspid valve at the time of mitral valve surgery for degenerative disease has been proposed, with guidelines from the American Heart Association/American College of Cardiology and European Society of Cardiology that support tricuspid repair based on the severity of TR and/or tricuspid annular size. Evolution of repair techniques from suture annuloplasty to remodeling annuloplasty with semi-rigid or rigid devices has also led to greater durability of the repair. In this issue of the Journal, Drs Chikwe and Megna review the evidence supporting concomitant tricuspid repair at the time of mitral valve surgery for degenerative disease and describe the key anatomic and physiologic changes that mediate secondary TR. The authors offer a robust discussion regarding the types of surgical repair strategies and their relative strengths and weaknesses. While catheter-based valvular interventions are gaining momentum for left-sided valvular lesions, devices for tricuspid repair remain in their infancy and their relative role for correction of secondary TR remains small. For the practicing cardiac surgeon, these authors provide a framework with the when, why, and how to manage the tricuspid valve at the time of mitral valve surgery for degenerative disease.

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Outcomes of Guideline-Directed Concomitant Annuloplasty for Functional Tricuspid Regurgitation

Cited by 48 publications

References 25 publications

Concomitant tricuspid valve surgery is beneficial at the time of left‐sided valve surgery

Concomitant tricuspid valve surgery is beneficial at the time of left‐sided valve surgery

Risk factors for postoperative recurrent tricuspid regurgitation after concomitant tricuspid annuloplasty during left heart surgery and the association between tricuspid annular circumference and secondary tricuspid regurgitation

Rationale and surgical strategy for concomitant tricuspid repair

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