What’s new
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Guidelines recommend concomitant tricuspid valve (TV) repair for severe tricuspid regurgitation (TR); however, less is known regarding the management of mild to moderate TR.
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Our study showed that in patients with moderate TR or less, undergoing mitral valve (MV) surgery without concomitant TV repair, significant late functional TR was seldom seen, and change in TR severity was not influenced by the MV aetiology.
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Clinical decision-making regarding concomitant TV repair during MV surgery can be safely based on the preoperative evaluation of TR grade: it is safe to waive concomitant TV repair in our specific patient cohort.
Introduction
Methods
Study population
Data collection
Statistical analysis
Results
Patient characteristics
Patient Characteristics
| |
Age (years) | 61.1 ± 13.1 |
Male gender | 125 (61.3) |
BSA (m2) | 2.2 ± 0.2 |
NYHA class ≥III | 92 (45.1) |
EuroSCORE II | 1.4 [0.8–3.5] |
Hypertension | 63 (30.9) |
Known coronary artery disease (n = 203) | 84 (40.9) |
Diabetes | 23 (11.3) |
COPD | 18 (8.8) |
Renal failure | 38 (18.6) |
Atrial fibrillation | 38 (18.6) |
Pacemaker or ICD | 8 (3.9) |
Surgical Characteristics
| |
Organic MV disease | 142 (69.6) |
– Myxomatous degeneration | 79 (38.7) |
– Fibroelastic degeneration | 47 (23.0) |
– Rheumatic disease | 13 (6.4) |
– Other | 3 (1.5) |
Functional MV disease | 62 (30.4) |
– Ischaemic cardiomyopathy | 46 (22.5) |
– Other | 16 (7.8) |
Preoperative MR (n = 203) | |
>Moderate | 164 (80.2) |
Preoperative TR | |
– No | 29 (14.2) |
– Trace or mild | 126 (61.8) |
– Moderate | 49 (24.0) |
>Moderate | 0 (0.0) |
Preoperative TA ≥ 40 mm (n = 165) | 14 (8.5) |
Preoperative TA diameter (mm) (n = 165) | 33 ± 4 |
MV replacement | 28 (13.7) |
– Mechanical | 17 (8.3) |
– Bioprosthesis | 11 (5.4) |
MV repair | 176 (86.3) |
– Physio ring | 137 (67.2) |
– Cosgrove band | 38 (18.6) |
Elevated RVSP (n = 118) | 51 (43.2) |
Concomitant CABG | 75 (36.8) |
Cross-clamp time (minutes) | 118 [92–149] |
Clinical results
Clinical Characteristics
| |
Early outcome
| |
Operative mortality | 0 (0.0) |
30 days mortality | 5 (2.5) |
New permanent pacemaker or ICD | 5 (2.5) |
Atrial fibrillation | 104 (51) |
Reoperation | 19 (9.3) |
– due to bleeding | 16 (7.8) |
– other | 3 (1.5) |
Late outcome
| |
Postoperative (for most recent FU analysis) (years) | 3.4 [1.8–5.2] |
Postoperative (for survival analysis) (years) | 5.5 [3.7–8.1] |
Mortality | 26 (12.7) |
– Cardiovascular | 20 (9.8) |
– Other | 6 (2.9) |
NYHA class ≥III (n = 184) | 12 (6.5) |
New reoperation (n = 184) | 7 (3.8) |
– Due to mitral stenosis post MV surgery | 1 (0.5) |
– Due to endocarditis | 2 (1.0) |
– Due to bleeding | 1 (0.5) |
Rehospitalisation (n = 187) | 66 (35.3) |
– Cardiovascular | 46 (22.5) |
Congestive heart failure (n = 183) | 19 (10.4) |
New permanent pacemaker or ICD (n = 185) | 14 (7.6) |
Atrial fibrillation (n = 183) | 38 (20.8) |
OAC (n = 180) | 78 (43.3) |
Stroke (n = 191) | 2 (1.0) |
Echocardiographic Characteristics
| |
Time after surgery, years (n = 164) | 3.1 [1.6–4.6] |
LV function, n (%) (n = 160) | |
– Poor (EF < 30%) or moderate (EF 30–44%) | 33 (20.6) |
LV EF, % ± SD (n = 103) | 55 ± 15 |
LA dilatation, n (%) (n = 135) | |
– Moderate or severe | 34 (25.2) |
RA dilatation, n (%) (n = 155) | |
– Moderate or severe | 11 (7.1) |
RV function, n (%) (n = 147) | |
– Poor or moderate | 11 (7.5) |
TAPSE, cm ± SD (n = 129) | 1.8 ± 0.5 |
MR grade, n (%) (n = 159) | |
>Moderate | 3 (1.9) |
TR grade, n (%) (n = 161) | |
– No | 24 (14.9) |
– Trace or mild | 107 (66.5) |
– Moderate | 28 (17.4) |
>Moderate | 2 (1.2) |
TA ≥ 40 mm, n (%) (n = 154) | 23 (14.9) |
– Of whom had pre-operative TA ≥ 40 mm | 3 (13.0) |
Elevated RVSP, n (%) (n = 97) | 14 (14.4) |
Echocardiographic results
Organic (n = 142) | Functional (n = 62) | P-value | |
---|---|---|---|
Baseline
| |||
LV function (n = 141/61) | |||
– Poor (EF < 30%) or moderate (EF 30–44%) | 4 (2.8) | 25 (41.0) | <0.0001 |
LA dilatation (n = 131/55) | |||
– Moderate or severe | 75 (57.3) | 27 (49.1) | 0.060 |
RA dilatation (n = 132/54) | |||
– Moderate or severe | 14 (10.6) | 6 (11.1) | 0.940 |
RV function (n = 127/55) | |||
– Poor or moderate | 1 (0.8) | 3 (5.5) | 0.003 |
TAPSE (cm) (n = 87/43) | 2.3 [2.1–2.8] | 2.0 [1.8–2.5] | 0.001 |
MR grade (n = 141/62) | |||
>Moderate | 122 (86.5) | 42 (67.7) | <0.0001 |
TR grade (n = 142/62) | 0.892 | ||
– No | 21 (14.8) | 8 (12.9) | |
– Trace or mild | 88 (62.0) | 38 (61.3) | |
– Moderate | 33 (23.2) | 16 (25.8) | |
>Moderate | 0 (0.0) | 0 (0.0) | |
TA ≥ 40 mm (n = 115/50) | 8 (7.0) | 6 (12.0) | 0.285 |
TA diameter (mm) (n = 115/50) | 33 ± 4 | 33 ± 5 | 0.994 |
MOST RECENT FOLLOW-UP
| |||
LV function (n = 114/46) | |||
– Poor (EF < 30%) or moderate (EF 30–44%) | 10 (8.3) | 23 (50.0) | <0.0001 |
LA dilatation (n = 94/41) | |||
– Moderate or severe | 23 (24.5) | 11 (26.8) | 0.181 |
RA dilatation (n = 109/46) | |||
– moderate or severe | 7 (6.4) | 4 (8.7) | 0.596 |
RV function (n = 105/42) | |||
– Poor or moderate | 3 (2.9) | 8 (19.0) | 0.002 |
TAPSE (cm) (n = 90/39) | 1.9 [1.6–2.1] | 1.6 [1.4–2.1] | 0.021 |
MR grade (n = 114/45) | |||
>Moderate | 2 (1.8) | 1 (2.2) | 0.218 |
TR grade (n = 115/46) | 0.754 | ||
– No | 16 (13.9) | 8 (17.4) | |
– Trace or mild | 79 (68. 8) | 28 (60.9) | |
– Moderate | 19 (16.5) | 9 (19.6) | |
>Moderate | 1 (0.9) | 1 (2.2) | |
TA ≥ 40 mm (n = 111/43) | 18 (16.2) | 5 (11.6) | 0.617 |
TA diameter (mm) (n = 110/43) | 34 ± 5 | 34 ± 5 | 0.869 |
Change in TR grade (n = 115/46) | 0.569 | ||
−2 | 4 (3.5) | 2 (4.3) | |
−1 | 23 (20.0) | 14 (30.4) | |
0 | 66 (57.4) | 20 (43.5) | |
1 | 20 (17.4) | 9 (19.6) | |
2 | 2 (1.7) | 1 (2.2) |