Mitral Valve Repair Without Repair of Moderate Tricuspid Regurgitation

doi:10.1016/j.athoracsur.2015.05.108

The Annals of Thoracic Surgery

Volume 100, Issue 6, December 2015, Pages 2206-2212

https://doi.org/10.1016/j.athoracsur.2015.05.108 Get rights and content

Background

The objective of this study was to assess the fate at long term of mild-to-moderate functional tricuspid regurgitation (TR) left untreated at the time of mitral valve repair in patients with dilated cardiomyopathy.

Methods

We selected from our prospective hospital database 84 patients (age, 64 ± 9.6 years; ejection fraction, 0.31 ± 0.064) who underwent mitral repair for secondary mitral regurgitation in whom concomitant mild-to-moderate TR (nonlinear scale 1 to 4+) was left untreated. Tricuspid regurgitation was classified as mild in 61 patients (72.6%) and moderate in 23 patients (27.3%). Annular dilatation itself was not systematically measured and was not used as a trigger for tricuspid annuloplasty. Most of the patients were in New York Heart Association functional class III or IV (56 of 84; 66.7%).

Results

At a median follow-up of 7.3 years (interquartile range, 4.5 to 9.3), 17 patients (20.2%) had moderate-to-severe TR and 21 patients (25%) showed a progression of at least two grades of their untreated preoperative TR. Freedom from moderate-to-severe TR or from progression of at least two grades of the baseline TR was 77% ± 5% at 5 years and 56.7% ± 8.4% at 10 years. Multivariate analysis identified preoperative right ventricular dysfunction (hazard ratio, 7.2; 95% confidence interval, 2.8 to 23; p = 0.001) and age (hazard ratio, 1; 95% confidence interval, 1.0 1.1; p = 0.03) as independent predictors of TR worsening.

Conclusions

A significant number of dilated cardiomyopathy patients with mild-to-moderate TR left untreated at the time of mitral repair show important TR at follow-up. In this setting, a more aggressive policy should be used taking into consideration the degree of annular dilatation and the function of the right ventricle and not simply the grade of TR.

Section snippets

Study Population

Two hospital databases (San Raffaele Hospital, Milan, and Fondazione Toscana Gabriele Monasterio, Massa, Italy) were used to select 84 patients with severe secondary MR and concomitant less than severe functional TR. All patients underwent MV repair between 1999 and 2008, and the associated functional TR was left untreated. Patients with primary or degenerative MR, acute MR caused by papillary muscle rupture, concomitant left ventricular (LV) reconstruction or aortic valve surgery, residual

Clinical and Echocardiographic Data

Follow-up was obtained for all patients between December 1, 2013, and March 1, 2014. The study population comprised 84 patients. Mean age was 64 ± 9.6 years, and all patients had severe secondary MR and significant LV dysfunction (ejection fraction, 0.31 ± 0.064). New York Heart Association functional class III or IV was present in 56 of 84 patients (66.5%; Table 1). Concomitant TR was classified as absent or mild in 61 patients (72.6%) and moderate in 23 patients (27.3%) and was left untreated.

Comment

The main finding of this study is that in DCM patients undergoing mitral repair for secondary MR, a preoperative condition of less than moderately severe TR, left untreated, may progress over the course of years in a significant proportion of patients. Therefore, deciding whether or not to perform a concomitant tricuspid annuloplasty at the time of MV surgery simply on the basis of the grade of TR should be avoided, particularly in the setting of functional MR. Current guidelines recommend

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Cited by (20)

Pacemaker implantation after concomitant tricuspid valve repair in patients undergoing minimally invasive mitral valve surgery: Results from the Mini-Mitral International Registry
2024, JTCVS Open
Randomized evidence suggests a high risk of pacemaker implantation for patients undergoing mitral valve (MV) surgery with concomitant tricuspid valve repair (cTVR). We investigated the impact of cTVR on outcomes in the Mini-Mitral International Registry.
From 2015 to 2021, 7513 patients underwent minimally invasive MV with or without cTVR in 17 international centers (MV: n = 5609, cTVR: n = 1113). Propensity matching generated 1110 well-balanced pairs. Multivariable analysis was applied.
Patients with cTVR were older and had more comorbidities. Propensity matching eliminated most differences except for more TR in patients who underwent cTVR (77.2% vs 22.1% MV, P < .001). Mean matched age was 71 years, and 45% were male. European System for Cardiac Operative Risk Evaluation II was still 2.68% (interquartile range [IQR], 0.80-2.63) vs 1.9% (IQR, 1.12-3.9) in matched MV (P < .001). MV replacement (30%) and atrial fibrillation surgery (32%) were similar in both groups. Cardiopulmonary bypass (161 minutes [IQR, 133-203] vs MV: 130 minutes [IQR, 103-166]; P < .001) and crossclamp times (93 minutes [IQR, 66-123] vs MV: 83 minutes [IQR, 64-107]; P < .001) were longer with cTVR. Although in-hospital mortality was similar (cTVR: 3.3% vs MV: 2.2%; P = .5), postoperative pacemaker implantations (9% vs MV: 5.8%; P = .02), low cardiac output syndrome (7.7% vs MV: 4.4%; P = .02), and acute kidney injury (13.8% vs MV: 10%; P = .01) were more frequent with cTVR. cTVR eliminated relevant TR in most patients (greater-than-moderate TR: 6.8%). Multivariable analysis identified MV replacement, atrial fibrillation, and cTVR as risk factors of postoperative pacemaker implantation.
cTVR in minimally invasive MV surgery is an independent risk factor for pacemaker implantation in this international registry. It is also associated with more bleeding, low output syndrome, and acute kidney injury. It remains unclear whether technical or patient factors (or both) explain these differences.
The long-term clinical course of moderate tricuspid regurgitation
2023, International Journal of Cardiology
To evaluate the long-term clinical outcome of a cohort of patients suffering from moderate tricuspid regurgitation (TR), regardless of its etiology.
Clinical and echocardiographic follow-up were assessed in 250 patients diagnosed with moderate TR between January 2016 and July 2020. TR progression at follow-up was defined as TR grade increase to at least severe. The primary endpoint was all-cause death; secondary endpoints were cardiovascular (CV) death and the composite of heart failure (HF) hospitalization plus tricuspid valve (TV) intervention.
After a median follow-up of 3.6 years, TR progression occurred in 84 patients (34%). At multivariate analyses, atrial fibrillation (AF, OR 1.81, CI 1.01–3.29, p = 0.045) and right ventricular end-diastolic diameter (RVEDD, OR 2.19, CI 1.26–3.78, p = 0.005) were independent predictors of TR progression. The primary endpoint occurred in 59 patients (24%) and was significantly more frequent in the group with TR progression (p = 0.009). At multivariate analyses, chronic kideney disease (OR 2.80, CI 1.30–6.03, p = 0.009), left ventricular ejection fraction (OR 0.97, CI 0.94–0.99, p = 0.041) and TR progression (OR 2.32, CI 1.31–4.12, p = 0.004) were independent predictors of the primary outcome. Moreover, both the secondary endpoints of CV death and HF hospitalization plus TV intervention were more frequent in the TR progression group (p = 0.001 and p < 0.001, respectively).
Moderate TR progresses in a significant proportion of patients over a long-term follow-up, leading to a worse prognosis. TR progression is an independent determinant of hard clinical events and AF and RVEDD are associated with TR progression.
Progression of Tricuspid Regurgitation After Surgery for Ischemic Mitral Regurgitation
2021, Journal of the American College of Cardiology
Citation Excerpt :
Matsunaga and Duran (7) observed ≥moderate TR in >50% of patients at 1 to 3 years after MV repair for IMR. Other groups report ≥moderate TR at 5 years after IMR surgery in 31% of patients with baseline trace or mild TR (8), or TR progression of at least 2 TR grades in 25% of patients ∼7 years after surgery for secondary MR (66% ischemic etiology) (9). TR severity, however, can be dynamic and load dependent (20), and retrospective database analyses predispose toward capturing sicker patients in a decompensated state, when seeking medical advice or at hospital admission.
Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.
The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.
Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.
Patients’ mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).
After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart’s Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040)
Percutaneous treatment of mitral valve regurgitation: Where do we stand?
2019, International Journal of Cardiology
Surgery has been the standard of care for mitral valve diseases to date. In the last fifteen years, due to increased aging of the population, with a great number of patients being high-risk for surgical treatment, transcatheter treatments for mitral valve disease have greatly developed. Further development and expansion of transcatheter treatments are expected. However, some limitations remain, such as efficacy and durability, which impact the widespread use of these devices.
Prevalence, Burden and Echocardiographic Features of Moderate to Severe Tricuspid Regurgitation: Insights from a Tertiary Referral Center
2019, Structural Heart
Although systematically underestimated in the past, the importance of tricuspid regurgitation (TR) is being progressively recognized. We aimed to evaluate the clinical significance of severe TR from a cohort of patients at a tertiary center.
A retrospective analysis was performed on 6309 consecutive patients undergoing echocardiography between October 2014 and September 2015 in a single center in Milan, Italy. The study endpoints included cardiovascular mortality, major adverse cardiac and cerebrovascular events (MACCE) and net adverse clinical events (NACE).
A total of 2336 (37%) patients were found to have TR of any severity, 272 (4.3%) had severe TR, 415 (6.6%) moderate TR, and 1649 (26.1%) mild TR. In the severe TR group, 40 (14.7%) patients suffered cardiovascular death, while 53 (19.5%) and 141 (51.8%) developed MACCE and NACE, respectively. In addition, there were 88 (32.4%) patients with severe TR who were re-hospitalized for cardiovascular-related events. Patients with severe TR were more likely to be in New York Heart Association functional class III–IV (p = 0.022) and on higher doses of loop diuretic (p = 0.022) than those with only moderate TR. Multivariable analysis revealed that blood urea nitrogen (BUN, p = 0.031) and abnormal liver function blood tests (p = 0.010) were independent predictors of mid-term cardiovascular mortality, while BUN and tricuspid annular plane systolic excursion were found to be independent predictors of mid-term NACE.
The prevalence of any TR was high in patients undergoing echocardiography at a tertiary referral center, and severe TR was not uncommon and associated with high mid-term morbidity and mortality.
Severity of tricuspid regurgitation is associated with long-term mortality
2018, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Unfortunately, both significant uncorrected TR and reoperation for TR are associated with increased mortality.11,17-20 Consequently, several authors have suggested that in the context of left-sided valve surgery, surgical correction of mild and moderate TR may be considered to prevent future progression.11,14,16,21,22 The most recent American Heart Association/American College of Cardiology guidelines have evolved to include indications for surgical intervention on the TV for less than severe grades of TR.
To determine the association between intraoperative/presurgical grade of tricuspid regurgitation (TR) and mortality, and to determine whether surgical correction of TR correlated with an increased chance of survival compared with patients with uncorrected TR.
The grade of TR assessed by intraoperative transesophageal echocardiography (TEE) before surgical intervention was reviewed for 23,685 cardiac surgery patients between 1990 and 2014. Cox proportional hazard regression models were used to determine association between grade of TR and the primary endpoint of all-cause mortality. Association between tricuspid valve (TV) surgery and survival was determined with Cox proportional hazard regression models after matching for grade of TR.
Kaplan-Meier survival curves demonstrated a relationship between all grades of TR. Multivariable analysis of the entire cohort demonstrated significantly increased mortality for moderate (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.1-1.4; P < .0001) and severe TR (HR, 2.02; 95% CI, 1.57-2.6; P < .0001). Mild TR displayed a trend for mortality (HR, 1.07; 95% CI, 0.99-1.16; P = .075). After matching for grade of TR and additional confounders, patients who underwent TV surgery had a statistically significant increased likelihood of survival (HR, 0.74; 95% CI, 0.61-0.91; P = .004).
Our study of more than 20,000 patients demonstrates that grade of TR is associated with increased risk of mortality after cardiac surgery. In addition, all patients who underwent TV surgery had a statistically significantly increased likelihood of survival compared with those with the same degree of TR who did not undergo TV surgery.

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Original articleAdult cardiacMitral Valve Repair Without Repair of Moderate Tricuspid Regurgitation

Background

Methods

Results

Conclusions

Section snippets

Study Population

Clinical and Echocardiographic Data

Comment

J Am Coll Cardiol

Ann Thorac Surg

Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Am Heart J

Ann Thorac Surg

Original article
Adult cardiac
Mitral Valve Repair Without Repair of Moderate Tricuspid Regurgitation