Elsevier

International Journal of Cardiology

Volume 240, 1 August 2017, Pages 138-144
International Journal of Cardiology

Tricuspid annuloplasty versus a conservative approach in patients with functional tricuspid regurgitation undergoing left-sided heart valve surgery: A study-level meta-analysis

https://doi.org/10.1016/j.ijcard.2017.05.014Get rights and content

Abstract

Background

Tricuspid valve (TV) repair at the time of left-sided valve surgery is indicated in patients with either severe functional tricuspid regurgitation (TR) or mild-to-moderate TR with coexistent tricuspid annular dilation or right heart failure. We assessed the benefits of a concomitant TV repair strategy during left-sided surgical valve interventions, focusing on mortality and echocardiographic TR-related outcomes.

Methods

A meta-analysis was performed of studies reporting outcomes of patients who underwent left-sided (mitral and/or aortic) valve surgery with or without concomitant TV repair. Primary endpoints were all-cause and cardiac-related mortality; secondary endpoints were the presence of more-than-moderate TR, TR progression, and TR severity grade. All endpoints were evaluated at the longest available follow-up.

Results

Fifteen studies were included for a total of 2840 patients. TV repair at the time of left-sided valve surgery was associated with a significantly lower risk of cardiac-related mortality (odds ratio [OR] 0.38; 95% confidence interval [CI]: 0.25–0.58; p < 0.001), with a trend towards a lower risk of all-cause mortality (OR 0.57; 95% CI: 0.32–1.05; p = 0.07) at a mean weighted follow-up of 6 years. The presence of more-than-moderate TR (OR 0.19; 95% CI: 0.12–0.30; p < 0.001), TR progression (OR 0.03; 95% CI: 0.01–0.05; p < 0.001), and TR grade (standardized mean difference − 1.11; 95% CI: − 1.57 to − 0.65; p < 0.001) were significantly lower in the TV repair group at a mean weighted follow-up of 4.7 years.

Conclusions

A concomitant TV repair strategy during left-sided valve surgery is associated with a reduction in cardiac-related mortality and improved echocardiographic TR outcomes at follow-up.

Introduction

In the majority of cases, tricuspid regurgitation (TR) results from a range of pathologies promoting tricuspid annular dilation, typically within the context of left-sided heart disease [1]. Commonly referred to as functional (or secondary) TR, its early stages are generally well tolerated; when left untreated, disease progression results in progressive right ventricular (RV) dilatation, dysfunction, and subsequent poor clinical outcomes [2]. Following successful left-sided heart valve surgery, late significant functional TR develops in approximately 25–30% of patients and its incidence increases with time [3], [4], [5], [6]. Current European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) and American Heart Association (AHA)/American College of Cardiology (ACC) guidelines recommend concomitant tricuspid valve (TV) surgery in patients with severe TR undergoing left-sided valve surgery (class I recommendation) [7], [8]. In patients with mild-to-moderate TR, there is a class IIa indication for concomitant TV surgery in the setting of tricuspid annular dilation [7], [8] or prior evidence of right heart failure [7]. Concomitant TV repair during mitral valve surgery seems not to increase operative mortality, regardless of TR severity [9], and associates with improved long-term right ventricular remodelling [10]. However, a long-term survival benefit of this approach has yet to be definitively established [1].

A prior meta-analysis of studies comparing TV annuloplasty versus no TV intervention at the time of mitral valve surgery in patients with mild-to-moderate TR did not investigate cardiac-related mortality, reporting similar all-cause mortality in patients irrespective of whether they underwent TV repair [11]. With the inclusion of more recent clinical data in addition to studies evaluating patients with any baseline TR grade, as well as studies including patients undergoing mitral or aortic valve interventions, the present meta-analysis was undertaken to more systematically assess the benefits of a concomitant TV repair strategy at the time of left-sided valve intervention versus a conservative approach, focusing on mortality (both overall and cardiac-related) and echocardiographic TR-related outcomes.

Section snippets

Search strategy and study selection

All prospective or retrospective studies evaluating patients with functional TR undergoing left-sided heart valve surgical interventions and comparing a prophylactic tricuspid annuloplasty during the surgical procedure with a conservative approach (no tricuspid annuloplasty) were evaluated for inclusion in this meta-analysis. Two authors (CM, AM) independently searched PubMed, Embase, BioMedCentral, Google Scholar, and the Cochrane Central Register of Controlled Trials for articles published

Results

Of 825 potentially relevant studies, 15 studies were included in the meta-analysis (Fig. 1) for a total of 2840 patients who underwent left-sided valve surgery with (n = 1356) or without (n = 1484) concomitant tricuspid annuloplasty [3], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31]. Only 2 studies had a randomized design [18], [28], while the other studies were observational in nature (1 prospective [20] and 12 retrospective) [3], [19], [21], [22], [23], [24],

Discussion

The main results of this meta-analysis evaluating patients with functional TR undergoing left-sided valve surgery with or without concomitant TV annuloplasty are as follows:

  • 1)

    compared with a conservative approach, concomitant TV repair was associated with a numerically lower (but non-statistically significant) all-cause mortality, yet significantly lower cardiac mortality during a mean clinical follow-up period of 6 years;

  • 2)

    concomitant TV repair was associated with lower rates of more-than-moderate

Statement of authorship

All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

Conflict of interest

Dr. Moat reports personal fees from Medtronic, Abbott, Tendyne, Edwards Lifesciences, and Mitralign. Dr. Rodés-Cabau has received research grants from Edwards Lifesciences. Dr. Latib is a consultant for Medtronic, Valtech Cardio, 4-Tech Cardio, and Mitralign. The other authors have no conflicts of interest to declare.

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