Tricuspid annuloplasty versus a conservative approach in patients with functional tricuspid regurgitation undergoing left-sided heart valve surgery: A study-level meta-analysis
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.
References (40)
- et al.
Diagnosis and treatment of tricuspid valve disease: current and future perspectives
Lancet
(2016) - et al.
Transcatheter therapies for treating tricuspid regurgitation
J. Am. Coll. Cardiol.
(2016) - et al.
Predictors of residual tricuspid regurgitation after mitral valve surger
Ann. Thorac. Surg.
(2003) - et al.
Development of tricuspid regurgitation late after left-sided valve surgery: a single-center experience with long-term echocardiographic examinations
Am. Heart J.
(2008) - et al.
Impact of concomitant tricuspid annuloplasty on tricuspid regurgitation, right ventricular function, and pulmonary artery hypertension after repair of mitral valve prolapse
J. Am. Coll. Cardiol.
(2015) - et al.
Outcomes of mild to moderate functional tricuspid regurgitation in patients undergoing mitral valve operations: a meta-analysis of 2,488 patients
Ann. Thorac. Surg.
(2015) - et al.
Meta-analysis in clinical trials
Control. Clin. Trials
(1986) - et al.
Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery
J. Thorac. Cardiovasc. Surg.
(2012) - et al.
Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair?
Ann. Thorac. Surg.
(2005) - et al.
Mitral valve surgery for functional mitral regurgitation: should moderate-or-more tricuspid regurgitation be treated? A propensity score analysis
Ann. Thorac. Surg.
(2009)
Clinical and hemodynamic influences of prophylactic tricuspid annuloplasty in mechanical mitral valve replacement
J. Thorac. Cardiovasc. Surg.
Moderate tricuspid regurgitation with left-sided degenerative heart valve disease: to repair or not to repair?
Ann. Thorac. Surg.
Mild-to-moderate functional tricuspid regurgitation in patients undergoing mitral valve surgery
J. Thorac. Cardiovasc. Surg.
Clinical and echocardiographic impact of functional tricuspid regurgitation repair at the time of mitral valve replacement
Ann. Thorac. Surg.
Tricuspid annuloplasty concomitant with mitral valve surgery: effects on right ventricular remodeling
J. Thorac. Cardiovasc. Surg.
Impact of tricuspid regurgitation on long-term survival
J. Am. Coll. Cardiol.
Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism, and management
J. Am. Coll. Cardiol.
The growing clinical importance of secondary tricuspid regurgitation
J. Am. Coll. Cardiol.
Mitral valve repair without repair of moderate tricuspid regurgitation
Ann. Thorac. Surg.
Transcatheter valve-in-ring implantation for the treatment of residual or recurrent tricuspid valve dysfunction after prior surgical repair
JACC Cardiovasc. Interv.
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