Commentary: Tricuspid repair for mild regurgitation: Should you put a ring on it?

Abstract

Central MessageThere is no benefit to tricuspid repair for mild regurgitation during mitral valve surgery for rheumatic disease; however, atrial fibrillation is a risk factor for progression of tricuspid disease.See Article page XXX. There is no benefit to tricuspid repair for mild regurgitation during mitral valve surgery for rheumatic disease; however, atrial fibrillation is a risk factor for progression of tricuspid disease. See Article page XXX. Management of concomitant tricuspid valve disease during cardiac surgery has long been debated. Our group has evaluated the outcomes of concomitant tricuspid valve repair (TVr) during aortic valve surgery and coronary artery bypass grafting and demonstrated no increased risk in patients with severe tricuspid valve regurgitation (TR).1Haywood N. Mehaffey J.H. Chancellor W.Z. Beller J.P. Speir A. Quader M. et al.Burden of tricuspid regurgitation in patients undergoing coronary artery bypass grafting.Ann Thorac Surg. 2021; 111: 44-50Abstract Full Text Full Text PDF Scopus (5) Google Scholar,2Chancellor W.Z. Mehaffey J.H. Beller J.P. Hawkins R.B. Speir A.M. Quader M.A. et al.Impact of tricuspid regurgitation with and without repair during aortic valve replacement.J Thorac Cardiovasc Surg. XXX, 2020; ([Epub ahead of print])Google Scholar The 2020 American College of Cardiology/American Heart Association guidelines highlight level 2A recommendation for concomitant repair of TR in patients with progressive TR undergoing left-sided valve surgery.3Otto C.M. Nishimura R.A. Bonow R.O. Carabello B.A. Erwin III, J.P. Gentile F. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.Circulation. 2021; 143: e72-e227PubMed Google Scholar They go on to specify that risk factors for persistence or progression of TR include tricuspid annulus dilation, degree of right ventricular dysfunction or remodeling, leaflet tethering height, pulmonary artery hypertension, atrial fibrillation, and intra-annular right ventricle pacemaker or implantable cardioverter defibrillator leads based on retrospective data.3Otto C.M. Nishimura R.A. Bonow R.O. Carabello B.A. Erwin III, J.P. Gentile F. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.Circulation. 2021; 143: e72-e227PubMed Google Scholar In this month's edition of Journal, Kim and colleagues4Kim W.K. Kim S.E. Yoo J.S. Jung J.H. Kim D.-H. Kim J.B. et al.Impact of valve repair on mild tricuspid insufficiency in rheumatic mitral surgery.J Thorac Cardiovasc Surg. June 2, 2021; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (5) Google Scholar present a propensity-matched analysis of patients undergoing concomitant TVr for mild TR during mitral valve surgery for rheumatic disease. They are to be commended on this large homogeneous sample of 1208 patients from 2 referral centers in South Korea during an 18-year period. On multivariable analysis, the study reports there is no advantage of performing TVr, with no differences in recurrent significant TR, survival, or survival free of TR. Furthermore, the findings demonstrate the only significant multivariable predictor of recurrent severe TR was failure to perform the maze procedure in the presence of atrial fibrillation. These findings are in line with current evidence and contribute to the global experience of management of TR. In conclusion, functional TR is common in the presence of mitral valve disease, particularly when there is rheumatic mitral valve involvement with some degree of stenosis. Isolated treatment of the mitral valve disease has proven to be insufficient to correct secondary TR, namely when there is severe TR or tricuspid annulus dilatation (>40 mm or 21 mm/m2).3Otto C.M. Nishimura R.A. Bonow R.O. Carabello B.A. Erwin III, J.P. Gentile F. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.Circulation. 2021; 143: e72-e227PubMed Google Scholar However, the authors demonstrate no benefit of TVr in patients with mild TR who underwent rheumatic mitral valve surgery. Impact of valve repair on mild tricuspid insufficiency in rheumatic mitral surgeryThe Journal of Thoracic and Cardiovascular SurgeryPreviewTricuspid valve repair for mild tricuspid regurgitation during rheumatic mitral valve surgery is controversial. We evaluated the benefit of tricuspid valve repair for mild tricuspid regurgitation in rheumatic mitral valve surgery. Full-Text PDF