Mitral valve surgery for functional mitral regurgitation: Should moderate to severe tricuspid regurgitation be treated? A propensity score analysis

Abstract

Any study designed to examine tricuspid valve intervention in patients with functional tricuspid valve regurgitation (FTR) associated with functional mitral valve regurgitation (FMR) begins with the understanding that FMR in this setting is different from FMR associated with structural mitral valve disease. Operations for structural mitral valve disease are anticipated to correct most of the abnormal physiologic characteristics associated with the volume overload of mitral regurgitation and to promote progressive and durable reverse remodeling. It is thus reasonable to intuit that mild degrees of FTR in this setting are likely to regress or remain the same as pulmonary artery pressures, right ventricular dimensions and function, and left ventricular properties improve with time. Such is not the case for FMR associated with abnormal left ventricular systolic function. FMR can be surgically corrected with low operative mortality. However, there remains a high recurrence rate, particularly when severe FMR is treated by isolated valve repair rather than replacement. The early changes of reverse left ventricular remodeling are not necessarily sustained, and the progressive nature of the intrinsic cardiomyopathy (ischemic or dilated) commonly resumes after an initial period of improvement. A study from the Mayo Clinic found a clear correlation between the extent of functional mitral regurgitation and late mortality. Wu and colleagues, however, reported no benefit in longevity for patients undergoing operation for FMR in association with either ischemic or dilated cardiomyopathy. Pending further understanding through additional studies, correction of FMR may be thought of as setting back the adverse physiologic clock for a while but not stopping it from running. Calafiore and colleagues used propensity matching to study a group of patients with FTR secondary to FMR. Almost all patients who had severe FTR underwent repair with a DeVega annuloplasty. Patients with mild to moderate FMR who did not have repair had decreased longevity and poorer survival in a low New York Heart Association functional class (ie, closer to class I). It was particularly interesting that patients with uncorrected mild to moderate FTR in