Late Tricuspid Regurgitation Research Articles

Long-Term Outcomes After Mitral Valve Replacement and Tricuspid Annuloplasty in Rheumatic Patients

Late tricuspid regurgitation is a common finding in patients with rheumatic valvular disease aftermitral valve replacement surgery. However, thelong-term benefit of concomitant tricuspid valveannuloplasty has not been established in this population. This was a single-center retrospective study in a tertiary hospital. The final cohort included 285 rheumatic patients who underwent either isolated mitral valve replacement (147 patients) or mitral valve replacement with concomitant tricuspid valve annuloplasty (138patients). Tricuspid regurgitation severity grade wasassessed according to current echocardiography guidelines and graded using a 0 to 3 scale (none or trivial, mild, moderate, severe). Patients were followed for a total median duration of 10.8 (interquartile range, 6.8 to 14.5) years. The majority of patients undergoing mitral valve replacement were women, with a median age at operation of 59 (interquartile range, 48 to 68) years. Patients undergoingconcomitant tricuspid valve annuloplasty had a 3.4-fold odds of improving their tricuspid regurgitationgrade at long-term follow-up by multivariate logistic regression. Furthermore, concomitant tricuspid valve annuloplasty was independently associated with a long-term survival benefit in patients with preoperative moderate or severe tricuspid regurgitation (hazard ratio, 0.44; 95% confidence interval, 0.23 to 0.87; p= 0.018). This study demonstrates good long-term results in patients with rheumatic heart disease undergoing mitral valve replacement with concomitant tricuspid valve annuloplasty.

Longitudinal echocardiographic and clinical follow-up of patients undergoing mitral valve surgery without concomitant tricuspid valve repair

BackgroundIn patients with mild to moderate functional tricuspid regurgitation (TR) and absence of right ventricular dysfunction or tricuspid annulus (TA) dilatation, there is currently no indication for concomitant tricuspid valve (TV) repair during elective mitral valve (MV) surgery. However, long-term results are conflicting. Here, we sought to determine the clinical outcome of this cohort, the rate of TR progression after MV surgery and the role of MV aetiology.MethodsPatients for elective MV surgery without concomitant TV repair were retrospectively analysed with longitudinal echocardiographic and clinical follow-up, focusing on TR progression and MV aetiology. Linear regression analysis was performed for change in TR at follow-up, using pre-determined variables and confounders.ResultsIn total 204 patients without TV repair were analysed. Development of more than moderate TR after a median of 3.1 [1.6–4.6] years was rarely seen: only in 2 out of 161 patients (1.2%) with known TR grade at follow-up. Overall, median preoperative and late postoperative TR grade were equal (p = 0.116). Subanalysis showed no significant difference in MV aetiology subgroups. Preoperative TR grade and male gender were inversely correlated to change in TR. Mortality was not influenced by the 1‑year postoperative TR severity.ConclusionOur data showed that in a study population of patients with mild to moderate TR undergoing MV surgery without concomitant TV repair, significant late TR was rarely seen. Based on our study, it is safe to waive concomitant TV repair in this specific patient cohort.Electronic supplementary materialThe online version of this article (10.1007/s12471-018-1159-4) contains supplementary material, which is available to authorized users.

Beating-Heart Totally Endoscopic Tricuspid Valvuloplasty in Reoperative Cardiac Surgery

The development of significant tricuspid regurgitation long after left-sided valve surgery is not uncommon and is closely associated with a poor prognosis. Traditional open-heart tricuspid procedures after previous cardiac surgery are reported with high mortality. Currently, role of endoscopic surgery treating late severe tricuspid regurgitation following cardiac surgery remains less investigated. We herein report the technique, which is a combination of the beating-heart minimally invasive approach and the leaflet augmentation technique treating tricuspid regurgitation after cardiac surgery. Outcomes of this technique for severe late tricuspid regurgitation following cardiac surgery are favorable.

P1598Tricuspid valve repair at the time of mitral valve surgery is safe and reduces the incidence of late tricuspid regurgitation and reoperation: a meta-analysis

P1598Tricuspid valve repair at the time of mitral valve surgery is safe and reduces the incidence of late tricuspid regurgitation and reoperation: a meta-analysis

Definitive Determinant of Late Significant Tricuspid Regurgitation After Aortic Valve Replacement.

Uncertainties remain regarding the course of existing tricuspid regurgitation (TR) after aortic valve replacement (AVR), and its long-term impact on outcome. We investigated changes in existing TR after isolated AVR for severe aortic stenosis (AS), the impact of preoperative TR on long-term outcome, and predictors of late significant TR.Methods and Results:After excluding mild mitral regurgitation and severe TR, 226 consecutive patients undergoing isolated AVR for severe AS between 2002 and 2015 were reviewed. Patients were classified into a non-TR (none/trivial preoperative TR, n=159) and a TR group (mild/moderate preoperative TR, n=67). During follow-up (median, 4.3 years), late significant TR was more prevalent in the TR group (n=20; 35.0%) than in the non-TR group (n=13; 9.6%; HR, 10.0; 95% CI: 4.44-24.7; P<0.001). The TR group developed more right heart failure (n=3; 5% vs. no patients in the non-TR group, P=0.007), and had a decreased estimated glomerular filtration rate (relative to baseline) until 5 years postoperatively. The tricuspid annulus diameter index was an independent predictor of late significant TR development. Preoperative mild or moderate TR is aggravated after isolated AVR, resulting in a high incidence of renal dysfunction and right heart failure. Concomitant tricuspid valve intervention should be considered in patients undergoing AVR for severe AS with mild or moderate TR accompanied by dilated tricuspid annulus.

Predictors of functional tricuspid regurgitation after successful left-sided valve surgery

Tricuspid regurgitation (TR) is probably the most common and anticipated complication of left-sided heart valve pathology, especially MV disease. Whether preoperative functional TR will regress or progress after successful left-sided valve surgery is unknown. The aim of this study was to identify the predictors of significant TR after successful left-sided valve surgery. A retrospective analysis was performed on a total of 56 patients who underwent left-sided valve surgery (mitral or mitro-aortic valve surgery). We have excluded patients who had organic TR. All patients had complete clinical examination and echocardiographic studies preoperatively and clinical and echocardiographic follow-up postoperatively. Mean operative age of patients was 49.3 ± 13.7 years with a sex ratio of 0.8. Tricuspid annuloplasty was associated to left-sided valve surgery in 18 (32%) patients. Postoperatively, significant TR was found in 13 patients (23%) with a mean follow-up of 20.5 ± 33 months. Patients with significant postoperative TR were more often female (83% vs. 48%, P = 0.03), had more often a previous mitral commissurotomy (58% vs. 23%, P = 0.02) and showed a higher prevalence of significant preoperative TR (69% vs. 42%, P = 0.04). Postoperatively, residual pulmonary hypertension ( P = 0.04), dilatation of left atrium ( P = 0.02) and dilatation of right cardiac cavities ( P = 0.01) were significant risk factors for development or progression of TR after surgery. Late onset or progression of functional TR after successful left-sided valve surgery is a significant clinical entity as it displays a great impact on patient prognosis. So, the identification of clinical and echocardiographic predictors of late TR allows an adequate screening of patients that will require tricuspid valve repair at the time of initial left-sided valve surgery.

Determinants of recurrent tricuspid regurgitation following tricuspid valve annuloplasty during mitral valve surgery.

The purpose of this study was to determine risk predictors for recurrent tricuspid regurgitation (TR) following tricuspid valve annuloplasty during mitral valve surgery. Ninety-eight consecutive patients underwent tricuspid valve annuloplasty concomitant with mitral valve repair (71 patients), replacement (16 patients), or other procedures over a 10-year period. Fifty-seven patients underwent surgery with a flexible band and 41 with a rigid ring. Late TR progression (≥2/4) occurred in eight (14.0%) of flexible band patients, and in nine (22.0%) rigid ring patients. Multivariate analysis did not identify the superiority of one annuloplasty device over the other to prevent recurrent TR. Multivariate risk predictors of late TR progression were late atrial fibrillation (hazard ratio [HR]: 3.78; 95% confidence interval [CI]: 1.19-12.0), and recurrent mitral regurgitation; HR; 4.46; 95%CI; 1.52-13.1). Freedom from TR progression at 5 years was 89.2% in atrial fibrillation-free patients compared to 56.8% in those with atrial fibrillation (log-rank, P = 0.018), and 89.8% in mitral regurgitation-free patients compared to 55.3% in those with recurrent mitral regurgitation (log-rank, P = 0.003). A durable mitral valve repair and preservation of sinus rhythm are the keys to preventing late TR progression.

Determinants of Late Tricuspid Regurgitation After Aortic-Mitral Double Valve Replacement

The aims of this study are to evaluate the long-term outcomes of double valve replacement (aortic and mitral valves) and to investigate the determinants of late tricuspid regurgitation (TR). A total of 239 consecutive patients who underwent double valve replacement were enrolled. Valve pathology was rheumatic in 86.6% (207/239) and degenerative in 13.4% (32/239) of patients. Among these patients, 116 patients underwent concomitant tricuspid annuloplasty, and follow-up was completed for all 239 patients (mean= 7.3 ± 4.1, maximum= 15.9years). We used propensity score matching to match 67 patients withouttricuspid annuloplasty to the 114 patients who underwent annuloplasty. There was 1 in-hospital death and 9.7% (23/238) of patients experienced late cardiac-related mortality. Analysis of aortic valves indicated that the transprosthetic mean pressure gradient increased with time (13.4 ± 5.2 vs 15.4 ± 9.0mm Hg, p= 0.002). Aortic transprosthetic mean pressure gradient increased more notably in woman and was associated with late TR(odds ratio 1.1, p= 0.010). In patients with mild TR, those who underwent tricuspid valve repair were less likely to experience a cardiac-related death within 10years of surgery(hazards ratio 6.1, p= 0.036).

Effect of Patient-Prosthesis Mismatch in Aortic Position on Late-Onset Tricuspid Regurgitation and Clinical Outcomes after Double Valve Replacement.

PurposeSignificant late-onset tricuspid regurgitation (TR) is unfortunately common after double valve replacement (DVR); however, its underlying factors remain undefined. We evaluated the effect of aortic patient-prosthesis mismatch (PPM) on late-onset TR and clinical outcomes after DVR.Materials and MethodsOf the 2392 consecutive patients who underwent aortic valve replacement between January 1990 and May 2014 at our institution, we retrospectively studied 462 patients who underwent DVR (excluding concomitant tricuspid valvular annuloplasty or replacement). Survival and freedom from grade >3 TR were compared between PPM (n=152) and non-PPM (n=310) groups using the Kaplan-Meier method.ResultsAlthough the overall survival rates were similar between the two groups at 5 and 10 years (95%, 91% vs. 96%, 93%, p=0.412), grade >3 TR-free survival was significantly lower in the PPM group (98%, 91% vs. 99%, 95%, p=0.014). Small body-surface area, atrial fibrillation, PPM, and subaortic pannus were risk factors for TR progression. However, aortic prosthesis size and trans-valvular pressure gradient were not significant factors for either TR progression or overall survival.ConclusionAortic PPM in DVR, regardless of mitral prosthesis size, was associated with late TR progression, but was not significantly correlated with overall survival. Therefore, we recommend careful echocardiographic follow-up for the early detection of TR progression in patients with aortic PPM in DVR.

Retrospective Study to Compare Ring Annuloplasty and Suture Annuloplasty in Tricuspid Valve Diseases

The Tricuspid regurgitation may be primary or secondary to left sided heart disease Residual tricuspid regurgitation is seen after tricuspid valve annuloplasty(TVA) - both ring and suture anuloplasty. A study was conducted in KEM Hospital as to validate the benefits of ring annuloplasty over suture anoloplasty. 80 patients undergoing MVR and TVA were studied. Of these 50 patients underwent MVR with ring annuloplasty and 30 underwent MVR with DeVegas annuloplasty. 2DECHO was done pre and postoperatively to determine pulmonary artery systolic pressure(PASP), grade of tricuspid regurgitation (TR), LV ejection fraction(LVEF) and tricuspid annulus. 82% of patients of ring annuloplasty group had reduction in PASP postoperatively compared to 56% in DeVegas annuloplasty . Grade of TR improved from moderately severe TR to mild TR in 86% in the ring annuloplasty group compared to53% in DeVegas annuloplasty group. 58% of patients of ring annuloplasty had maintained LV function postoperatively compared to 46% of patients in DeVegas annuloplasty.The mean tricuspid annulus showed reduction from preoperative annulus size of 37.72 to 27.5 in ring annuloplasty group and from 37.9to 27.13 in DeVegas annuloplasty group. Tricuspid ring annuloplasty is a better and durable repaire compared to suture annuloplasty for secondary TR. Aggressive management of secondary TR such as this could hopefully decreas the occurence of late TR following previous left sided valve surgery

Limited Utility of Tricuspid Valve Repair at the Time of Left Ventricular Assist Device Implantation

The optimal management of tricuspid regurgitation (TR) in patients undergoing left ventricular assist device (LVAD) implantation is controversial. This study was undertaken to determine the impact of tricuspid valve repair (TVR) at the time of LVAD implantation on survival. The Interagency Registry for Mechanically Assisted Circulatory Support was used to analyze the outcomes of patients undergoing LVAD implantation as destination therapy with or without concomitant TVR. Among 2,527 patients undergoing implant of a continuous flow LVAD as destination therapy during the study period, 989 (39%) had moderate or severe TR. The management of TR was not uniform among these patients. Patients with moderate and severe TR underwent TVR in 16.7% and 35.3% of cases, respectively. Moderate and severe TR at the time of LVAD implantation were associated with poorer survival over the entire follow-up period (p= 0.009). Interestingly, TVR at the time of LVAD implantation did not confer improved survival, even among patients with preimplant moderate or severe TR. A potential explanation for this finding is that patients with preimplant moderate or severe TR who underwent LVAD implant with concomitant TVR commonly experienced recurrent, late TR (21% to 27%). Tricuspid valve repair is performed commonly at the time of LVAD implant despite the fact that it does not confer a clear survival benefit. For many patients, LVAD implant alone relieves preimplant TR as effectively as LVAD implant with TVR. Further study is necessary to determine what factors lead to recurrence of late TR in LVAD patients both with and without TVR.

0552: Predictors of functional tricuspid regurgitation after successful left-sided valve surgery

Tricuspid regurgitation (TR) is probably the most common and anticipated complication of left-sided heart valve pathology, especially MV disease. Whether preoperative functional TR will regress or progress after successful left-sided valve surgery is unknown. The aim of this study was to identify the predictors of significant TR after successful left-sided valve surgery. A retrospective analysis was performed on a total of 56 patients who underwent left-sided valve surgery (mitral or mitro-aortic valve surgery). We have excluded patients who had organic TR. All patients had complete clinical examination and echocardiographic studies preoperatively and clinical and echocardiographic follow-up postoperatively. Mean operative age of patients was 49,3±13,7 years with a sex-ratio of 0,8. Tricuspid annuloplasty was associated to left-sided valve surgery in 18 (32%) patients. Postoperatively, significant TR was found in 13 patients (23%) with a mean follow-up of 20,5±33 months. Patients with significant postoperative TR were more often female (83% vs 48%, p=0,03), had more often a previous mitral commissurotomy (58% vs 23%, p=0,02) and showed a higher prevalence of significant preoperative TR (69% vs 42%, p=0,04). Postoperatively, residual pulmonary hypertension (p=0,04), dilatation of left atrium (p=0,02) and dilatation of right cardiac cavities (p=0,01) were significant risk factors for development or progression of TR after surgery. Late onset or progression of functional TR after successful left-sided valve surgery is a significant clinical entity as it displays a great impact on patient prognosis. So, the identification of clinical and echocardio-graphic predictors of late TR allows an adequate screening of patients that will require tricuspid valve repair at the time of initial left-sided valve surgery.

Clinical and hemodynamic influences of prophylactic tricuspid annuloplasty in mechanical mitral valve replacement

ObjectiveThe aim of this study was to evaluate the long-term clinical and hemodynamic influences of prophylactic tricuspid annuloplasty (TAP) in patients with less-than-moderate tricuspid regurgitation (TR) who underwent mitral valve replacement (MVR). MethodsBetween November 1994 and December 2010, 293 patients with less-than-moderate TR who underwent primary mechanical MVR were categorized into 2 groups: TAP (n = 151) or no TAP (n = 142). The median age was 51 years (quartile (Q)1-Q3, 43-59 years). The cause of valve pathology was rheumatic in 92.5% of patients (n = 271). The prevalence of preoperative atrial fibrillation was in 73.0%. Using propensity score matching based on demographic information, 91 TAP patients could be matched to 91 no TAP patients. Median follow-up duration was 107 months (Q1-Q3, 76-162 months). ResultsThere was no early mortality in either group. Early morbidities, including heart block were not different between groups. Although overall survival and freedom from cardiac-related mortality did not differ between groups (P = .519 and P = .115, respectively), freedom from recurrence of moderate or higher TR grade were significantly higher in the TAP group (P = .043). In subgroup analyses, these group differences of TAP were especially prominent in patients with sinus rhythm compared with patients with atrial fibrillation at discharge (P = .047 vs P = .460). ConclusionsProphylactic TAP for patients with less-than-moderate TR grade who underwent mechanical MVR can prevent late TR progression without increasing early surgical risks. Longer-term follow-up is required to determine the clinical beneficial effect of prophylactic TAP.

Impact of Concomitant Tricuspid Annuloplasty on Tricuspid Regurgitation, Right Ventricular Function, and Pulmonary Artery Hypertension After Repair of Mitral Valve Prolapse

BackgroundFor patients undergoing mitral valve (MV) repair, the indications for and results of concomitant tricuspid annuloplasty remain controversial. ObjectivesThis study was designed to compare a strategy of routine concomitant tricuspid annuloplasty for moderate tricuspid regurgitation (TR) or tricuspid annular dilation in patients undergoing degenerative MV surgery. MethodsOf 645 consecutive patients (mean age 57 ± 13 years) undergoing primary repair of degenerative mitral regurgitation between 2003 and 2011, 419 (65%) underwent concomitant tricuspid annuloplasty for moderate TR and/or tricuspid annular dilation. These patients were retrospectively analyzed with longitudinal echocardiographic follow-up. ResultsPatients undergoing tricuspid valve repair were older (mean age 59.2 years vs. 52.3 years), had worse right and left ventricular function and higher pulmonary artery pressures, and were more likely to have had atrial fibrillation than patients undergoing isolated MV repair (all p < 0.05). No significant difference in 30-day mortality, morbidity, or permanent pacemaker requirement was seen between treatment groups. Freedom from moderate TR at 7 years was not significantly different in the 2 groups, but multivariate analysis showed that tricuspid annuloplasty was independently associated with freedom from late moderate TR (p = 0.04), and was an independent predictor of recovery of right ventricular function (p = 0.02). ConclusionsIn patients with moderate TR or tricuspid annular dilation who were undergoing degenerative mitral repair, concomitant tricuspid annuloplasty is safe, effective, and associated with improved long-term right-sided remodeling. Routine treatment of moderate TR or tricuspid annular dilation at the time of MV repair appears to be beneficial.

0398: Predictors of functional tricuspid regurgitation after successful left-sided valve surgery

Functional tricuspid regurgitation (TR) is probably the most common and anticipated complication of left-sided heart valve pathology, especially mitral valve diseases. Whether preoperative functional TR will regress or progress after successful left-sided valve surgery is unknown. The aim of this study was to identify the predictors of significant TR after successful left-sided valve surgery. A retrospective analysis was performed on a total of 56 patients who underwent left-sided valve surgery (mitral or mitro-aortic valve surgery). We have excluded patients who had organic TR. All patients had complete clinical examination and echocardiographic studies preoperatively and clinical and echocardiographic follow-up postoperatively. Mean operative age of patients was 49,3±13,7 years with a sex-ratio of 0,8. Tricuspid annuloplasty was associated to left-sided valve surgery in 18 (32%) patients. Postoperatively, significant TR was found in 13 patients (23%) with a mean follow-up of 20,5±33 months. Patients with significant postoperative TR were more often female (83% vs 48%, p = 0,03), had more often a previous mitral commissurotomy (58% vs 23%, p=0,02) and showed a higher prevalence of significant preoperative TR (69% vs 42%, p=0,04). Postoperatively, residual pulmonary hypertension (p=0,04), dilatation of left atrium (p=0,02) and dilatation of right cardiac cavities (p=0,01) were significant risk factors for development or progression of TR after surgery. Late onset or progression of functional TR after successful left-sided valve surgery is a significant clinical entity as it displays a great impact on patient prognosis. So, the identification of clinical and echocardiographic predictors of late TR allows an adequate screening of patients that will require tricuspid valve repair at the time of initial left-sided valve surgery.

Predictors of Late Improvement of Significant Remnant Tricuspid Regurgitation Detected Early After Tricuspid Annuloplasty

BackgroundIn some patients with severe tricuspid regurgitation (TR) who undergo tricuspid annuloplasty (TAP), significant remnant TR is detected early after TAP but diminishes after long-term follow-up. We sought to investigate the outcome of significant residual TR early after TAP and the predictors for late improvement of TR. MethodsA total of 58 consecutive patients presenting with moderate to severe TR early (5.7 ± 2.0 days) after TAP and before discharge were enrolled in this study. Echocardiography was repeated for 32.3 ± 28.6 months after TAP, and improvements in TR were defined as mild or less TR. Clinical data and echocardiographic studies were retrospectively analyzed. ResultsTwenty-nine (50%) patients showed late improvement in TR during follow-up. Multivariate Cox regression analysis revealed that tricuspid valve (TV) tenting height measured early after TAP (P = 0.020) and execution of the Maze procedure with TAP (P = 0.049) were independent predictors for late improvement of significant early remnant TR. The rates of late TR improvement were higher in patients with an early postoperative TV tenting height ≥ 9.1 mm (P = 0.026) and in patients who underwent a Maze procedure (P = 0.033) than in other groups of patients. ConclusionsHalf of patients with significant remnant TR early after TAP show late improvement in TR. Evaluation of a combined Maze procedure and TV tenting height early after TAP will help identify patients for whom repeated TV surgery may be deferred.

Preoperative Risk Factors for Residual Tricuspid Regurgitation after Isolated Left-Sided Valve Surgery: A Systematic Review and Meta-Analysis

Objectives: Residual tricuspid regurgitation (TR) that has developed after isolated left-sided valve surgery is not uncommon. Indications for concomitant tricuspid repair at the initial operation have not been well established. The selection of high-risk preoperative patients is of great importance in this situation. Methods: Six databases were searched to access eligible articles reporting potential risk factors for the development of residual TR. The pooled analysis of risk factors was based on odds ratios or mean differences with their 95% confidence intervals. Results: A total of 3,138 patients with 487 residual TR in 11 studies were analyzed. Of the 14 candidate parameters in our meta-analysis, 10 factors, i.e. older age, female gender, atrial fibrillation, rheumatic etiology, mitral valve surgery, previous valve surgery, a long time from onset to surgery, 2+/3+ TR and enlarged left and right atria, were found to be significantly associated with the development of residual TR. Conclusions: Our study highlights the role of the above preoperative risk factors in the development of residual TR after isolated left-sided valve surgery and emphasizes the need of further studies to investigate other potential predictors. Moreover, predictive models or scoring systems for the identification of patients at a high risk for developing late TR are urgently needed.

Natural history of coexistent tricuspid regurgitation in patients with degenerative mitral valve disease: Implications for future guidelines

The management of coexistent tricuspid regurgitation in patients with mitral regurgitation remains controversial. We sought to define the incidence and natural history of coexistent tricuspid regurgitation in patients undergoing isolated mitral surgery for degenerative mitral regurgitation, as well as the effect of late secondary tricuspid regurgitation on cardiovascular symptom burden and survival. To minimize confounding, analysis was limited to 495 consecutive patients who underwent isolated mitral surgery for degenerative mitral valve disease between 2002 and 2011. Patients with coexistent severe tricuspid regurgitation were excluded because such patients typically undergo concomitant tricuspid intervention. Grade 1 to 3 coexistent tricuspid regurgitation was present in 215 patients (43%) preoperatively. Actuarial freedom from grade 3 to 4 tricuspid regurgitation 1, 5, and 9 years after surgery was 100% ± 0%, 90% ± 2%, and 64% ± 7%, respectively. Older age (P < .001) and grade of preoperative tricuspid regurgitation (P = .006) independently predicted postoperative progression of tricuspid regurgitation on multivariable analysis. However, when limited to patients with mild or absent tricuspid regurgitation, indexed tricuspid annular diameter was the only significant risk factor for late tricuspid regurgitation (P = .04). New York Heart Association functional class and long-term survival did not worsen with development of late secondary tricuspid regurgitation (P = .4 and P = .6, respectively). However, right ventricular dysfunction was significantly more common in patients with more severe late tricuspid regurgitation (P = .007). Despite durable correction of degenerative mitral regurgitation, less than severe tricuspid regurgitation is likely to progress after surgery if uncorrected. Given the low incremental risk of tricuspid annuloplasty, a more aggressive strategy of concomitant tricuspid repair may be warranted.

Influence of mitral valve repair versus replacement on the development of late functional tricuspid regurgitation

To study the determinants of functional tricuspid regurgitation (TR) progression after surgical correction of mitral regurgitation, including the influence of mitral valve (MV) repair (MVr) versus replacement (MVR) for degenerative mitral regurgitation. From January 1995 to January 2006, 747 adults with MV prolapse underwent isolated MVr (n=683) or MVR (n=64; mechanical in 32). The mean age was 60.8 years, and 491 were men (66.0%). Moderate preoperative functional TR was present in 115 (15.4%). The MVR group had a greater likelihood of New York Heart Association class III or IV (75.0% vs 34.4%, P<.001), atrial fibrillation (20.3% vs 8.3%, P=.002), a lower left ventricular ejection fraction (61.0% vs 65.2%, P<.003), and a higher pulmonary artery pressure (50.1 vs 41.2 mm Hg, P=.001). The patients were monitored for a mean of 6.9 years (MVr) or 7.7 years (MVR; P=.075). During late follow-up, no difference was found between the groups in the development of moderately severe or severe TR: 1 to 5 years (3.0% vs 3.3%, P=.91) and >5 years (6.1% vs 6.5%; P=.93). The univariate predictors of severe TR after 5 years were older age (hazard ratio [HR], 1.1; P=.011), female gender (HR, 6.86; P=.005), higher pulmonary artery pressure (HR, 1.05; P=.022), and larger left atrial size (HR, 2.11; P=.035). Two patients (0.26%) who had undergone initial MVr required reoperation for late functional TR. Another 2 patients had had the tricuspid valve addressed concurrent with reoperation for MVr failure. No tricuspid reoperations were required in the MVR group. The risk of TR progression was low after MVr or MVR for MV prolapse. Timely MV surgery before the development of left atrial dilatation or pulmonary hypertension could further decrease the risk of TR progression during follow-up.

Effects of tricuspid valve surgery on tricuspid regurgitation in patients with hypoplastic left heart syndrome: a non-randomized series comparing surgical and non-surgical cases

Tricuspid regurgitation (TR) remains a significant risk factor affecting the survival of patients with hypoplastic left heart syndrome (HLHS). We performed this study to investigate differences in the clinical course based on the timing of the development of TR and the effects of tricuspid valve surgery (TVS). One hundred and five patients of classic HLHS underwent staged operations from May 1991 to July 2010. Forty-four patients (41.9%) exhibited moderate or greater TR during the follow-up. We defined the early TR group (30 patients, around the first palliative surgery) and the late TR group (14 patients, the later period) based on the timing of the appearance of moderate or greater TR. We performed TVS when moderate or greater TR was detected in 28 patients. The follow-up period was 5.5 ± 5.1 (plus/minus values are means ± SD) years (range: 0.01-14.6 years) after the first palliative surgery and 4.9 ± 4.4 years (range: 0.01-13.3 years) after TVS. The early TR group exhibited poorer survival than the late TR group (42.9 vs 92.9% at 5 years, P = 0.003). However, in the early TR group, the TVS significantly improved survival compared with that observed in the non-TVS cases (52.1 vs 23.3% at 5 years, P = 0.046). The right ventricular ejection fraction (RVEF) significantly decreased (62.7 ± 11.4 → 57.2 ± 12.6% (plus/minus values are means ± SD), P = 0.040) and the right ventricular end-diastolic diameter (RVDd) became significantly enlarged (27.7 ± 7.6 → 36.7 ± 3.4 mm, P < 0.001) in association with deterioration of the TR degree. TVS significantly improved the degree of TR (2.5 ± 0.5 → 1.5 ± 0.9°, P < 0.001) and RVDd (37.7 ± 7.4 → 30.4 ± 5.0 mm, P = 0.007); however, the RVEF was not improved 1 month after surgery (54.4 ± 12.1 → 54.3 ± 12.4%, P = 0.931) or at the latest follow-up (53.7 ± 14.9%, P = 0.836). The survival of HLHS patients who develop moderate or greater TR around the time of the first palliative surgery is worse than that of HLHS patients who develop moderate or greater TR at a later time. In this study, TVS for early TR improved survival and decreased right ventricular dimensions during the 4.9-year follow-up period.