The assessment of the etiology and severity of functional tricuspid regurgitation (FTR) has many limitations, especially when tricuspid regurgitation (TR) is more than severe. Instead of relying solely on TR severity, a new approach not only takes into account the severity of TR, but also pays strict attention to tricuspid annular dilation (size), the mode of tricuspid leaflet coaptation, and tricuspid leaflet tethering-factors often influenced by right ventricular enlargement and dysfunction. To simplify things, we propose a new staging system for functional tricuspid valve pathology using 3 parameters that may more accurately reflect the severity of the disease: TR severity, annular dilation, and mode of leaflet coaptation (extent of tethering). We believe that by utilizing these parameters, cardiologists and cardiac surgeons will be offered a better system for appraisal and decision-making in FTR.

Objective: Avoiding resection to treat posterior leaflet prolapse has become popular to repair degenerative mitral regurgitation. We never subscribed to such simplification but advocated an alternative approach based on the ''respect when you can, resect when you should'' concept. The present study reviewed posterior leaflet prolapse in degenerative disease with the aim to expose the 10-year experience with this surgical policy, in particular long-term outcomes such as survival, recurrent/severe mitral regurgitation, and reoperation. Methods: From January 2005 to December 2015, 701 consecutive patients with severe mitral regurgitation underwent mitral valve repair in 2 distinct institutions. Mitral regurgitation was degenerative in 441 patients, of whom the 376 with posterior leaflet prolapse constituted the study population. Patients were followed up by echocardiograms until December 2017. Longitudinal data stratified by institution were analyzed by mixed-effects models. Outcome measures were analyzed by Kaplan-Meier test. Results: Patients with posterior leaflet prolapse (24.7% isolated P2 and 75.3% P2 associated with other segments) were aged 65.8 AE 13 years, and 70.5% were male. Median follow-up was 61.1 months. There were 3 hospital deaths (0.8%). Reoperation was necessary in 7 patients (1.9%). After 1, 5, and 10 years, overall survival was 97.8%, 93.6%, and 86.7%, respectively; the overall survival of the proportion of patients with recurrent/residual>2þ mitral regurgitation was estimated at 0.7%, 1.9%, and 5.9% and that of patients with New York Heart Association III/IV at 0.8%, 1.9%, and 5.3%. Conclusions: The ''resect with respect'' approach yields low operative mortality, no systolic anterior motion, good surface of coaptation, and low incidence of residual/recurrent mitral regurgitation and of reoperation, thus supporting resection when required concept.

Our good mid-term results support the concept that HOCM is not only a septal disease and that the mitral valve pathology is a key component that should be addressed. For most patients, the ideal surgical treatment should consist in a two-step procedure. It is even necessary to be studied whether treating the mitral valve alone could not suffice.

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Objectives: Despite coherent guidelines, management of functional tricuspid regurgitation (FTR) consequences on outcome in the context of degenerative mitral regurgitation (DMR) remains controversial due to lacking series of large magnitude with rigorous application of tricuspid guidelines and strict long-term echocardiographic follow-up. Thus, we aimed at gathering such a cohort to examine outcomes of patients undergoing DMR surgery following tricuspid surgery guidelines.Methods: All consecutive patients with isolated DMR 2005-2015 operated on with baseline FTR assessment and tricuspid annulus diameter measurement were identified. Operative complications, postoperative tricuspid regurgitation incidence, and survival were assessed overall and stratified by guideline-based tricuspid annuloplasty (TA) indication (severe FTR or tricuspid annulus diameter !40 mm).Results: Among 441 patients with DMR undergoing mitral repair (66 AE 13 years, 30% female, ejection fraction 66 AE 10%, systolic pulmonary artery pressures 39 AE 12 mm Hg) followed 6 [3-9] years, patients with TA (n ¼ 234, 53%) had generally similar presentation versus without TA (n ¼ 207, 47%; all P ! .2) except for more atrial fibrillation and larger left ventricle (both P ! .0003). Patients with TA showed longer bypass time, more maze procedures (all P .001), but hospital stay, renal-failure, pacemaker implantation, and operative mortality (overall 0.9%) were comparable (all P ! .2). Postoperative incidence of moderate/severe FTR (0% at 1 year) became over time greater among patients without TA (5year 8% [4%-13%] vs 3% [1%-11%] and 10-year 10% [6%-16%] vs 4% [1%-16%], P ¼ .01). Survival (95% confidence interval) throughout follow-up was 85% (77%-89%) at 10 years, with hazard ratio 0.57 (0.29-1.10), P ¼ .09. for patients with TA versus without. Conclusions:In this large surgical DMR cohort, guideline-based FTR management was safe and effective. While long-term mortality did not reach significance, postoperative incidence of moderate/severe FTR, overall low, was nevertheless greater in patients who did not appear to require TA at surgery and linked to tricuspid annular dimension. Thus, future multicenter prospective cohorts with long-term follow-up are warranted to re-examine thresholds for TA performance and impact on survival.