Outcome of consistent guideline-based tricuspid management in patients undergoing degenerative mitral regurgitation correction

Abstract

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.

Commentary: Should prophylactic tricuspid annuloplasty be routinely performed? If so, how? The jury is still out

“…In the authors’ study population, 39% of the TA group had preoperative atrial fibrillation (AF) compared with 23% in the no-TA group. 2 Preoperative AF was associated with TR progression in the group with no TA, although 10% of the patients in the no-TA group underwent surgical ablation versus 23% in the TA group. Kim and colleagues 7 found that the omission of AF ablation was associated with deterioration of TR in patients with preoperative mild TR following tricuspid repair during rheumatic mitral surgery.…”

“…Perhaps the most important finding from the article by Dreyfus and colleagues 2 is the reaffirmation of the inadequacy of our understanding of the complex topic of FTR. Dreyfus acknowledged that there is uncertainty about the factors that contribute to annular dilatation in patients with FTR, and clearly factors other than the severity of TR and the annular size influence TR progression and clinical outcomes.…”

“…Dreyfus and colleagues 2 summarize data from 441 patients undergoing mitral valve repair for degenerative mitral regurgitation with stringent adherence to guideline-directed FTR management. Patients with a tricuspid annular diameter ≥40 mm (n = 234), regardless of the severity of TR (71% with no or mild TR, 27% with moderate TR, and 2% with severe TR), underwent TA.…”

“…Finally, the selection of a tricuspid annuloplasty ring and its appropriate size may also be a critical factor affecting long-term clinical outcomes. 8 In the study presented by Dreyfus and colleagues, 2 a Carpentier-Edwards classic tricuspid ring with a mean size of 32 mm was used. However, a recent US trial recommended using an undersized (ie, 26 mm or 28 mm) rigid nonplanar annuloplasty ring.…”

Tricuspid surgery at the time of LVAD implant: A critique

“…Annular pathology seems such a correctable target for surgical intervention, particularly given the association between tricuspid annular diameter (>40 mm) and late right heart failure ( 21 ). However, recent studies of patients undergoing guideline—directed repair of functional TR (annular diameter > 40 mm independent of TR severity) at the time of mitral surgery demonstrate no differences in survival and the incidence of “late TR” is low in patients with unrepaired mild TR ( 22 ). While Gammie et al ( 23 ) recently demonstrated a lower incidence of progression to TR in patients who underwent tricuspid annuloplasty at the time of mitral valve repair, preliminary data do not address the role of recurrent mitral regurgitation on the subsequent evolution of tricuspid insufficiency.…”