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Interact CardioVasc Thorac Surg 2009;9:1009-1020. doi:10.1510/icvts.2009.217570 © 2009 European Association of Cardio-Thoracic Surgery
Which patient undergoing mitral valve surgery should also have the tricuspid repair?Department of Adult Cardiac Surgery, Heart Hospital ‘G. Monasterio’ Foundation, Massa, Italy Received 29 July 2009; received in revised form 20 August 2009; accepted 9 September 2009
*Corresponding author. Mobile: +393404680379; +14438138914.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘Which patient undergoing mitral valve surgery should also have the tricuspid repair?’ Altogether 390 papers were found using the reported search, of which 17 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. While a general agreement exists for tricuspid valve (TV) repair in cases of severe regurgitation and concomitant multivalvular disease requiring surgical intervention, current guidelines provide more vague indications for patients with less severe tricuspid regurgitation (TR). Since this condition has a lower event-free survival rate and the prognosis after symptoms development is dismal, a lower threshold and a more aggressive strategy for intervention is needed. In rheumatic valve disease, mitral valve involvement and disease spreading to TV may be responsible for further regurgitation. Although patients with pulmonary hypertension (PH) may benefit from mitral valve replacement (MVR) or balloon valvotomy, many studies found that preoperative PH does not predict late TR. However, patients with high pulmonary pressure have a lower occurrence of late TR. Tricuspid annular dilation is probably the most important factor for late TR. Once established, it might be irreversible even after resolution of PH as well as absence of ‘reverse remodelling’. It has been proposed to treat TR independently from the grade of regurgitation when the annular dimension is over 21 mm/m2 or  3.5 cm at echo measurement or when the intra-operative tricuspid annulus (TA) diameter is >70 mm. TV repair should be accomplished in patients with preoperative atrial fibrillation (AF), since it may cause late significant TR development and affect the patient's long-term survival. The presence of a trans-tricuspid pacemaker lead is another known factor for late TR development secondary to adhesions and fibrous retraction. TV repair is probably better than replacement in non-severe organic TV disease. Annuloplasty ring repair has better outcome compared with non-ring based repair techniques; the beneficial effect is also independent of the type of mitral valve surgery performed.
Key Words: Left-sided valve surgery; Tricuspid valve repair; Outcome
A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
In [patients undergoing mitral valve surgery with moderate tricuspid regurgitation] is [Tricuspid repair] superior to [mitral surgery alone] to prevent [late tricuspid valve regurgitation]?
A 65-year-old woman with severe mitral valve regurgitation and atrial fibrillation (AF) is scheduled for intervention; tricuspid annulus is 40 mm with mild tricuspid regurgitation (TR) and right ventricular (RV) dilation but no increase in pulmonary artery systolic pressure (PASP). Should tricuspid valve (TV) be repaired and what further operative risk and impacts will this have on your patient's early and late outcomes?
Medline 1950 to August week 1 2009 using OVID interface: [tricuspid regurgitation.mp. OR exp Tricuspid Valve Insufficiency/] AND [mitral regurgitation.mp. OR exp Mitral Valve Insufficiency/] AND [mitral valve repair.mp. OR mitral valve replacement.mp. OR tricuspid valve repair.mp OR tricuspid valve replacement.mp. OR exp Thoracic Surgery/OR valve surgery.mp. OR exp Heart Valve Prosthesis/]
Three hundred and ninety papers were found using the reported search. From these, seventeen papers were identified that provided the best evidence to answer the question. These are presented in Table 1.
In 1999, Turina et al. [2] reported that significant tricuspid regurgitation (TR) requiring TV surgery predicts poor survival in patients undergoing valve surgery. Nath et al. [3] found that the survival rate at one year changes significantly in moderate and severe TR groups. Moderate and severe TR increases the mortality regardless of PASP degree and ejection fraction. Porter et al. [4] outlined that among patients who underwent mitral valve replacement (MVR) without TV surgery, 44 (67%) developed late TR (moderate to severe in 34 patients, 77.4%). Matsuyama et al. [5] analyzed the outcome of 174 patients that did not receive TV surgery at the time of intervention. Despite a low percentage in the early postoperative period, 28 patients (16%) developed a TR grade of 3+ or more and, out of those with preoperative TR 2+/4+, a progression was observed in 17 patients (37%). Early postoperative TR grade is unreliable for estimation of TR progression. In their series of 124 patients with functional mitral regurgitation (fMR) who underwent CABG and mitral valve repair (MVRep), Matsunaga et al. [6] found no difference in early postoperative TR among corrected-TR and uncorrected-TR groups, but at the last follow-up, 34 patients (49%) had significant TR. The incidence of TR increased from 25% at <1 year to 53% between 1 and 3 years and 74% at >3 years. In the analysis of Calafiore et al. [7], fTR progression is not related to MVR progression and untreated moderate or more functional TR can impair both mid-term survival and functional status, as outlined by the study of Boyaci et al. [8]. Recently, Song et al. [9] found that TV annulus size tends to increase over time in either corrected or uncorrected TR. Rheumatic aetiology of mitral valve (MV) disease is also associated with development of significant late TR (15% vs. 5%, P=0.017).
In the series of Colombo et al. [10], 50 patients undergoing mitral valve surgery had their TV corrected if the indexed tricuspid annulus dimension was
In 2005, Dreyfus et al. [11] reported a series of 148 patients where an intra-operative TV annular diameter [tricuspid annulus (TA)] In 2004, McCarthy et al. [12] analyzed 790 patients who had TV repair using two ‘ring’ (Carpentier–Edwards, Edwards flexible band) or two ‘non-ring’ techniques (De Vega–Peri-Guard). Freedom from re-operation was 97% at follow-up. TR severity was stable across time with Carpentier–Edwards ring (P=0.7), increased slowly with Cosgrove–Edwards band (P=0.05), but rose more rapidly with the De Vega (P=0.002) and Peri-Guard (P=0.0009) approach. The ‘non-ring’ annuloplasties showed to be ineffective in preventing late TR development. Presence of pacemaker (PMK) leads were also identified as a risk factor (42% at 5 years). Significant improvement with ‘ring’ annuloplasty over the De Vega technique in terms of long-term survival, event-free survival and recurrence of TR has been confirmed by Tang et al. [13]; furthermore, the beneficial effects are independent of the type of the MV surgery performed. Kim et al. [14] outlined that when AF persists after surgery for left-sided valve or when the left atrium mechanical activity is not restored, progression to high grade TR occurs. A recent paper from Kwak et al. [15] reported that 90 patients (26.9%) of 335 with no preoperative TR, undergoing left-sided valve surgery, developed de novo significant TR. Preoperative AF was found to independently contribute to late TR. In the setting of end-stage heart disease, the group of Jonjev et al. [16] outlined that reductive annuloplasty of mitral and TV is an effective procedure with early and long-term beneficial effects on survival, freedom from hospitalization and improvement of functional class. Of 91 patients with dilatative cardiomyopathy submitted to MV repair, De Bonis et al. [17] found that, among those who did not have TR repair, TR worsening of at least 2 grades occurred. Right ventricle dilatation, preoperative RV dysfunction and TR grade at discharge were strong predictors of late significant TR development. Pulmonary hypertension (PH) was also associated with significant TR (grade 3+or more) at follow-up. The absence of ‘reverse remodelling’ occurred in a significant percentage of patients with late TR (10 patients; 23.8% P=0.04).
TV insufficiency should be treated during left-sided valve surgery when TR annulus is dilated ( 21 mm/m2; >70 mm intra-operatively; 3.5 cm at trans-thoracic echocardiography (TTE) [18]) regardless of the absolute grade of regurgitation, in cases of preoperative AF, trans-tricuspid PMK lead and underlying rheumatic disease. Also, ‘ring’ annuloplasty techniques should be preferred over the ‘non-ring’ techniques.
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Abstract
1. Introduction
S, Radovanovi
