Long-term echocardiographic follow-up of untreated 2+ functional tricuspid regurgitation in patients undergoing mitral valve surgery†

Interactive CardioVascular and Thoracic Surgery, Jun 2016

OBJECTIVES Concomitant tricuspid valve surgery with mitral valve surgery is recommended for patients with severe functional tricuspid regurgitation (TR). However, the treatment for 2+ TR (mild TR) remains controversial. Here, we evaluated the long-term results of untreated 2+ TR in patients undergoing mitral valve surgery.

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Long-term echocardiographic follow-up of untreated 2+ functional tricuspid regurgitation in patients undergoing mitral valve surgery†

Interactive CardioVascular and Thoracic Surgery Long-term echocardiographic follow-up of untreated 2+ functional † tricuspid regurgitation in patients undergoing mitral valve surgery Kunio Kusajima 1 2 Tomoyuki Fujita 1 2 Hiroki Hata 1 2 Yusuke Shimahara 1 2 Sayaka Miura 1 2 Junjiro Kobayashi 1 2 0 Presented at the 29th Annual Meeting of the European Association for Cardio-Thoracic Surgery , Amsterdam, Netherlands, 3-7 October 2015 1 Department of Cardiac Surgery, National Cerebral and Cardiovascular Center , Suita , Japan 2 Authors: Mustafa Aparci, Zafer Isilak and Omer Uz Department of Cardiology, GATA Haydarpasa Training and Research Hospital , Istanbul , Turkey doi : 10.1093/icvts/ivw118 © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved OBJECTIVES: Concomitant tricuspid valve surgery with mitral valve surgery is recommended for patients with severe functional tricuspid regurgitation (TR). However, the treatment for 2+ TR (mild TR) remains controversial. Here, we evaluated the long-term results of untreated 2+ TR in patients undergoing mitral valve surgery. METHODS: We retrospectively reviewed the records of 96 patients with untreated 2+ TR among 885 patients who underwent mitral valve surgery from 2003 to 2010. Exclusion criteria were tricuspid valve surgery (TVS), emergency surgery, primary TR and pacemaker lead through the tricuspid valve. We assessed survival and freedom from heart failure. The freedom from 3+ (moderate) or 4+ (severe) TR was investigated by echocardiographic data at pre- and postoperative week 1, then at 1, 3, 5, 7 and 10 postoperative years, which were compared with those in patients who had 2+ TR preoperatively and underwent concomitant TVS in the same period (n = 47). RESULTS: The mean follow-up was 7.1 ± 2.7 years. There was no 30-day mortality. The survival rate was 97.5% at 5 years and 87.5% at 10 years. The independent risk factors for mortality were age (OR 1.2, P = 0.03) and left ventricular ejection fraction (OR 0.9, P = 0.03). Untreated 2+ TR improved transiently within the first postoperative year (P < 0.001), but progressed again in the mid- to long term. Freedom from ≥3+ TR was 64.2% at 5 years and 46.7% at 10 years, which was significantly lower than that from ≥3+ TR in patients who underwent concomitant TVS (P = 0.006). The independent risk factors for TR progression (≥3 + TR) were age (OR 1.1, P = 0.005), atrial fibrillation (OR 2.2, P = 0.04) and tricuspid annular diameter (TAD) index (mm/m2; OR 1.1, P = 0.02). Receiver operating characteristic curves showed that the optimal TAD index cut-off value was 21.0 for long-term survival [area under the curve (AUC) = 0.72] and 21.2 for TR progression (AUC = 0.64). CONCLUSIONS: Although untreated, 2+ TR significantly improved after mitral valve surgery, it then progressed again in the mid- to long term. Therefore, concomitant TVS should be considered in patients with 2+ TR who have dilated tricuspid annulus or atrial fibrillation, if feasible. Tricuspid regurgitation; Mitral valve surgery; Long term; Tricuspid annular diameter; Atrial fibrillation INTRODUCTION Functional tricuspid regurgitation (TR) is frequently present in patients with degenerative mitral valve disease [ 1 ]. TR is mainly caused by dilatation of the tricuspid annulus and tethering of the tricuspid valve leaflets secondary to right ventricular dysfunction due to chronic pressure and volume overload [ 2, 3 ]. Historically, TR secondary to mitral valve disease was thought to improve after mitral valve surgery [ 4, 5 ], which has led to a conservative non-surgical approach to TR. However, recent studies have not supported this concept [ 6–11 ]. Indeed, right ventricular dilatation causes deformity of the tricuspid annulus shape and displacement of the papillary muscles, which contributes to reduction of the tricuspid valve leaflet coaptation and resulting residual regurgitation [ 3, 12 ]. Therefore, mitral valve surgery alone in a subset of patients cannot be expected to result in effective TR control. Survival is worse for patients with moderate and severe TR than for those without TR [ 13 ]. The 2014 American Heart Association/ American College of Cardiology (AHA/ACC) guidelines for valvular heart disease recommend tricuspid valve surgery (TVS) for patients with severe TR undergoing left-sided valve surgery (Class 1), and suggest that TVS can be beneficial for patients with mild, moderate or greater TR with either tricuspid annular dilatation or prior evidence of right heart failure (Class 2a) [ 14 ]. However, there are a few studies showing the long-term outcomes and prognosis of TR in patients with mild TR (2+ TR). General agreement regarding appropriate patient selection and optimal index of surgical treatment is clinically important. Thus, the aim of the present study was to evaluate the long-term results of untreated 2+ TR patients undergoi (...truncated)


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Kunio Kusajima, Tomoyuki Fujita, Hiroki Hata, Yusuke Shimahara, Sayaka Miura, Junjiro Kobayashi. Long-term echocardiographic follow-up of untreated 2+ functional tricuspid regurgitation in patients undergoing mitral valve surgery†, Interactive CardioVascular and Thoracic Surgery, 2016, pp. 96-103, 23/1, DOI: 10.1093/icvts/ivw065