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Giacomo Bianchi, Marco Solinas, Stefano Bevilacqua, Mattia Glauber, Which patient undergoing mitral valve surgery should also have the tricuspid repair?, Interactive CardioVascular and Thoracic Surgery, Volume 9, Issue 6, December 2009, Pages 1009–1020, https://doi.org/10.1510/icvts.2009.217570
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Summary
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.
1. Introduction
A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
2. Three-part question
In [patients undergoing mitral valve surgery with moderate tricuspid regurgitation] is [Tricuspid repair] superior to [mitral surgery alone] to prevent [late tricuspid valve regurgitation]?
3. Clinical scenario
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?
4. Search strategy
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/]
5. Search outcome
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 .
| Author, date | Patient group | Outcomes | Key results | Comments |
| and country, | ||||
| Study type | ||||
| (level of evidence) | ||||
| Bonow et al., | Class I | Severe TR in the setting of | ||
| ACC/AHA VHD | surgery for multivalvular | |||
| Guidelines: (2008), | disease should be | |||
| focused update | corrected | |||
| (level of evidence: c) | Class II | Tricuspid annuloplasty is | ||
| reasonable for mild TR in | ||||
| patients undergoing MV surgery | ||||
| when there is pulmonary | ||||
| hypertension or tricuspid | ||||
| annular dilatation | ||||
| Vahanian et al., | Class IIa | Concomitant TV repair if | ||
| (2007), Eur | TA diameter >40 mm | |||
| Heart J, ESC | ||||
| guidelines | TV repair in patients with | |||
| symptomatic, isolated TR late | ||||
| after left-sided valve surgery, | ||||
| in absence of left-sided | ||||
| myocardial or RV dysfunction | ||||
| and without severe pulmonary | ||||
| hypertension | ||||
| Turina et al., | 170 patients | Follow-up | Mean 10.6 years (1802 | Retrospective study |
| (1999), | (between 1975 | patient-years) | ||
| Circulation, | and 1989) who | Significant TV regurgitation requiring | ||
| Switzerland, [2] | underwent surgery | Surgical procedures | Double valve surgery 170 | surgical repair worsened the prognosis |
| for chronic | patients | |||
| Retrospective | combined aortic | Advice for TV repair when hemodynamic | ||
| study (level IIb) | and mitral valvular | TV surgery 29 patients (17%) | significant regurgitation is present | |
| disease | ||||
| CABG 7 patients (4%) | ||||
| Ascending aorta surgery 7 | ||||
| patients (4%) | ||||
| Reoperation involving | Tricuspid replacement 2 | |||
| TV | patients | |||
| Tricuspid reconstruction | ||||
| 2 patients | ||||
| Survival rate in | At 10 years (cumulative survival) | |||
| patients with TR | ||||
| With TV reconstruction 57% | ||||
| Without TV reconstruction 68% | ||||
| Predictors of late | Age (P=0.0011) LVEF | |||
| outcome | (P=0.0008) Additional TV | |||
| regurgitation | ||||
| (P=0.007) | ||||
| Nath et al., | 5223 patients | One-year survival | 91.7% with no TR, | Retrospective study |
| (2004), J Am Coll | undergoing | 90.3% with mild TR, | ||
| Cardiol, USA, [3] | echocardiography; | 78.9% with moderate TR, | Huge cohort of patients | |
| four years follow- | 63.9% with severe TR | |||
| Retrospective | up; comparison | Long follow-up | ||
| study (level IIb) | survival differences | TR grade, pulmonary | Moderate or greater TR | |
| among TR grades | artery pressure and | increased mortality regardless | Unknown NYHA class at follow-up | |
| mortality | of PASP HR 1.31 for PASP | |||
| >40 mmHg; HR 1.32 PA | No data correlation with MR grade and TR | |||
| <40 mmHg | ||||
| TR grade, LVEF and | Moderate or greater TR | |||
| mortality | increased mortality | |||
| regardless of EF | ||||
| HR 1.49 EF<50% | ||||
| HR 1.54 EF>50% | ||||
| Porter et al., | 65 patients with | Follow-up duration | 11.3±8 years (range | Retrospective study |
| (1999), J Heart | rheumatic heart | 1–30 years) | ||
| Valve Dis, | disease who had | No data about preoperative TR | ||
| Israel, [4] | undergone MVR | Left-sided valve | MV stenosis 44 patients (67%) | |
| without TV | pathology and surgical | MV regurgitation 21 patients | No data on preoperative RV status | |
| Retrospective | surgery | intervention | (33%) | |
| study case series | Outlines the late development rate of TR | |||
| (level IIIb) | Mitral valve replacement in all | when uncorrected at the time of left-sided | ||
| cases | valve surgery | |||
| Outcomes | 44 patients (67%) developed | |||
| late TR | ||||
| Moderate 16 patients (36.4%) | ||||
| Severe 18 patients (41%) | ||||
| Risk factors | Age RR 1.1 female gender 1.8 | |||
| Matsuyama et al., | Between March | Mean follow-up | 8.2±3.6 years (range 1.0–14.5 | Retrospective study |
| (2003), Ann Thor | 1988 and | years) | ||
| Surg, Japan, [5] | September 2001 of | Long overall follow-up but high variability | ||
| 174 of 274 patients | Late deaths | 14 late deaths (8%) | of time (may underestimate late TR | |
| Retrospective | undergoing MV | development in some early patients) | ||
| study (level IIb) | surgery did not | Early postoperative | TR (3+/4+ or more) in 4 | |
| receive concomitant | outcome | patients (2%) | Mitral valve repair as left-side valve | |
| TV surgery | surgery in 53% of patients | |||
| Follow-up of TR grade | 28 patients developed TR grade | |||
| 3+ or more (16%) 46 patients | Progression of TR over time | |||
| with preopearative TR 2+/4+, | ||||
| TR had progression in | Early postoperative TR grade is unreliable | |||
| 17 patients (37%) | for estimation of late TR progression | |||
| Risk factors for | Preoperative 2+ TR: OR 3.9 | No assessment of right ventricular | ||
| significant TR (3+ | (P=0.004) AF: OR 9.2 (P=0.03) | dysfunction or tricuspid annulus dilatation | ||
| or more) | left atrium size: OR 2.8 | |||
| (P=0.03) | Strong correlation with AF and atrial size | |||
| Recommendation for aggressive TR repair | ||||
| in selected cases | ||||
| Matsunaga et al., | From January | Tricuspid annuloplasty | 21 patients had preoperative | Retrospective study |
| (2005), Circulation, | 1992 to December | TR (moderate or greater) | ||
| USA; Japan, [6] | 2001, 124 | 9 patients underwent TVRep | Relatively small number of patients | |
| consecutive | (TR-group) 12 patients TR was | |||
| Retrospective | patients with fMR | ignored (no-TR group) | Long and complete follow-up | |
| study (level IIb) | underwent CABG | |||
| and MVRep. 21 | TR moderate or greater | 4 patients (44%) of TR group | 50% of patients after MVRep showed | |
| patients (30%) had | at follow-up | 8 patients (67%) of no-TR group | significant TR at follow-up | |
| TR before surgery | (P=NS) | |||
| Presence or absence of residual MR do not | ||||
| Progression of TR after | Significant TR 25% at 1 year, | affect the incidence of follow-up TR | ||
| MVRep | 53% at 1–3 years, 74% | |||
| over 3 years | Revascularization and MVRep do not | |||
| reduce RV pressure overload and do not | ||||
| Follow-up MR and TR | 14 of 21 patients (64%) with | prevent late TR | ||
| significant recurrent MR had | ||||
| also significant TR | Incidence of late TR was independent of | |||
| whether the TR was surgically treated or | ||||
| 20 of 48 patients (42%) with no | ignored (44% vs. 67%; P=NS) | |||
| recurrent MR had significant TR | ||||
| (P=NS) | Significant recurrent MR (31%) reinforces | |||
| the significance of ventricular geometric | ||||
| Follow-up echo data | RV systolic pressure in the TR | distortion as ongoing remodelling affecting | ||
| group was higher than the no-TR | RV and LV geometries | |||
| group | ||||
| LV ejection fraction was not | ||||
| different between the groups | ||||
| Calafiore et al., | From January | Follow-up duration | 68 months (100% complete) | Moderate-or-more fTR, if untreated, can |
| (2009), Ann | 1988 to March | impair both midterm survival and functional | ||
| Thorac Surg, | 2003, 110 patients | Mortality | Treated vs. untreated TR group | status, even if it seems not to affect early |
| Italy, [7] | with functional | 30 days: 2% vs. 8.5% | outcome | |
| mitral regurgitation | (P=0.213) long-term (46/104 | |||
| Retrospective | undergoing mitral | patients) 16 patients vs. | Reversal of TV remodeling cannot be | |
| study (level IIb) | valve surgery | 30 patients | expected with MV surgery alone | |
| showed moderate- | ||||
| or-more functional | TR | At 12 months follow-up | Functional TR progression is not related to | |
| TR repaired with | (77 patients) | functional MVR progression | ||
| De Vega technique | ||||
| Treated group (42 patients) | Surgical technique can then influence the | |||
| No TR: 50% | late results of TR correction | |||
| TR 1+: 31% | ||||
| TR 2+: 14% | ||||
| TR 3+: 5% | ||||
| Untreated group (35 patients) | ||||
| No TR: 0% | ||||
| TR 1+: 23% | ||||
| TR 2+: 37% | ||||
| TR 3+: 34% | ||||
| TR 4+: 6% | ||||
| MVR progression and | MV repair (60 patients) MR | |||
| influence on fTR | 3+: >3 patients (5%) Late | |||
| recurrence/progression | fTR group vs. non late fTR | |||
| 2/47 (4.3%) vs. 1/13 (7.7%) | ||||
| P=0.625 | ||||
| Survival | 5 years – treated vs. untreated | |||
| TR 45.0±6.1% vs. 74.5±5.1% | ||||
| (P=0.044) | ||||
| Risk factors of | Lower mid-term survival (HR 2.7) | |||
| untreated | ||||
| moderate-or-more TR | Survival in NYHA class II or II | |||
| (HR 1.9) | ||||
| Boyaci et al., | Sixty-eight (68) | TR grade, LVEF and | Moderate or greater | Retrospective study |
| (2007), | patients undergone | mortality | TR increased mortality | |
| Angiology, | MVR without | regardless of EF | Improvement of functional capacity | |
| Turkey, [8] | TV surgery | HR 1.49 EF<50% | in 86% of patients with mild | |
| HR 1.54 EF>50% | preop TR vs. 54% of those with | |||
| Retrospective | significant TR | |||
| study (level IIb) | Preoperative TR | Mild TR (group I) 42 patients | ||
| (62%) | Right ventricular pressure fell and remained | |||
| lower in patients with mild TR, but not in | ||||
| Significant TR (group II) 26 | patients with moderate to severe TR | |||
| patients (38%) | ||||
| Transmitral F-U | Group I vs. Group II (mmHg) | |||
| gradient | 5.2±2.5 vs. 5.6±3.0 | |||
| (P=NS) | ||||
| Right ventricular | Group I (mmHg) 47±1.0 to | |||
| systolic pressure | 31±10 | |||
| trend pre- | ||||
| postoperative | Group II 45±9 to 42±12 | |||
| Pulmonary | Group I vs. Group II (mmHg) | |||
| hypertension at F-U | 31±10 vs. 42±12 | |||
| (P<0.05) | ||||
| NYHA Class at F-U | Group I vs. Group II | |||
| NYHA I 19% vs. 2% (P<0.05) | ||||
| NYHA II 67% vs. 46% (P<0.05) | ||||
| NYHA III 14% vs. 38% | ||||
| (P<0.05) | ||||
| Hospitalization/year | Group I vs. Group II 1.1±0.4 | |||
| vs. 1.8±0.7 | ||||
| (P<0.05) | ||||
| Song et al., | Between 1995 and | Follow-up | Clinical 101±24 months (range | Retrospective study |
| (2009), | 2000, 638 patients | 12–146 months) | ||
| Heart, | (356 men) with | Extensive number of patients | ||
| Korea, [9] | mild (≤grade 2/4) | Echocardiographical | ||
| TR underwent | 64±30 months (range 14–141 | Outlines the natural history of late TR | ||
| Retrospective | surgery without | months) | development | |
| study | any procedure on | |||
| (level IIb) | the TV | Left-side valve surgery | Mitral valve surgery | Rheumatic aetiology is strongly associated |
| 323 patients | with development of late significant TR | |||
| Aortic valve surgery 221 patients | Female gender has higher incidence | |||
| probably due to higher prevalence of | ||||
| Double-valve surgery | rheumatic disease in this population | |||
| 94 patients | ||||
| AF is the most striking risk factor for | ||||
| Significant late TR | Mitral valve surgery 9.6% | development of late significant TR | ||
| development | (31/323 patients) | |||
| PH is not associated with TR progression | ||||
| Aortic valve surgery 3.2% | ||||
| (7/221 patients) | Right ventricular distortion or annular | |||
| dilatation is associated with late TR | ||||
| Double-valve surgery 11.7% | development | |||
| (11/94 patients) | ||||
| Impact of rheumatic | Rheumatic MR 15% (10/65 | |||
| disease on late TR | patients) | |||
| Non-rheumatic MR 5% (7/133 | ||||
| patients) | ||||
| (P=0.017) | ||||
| AF | 239 patients (37%) before | |||
| surgery | ||||
| 184 patients persistent AF | ||||
| 18 patients (5%) developed | ||||
| AF at follow-up | ||||
| TV annular dilatation | TV annulus increased in both | |||
| group | ||||
| Late TR 32±6 to 40±7 mm | ||||
| Non late TR 40±7 mm | ||||
| P<0.001 | ||||
| Late TR risk factors | Age (HR 1.0; P=0.005) | |||
| Female gender (HR 5.0; | ||||
| P=0.001) rheumatic aetiology | ||||
| (HR 3.8; P=0.011) AF (HR | ||||
| 2.6; P=0.035) peak pressure | ||||
| gradient of TR (HR 1.1; <0.001) | ||||
| Mortality | Significant TR vs. non late TR | |||
| 4.9% vs. 16.3% | ||||
| (P=0.004) | ||||
| Event-free survival | Late TR vs. non-late TR | |||
| 76±6% vs. 91±1% | ||||
| (P<0.001) | ||||
| Colombo et al., | From January | Follow-up | 25±15.9 months (range 3–49 | Prospective study |
| (2001), Cardiovasc | 1995 to December | months) | ||
| Surg, Italy, [10] | 1998, 50 patients | Absence or mild to moderate TR in 83.9% | ||
| with rheumatic | Surgical procedure | MVR with mechanical valve: | of patients who underwent tricuspid | |
| Prospective | mitral valve | 47 patients | procedure | |
| single center | disease and | |||
| cohort study | functional | MVR with bioprosthesis: | Undersizing of TV annulus has been | |
| (level IIb) | TR underwent | 3 patients | effective even with the De Vega procedure | |
| surgery for | TVRep with De Vega procedure: | |||
| MVR and TV | 33 patients | |||
| repair | ||||
| Outcome | TVRep group with 3+ or 4+ | |||
| TV repair | TR Grade 0 or 1+: 19 patients | |||
| performed if | (73%) Grade 1+ or 2+: | |||
| indexed TV | 3 patients (11.5%) Grade 2+ | |||
| annular dimension | or 3+: 1 pt (3.8%) Grade 3+ to | |||
| >21 mm/m2 | 4+: 3 patients (11.5%) | |||
| Two patients of five with TV | ||||
| annulus >21 mm/m2 who did | ||||
| not undergo TV annuloplasty had | ||||
| significant TR at follow-up | ||||
| Dreyfus et al., | Between 1989 and | Mortality | No significant difference | Retrospective study; consecutive patients |
| (2005), Ann | 2001, 311 patients | (group 1=1.8%; group 2=0.7%) | ||
| Thorac Surg, | underwent mitral | 10 years follow-up patients | ||
| UK, [11] | valve repair | Actuarial survival rate | Group 1=97.3%, 96.2%, and | |
| (MVR). Tricuspid | 85.5%; group 2=98.5%, | Precise and reproducible method of TV | ||
| Retrospective | annuloplasty | 98.5%, and 90.3% at 3, 5, and | sizing is used | |
| study (level IIb) | performed if | 10 years, respectively | ||
| tricuspid annular | Demonstrates little or no correlation | |||
| diameter ≥70 mm | NYHA class | Improved in group MVR+TV | between tricuspid dilatation and | |
| regardless of the | annuloplasty (group | regurgitation | ||
| grade of | 1=1.59±0.84; group | |||
| regurgitation. | 2=1.11±0.31; | Tricuspid dilatation is more reliable than | ||
| Group 1 MVR | P<0.001) | TR when assessing secondary TV disease | ||
| alone (163 | ||||
| patients; 54.4%); | TR grade | Increased >2 grades in | ||
| Group 2 MVR | 48% of group 1 (MVR alone) | |||
| plus tricuspid | and only 2% in group 2 (MVR+ | |||
| annuloplasty (148 | TV annuloplasty) | |||
| patients; 47.6%) | ||||
| McCarthy et al., | From 1990 to | Follow-up | 8 years (3302 patient-years) | Retrospective study no consistent, |
| (2004), J Thorac | 1999, 790 patients | accurate data for right ventricular function, | ||
| Cardiovasc Surg, | underwent | Left-sided valve | MVR 425 patients (54%) | size and geometry, TV annular size, PAPs |
| USA, [12] | TV annuloplasty | surgery and other | ||
| for functional | procedures | MVRep 276 patients (35%) | No analysis of residual MR | |
| Cohort study | regurgitation using | |||
| (level IIb) | 4 techniques: | AVR 199 patients (25%) | No analytical correlation between TR and | |
| 1. Carpentier– | survival or progression of NYHA class | |||
| Edwards semi-rigid | AVRep 15 patients (2%) | |||
| ring | Residual TR in 14% of patients early after | |||
| 2. Cosgrove– | CABG 205 patients (265) | operation | ||
| Edwards flexible | ||||
| band | Distribution of patients | Carpentier: 139 patients | Late worsening (beyond 6 months) | |
| 3. De Vega | according to TV repair | (17%) | associated with patient disease factors | |
| procedure | technique | AND with avoidable causes such as trans- | ||
| 4. Peri-Guard | Cosgrove: 291 patients (37%) | tricuspid pacing leads and type of | ||
| annuloplasty | annuloplasty | |||
| De Vega: 116 patients (15%) | ||||
| 2 non-ring annuloplasties, De Vega and | ||||
| Peri-Guard: 243 patients (31%) | Peri-Guard, worsening of TR. | |||
| Reoperation rate | Freedom from reoperation | |||
| 1 month: 99% | ||||
| 8 years: 97% | ||||
| Progression to grade | Carpentier 3+: 10% - 10% - | |||
| 3+ or 4+ TR according | 11% - 11% 4+: 5.2% - 5.5% - | |||
| to TV repair technique | 6% - 6% (P=0.7) | |||
| 1 month | Cosgrove 3+: 10% - 12% - | |||
| 1 year | 12% - NA 4+: 5.3% - 6% - 6% - NA | |||
| 5 years | (P=0.05) | |||
| 8 years | ||||
| De Vega 3+: 9% - 12% - 17% - | ||||
| 20% 4+: 4.6 - 6% - 11% - 13% | ||||
| (P=0.002) | ||||
| Peri-Guard 3+: 10% - 13% - | ||||
| 19% - 22% 4+: 5.4% - 7% - 13% - | ||||
| 15% (P=0.0009) | ||||
| Pacemaker lead | Preop PMK Lead vs. No PMK | |||
| influence on 3+ and 4+ | Lead | |||
| TR prevalence | ||||
| 16% - 42% vs. 15% - 23% | ||||
| (1 month–5 years) | ||||
| Preop TR influence of | 9% - 14% - 22% at 1 month | |||
| late TR development | ||||
| (Prevalence of 3+ or | 18% - 23% - 29% at 5 years | |||
| 4+) | ||||
| 1. grades 0 vs. 1+ | ||||
| 2. 2+ vs. 3+ | ||||
| 3. vs. 4+ | ||||
| Risk factors for late TR | LV dysfunction (P=0.0002) | |||
| worsening | One-system disease (P=0.007) | |||
| AF (P=0.01) PMK lead | ||||
| (P=0.04) | ||||
| Tang et al., | Between 1978 and | Follow-up duration | 5.9±4.9 years (range | Majority of patients undergoing TV repair |
| (2006), Circulation, | 2003, 702 patients | 0–21 years) | have secondary (‘functional’) regurgitation | |
| Canada, [13] | underwent TV | |||
| repair in the setting | TR repair | De Vega procedure 493 | Uncorrected moderate and severe TR may | |
| Retrospective | of concomitant | patients | persist or even worsen after mitral valve | |
| study (level IIb) | left-sided valve | surgery | ||
| surgery and | ‘Ring’ annuloplasty 209 patients: | |||
| revascularization | Carpentier n. 114 (54%) | Annuloplasty ring refers significant | ||
| Duran n. 52 (25%) | improvement over De Vega repair in long- | |||
| Cosgrove n. 43 (21%) | term survival and event-free survival, as | |||
| well as recurrence of TR | ||||
| Functional class | Ring vs. non ring TV repair | |||
| NYHA III–IV 20% vs. 25% | Beneficial effects of a TV annuloplasty | |||
| ring were independent of the type of | ||||
| Late TR | Ring group No TR 15% | mitral valve surgery performed | ||
| Trivial-to-mild TR 55% | ||||
| Moderate-to-severe TR 30% | Recurrence of TR was not significantly | |||
| associated with the recurrence of MR | ||||
| Non-ring group No TR 10% | ||||
| Trivial-to-mild TR 54% | ||||
| Moderate-to-severe TR 36% | ||||
| Outcomes | No ring vs. ring (15 years) | |||
| Freedom from TR 39±11% vs. | ||||
| 82±5% (P=0.003) | ||||
| Long-term survival 36±8% vs. | ||||
| 49±5% (P=0.007) | ||||
| Event-free survival 17±6% | ||||
| vs. 34±5% | ||||
| Predictors | Annuloplasty ring | |||
| Long-term survival (HR 0.7; | ||||
| P=0.03) | ||||
| Event-free survival (HR 0.8; | ||||
| P=0.04) | ||||
| Kim et al., | From January | Distribution of patients | Carpentier: 139 patients (17%) | Retrospective study |
| (2005), | 1994 to December | according to TV repair | ||
| Circulation, | 1997, 170 patients | technique | Cosgrove: 291 patients (37%) | Long follow-up |
| Korea, [14] | underwent left- | |||
| side valve surgery | De Vega: 116 patients (15%) | Tricuspid repair techniques used are also | ||
| Retrospective | and MAZE (Cox | known to be burden by high late TR | ||
| study | III) operation for | Peri-Guard: 243 patients (31%) | recurrence | |
| (level IIb) | AF Group I 44 | |||
| patients in sinus | Reoperation rate | Freedom from reoperation | AF affects the worsening of TR over time | |
| rhythm; Group II | 1 month: 99% | |||
| 48 patients in AF | 8 years: 97% | MAZE can prevent this course | ||
| with MAZE and | ||||
| Group III 78 | Preoperative TR grade | Group I 12 patients (27.3%) | Recovery and maintenance of atrial | |
| patients without | Group II 8 patients (16.7%) | mechanical activity are of great value for | ||
| MAZE | Group III 26 patients (33.3%) | such a benefit | ||
| Progression of TR at | Immediate results (significant | |||
| follow-up | TR) Group I 3 patients | |||
| (6.8%) Group II 1 pt (2.1%) | ||||
| Group III 11 patients (14.1%) | ||||
| P=NS among groups | ||||
| Post-op results (significant TR) | ||||
| Group I 3/41 patients | ||||
| (7.3%) Group II 6/47 pt (12.8%) | ||||
| Group III 26/67 patients (38.8%) | ||||
| P=0.001 Group I vs. Group III | ||||
| P=0.005 Group II vs. Group III | ||||
| Atrial contractility | Group II (+MAZE) 38 patients | |||
| contribution and | of Group II maintained sinus | |||
| analysis | rhythm (Group IIa) 10 patients | |||
| with no LA mechanical activity | ||||
| (AF, accelerated junctional | ||||
| rhythm, sinus rhythm) | ||||
| Group IIa had smaller | ||||
| LA size preoperatively and | ||||
| lower TR grade at the final | ||||
| follow-up than those in Group IIb | ||||
| (P=0.038; P=0.025) | ||||
| Left-side valve surgery | MVR/MVRep 174 patients | |||
| (51.9%) | ||||
| AV surgery alone 74 patients | ||||
| (22.1%) | ||||
| Combined MV+AV surgery | ||||
| 87 patients (4.5%) MVR/MVRep | ||||
| 174 patients (51.9%) | ||||
| AV surgery alone 74 patients | ||||
| (22.1%) | ||||
| Combined MV+AV surgery | ||||
| 87 patients (4.5%) | ||||
| TV surgery and | Annuloplasty 15 patients (4.5%) | |||
| technique | ||||
| TR development | Significant: 90 patients (26.9%) | |||
| Severe in 25 patients (7.5%) | ||||
| TR population and risk | Age (47.6±13.4 vs. 44.3±13.2 | |||
| factors (TR+ vs. TR-) | years, P=0.04) | |||
| Preop AF (83.3 vs. 46.5%, | ||||
| P<0.001) | ||||
| LA dimension (56.9±13.2 | ||||
| vs. 52.4 ±11.5 mm, P=0.006) | ||||
| Prior valve surgery (40.0 vs. | ||||
| 25.3%, P=0.01). | ||||
| Event-free survival | TR- group | |||
| at 100, 140, 160 and | 97.0±1.1% | |||
| 175 months | 87.7±2.8% | |||
| 85.9±2.6% | ||||
| 85.9±2.6% | ||||
| TR+ group | ||||
| 94.4±2.4% | ||||
| 86.2±3.7% | ||||
| 70.9±5.9% | ||||
| 62.0±9.8% | ||||
| P=0.03 | ||||
| Jonjev et al., | From July 1994 | Follow-up duration | Mean 42 months (range | In end-stage heart disease and selected |
| (2007), J Card | to July 2004, | 1–120 months) | patient population the RADO procedure is | |
| Surg, Serbia and | 226 of 294 | effective | ||
| Montenegro, [16] | patients who | Functional status | Preopertative NYHA class III | |
| underwent surgical | 70 patients (39.88%) | Concomitant reduction of mitral and | ||
| Prospective | intervention for | NYHA class IV 126 patients | tricuspid insufficiency provides early and | |
| study (level IIb) | chronic ischemic | (69.02%) mean NYHA class | long-term beneficial effect, according with | |
| mitral | 3.9 | the natural history of the disease | ||
| regurgitation | ||||
| had reductive | Surgical procedure | Mitral valve surgery | No data are provided about the long-term | |
| annuloplasty of | efficacy of De Vega annuloplasty for the | |||
| double orifices | Carpentier mitral ring | prevention of late TR development | ||
| (RADO) | 37 patients (16.38%) | |||
| Semicircular posterior annuloplasty | ||||
| 189 patients (69.02%) | ||||
| TV surgery | ||||
| De Vega annuloplasty | ||||
| 226 patients (100%) | ||||
| Follow-up | Mean NYHA class 1.9 mean | |||
| EF preoperative 25% to | ||||
| postoperative 34% | ||||
| RADO results | Mitral valve insufficiency | |||
| mean grade 3.7±0.4 | ||||
| preoperative to 0.7±0.3 | ||||
| postoperative | ||||
| TV insufficiency mean grade | ||||
| 3.4±0.4 preoperative to | ||||
| 0.9±0.2 prostoperative | ||||
| Survival | 5 years–10 years | |||
| 61.5±4.0% – 38.05±8.0% | ||||
| Freedom from | At 10 years 60.0±6.7% | |||
| decompensation | ||||
| De Bonis et al., | Ninety-one DCM | Follow-up | 1.8±1.2 years (range 0.5–5.7 | Retrospective study |
| (2008), Eur J | patients (mean age | years) | ||
| Cardiothorac Surg, | 61±11.3) | No consistent, accurate data were available | ||
| Italy, [17] | submitted to MV | Left-sided surgery | Edge-to-edge+undersized | preoperatively and at follow-up regarding |
| repair (±tricuspid | and concomitant | annuloplasty 46 patients | right atrial dimension, tricuspid annular size | |
| Cohort study | repair) for | procedures | (50.5%) undersized | and degree of leaflet tethering |
| (level IIb) | functional MR | annuloplasty 45 patients (49.4%) | ||
| Small number of patients included | ||||
| CABG 41 patients (45%) | ||||
| uncorrected moderate or less TR in patients | ||||
| AF surgery 14 patients (15.3%) | with functional MR often persist and | |||
| worsen over time | ||||
| TV surgical | 13 patients (3+/4+ or | |||
| intervention | >TR) had TV annuloplasty: | Annular dilatation and tethering as | ||
| underlying mechanisms of late TR | ||||
| De Vega Procedure: 7 patients | ||||
| Ring annuloplasty: | RV function assessment is essential to | |||
| 6 patients | guide the surgical intervention | |||
| No TV annuloplasty: 78 patients | Absence of ‘reverse remodelling’ influences | |||
| (with TR<2+/4+) | late TR development | |||
| Evolution of fTR | Absent/mild 52 patients (57.1%) | |||
| Moderate 28 patients (30.7%) | ||||
| Moderately severe 9 patients | ||||
| (9.8%) | ||||
| Severe 2 patients (2.2%) | ||||
| 11 of 91 patients (12%) had | ||||
| progression of TR | ||||
| 14 of the 78 patients (17.9%) | ||||
| no-TR had worsening of TR at | ||||
| least of 2 grades | ||||
| TR evolution | Annular dilatation in 75 patients | |||
| mechanisms | tethering in 6 patients | |||
| Predictors of significant | RV dilatation (OR 8.3, P=0.009) | |||
| late TR | ||||
| Pre-op. RV dysfunction (OR | ||||
| 13.7, P=0.0001) | ||||
| TR grade at discharge (OR 5.4, | ||||
| P=0.01) | ||||
| Pulmonary | Significant (>3+) TR at | |||
| hypertension | follow-up: | |||
| 37% (9/24) among the patients | ||||
| with pulmonary hypertension | ||||
| 3% (2/67) among those with | ||||
| SPAP <40 mmHg at the last | ||||
| echocardiogram | ||||
| (P<0.0001) | ||||
| Pattern of LV | ‘reverse remodeling’ group: | |||
| remodeling | Significant TR in only 1 of 49 | |||
| patients (2%) that demonstrated | ||||
| reverse remodeling | ||||
| No ‘reverse remodeling group’ | ||||
| significant TR in 10 of 42 | ||||
| patients (23.8%) | ||||
| (P=0.04) | ||||
| Author, date | Patient group | Outcomes | Key results | Comments |
| and country, | ||||
| Study type | ||||
| (level of evidence) | ||||
| Bonow et al., | Class I | Severe TR in the setting of | ||
| ACC/AHA VHD | surgery for multivalvular | |||
| Guidelines: (2008), | disease should be | |||
| focused update | corrected | |||
| (level of evidence: c) | Class II | Tricuspid annuloplasty is | ||
| reasonable for mild TR in | ||||
| patients undergoing MV surgery | ||||
| when there is pulmonary | ||||
| hypertension or tricuspid | ||||
| annular dilatation | ||||
| Vahanian et al., | Class IIa | Concomitant TV repair if | ||
| (2007), Eur | TA diameter >40 mm | |||
| Heart J, ESC | ||||
| guidelines | TV repair in patients with | |||
| symptomatic, isolated TR late | ||||
| after left-sided valve surgery, | ||||
| in absence of left-sided | ||||
| myocardial or RV dysfunction | ||||
| and without severe pulmonary | ||||
| hypertension | ||||
| Turina et al., | 170 patients | Follow-up | Mean 10.6 years (1802 | Retrospective study |
| (1999), | (between 1975 | patient-years) | ||
| Circulation, | and 1989) who | Significant TV regurgitation requiring | ||
| Switzerland, [2] | underwent surgery | Surgical procedures | Double valve surgery 170 | surgical repair worsened the prognosis |
| for chronic | patients | |||
| Retrospective | combined aortic | Advice for TV repair when hemodynamic | ||
| study (level IIb) | and mitral valvular | TV surgery 29 patients (17%) | significant regurgitation is present | |
| disease | ||||
| CABG 7 patients (4%) | ||||
| Ascending aorta surgery 7 | ||||
| patients (4%) | ||||
| Reoperation involving | Tricuspid replacement 2 | |||
| TV | patients | |||
| Tricuspid reconstruction | ||||
| 2 patients | ||||
| Survival rate in | At 10 years (cumulative survival) | |||
| patients with TR | ||||
| With TV reconstruction 57% | ||||
| Without TV reconstruction 68% | ||||
| Predictors of late | Age (P=0.0011) LVEF | |||
| outcome | (P=0.0008) Additional TV | |||
| regurgitation | ||||
| (P=0.007) | ||||
| Nath et al., | 5223 patients | One-year survival | 91.7% with no TR, | Retrospective study |
| (2004), J Am Coll | undergoing | 90.3% with mild TR, | ||
| Cardiol, USA, [3] | echocardiography; | 78.9% with moderate TR, | Huge cohort of patients | |
| four years follow- | 63.9% with severe TR | |||
| Retrospective | up; comparison | Long follow-up | ||
| study (level IIb) | survival differences | TR grade, pulmonary | Moderate or greater TR | |
| among TR grades | artery pressure and | increased mortality regardless | Unknown NYHA class at follow-up | |
| mortality | of PASP HR 1.31 for PASP | |||
| >40 mmHg; HR 1.32 PA | No data correlation with MR grade and TR | |||
| <40 mmHg | ||||
| TR grade, LVEF and | Moderate or greater TR | |||
| mortality | increased mortality | |||
| regardless of EF | ||||
| HR 1.49 EF<50% | ||||
| HR 1.54 EF>50% | ||||
| Porter et al., | 65 patients with | Follow-up duration | 11.3±8 years (range | Retrospective study |
| (1999), J Heart | rheumatic heart | 1–30 years) | ||
| Valve Dis, | disease who had | No data about preoperative TR | ||
| Israel, [4] | undergone MVR | Left-sided valve | MV stenosis 44 patients (67%) | |
| without TV | pathology and surgical | MV regurgitation 21 patients | No data on preoperative RV status | |
| Retrospective | surgery | intervention | (33%) | |
| study case series | Outlines the late development rate of TR | |||
| (level IIIb) | Mitral valve replacement in all | when uncorrected at the time of left-sided | ||
| cases | valve surgery | |||
| Outcomes | 44 patients (67%) developed | |||
| late TR | ||||
| Moderate 16 patients (36.4%) | ||||
| Severe 18 patients (41%) | ||||
| Risk factors | Age RR 1.1 female gender 1.8 | |||
| Matsuyama et al., | Between March | Mean follow-up | 8.2±3.6 years (range 1.0–14.5 | Retrospective study |
| (2003), Ann Thor | 1988 and | years) | ||
| Surg, Japan, [5] | September 2001 of | Long overall follow-up but high variability | ||
| 174 of 274 patients | Late deaths | 14 late deaths (8%) | of time (may underestimate late TR | |
| Retrospective | undergoing MV | development in some early patients) | ||
| study (level IIb) | surgery did not | Early postoperative | TR (3+/4+ or more) in 4 | |
| receive concomitant | outcome | patients (2%) | Mitral valve repair as left-side valve | |
| TV surgery | surgery in 53% of patients | |||
| Follow-up of TR grade | 28 patients developed TR grade | |||
| 3+ or more (16%) 46 patients | Progression of TR over time | |||
| with preopearative TR 2+/4+, | ||||
| TR had progression in | Early postoperative TR grade is unreliable | |||
| 17 patients (37%) | for estimation of late TR progression | |||
| Risk factors for | Preoperative 2+ TR: OR 3.9 | No assessment of right ventricular | ||
| significant TR (3+ | (P=0.004) AF: OR 9.2 (P=0.03) | dysfunction or tricuspid annulus dilatation | ||
| or more) | left atrium size: OR 2.8 | |||
| (P=0.03) | Strong correlation with AF and atrial size | |||
| Recommendation for aggressive TR repair | ||||
| in selected cases | ||||
| Matsunaga et al., | From January | Tricuspid annuloplasty | 21 patients had preoperative | Retrospective study |
| (2005), Circulation, | 1992 to December | TR (moderate or greater) | ||
| USA; Japan, [6] | 2001, 124 | 9 patients underwent TVRep | Relatively small number of patients | |
| consecutive | (TR-group) 12 patients TR was | |||
| Retrospective | patients with fMR | ignored (no-TR group) | Long and complete follow-up | |
| study (level IIb) | underwent CABG | |||
| and MVRep. 21 | TR moderate or greater | 4 patients (44%) of TR group | 50% of patients after MVRep showed | |
| patients (30%) had | at follow-up | 8 patients (67%) of no-TR group | significant TR at follow-up | |
| TR before surgery | (P=NS) | |||
| Presence or absence of residual MR do not | ||||
| Progression of TR after | Significant TR 25% at 1 year, | affect the incidence of follow-up TR | ||
| MVRep | 53% at 1–3 years, 74% | |||
| over 3 years | Revascularization and MVRep do not | |||
| reduce RV pressure overload and do not | ||||
| Follow-up MR and TR | 14 of 21 patients (64%) with | prevent late TR | ||
| significant recurrent MR had | ||||
| also significant TR | Incidence of late TR was independent of | |||
| whether the TR was surgically treated or | ||||
| 20 of 48 patients (42%) with no | ignored (44% vs. 67%; P=NS) | |||
| recurrent MR had significant TR | ||||
| (P=NS) | Significant recurrent MR (31%) reinforces | |||
| the significance of ventricular geometric | ||||
| Follow-up echo data | RV systolic pressure in the TR | distortion as ongoing remodelling affecting | ||
| group was higher than the no-TR | RV and LV geometries | |||
| group | ||||
| LV ejection fraction was not | ||||
| different between the groups | ||||
| Calafiore et al., | From January | Follow-up duration | 68 months (100% complete) | Moderate-or-more fTR, if untreated, can |
| (2009), Ann | 1988 to March | impair both midterm survival and functional | ||
| Thorac Surg, | 2003, 110 patients | Mortality | Treated vs. untreated TR group | status, even if it seems not to affect early |
| Italy, [7] | with functional | 30 days: 2% vs. 8.5% | outcome | |
| mitral regurgitation | (P=0.213) long-term (46/104 | |||
| Retrospective | undergoing mitral | patients) 16 patients vs. | Reversal of TV remodeling cannot be | |
| study (level IIb) | valve surgery | 30 patients | expected with MV surgery alone | |
| showed moderate- | ||||
| or-more functional | TR | At 12 months follow-up | Functional TR progression is not related to | |
| TR repaired with | (77 patients) | functional MVR progression | ||
| De Vega technique | ||||
| Treated group (42 patients) | Surgical technique can then influence the | |||
| No TR: 50% | late results of TR correction | |||
| TR 1+: 31% | ||||
| TR 2+: 14% | ||||
| TR 3+: 5% | ||||
| Untreated group (35 patients) | ||||
| No TR: 0% | ||||
| TR 1+: 23% | ||||
| TR 2+: 37% | ||||
| TR 3+: 34% | ||||
| TR 4+: 6% | ||||
| MVR progression and | MV repair (60 patients) MR | |||
| influence on fTR | 3+: >3 patients (5%) Late | |||
| recurrence/progression | fTR group vs. non late fTR | |||
| 2/47 (4.3%) vs. 1/13 (7.7%) | ||||
| P=0.625 | ||||
| Survival | 5 years – treated vs. untreated | |||
| TR 45.0±6.1% vs. 74.5±5.1% | ||||
| (P=0.044) | ||||
| Risk factors of | Lower mid-term survival (HR 2.7) | |||
| untreated | ||||
| moderate-or-more TR | Survival in NYHA class II or II | |||
| (HR 1.9) | ||||
| Boyaci et al., | Sixty-eight (68) | TR grade, LVEF and | Moderate or greater | Retrospective study |
| (2007), | patients undergone | mortality | TR increased mortality | |
| Angiology, | MVR without | regardless of EF | Improvement of functional capacity | |
| Turkey, [8] | TV surgery | HR 1.49 EF<50% | in 86% of patients with mild | |
| HR 1.54 EF>50% | preop TR vs. 54% of those with | |||
| Retrospective | significant TR | |||
| study (level IIb) | Preoperative TR | Mild TR (group I) 42 patients | ||
| (62%) | Right ventricular pressure fell and remained | |||
| lower in patients with mild TR, but not in | ||||
| Significant TR (group II) 26 | patients with moderate to severe TR | |||
| patients (38%) | ||||
| Transmitral F-U | Group I vs. Group II (mmHg) | |||
| gradient | 5.2±2.5 vs. 5.6±3.0 | |||
| (P=NS) | ||||
| Right ventricular | Group I (mmHg) 47±1.0 to | |||
| systolic pressure | 31±10 | |||
| trend pre- | ||||
| postoperative | Group II 45±9 to 42±12 | |||
| Pulmonary | Group I vs. Group II (mmHg) | |||
| hypertension at F-U | 31±10 vs. 42±12 | |||
| (P<0.05) | ||||
| NYHA Class at F-U | Group I vs. Group II | |||
| NYHA I 19% vs. 2% (P<0.05) | ||||
| NYHA II 67% vs. 46% (P<0.05) | ||||
| NYHA III 14% vs. 38% | ||||
| (P<0.05) | ||||
| Hospitalization/year | Group I vs. Group II 1.1±0.4 | |||
| vs. 1.8±0.7 | ||||
| (P<0.05) | ||||
| Song et al., | Between 1995 and | Follow-up | Clinical 101±24 months (range | Retrospective study |
| (2009), | 2000, 638 patients | 12–146 months) | ||
| Heart, | (356 men) with | Extensive number of patients | ||
| Korea, [9] | mild (≤grade 2/4) | Echocardiographical | ||
| TR underwent | 64±30 months (range 14–141 | Outlines the natural history of late TR | ||
| Retrospective | surgery without | months) | development | |
| study | any procedure on | |||
| (level IIb) | the TV | Left-side valve surgery | Mitral valve surgery | Rheumatic aetiology is strongly associated |
| 323 patients | with development of late significant TR | |||
| Aortic valve surgery 221 patients | Female gender has higher incidence | |||
| probably due to higher prevalence of | ||||
| Double-valve surgery | rheumatic disease in this population | |||
| 94 patients | ||||
| AF is the most striking risk factor for | ||||
| Significant late TR | Mitral valve surgery 9.6% | development of late significant TR | ||
| development | (31/323 patients) | |||
| PH is not associated with TR progression | ||||
| Aortic valve surgery 3.2% | ||||
| (7/221 patients) | Right ventricular distortion or annular | |||
| dilatation is associated with late TR | ||||
| Double-valve surgery 11.7% | development | |||
| (11/94 patients) | ||||
| Impact of rheumatic | Rheumatic MR 15% (10/65 | |||
| disease on late TR | patients) | |||
| Non-rheumatic MR 5% (7/133 | ||||
| patients) | ||||
| (P=0.017) | ||||
| AF | 239 patients (37%) before | |||
| surgery | ||||
| 184 patients persistent AF | ||||
| 18 patients (5%) developed | ||||
| AF at follow-up | ||||
| TV annular dilatation | TV annulus increased in both | |||
| group | ||||
| Late TR 32±6 to 40±7 mm | ||||
| Non late TR 40±7 mm | ||||
| P<0.001 | ||||
| Late TR risk factors | Age (HR 1.0; P=0.005) | |||
| Female gender (HR 5.0; | ||||
| P=0.001) rheumatic aetiology | ||||
| (HR 3.8; P=0.011) AF (HR | ||||
| 2.6; P=0.035) peak pressure | ||||
| gradient of TR (HR 1.1; <0.001) | ||||
| Mortality | Significant TR vs. non late TR | |||
| 4.9% vs. 16.3% | ||||
| (P=0.004) | ||||
| Event-free survival | Late TR vs. non-late TR | |||
| 76±6% vs. 91±1% | ||||
| (P<0.001) | ||||
| Colombo et al., | From January | Follow-up | 25±15.9 months (range 3–49 | Prospective study |
| (2001), Cardiovasc | 1995 to December | months) | ||
| Surg, Italy, [10] | 1998, 50 patients | Absence or mild to moderate TR in 83.9% | ||
| with rheumatic | Surgical procedure | MVR with mechanical valve: | of patients who underwent tricuspid | |
| Prospective | mitral valve | 47 patients | procedure | |
| single center | disease and | |||
| cohort study | functional | MVR with bioprosthesis: | Undersizing of TV annulus has been | |
| (level IIb) | TR underwent | 3 patients | effective even with the De Vega procedure | |
| surgery for | TVRep with De Vega procedure: | |||
| MVR and TV | 33 patients | |||
| repair | ||||
| Outcome | TVRep group with 3+ or 4+ | |||
| TV repair | TR Grade 0 or 1+: 19 patients | |||
| performed if | (73%) Grade 1+ or 2+: | |||
| indexed TV | 3 patients (11.5%) Grade 2+ | |||
| annular dimension | or 3+: 1 pt (3.8%) Grade 3+ to | |||
| >21 mm/m2 | 4+: 3 patients (11.5%) | |||
| Two patients of five with TV | ||||
| annulus >21 mm/m2 who did | ||||
| not undergo TV annuloplasty had | ||||
| significant TR at follow-up | ||||
| Dreyfus et al., | Between 1989 and | Mortality | No significant difference | Retrospective study; consecutive patients |
| (2005), Ann | 2001, 311 patients | (group 1=1.8%; group 2=0.7%) | ||
| Thorac Surg, | underwent mitral | 10 years follow-up patients | ||
| UK, [11] | valve repair | Actuarial survival rate | Group 1=97.3%, 96.2%, and | |
| (MVR). Tricuspid | 85.5%; group 2=98.5%, | Precise and reproducible method of TV | ||
| Retrospective | annuloplasty | 98.5%, and 90.3% at 3, 5, and | sizing is used | |
| study (level IIb) | performed if | 10 years, respectively | ||
| tricuspid annular | Demonstrates little or no correlation | |||
| diameter ≥70 mm | NYHA class | Improved in group MVR+TV | between tricuspid dilatation and | |
| regardless of the | annuloplasty (group | regurgitation | ||
| grade of | 1=1.59±0.84; group | |||
| regurgitation. | 2=1.11±0.31; | Tricuspid dilatation is more reliable than | ||
| Group 1 MVR | P<0.001) | TR when assessing secondary TV disease | ||
| alone (163 | ||||
| patients; 54.4%); | TR grade | Increased >2 grades in | ||
| Group 2 MVR | 48% of group 1 (MVR alone) | |||
| plus tricuspid | and only 2% in group 2 (MVR+ | |||
| annuloplasty (148 | TV annuloplasty) | |||
| patients; 47.6%) | ||||
| McCarthy et al., | From 1990 to | Follow-up | 8 years (3302 patient-years) | Retrospective study no consistent, |
| (2004), J Thorac | 1999, 790 patients | accurate data for right ventricular function, | ||
| Cardiovasc Surg, | underwent | Left-sided valve | MVR 425 patients (54%) | size and geometry, TV annular size, PAPs |
| USA, [12] | TV annuloplasty | surgery and other | ||
| for functional | procedures | MVRep 276 patients (35%) | No analysis of residual MR | |
| Cohort study | regurgitation using | |||
| (level IIb) | 4 techniques: | AVR 199 patients (25%) | No analytical correlation between TR and | |
| 1. Carpentier– | survival or progression of NYHA class | |||
| Edwards semi-rigid | AVRep 15 patients (2%) | |||
| ring | Residual TR in 14% of patients early after | |||
| 2. Cosgrove– | CABG 205 patients (265) | operation | ||
| Edwards flexible | ||||
| band | Distribution of patients | Carpentier: 139 patients | Late worsening (beyond 6 months) | |
| 3. De Vega | according to TV repair | (17%) | associated with patient disease factors | |
| procedure | technique | AND with avoidable causes such as trans- | ||
| 4. Peri-Guard | Cosgrove: 291 patients (37%) | tricuspid pacing leads and type of | ||
| annuloplasty | annuloplasty | |||
| De Vega: 116 patients (15%) | ||||
| 2 non-ring annuloplasties, De Vega and | ||||
| Peri-Guard: 243 patients (31%) | Peri-Guard, worsening of TR. | |||
| Reoperation rate | Freedom from reoperation | |||
| 1 month: 99% | ||||
| 8 years: 97% | ||||
| Progression to grade | Carpentier 3+: 10% - 10% - | |||
| 3+ or 4+ TR according | 11% - 11% 4+: 5.2% - 5.5% - | |||
| to TV repair technique | 6% - 6% (P=0.7) | |||
| 1 month | Cosgrove 3+: 10% - 12% - | |||
| 1 year | 12% - NA 4+: 5.3% - 6% - 6% - NA | |||
| 5 years | (P=0.05) | |||
| 8 years | ||||
| De Vega 3+: 9% - 12% - 17% - | ||||
| 20% 4+: 4.6 - 6% - 11% - 13% | ||||
| (P=0.002) | ||||
| Peri-Guard 3+: 10% - 13% - | ||||
| 19% - 22% 4+: 5.4% - 7% - 13% - | ||||
| 15% (P=0.0009) | ||||
| Pacemaker lead | Preop PMK Lead vs. No PMK | |||
| influence on 3+ and 4+ | Lead | |||
| TR prevalence | ||||
| 16% - 42% vs. 15% - 23% | ||||
| (1 month–5 years) | ||||
| Preop TR influence of | 9% - 14% - 22% at 1 month | |||
| late TR development | ||||
| (Prevalence of 3+ or | 18% - 23% - 29% at 5 years | |||
| 4+) | ||||
| 1. grades 0 vs. 1+ | ||||
| 2. 2+ vs. 3+ | ||||
| 3. vs. 4+ | ||||
| Risk factors for late TR | LV dysfunction (P=0.0002) | |||
| worsening | One-system disease (P=0.007) | |||
| AF (P=0.01) PMK lead | ||||
| (P=0.04) | ||||
| Tang et al., | Between 1978 and | Follow-up duration | 5.9±4.9 years (range | Majority of patients undergoing TV repair |
| (2006), Circulation, | 2003, 702 patients | 0–21 years) | have secondary (‘functional’) regurgitation | |
| Canada, [13] | underwent TV | |||
| repair in the setting | TR repair | De Vega procedure 493 | Uncorrected moderate and severe TR may | |
| Retrospective | of concomitant | patients | persist or even worsen after mitral valve | |
| study (level IIb) | left-sided valve | surgery | ||
| surgery and | ‘Ring’ annuloplasty 209 patients: | |||
| revascularization | Carpentier n. 114 (54%) | Annuloplasty ring refers significant | ||
| Duran n. 52 (25%) | improvement over De Vega repair in long- | |||
| Cosgrove n. 43 (21%) | term survival and event-free survival, as | |||
| well as recurrence of TR | ||||
| Functional class | Ring vs. non ring TV repair | |||
| NYHA III–IV 20% vs. 25% | Beneficial effects of a TV annuloplasty | |||
| ring were independent of the type of | ||||
| Late TR | Ring group No TR 15% | mitral valve surgery performed | ||
| Trivial-to-mild TR 55% | ||||
| Moderate-to-severe TR 30% | Recurrence of TR was not significantly | |||
| associated with the recurrence of MR | ||||
| Non-ring group No TR 10% | ||||
| Trivial-to-mild TR 54% | ||||
| Moderate-to-severe TR 36% | ||||
| Outcomes | No ring vs. ring (15 years) | |||
| Freedom from TR 39±11% vs. | ||||
| 82±5% (P=0.003) | ||||
| Long-term survival 36±8% vs. | ||||
| 49±5% (P=0.007) | ||||
| Event-free survival 17±6% | ||||
| vs. 34±5% | ||||
| Predictors | Annuloplasty ring | |||
| Long-term survival (HR 0.7; | ||||
| P=0.03) | ||||
| Event-free survival (HR 0.8; | ||||
| P=0.04) | ||||
| Kim et al., | From January | Distribution of patients | Carpentier: 139 patients (17%) | Retrospective study |
| (2005), | 1994 to December | according to TV repair | ||
| Circulation, | 1997, 170 patients | technique | Cosgrove: 291 patients (37%) | Long follow-up |
| Korea, [14] | underwent left- | |||
| side valve surgery | De Vega: 116 patients (15%) | Tricuspid repair techniques used are also | ||
| Retrospective | and MAZE (Cox | known to be burden by high late TR | ||
| study | III) operation for | Peri-Guard: 243 patients (31%) | recurrence | |
| (level IIb) | AF Group I 44 | |||
| patients in sinus | Reoperation rate | Freedom from reoperation | AF affects the worsening of TR over time | |
| rhythm; Group II | 1 month: 99% | |||
| 48 patients in AF | 8 years: 97% | MAZE can prevent this course | ||
| with MAZE and | ||||
| Group III 78 | Preoperative TR grade | Group I 12 patients (27.3%) | Recovery and maintenance of atrial | |
| patients without | Group II 8 patients (16.7%) | mechanical activity are of great value for | ||
| MAZE | Group III 26 patients (33.3%) | such a benefit | ||
| Progression of TR at | Immediate results (significant | |||
| follow-up | TR) Group I 3 patients | |||
| (6.8%) Group II 1 pt (2.1%) | ||||
| Group III 11 patients (14.1%) | ||||
| P=NS among groups | ||||
| Post-op results (significant TR) | ||||
| Group I 3/41 patients | ||||
| (7.3%) Group II 6/47 pt (12.8%) | ||||
| Group III 26/67 patients (38.8%) | ||||
| P=0.001 Group I vs. Group III | ||||
| P=0.005 Group II vs. Group III | ||||
| Atrial contractility | Group II (+MAZE) 38 patients | |||
| contribution and | of Group II maintained sinus | |||
| analysis | rhythm (Group IIa) 10 patients | |||
| with no LA mechanical activity | ||||
| (AF, accelerated junctional | ||||
| rhythm, sinus rhythm) | ||||
| Group IIa had smaller | ||||
| LA size preoperatively and | ||||
| lower TR grade at the final | ||||
| follow-up than those in Group IIb | ||||
| (P=0.038; P=0.025) | ||||
| Left-side valve surgery | MVR/MVRep 174 patients | |||
| (51.9%) | ||||
| AV surgery alone 74 patients | ||||
| (22.1%) | ||||
| Combined MV+AV surgery | ||||
| 87 patients (4.5%) MVR/MVRep | ||||
| 174 patients (51.9%) | ||||
| AV surgery alone 74 patients | ||||
| (22.1%) | ||||
| Combined MV+AV surgery | ||||
| 87 patients (4.5%) | ||||
| TV surgery and | Annuloplasty 15 patients (4.5%) | |||
| technique | ||||
| TR development | Significant: 90 patients (26.9%) | |||
| Severe in 25 patients (7.5%) | ||||
| TR population and risk | Age (47.6±13.4 vs. 44.3±13.2 | |||
| factors (TR+ vs. TR-) | years, P=0.04) | |||
| Preop AF (83.3 vs. 46.5%, | ||||
| P<0.001) | ||||
| LA dimension (56.9±13.2 | ||||
| vs. 52.4 ±11.5 mm, P=0.006) | ||||
| Prior valve surgery (40.0 vs. | ||||
| 25.3%, P=0.01). | ||||
| Event-free survival | TR- group | |||
| at 100, 140, 160 and | 97.0±1.1% | |||
| 175 months | 87.7±2.8% | |||
| 85.9±2.6% | ||||
| 85.9±2.6% | ||||
| TR+ group | ||||
| 94.4±2.4% | ||||
| 86.2±3.7% | ||||
| 70.9±5.9% | ||||
| 62.0±9.8% | ||||
| P=0.03 | ||||
| Jonjev et al., | From July 1994 | Follow-up duration | Mean 42 months (range | In end-stage heart disease and selected |
| (2007), J Card | to July 2004, | 1–120 months) | patient population the RADO procedure is | |
| Surg, Serbia and | 226 of 294 | effective | ||
| Montenegro, [16] | patients who | Functional status | Preopertative NYHA class III | |
| underwent surgical | 70 patients (39.88%) | Concomitant reduction of mitral and | ||
| Prospective | intervention for | NYHA class IV 126 patients | tricuspid insufficiency provides early and | |
| study (level IIb) | chronic ischemic | (69.02%) mean NYHA class | long-term beneficial effect, according with | |
| mitral | 3.9 | the natural history of the disease | ||
| regurgitation | ||||
| had reductive | Surgical procedure | Mitral valve surgery | No data are provided about the long-term | |
| annuloplasty of | efficacy of De Vega annuloplasty for the | |||
| double orifices | Carpentier mitral ring | prevention of late TR development | ||
| (RADO) | 37 patients (16.38%) | |||
| Semicircular posterior annuloplasty | ||||
| 189 patients (69.02%) | ||||
| TV surgery | ||||
| De Vega annuloplasty | ||||
| 226 patients (100%) | ||||
| Follow-up | Mean NYHA class 1.9 mean | |||
| EF preoperative 25% to | ||||
| postoperative 34% | ||||
| RADO results | Mitral valve insufficiency | |||
| mean grade 3.7±0.4 | ||||
| preoperative to 0.7±0.3 | ||||
| postoperative | ||||
| TV insufficiency mean grade | ||||
| 3.4±0.4 preoperative to | ||||
| 0.9±0.2 prostoperative | ||||
| Survival | 5 years–10 years | |||
| 61.5±4.0% – 38.05±8.0% | ||||
| Freedom from | At 10 years 60.0±6.7% | |||
| decompensation | ||||
| De Bonis et al., | Ninety-one DCM | Follow-up | 1.8±1.2 years (range 0.5–5.7 | Retrospective study |
| (2008), Eur J | patients (mean age | years) | ||
| Cardiothorac Surg, | 61±11.3) | No consistent, accurate data were available | ||
| Italy, [17] | submitted to MV | Left-sided surgery | Edge-to-edge+undersized | preoperatively and at follow-up regarding |
| repair (±tricuspid | and concomitant | annuloplasty 46 patients | right atrial dimension, tricuspid annular size | |
| Cohort study | repair) for | procedures | (50.5%) undersized | and degree of leaflet tethering |
| (level IIb) | functional MR | annuloplasty 45 patients (49.4%) | ||
| Small number of patients included | ||||
| CABG 41 patients (45%) | ||||
| uncorrected moderate or less TR in patients | ||||
| AF surgery 14 patients (15.3%) | with functional MR often persist and | |||
| worsen over time | ||||
| TV surgical | 13 patients (3+/4+ or | |||
| intervention | >TR) had TV annuloplasty: | Annular dilatation and tethering as | ||
| underlying mechanisms of late TR | ||||
| De Vega Procedure: 7 patients | ||||
| Ring annuloplasty: | RV function assessment is essential to | |||
| 6 patients | guide the surgical intervention | |||
| No TV annuloplasty: 78 patients | Absence of ‘reverse remodelling’ influences | |||
| (with TR<2+/4+) | late TR development | |||
| Evolution of fTR | Absent/mild 52 patients (57.1%) | |||
| Moderate 28 patients (30.7%) | ||||
| Moderately severe 9 patients | ||||
| (9.8%) | ||||
| Severe 2 patients (2.2%) | ||||
| 11 of 91 patients (12%) had | ||||
| progression of TR | ||||
| 14 of the 78 patients (17.9%) | ||||
| no-TR had worsening of TR at | ||||
| least of 2 grades | ||||
| TR evolution | Annular dilatation in 75 patients | |||
| mechanisms | tethering in 6 patients | |||
| Predictors of significant | RV dilatation (OR 8.3, P=0.009) | |||
| late TR | ||||
| Pre-op. RV dysfunction (OR | ||||
| 13.7, P=0.0001) | ||||
| TR grade at discharge (OR 5.4, | ||||
| P=0.01) | ||||
| Pulmonary | Significant (>3+) TR at | |||
| hypertension | follow-up: | |||
| 37% (9/24) among the patients | ||||
| with pulmonary hypertension | ||||
| 3% (2/67) among those with | ||||
| SPAP <40 mmHg at the last | ||||
| echocardiogram | ||||
| (P<0.0001) | ||||
| Pattern of LV | ‘reverse remodeling’ group: | |||
| remodeling | Significant TR in only 1 of 49 | |||
| patients (2%) that demonstrated | ||||
| reverse remodeling | ||||
| No ‘reverse remodeling group’ | ||||
| significant TR in 10 of 42 | ||||
| patients (23.8%) | ||||
| (P=0.04) | ||||
fMR, functional mitral regurgitation; MVRep, mitral valve repair; FTR, functional tricuspid regurgitation; TVRep, tricuspid valve repair; PMK, pacemaker; TTE, trans-thoracic echocardiography; TA, tricuspid annulus; MR, mitral regurgitation; AVR, aortic valve replacement; AVRep, aortic valve repair; AV, aortic valve; HR, hazard ratio; OR, odds ratio.
| Author, date | Patient group | Outcomes | Key results | Comments |
| and country, | ||||
| Study type | ||||
| (level of evidence) | ||||
| Bonow et al., | Class I | Severe TR in the setting of | ||
| ACC/AHA VHD | surgery for multivalvular | |||
| Guidelines: (2008), | disease should be | |||
| focused update | corrected | |||
| (level of evidence: c) | Class II | Tricuspid annuloplasty is | ||
| reasonable for mild TR in | ||||
| patients undergoing MV surgery | ||||
| when there is pulmonary | ||||
| hypertension or tricuspid | ||||
| annular dilatation | ||||
| Vahanian et al., | Class IIa | Concomitant TV repair if | ||
| (2007), Eur | TA diameter >40 mm | |||
| Heart J, ESC | ||||
| guidelines | TV repair in patients with | |||
| symptomatic, isolated TR late | ||||
| after left-sided valve surgery, | ||||
| in absence of left-sided | ||||
| myocardial or RV dysfunction | ||||
| and without severe pulmonary | ||||
| hypertension | ||||
| Turina et al., | 170 patients | Follow-up | Mean 10.6 years (1802 | Retrospective study |
| (1999), | (between 1975 | patient-years) | ||
| Circulation, | and 1989) who | Significant TV regurgitation requiring | ||
| Switzerland, [2] | underwent surgery | Surgical procedures | Double valve surgery 170 | surgical repair worsened the prognosis |
| for chronic | patients | |||
| Retrospective | combined aortic | Advice for TV repair when hemodynamic | ||
| study (level IIb) | and mitral valvular | TV surgery 29 patients (17%) | significant regurgitation is present | |
| disease | ||||
| CABG 7 patients (4%) | ||||
| Ascending aorta surgery 7 | ||||
| patients (4%) | ||||
| Reoperation involving | Tricuspid replacement 2 | |||
| TV | patients | |||
| Tricuspid reconstruction | ||||
| 2 patients | ||||
| Survival rate in | At 10 years (cumulative survival) | |||
| patients with TR | ||||
| With TV reconstruction 57% | ||||
| Without TV reconstruction 68% | ||||
| Predictors of late | Age (P=0.0011) LVEF | |||
| outcome | (P=0.0008) Additional TV | |||
| regurgitation | ||||
| (P=0.007) | ||||
| Nath et al., | 5223 patients | One-year survival | 91.7% with no TR, | Retrospective study |
| (2004), J Am Coll | undergoing | 90.3% with mild TR, | ||
| Cardiol, USA, [3] | echocardiography; | 78.9% with moderate TR, | Huge cohort of patients | |
| four years follow- | 63.9% with severe TR | |||
| Retrospective | up; comparison | Long follow-up | ||
| study (level IIb) | survival differences | TR grade, pulmonary | Moderate or greater TR | |
| among TR grades | artery pressure and | increased mortality regardless | Unknown NYHA class at follow-up | |
| mortality | of PASP HR 1.31 for PASP | |||
| >40 mmHg; HR 1.32 PA | No data correlation with MR grade and TR | |||
| <40 mmHg | ||||
| TR grade, LVEF and | Moderate or greater TR | |||
| mortality | increased mortality | |||
| regardless of EF | ||||
| HR 1.49 EF<50% | ||||
| HR 1.54 EF>50% | ||||
| Porter et al., | 65 patients with | Follow-up duration | 11.3±8 years (range | Retrospective study |
| (1999), J Heart | rheumatic heart | 1–30 years) | ||
| Valve Dis, | disease who had | No data about preoperative TR | ||
| Israel, [4] | undergone MVR | Left-sided valve | MV stenosis 44 patients (67%) | |
| without TV | pathology and surgical | MV regurgitation 21 patients | No data on preoperative RV status | |
| Retrospective | surgery | intervention | (33%) | |
| study case series | Outlines the late development rate of TR | |||
| (level IIIb) | Mitral valve replacement in all | when uncorrected at the time of left-sided | ||
| cases | valve surgery | |||
| Outcomes | 44 patients (67%) developed | |||
| late TR | ||||
| Moderate 16 patients (36.4%) | ||||
| Severe 18 patients (41%) | ||||
| Risk factors | Age RR 1.1 female gender 1.8 | |||
| Matsuyama et al., | Between March | Mean follow-up | 8.2±3.6 years (range 1.0–14.5 | Retrospective study |
| (2003), Ann Thor | 1988 and | years) | ||
| Surg, Japan, [5] | September 2001 of | Long overall follow-up but high variability | ||
| 174 of 274 patients | Late deaths | 14 late deaths (8%) | of time (may underestimate late TR | |
| Retrospective | undergoing MV | development in some early patients) | ||
| study (level IIb) | surgery did not | Early postoperative | TR (3+/4+ or more) in 4 | |
| receive concomitant | outcome | patients (2%) | Mitral valve repair as left-side valve | |
| TV surgery | surgery in 53% of patients | |||
| Follow-up of TR grade | 28 patients developed TR grade | |||
| 3+ or more (16%) 46 patients | Progression of TR over time | |||
| with preopearative TR 2+/4+, | ||||
| TR had progression in | Early postoperative TR grade is unreliable | |||
| 17 patients (37%) | for estimation of late TR progression | |||
| Risk factors for | Preoperative 2+ TR: OR 3.9 | No assessment of right ventricular | ||
| significant TR (3+ | (P=0.004) AF: OR 9.2 (P=0.03) | dysfunction or tricuspid annulus dilatation | ||
| or more) | left atrium size: OR 2.8 | |||
| (P=0.03) | Strong correlation with AF and atrial size | |||
| Recommendation for aggressive TR repair | ||||
| in selected cases | ||||
| Matsunaga et al., | From January | Tricuspid annuloplasty | 21 patients had preoperative | Retrospective study |
| (2005), Circulation, | 1992 to December | TR (moderate or greater) | ||
| USA; Japan, [6] | 2001, 124 | 9 patients underwent TVRep | Relatively small number of patients | |
| consecutive | (TR-group) 12 patients TR was | |||
| Retrospective | patients with fMR | ignored (no-TR group) | Long and complete follow-up | |
| study (level IIb) | underwent CABG | |||
| and MVRep. 21 | TR moderate or greater | 4 patients (44%) of TR group | 50% of patients after MVRep showed | |
| patients (30%) had | at follow-up | 8 patients (67%) of no-TR group | significant TR at follow-up | |
| TR before surgery | (P=NS) | |||
| Presence or absence of residual MR do not | ||||
| Progression of TR after | Significant TR 25% at 1 year, | affect the incidence of follow-up TR | ||
| MVRep | 53% at 1–3 years, 74% | |||
| over 3 years | Revascularization and MVRep do not | |||
| reduce RV pressure overload and do not | ||||
| Follow-up MR and TR | 14 of 21 patients (64%) with | prevent late TR | ||
| significant recurrent MR had | ||||
| also significant TR | Incidence of late TR was independent of | |||
| whether the TR was surgically treated or | ||||
| 20 of 48 patients (42%) with no | ignored (44% vs. 67%; P=NS) | |||
| recurrent MR had significant TR | ||||
| (P=NS) | Significant recurrent MR (31%) reinforces | |||
| the significance of ventricular geometric | ||||
| Follow-up echo data | RV systolic pressure in the TR | distortion as ongoing remodelling affecting | ||
| group was higher than the no-TR | RV and LV geometries | |||
| group | ||||
| LV ejection fraction was not | ||||
| different between the groups | ||||
| Calafiore et al., | From January | Follow-up duration | 68 months (100% complete) | Moderate-or-more fTR, if untreated, can |
| (2009), Ann | 1988 to March | impair both midterm survival and functional | ||
| Thorac Surg, | 2003, 110 patients | Mortality | Treated vs. untreated TR group | status, even if it seems not to affect early |
| Italy, [7] | with functional | 30 days: 2% vs. 8.5% | outcome | |
| mitral regurgitation | (P=0.213) long-term (46/104 | |||
| Retrospective | undergoing mitral | patients) 16 patients vs. | Reversal of TV remodeling cannot be | |
| study (level IIb) | valve surgery | 30 patients | expected with MV surgery alone | |
| showed moderate- | ||||
| or-more functional | TR | At 12 months follow-up | Functional TR progression is not related to | |
| TR repaired with | (77 patients) | functional MVR progression | ||
| De Vega technique | ||||
| Treated group (42 patients) | Surgical technique can then influence the | |||
| No TR: 50% | late results of TR correction | |||
| TR 1+: 31% | ||||
| TR 2+: 14% | ||||
| TR 3+: 5% | ||||
| Untreated group (35 patients) | ||||
| No TR: 0% | ||||
| TR 1+: 23% | ||||
| TR 2+: 37% | ||||
| TR 3+: 34% | ||||
| TR 4+: 6% | ||||
| MVR progression and | MV repair (60 patients) MR | |||
| influence on fTR | 3+: >3 patients (5%) Late | |||
| recurrence/progression | fTR group vs. non late fTR | |||
| 2/47 (4.3%) vs. 1/13 (7.7%) | ||||
| P=0.625 | ||||
| Survival | 5 years – treated vs. untreated | |||
| TR 45.0±6.1% vs. 74.5±5.1% | ||||
| (P=0.044) | ||||
| Risk factors of | Lower mid-term survival (HR 2.7) | |||
| untreated | ||||
| moderate-or-more TR | Survival in NYHA class II or II | |||
| (HR 1.9) | ||||
| Boyaci et al., | Sixty-eight (68) | TR grade, LVEF and | Moderate or greater | Retrospective study |
| (2007), | patients undergone | mortality | TR increased mortality | |
| Angiology, | MVR without | regardless of EF | Improvement of functional capacity | |
| Turkey, [8] | TV surgery | HR 1.49 EF<50% | in 86% of patients with mild | |
| HR 1.54 EF>50% | preop TR vs. 54% of those with | |||
| Retrospective | significant TR | |||
| study (level IIb) | Preoperative TR | Mild TR (group I) 42 patients | ||
| (62%) | Right ventricular pressure fell and remained | |||
| lower in patients with mild TR, but not in | ||||
| Significant TR (group II) 26 | patients with moderate to severe TR | |||
| patients (38%) | ||||
| Transmitral F-U | Group I vs. Group II (mmHg) | |||
| gradient | 5.2±2.5 vs. 5.6±3.0 | |||
| (P=NS) | ||||
| Right ventricular | Group I (mmHg) 47±1.0 to | |||
| systolic pressure | 31±10 | |||
| trend pre- | ||||
| postoperative | Group II 45±9 to 42±12 | |||
| Pulmonary | Group I vs. Group II (mmHg) | |||
| hypertension at F-U | 31±10 vs. 42±12 | |||
| (P<0.05) | ||||
| NYHA Class at F-U | Group I vs. Group II | |||
| NYHA I 19% vs. 2% (P<0.05) | ||||
| NYHA II 67% vs. 46% (P<0.05) | ||||
| NYHA III 14% vs. 38% | ||||
| (P<0.05) | ||||
| Hospitalization/year | Group I vs. Group II 1.1±0.4 | |||
| vs. 1.8±0.7 | ||||
| (P<0.05) | ||||
| Song et al., | Between 1995 and | Follow-up | Clinical 101±24 months (range | Retrospective study |
| (2009), | 2000, 638 patients | 12–146 months) | ||
| Heart, | (356 men) with | Extensive number of patients | ||
| Korea, [9] | mild (≤grade 2/4) | Echocardiographical | ||
| TR underwent | 64±30 months (range 14–141 | Outlines the natural history of late TR | ||
| Retrospective | surgery without | months) | development | |
| study | any procedure on | |||
| (level IIb) | the TV | Left-side valve surgery | Mitral valve surgery | Rheumatic aetiology is strongly associated |
| 323 patients | with development of late significant TR | |||
| Aortic valve surgery 221 patients | Female gender has higher incidence | |||
| probably due to higher prevalence of | ||||
| Double-valve surgery | rheumatic disease in this population | |||
| 94 patients | ||||
| AF is the most striking risk factor for | ||||
| Significant late TR | Mitral valve surgery 9.6% | development of late significant TR | ||
| development | (31/323 patients) | |||
| PH is not associated with TR progression | ||||
| Aortic valve surgery 3.2% | ||||
| (7/221 patients) | Right ventricular distortion or annular | |||
| dilatation is associated with late TR | ||||
| Double-valve surgery 11.7% | development | |||
| (11/94 patients) | ||||
| Impact of rheumatic | Rheumatic MR 15% (10/65 | |||
| disease on late TR | patients) | |||
| Non-rheumatic MR 5% (7/133 | ||||
| patients) | ||||
| (P=0.017) | ||||
| AF | 239 patients (37%) before | |||
| surgery | ||||
| 184 patients persistent AF | ||||
| 18 patients (5%) developed | ||||
| AF at follow-up | ||||
| TV annular dilatation | TV annulus increased in both | |||
| group | ||||
| Late TR 32±6 to 40±7 mm | ||||
| Non late TR 40±7 mm | ||||
| P<0.001 | ||||
| Late TR risk factors | Age (HR 1.0; P=0.005) | |||
| Female gender (HR 5.0; | ||||
| P=0.001) rheumatic aetiology | ||||
| (HR 3.8; P=0.011) AF (HR | ||||
| 2.6; P=0.035) peak pressure | ||||
| gradient of TR (HR 1.1; <0.001) | ||||
| Mortality | Significant TR vs. non late TR | |||
| 4.9% vs. 16.3% | ||||
| (P=0.004) | ||||
| Event-free survival | Late TR vs. non-late TR | |||
| 76±6% vs. 91±1% | ||||
| (P<0.001) | ||||
| Colombo et al., | From January | Follow-up | 25±15.9 months (range 3–49 | Prospective study |
| (2001), Cardiovasc | 1995 to December | months) | ||
| Surg, Italy, [10] | 1998, 50 patients | Absence or mild to moderate TR in 83.9% | ||
| with rheumatic | Surgical procedure | MVR with mechanical valve: | of patients who underwent tricuspid | |
| Prospective | mitral valve | 47 patients | procedure | |
| single center | disease and | |||
| cohort study | functional | MVR with bioprosthesis: | Undersizing of TV annulus has been | |
| (level IIb) | TR underwent | 3 patients | effective even with the De Vega procedure | |
| surgery for | TVRep with De Vega procedure: | |||
| MVR and TV | 33 patients | |||
| repair | ||||
| Outcome | TVRep group with 3+ or 4+ | |||
| TV repair | TR Grade 0 or 1+: 19 patients | |||
| performed if | (73%) Grade 1+ or 2+: | |||
| indexed TV | 3 patients (11.5%) Grade 2+ | |||
| annular dimension | or 3+: 1 pt (3.8%) Grade 3+ to | |||
| >21 mm/m2 | 4+: 3 patients (11.5%) | |||
| Two patients of five with TV | ||||
| annulus >21 mm/m2 who did | ||||
| not undergo TV annuloplasty had | ||||
| significant TR at follow-up | ||||
| Dreyfus et al., | Between 1989 and | Mortality | No significant difference | Retrospective study; consecutive patients |
| (2005), Ann | 2001, 311 patients | (group 1=1.8%; group 2=0.7%) | ||
| Thorac Surg, | underwent mitral | 10 years follow-up patients | ||
| UK, [11] | valve repair | Actuarial survival rate | Group 1=97.3%, 96.2%, and | |
| (MVR). Tricuspid | 85.5%; group 2=98.5%, | Precise and reproducible method of TV | ||
| Retrospective | annuloplasty | 98.5%, and 90.3% at 3, 5, and | sizing is used | |
| study (level IIb) | performed if | 10 years, respectively | ||
| tricuspid annular | Demonstrates little or no correlation | |||
| diameter ≥70 mm | NYHA class | Improved in group MVR+TV | between tricuspid dilatation and | |
| regardless of the | annuloplasty (group | regurgitation | ||
| grade of | 1=1.59±0.84; group | |||
| regurgitation. | 2=1.11±0.31; | Tricuspid dilatation is more reliable than | ||
| Group 1 MVR | P<0.001) | TR when assessing secondary TV disease | ||
| alone (163 | ||||
| patients; 54.4%); | TR grade | Increased >2 grades in | ||
| Group 2 MVR | 48% of group 1 (MVR alone) | |||
| plus tricuspid | and only 2% in group 2 (MVR+ | |||
| annuloplasty (148 | TV annuloplasty) | |||
| patients; 47.6%) | ||||
| McCarthy et al., | From 1990 to | Follow-up | 8 years (3302 patient-years) | Retrospective study no consistent, |
| (2004), J Thorac | 1999, 790 patients | accurate data for right ventricular function, | ||
| Cardiovasc Surg, | underwent | Left-sided valve | MVR 425 patients (54%) | size and geometry, TV annular size, PAPs |
| USA, [12] | TV annuloplasty | surgery and other | ||
| for functional | procedures | MVRep 276 patients (35%) | No analysis of residual MR | |
| Cohort study | regurgitation using | |||
| (level IIb) | 4 techniques: | AVR 199 patients (25%) | No analytical correlation between TR and | |
| 1. Carpentier– | survival or progression of NYHA class | |||
| Edwards semi-rigid | AVRep 15 patients (2%) | |||
| ring | Residual TR in 14% of patients early after | |||
| 2. Cosgrove– | CABG 205 patients (265) | operation | ||
| Edwards flexible | ||||
| band | Distribution of patients | Carpentier: 139 patients | Late worsening (beyond 6 months) | |
| 3. De Vega | according to TV repair | (17%) | associated with patient disease factors | |
| procedure | technique | AND with avoidable causes such as trans- | ||
| 4. Peri-Guard | Cosgrove: 291 patients (37%) | tricuspid pacing leads and type of | ||
| annuloplasty | annuloplasty | |||
| De Vega: 116 patients (15%) | ||||
| 2 non-ring annuloplasties, De Vega and | ||||
| Peri-Guard: 243 patients (31%) | Peri-Guard, worsening of TR. | |||
| Reoperation rate | Freedom from reoperation | |||
| 1 month: 99% | ||||
| 8 years: 97% | ||||
| Progression to grade | Carpentier 3+: 10% - 10% - | |||
| 3+ or 4+ TR according | 11% - 11% 4+: 5.2% - 5.5% - | |||
| to TV repair technique | 6% - 6% (P=0.7) | |||
| 1 month | Cosgrove 3+: 10% - 12% - | |||
| 1 year | 12% - NA 4+: 5.3% - 6% - 6% - NA | |||
| 5 years | (P=0.05) | |||
| 8 years | ||||
| De Vega 3+: 9% - 12% - 17% - | ||||
| 20% 4+: 4.6 - 6% - 11% - 13% | ||||
| (P=0.002) | ||||
| Peri-Guard 3+: 10% - 13% - | ||||
| 19% - 22% 4+: 5.4% - 7% - 13% - | ||||
| 15% (P=0.0009) | ||||
| Pacemaker lead | Preop PMK Lead vs. No PMK | |||
| influence on 3+ and 4+ | Lead | |||
| TR prevalence | ||||
| 16% - 42% vs. 15% - 23% | ||||
| (1 month–5 years) | ||||
| Preop TR influence of | 9% - 14% - 22% at 1 month | |||
| late TR development | ||||
| (Prevalence of 3+ or | 18% - 23% - 29% at 5 years | |||
| 4+) | ||||
| 1. grades 0 vs. 1+ | ||||
| 2. 2+ vs. 3+ | ||||
| 3. vs. 4+ | ||||
| Risk factors for late TR | LV dysfunction (P=0.0002) | |||
| worsening | One-system disease (P=0.007) | |||
| AF (P=0.01) PMK lead | ||||
| (P=0.04) | ||||
| Tang et al., | Between 1978 and | Follow-up duration | 5.9±4.9 years (range | Majority of patients undergoing TV repair |
| (2006), Circulation, | 2003, 702 patients | 0–21 years) | have secondary (‘functional’) regurgitation | |
| Canada, [13] | underwent TV | |||
| repair in the setting | TR repair | De Vega procedure 493 | Uncorrected moderate and severe TR may | |
| Retrospective | of concomitant | patients | persist or even worsen after mitral valve | |
| study (level IIb) | left-sided valve | surgery | ||
| surgery and | ‘Ring’ annuloplasty 209 patients: | |||
| revascularization | Carpentier n. 114 (54%) | Annuloplasty ring refers significant | ||
| Duran n. 52 (25%) | improvement over De Vega repair in long- | |||
| Cosgrove n. 43 (21%) | term survival and event-free survival, as | |||
| well as recurrence of TR | ||||
| Functional class | Ring vs. non ring TV repair | |||
| NYHA III–IV 20% vs. 25% | Beneficial effects of a TV annuloplasty | |||
| ring were independent of the type of | ||||
| Late TR | Ring group No TR 15% | mitral valve surgery performed | ||
| Trivial-to-mild TR 55% | ||||
| Moderate-to-severe TR 30% | Recurrence of TR was not significantly | |||
| associated with the recurrence of MR | ||||
| Non-ring group No TR 10% | ||||
| Trivial-to-mild TR 54% | ||||
| Moderate-to-severe TR 36% | ||||
| Outcomes | No ring vs. ring (15 years) | |||
| Freedom from TR 39±11% vs. | ||||
| 82±5% (P=0.003) | ||||
| Long-term survival 36±8% vs. | ||||
| 49±5% (P=0.007) | ||||
| Event-free survival 17±6% | ||||
| vs. 34±5% | ||||
| Predictors | Annuloplasty ring | |||
| Long-term survival (HR 0.7; | ||||
| P=0.03) | ||||
| Event-free survival (HR 0.8; | ||||
| P=0.04) | ||||
| Kim et al., | From January | Distribution of patients | Carpentier: 139 patients (17%) | Retrospective study |
| (2005), | 1994 to December | according to TV repair | ||
| Circulation, | 1997, 170 patients | technique | Cosgrove: 291 patients (37%) | Long follow-up |
| Korea, [14] | underwent left- | |||
| side valve surgery | De Vega: 116 patients (15%) | Tricuspid repair techniques used are also | ||
| Retrospective | and MAZE (Cox | known to be burden by high late TR | ||
| study | III) operation for | Peri-Guard: 243 patients (31%) | recurrence | |
| (level IIb) | AF Group I 44 | |||
| patients in sinus | Reoperation rate | Freedom from reoperation | AF affects the worsening of TR over time | |
| rhythm; Group II | 1 month: 99% | |||
| 48 patients in AF | 8 years: 97% | MAZE can prevent this course | ||
| with MAZE and | ||||
| Group III 78 | Preoperative TR grade | Group I 12 patients (27.3%) | Recovery and maintenance of atrial | |
| patients without | Group II 8 patients (16.7%) | mechanical activity are of great value for | ||
| MAZE | Group III 26 patients (33.3%) | such a benefit | ||
| Progression of TR at | Immediate results (significant | |||
| follow-up | TR) Group I 3 patients | |||
| (6.8%) Group II 1 pt (2.1%) | ||||
| Group III 11 patients (14.1%) | ||||
| P=NS among groups | ||||
| Post-op results (significant TR) | ||||
| Group I 3/41 patients | ||||
| (7.3%) Group II 6/47 pt (12.8%) | ||||
| Group III 26/67 patients (38.8%) | ||||
| P=0.001 Group I vs. Group III | ||||
| P=0.005 Group II vs. Group III | ||||
| Atrial contractility | Group II (+MAZE) 38 patients | |||
| contribution and | of Group II maintained sinus | |||
| analysis | rhythm (Group IIa) 10 patients | |||
| with no LA mechanical activity | ||||
| (AF, accelerated junctional | ||||
| rhythm, sinus rhythm) | ||||
| Group IIa had smaller | ||||
| LA size preoperatively and | ||||
| lower TR grade at the final | ||||
| follow-up than those in Group IIb | ||||
| (P=0.038; P=0.025) | ||||
| Left-side valve surgery | MVR/MVRep 174 patients | |||
| (51.9%) | ||||
| AV surgery alone 74 patients | ||||
| (22.1%) | ||||
| Combined MV+AV surgery | ||||
| 87 patients (4.5%) MVR/MVRep | ||||
| 174 patients (51.9%) | ||||
| AV surgery alone 74 patients | ||||
| (22.1%) | ||||
| Combined MV+AV surgery | ||||
| 87 patients (4.5%) | ||||
| TV surgery and | Annuloplasty 15 patients (4.5%) | |||
| technique | ||||
| TR development | Significant: 90 patients (26.9%) | |||
| Severe in 25 patients (7.5%) | ||||
| TR population and risk | Age (47.6±13.4 vs. 44.3±13.2 | |||
| factors (TR+ vs. TR-) | years, P=0.04) | |||
| Preop AF (83.3 vs. 46.5%, | ||||
| P<0.001) | ||||
| LA dimension (56.9±13.2 | ||||
| vs. 52.4 ±11.5 mm, P=0.006) | ||||
| Prior valve surgery (40.0 vs. | ||||
| 25.3%, P=0.01). | ||||
| Event-free survival | TR- group | |||
| at 100, 140, 160 and | 97.0±1.1% | |||
| 175 months | 87.7±2.8% | |||
| 85.9±2.6% | ||||
| 85.9±2.6% | ||||
| TR+ group | ||||
| 94.4±2.4% | ||||
| 86.2±3.7% | ||||
| 70.9±5.9% | ||||
| 62.0±9.8% | ||||
| P=0.03 | ||||
| Jonjev et al., | From July 1994 | Follow-up duration | Mean 42 months (range | In end-stage heart disease and selected |
| (2007), J Card | to July 2004, | 1–120 months) | patient population the RADO procedure is | |
| Surg, Serbia and | 226 of 294 | effective | ||
| Montenegro, [16] | patients who | Functional status | Preopertative NYHA class III | |
| underwent surgical | 70 patients (39.88%) | Concomitant reduction of mitral and | ||
| Prospective | intervention for | NYHA class IV 126 patients | tricuspid insufficiency provides early and | |
| study (level IIb) | chronic ischemic | (69.02%) mean NYHA class | long-term beneficial effect, according with | |
| mitral | 3.9 | the natural history of the disease | ||
| regurgitation | ||||
| had reductive | Surgical procedure | Mitral valve surgery | No data are provided about the long-term | |
| annuloplasty of | efficacy of De Vega annuloplasty for the | |||
| double orifices | Carpentier mitral ring | prevention of late TR development | ||
| (RADO) | 37 patients (16.38%) | |||
| Semicircular posterior annuloplasty | ||||
| 189 patients (69.02%) | ||||
| TV surgery | ||||
| De Vega annuloplasty | ||||
| 226 patients (100%) | ||||
| Follow-up | Mean NYHA class 1.9 mean | |||
| EF preoperative 25% to | ||||
| postoperative 34% | ||||
| RADO results | Mitral valve insufficiency | |||
| mean grade 3.7±0.4 | ||||
| preoperative to 0.7±0.3 | ||||
| postoperative | ||||
| TV insufficiency mean grade | ||||
| 3.4±0.4 preoperative to | ||||
| 0.9±0.2 prostoperative | ||||
| Survival | 5 years–10 years | |||
| 61.5±4.0% – 38.05±8.0% | ||||
| Freedom from | At 10 years 60.0±6.7% | |||
| decompensation | ||||
| De Bonis et al., | Ninety-one DCM | Follow-up | 1.8±1.2 years (range 0.5–5.7 | Retrospective study |
| (2008), Eur J | patients (mean age | years) | ||
| Cardiothorac Surg, | 61±11.3) | No consistent, accurate data were available | ||
| Italy, [17] | submitted to MV | Left-sided surgery | Edge-to-edge+undersized | preoperatively and at follow-up regarding |
| repair (±tricuspid | and concomitant | annuloplasty 46 patients | right atrial dimension, tricuspid annular size | |
| Cohort study | repair) for | procedures | (50.5%) undersized | and degree of leaflet tethering |
| (level IIb) | functional MR | annuloplasty 45 patients (49.4%) | ||
| Small number of patients included | ||||
| CABG 41 patients (45%) | ||||
| uncorrected moderate or less TR in patients | ||||
| AF surgery 14 patients (15.3%) | with functional MR often persist and | |||
| worsen over time | ||||
| TV surgical | 13 patients (3+/4+ or | |||
| intervention | >TR) had TV annuloplasty: | Annular dilatation and tethering as | ||
| underlying mechanisms of late TR | ||||
| De Vega Procedure: 7 patients | ||||
| Ring annuloplasty: | RV function assessment is essential to | |||
| 6 patients | guide the surgical intervention | |||
| No TV annuloplasty: 78 patients | Absence of ‘reverse remodelling’ influences | |||
| (with TR<2+/4+) | late TR development | |||
| Evolution of fTR | Absent/mild 52 patients (57.1%) | |||
| Moderate 28 patients (30.7%) | ||||
| Moderately severe 9 patients | ||||
| (9.8%) | ||||
| Severe 2 patients (2.2%) | ||||
| 11 of 91 patients (12%) had | ||||
| progression of TR | ||||
| 14 of the 78 patients (17.9%) | ||||
| no-TR had worsening of TR at | ||||
| least of 2 grades | ||||
| TR evolution | Annular dilatation in 75 patients | |||
| mechanisms | tethering in 6 patients | |||
| Predictors of significant | RV dilatation (OR 8.3, P=0.009) | |||
| late TR | ||||
| Pre-op. RV dysfunction (OR | ||||
| 13.7, P=0.0001) | ||||
| TR grade at discharge (OR 5.4, | ||||
| P=0.01) | ||||
| Pulmonary | Significant (>3+) TR at | |||
| hypertension | follow-up: | |||
| 37% (9/24) among the patients | ||||
| with pulmonary hypertension | ||||
| 3% (2/67) among those with | ||||
| SPAP <40 mmHg at the last | ||||
| echocardiogram | ||||
| (P<0.0001) | ||||
| Pattern of LV | ‘reverse remodeling’ group: | |||
| remodeling | Significant TR in only 1 of 49 | |||
| patients (2%) that demonstrated | ||||
| reverse remodeling | ||||
| No ‘reverse remodeling group’ | ||||
| significant TR in 10 of 42 | ||||
| patients (23.8%) | ||||
| (P=0.04) | ||||
| Author, date | Patient group | Outcomes | Key results | Comments |
| and country, | ||||
| Study type | ||||
| (level of evidence) | ||||
| Bonow et al., | Class I | Severe TR in the setting of | ||
| ACC/AHA VHD | surgery for multivalvular | |||
| Guidelines: (2008), | disease should be | |||
| focused update | corrected | |||
| (level of evidence: c) | Class II | Tricuspid annuloplasty is | ||
| reasonable for mild TR in | ||||
| patients undergoing MV surgery | ||||
| when there is pulmonary | ||||
| hypertension or tricuspid | ||||
| annular dilatation | ||||
| Vahanian et al., | Class IIa | Concomitant TV repair if | ||
| (2007), Eur | TA diameter >40 mm | |||
| Heart J, ESC | ||||
| guidelines | TV repair in patients with | |||
| symptomatic, isolated TR late | ||||
| after left-sided valve surgery, | ||||
| in absence of left-sided | ||||
| myocardial or RV dysfunction | ||||
| and without severe pulmonary | ||||
| hypertension | ||||
| Turina et al., | 170 patients | Follow-up | Mean 10.6 years (1802 | Retrospective study |
| (1999), | (between 1975 | patient-years) | ||
| Circulation, | and 1989) who | Significant TV regurgitation requiring | ||
| Switzerland, [2] | underwent surgery | Surgical procedures | Double valve surgery 170 | surgical repair worsened the prognosis |
| for chronic | patients | |||
| Retrospective | combined aortic | Advice for TV repair when hemodynamic | ||
| study (level IIb) | and mitral valvular | TV surgery 29 patients (17%) | significant regurgitation is present | |
| disease | ||||
| CABG 7 patients (4%) | ||||
| Ascending aorta surgery 7 | ||||
| patients (4%) | ||||
| Reoperation involving | Tricuspid replacement 2 | |||
| TV | patients | |||
| Tricuspid reconstruction | ||||
| 2 patients | ||||
| Survival rate in | At 10 years (cumulative survival) | |||
| patients with TR | ||||
| With TV reconstruction 57% | ||||
| Without TV reconstruction 68% | ||||
| Predictors of late | Age (P=0.0011) LVEF | |||
| outcome | (P=0.0008) Additional TV | |||
| regurgitation | ||||
| (P=0.007) | ||||
| Nath et al., | 5223 patients | One-year survival | 91.7% with no TR, | Retrospective study |
| (2004), J Am Coll | undergoing | 90.3% with mild TR, | ||
| Cardiol, USA, [3] | echocardiography; | 78.9% with moderate TR, | Huge cohort of patients | |
| four years follow- | 63.9% with severe TR | |||
| Retrospective | up; comparison | Long follow-up | ||
| study (level IIb) | survival differences | TR grade, pulmonary | Moderate or greater TR | |
| among TR grades | artery pressure and | increased mortality regardless | Unknown NYHA class at follow-up | |
| mortality | of PASP HR 1.31 for PASP | |||
| >40 mmHg; HR 1.32 PA | No data correlation with MR grade and TR | |||
| <40 mmHg | ||||
| TR grade, LVEF and | Moderate or greater TR | |||
| mortality | increased mortality | |||
| regardless of EF | ||||
| HR 1.49 EF<50% | ||||
| HR 1.54 EF>50% | ||||
| Porter et al., | 65 patients with | Follow-up duration | 11.3±8 years (range | Retrospective study |
| (1999), J Heart | rheumatic heart | 1–30 years) | ||
| Valve Dis, | disease who had | No data about preoperative TR | ||
| Israel, [4] | undergone MVR | Left-sided valve | MV stenosis 44 patients (67%) | |
| without TV | pathology and surgical | MV regurgitation 21 patients | No data on preoperative RV status | |
| Retrospective | surgery | intervention | (33%) | |
| study case series | Outlines the late development rate of TR | |||
| (level IIIb) | Mitral valve replacement in all | when uncorrected at the time of left-sided | ||
| cases | valve surgery | |||
| Outcomes | 44 patients (67%) developed | |||
| late TR | ||||
| Moderate 16 patients (36.4%) | ||||
| Severe 18 patients (41%) | ||||
| Risk factors | Age RR 1.1 female gender 1.8 | |||
| Matsuyama et al., | Between March | Mean follow-up | 8.2±3.6 years (range 1.0–14.5 | Retrospective study |
| (2003), Ann Thor | 1988 and | years) | ||
| Surg, Japan, [5] | September 2001 of | Long overall follow-up but high variability | ||
| 174 of 274 patients | Late deaths | 14 late deaths (8%) | of time (may underestimate late TR | |
| Retrospective | undergoing MV | development in some early patients) | ||
| study (level IIb) | surgery did not | Early postoperative | TR (3+/4+ or more) in 4 | |
| receive concomitant | outcome | patients (2%) | Mitral valve repair as left-side valve | |
| TV surgery | surgery in 53% of patients | |||
| Follow-up of TR grade | 28 patients developed TR grade | |||
| 3+ or more (16%) 46 patients | Progression of TR over time | |||
| with preopearative TR 2+/4+, | ||||
| TR had progression in | Early postoperative TR grade is unreliable | |||
| 17 patients (37%) | for estimation of late TR progression | |||
| Risk factors for | Preoperative 2+ TR: OR 3.9 | No assessment of right ventricular | ||
| significant TR (3+ | (P=0.004) AF: OR 9.2 (P=0.03) | dysfunction or tricuspid annulus dilatation | ||
| or more) | left atrium size: OR 2.8 | |||
| (P=0.03) | Strong correlation with AF and atrial size | |||
| Recommendation for aggressive TR repair | ||||
| in selected cases | ||||
| Matsunaga et al., | From January | Tricuspid annuloplasty | 21 patients had preoperative | Retrospective study |
| (2005), Circulation, | 1992 to December | TR (moderate or greater) | ||
| USA; Japan, [6] | 2001, 124 | 9 patients underwent TVRep | Relatively small number of patients | |
| consecutive | (TR-group) 12 patients TR was | |||
| Retrospective | patients with fMR | ignored (no-TR group) | Long and complete follow-up | |
| study (level IIb) | underwent CABG | |||
| and MVRep. 21 | TR moderate or greater | 4 patients (44%) of TR group | 50% of patients after MVRep showed | |
| patients (30%) had | at follow-up | 8 patients (67%) of no-TR group | significant TR at follow-up | |
| TR before surgery | (P=NS) | |||
| Presence or absence of residual MR do not | ||||
| Progression of TR after | Significant TR 25% at 1 year, | affect the incidence of follow-up TR | ||
| MVRep | 53% at 1–3 years, 74% | |||
| over 3 years | Revascularization and MVRep do not | |||
| reduce RV pressure overload and do not | ||||
| Follow-up MR and TR | 14 of 21 patients (64%) with | prevent late TR | ||
| significant recurrent MR had | ||||
| also significant TR | Incidence of late TR was independent of | |||
| whether the TR was surgically treated or | ||||
| 20 of 48 patients (42%) with no | ignored (44% vs. 67%; P=NS) | |||
| recurrent MR had significant TR | ||||
| (P=NS) | Significant recurrent MR (31%) reinforces | |||
| the significance of ventricular geometric | ||||
| Follow-up echo data | RV systolic pressure in the TR | distortion as ongoing remodelling affecting | ||
| group was higher than the no-TR | RV and LV geometries | |||
| group | ||||
| LV ejection fraction was not | ||||
| different between the groups | ||||
| Calafiore et al., | From January | Follow-up duration | 68 months (100% complete) | Moderate-or-more fTR, if untreated, can |
| (2009), Ann | 1988 to March | impair both midterm survival and functional | ||
| Thorac Surg, | 2003, 110 patients | Mortality | Treated vs. untreated TR group | status, even if it seems not to affect early |
| Italy, [7] | with functional | 30 days: 2% vs. 8.5% | outcome | |
| mitral regurgitation | (P=0.213) long-term (46/104 | |||
| Retrospective | undergoing mitral | patients) 16 patients vs. | Reversal of TV remodeling cannot be | |
| study (level IIb) | valve surgery | 30 patients | expected with MV surgery alone | |
| showed moderate- | ||||
| or-more functional | TR | At 12 months follow-up | Functional TR progression is not related to | |
| TR repaired with | (77 patients) | functional MVR progression | ||
| De Vega technique | ||||
| Treated group (42 patients) | Surgical technique can then influence the | |||
| No TR: 50% | late results of TR correction | |||
| TR 1+: 31% | ||||
| TR 2+: 14% | ||||
| TR 3+: 5% | ||||
| Untreated group (35 patients) | ||||
| No TR: 0% | ||||
| TR 1+: 23% | ||||
| TR 2+: 37% | ||||
| TR 3+: 34% | ||||
| TR 4+: 6% | ||||
| MVR progression and | MV repair (60 patients) MR | |||
| influence on fTR | 3+: >3 patients (5%) Late | |||
| recurrence/progression | fTR group vs. non late fTR | |||
| 2/47 (4.3%) vs. 1/13 (7.7%) | ||||
| P=0.625 | ||||
| Survival | 5 years – treated vs. untreated | |||
| TR 45.0±6.1% vs. 74.5±5.1% | ||||
| (P=0.044) | ||||
| Risk factors of | Lower mid-term survival (HR 2.7) | |||
| untreated | ||||
| moderate-or-more TR | Survival in NYHA class II or II | |||
| (HR 1.9) | ||||
| Boyaci et al., | Sixty-eight (68) | TR grade, LVEF and | Moderate or greater | Retrospective study |
| (2007), | patients undergone | mortality | TR increased mortality | |
| Angiology, | MVR without | regardless of EF | Improvement of functional capacity | |
| Turkey, [8] | TV surgery | HR 1.49 EF<50% | in 86% of patients with mild | |
| HR 1.54 EF>50% | preop TR vs. 54% of those with | |||
| Retrospective | significant TR | |||
| study (level IIb) | Preoperative TR | Mild TR (group I) 42 patients | ||
| (62%) | Right ventricular pressure fell and remained | |||
| lower in patients with mild TR, but not in | ||||
| Significant TR (group II) 26 | patients with moderate to severe TR | |||
| patients (38%) | ||||
| Transmitral F-U | Group I vs. Group II (mmHg) | |||
| gradient | 5.2±2.5 vs. 5.6±3.0 | |||
| (P=NS) | ||||
| Right ventricular | Group I (mmHg) 47±1.0 to | |||
| systolic pressure | 31±10 | |||
| trend pre- | ||||
| postoperative | Group II 45±9 to 42±12 | |||
| Pulmonary | Group I vs. Group II (mmHg) | |||
| hypertension at F-U | 31±10 vs. 42±12 | |||
| (P<0.05) | ||||
| NYHA Class at F-U | Group I vs. Group II | |||
| NYHA I 19% vs. 2% (P<0.05) | ||||
| NYHA II 67% vs. 46% (P<0.05) | ||||
| NYHA III 14% vs. 38% | ||||
| (P<0.05) | ||||
| Hospitalization/year | Group I vs. Group II 1.1±0.4 | |||
| vs. 1.8±0.7 | ||||
| (P<0.05) | ||||
| Song et al., | Between 1995 and | Follow-up | Clinical 101±24 months (range | Retrospective study |
| (2009), | 2000, 638 patients | 12–146 months) | ||
| Heart, | (356 men) with | Extensive number of patients | ||
| Korea, [9] | mild (≤grade 2/4) | Echocardiographical | ||
| TR underwent | 64±30 months (range 14–141 | Outlines the natural history of late TR | ||
| Retrospective | surgery without | months) | development | |
| study | any procedure on | |||
| (level IIb) | the TV | Left-side valve surgery | Mitral valve surgery | Rheumatic aetiology is strongly associated |
| 323 patients | with development of late significant TR | |||
| Aortic valve surgery 221 patients | Female gender has higher incidence | |||
| probably due to higher prevalence of | ||||
| Double-valve surgery | rheumatic disease in this population | |||
| 94 patients | ||||
| AF is the most striking risk factor for | ||||
| Significant late TR | Mitral valve surgery 9.6% | development of late significant TR | ||
| development | (31/323 patients) | |||
| PH is not associated with TR progression | ||||
| Aortic valve surgery 3.2% | ||||
| (7/221 patients) | Right ventricular distortion or annular | |||
| dilatation is associated with late TR | ||||
| Double-valve surgery 11.7% | development | |||
| (11/94 patients) | ||||
| Impact of rheumatic | Rheumatic MR 15% (10/65 | |||
| disease on late TR | patients) | |||
| Non-rheumatic MR 5% (7/133 | ||||
| patients) | ||||
| (P=0.017) | ||||
| AF | 239 patients (37%) before | |||
| surgery | ||||
| 184 patients persistent AF | ||||
| 18 patients (5%) developed | ||||
| AF at follow-up | ||||
| TV annular dilatation | TV annulus increased in both | |||
| group | ||||
| Late TR 32±6 to 40±7 mm | ||||
| Non late TR 40±7 mm | ||||
| P<0.001 | ||||
| Late TR risk factors | Age (HR 1.0; P=0.005) | |||
| Female gender (HR 5.0; | ||||
| P=0.001) rheumatic aetiology | ||||
| (HR 3.8; P=0.011) AF (HR | ||||
| 2.6; P=0.035) peak pressure | ||||
| gradient of TR (HR 1.1; <0.001) | ||||
| Mortality | Significant TR vs. non late TR | |||
| 4.9% vs. 16.3% | ||||
| (P=0.004) | ||||
| Event-free survival | Late TR vs. non-late TR | |||
| 76±6% vs. 91±1% | ||||
| (P<0.001) | ||||
| Colombo et al., | From January | Follow-up | 25±15.9 months (range 3–49 | Prospective study |
| (2001), Cardiovasc | 1995 to December | months) | ||
| Surg, Italy, [10] | 1998, 50 patients | Absence or mild to moderate TR in 83.9% | ||
| with rheumatic | Surgical procedure | MVR with mechanical valve: | of patients who underwent tricuspid | |
| Prospective | mitral valve | 47 patients | procedure | |
| single center | disease and | |||
| cohort study | functional | MVR with bioprosthesis: | Undersizing of TV annulus has been | |
| (level IIb) | TR underwent | 3 patients | effective even with the De Vega procedure | |
| surgery for | TVRep with De Vega procedure: | |||
| MVR and TV | 33 patients | |||
| repair | ||||
| Outcome | TVRep group with 3+ or 4+ | |||
| TV repair | TR Grade 0 or 1+: 19 patients | |||
| performed if | (73%) Grade 1+ or 2+: | |||
| indexed TV | 3 patients (11.5%) Grade 2+ | |||
| annular dimension | or 3+: 1 pt (3.8%) Grade 3+ to | |||
| >21 mm/m2 | 4+: 3 patients (11.5%) | |||
| Two patients of five with TV | ||||
| annulus >21 mm/m2 who did | ||||
| not undergo TV annuloplasty had | ||||
| significant TR at follow-up | ||||
| Dreyfus et al., | Between 1989 and | Mortality | No significant difference | Retrospective study; consecutive patients |
| (2005), Ann | 2001, 311 patients | (group 1=1.8%; group 2=0.7%) | ||
| Thorac Surg, | underwent mitral | 10 years follow-up patients | ||
| UK, [11] | valve repair | Actuarial survival rate | Group 1=97.3%, 96.2%, and | |
| (MVR). Tricuspid | 85.5%; group 2=98.5%, | Precise and reproducible method of TV | ||
| Retrospective | annuloplasty | 98.5%, and 90.3% at 3, 5, and | sizing is used | |
| study (level IIb) | performed if | 10 years, respectively | ||
| tricuspid annular | Demonstrates little or no correlation | |||
| diameter ≥70 mm | NYHA class | Improved in group MVR+TV | between tricuspid dilatation and | |
| regardless of the | annuloplasty (group | regurgitation | ||
| grade of | 1=1.59±0.84; group | |||
| regurgitation. | 2=1.11±0.31; | Tricuspid dilatation is more reliable than | ||
| Group 1 MVR | P<0.001) | TR when assessing secondary TV disease | ||
| alone (163 | ||||
| patients; 54.4%); | TR grade | Increased >2 grades in | ||
| Group 2 MVR | 48% of group 1 (MVR alone) | |||
| plus tricuspid | and only 2% in group 2 (MVR+ | |||
| annuloplasty (148 | TV annuloplasty) | |||
| patients; 47.6%) | ||||
| McCarthy et al., | From 1990 to | Follow-up | 8 years (3302 patient-years) | Retrospective study no consistent, |
| (2004), J Thorac | 1999, 790 patients | accurate data for right ventricular function, | ||
| Cardiovasc Surg, | underwent | Left-sided valve | MVR 425 patients (54%) | size and geometry, TV annular size, PAPs |
| USA, [12] | TV annuloplasty | surgery and other | ||
| for functional | procedures | MVRep 276 patients (35%) | No analysis of residual MR | |
| Cohort study | regurgitation using | |||
| (level IIb) | 4 techniques: | AVR 199 patients (25%) | No analytical correlation between TR and | |
| 1. Carpentier– | survival or progression of NYHA class | |||
| Edwards semi-rigid | AVRep 15 patients (2%) | |||
| ring | Residual TR in 14% of patients early after | |||
| 2. Cosgrove– | CABG 205 patients (265) | operation | ||
| Edwards flexible | ||||
| band | Distribution of patients | Carpentier: 139 patients | Late worsening (beyond 6 months) | |
| 3. De Vega | according to TV repair | (17%) | associated with patient disease factors | |
| procedure | technique | AND with avoidable causes such as trans- | ||
| 4. Peri-Guard | Cosgrove: 291 patients (37%) | tricuspid pacing leads and type of | ||
| annuloplasty | annuloplasty | |||
| De Vega: 116 patients (15%) | ||||
| 2 non-ring annuloplasties, De Vega and | ||||
| Peri-Guard: 243 patients (31%) | Peri-Guard, worsening of TR. | |||
| Reoperation rate | Freedom from reoperation | |||
| 1 month: 99% | ||||
| 8 years: 97% | ||||
| Progression to grade | Carpentier 3+: 10% - 10% - | |||
| 3+ or 4+ TR according | 11% - 11% 4+: 5.2% - 5.5% - | |||
| to TV repair technique | 6% - 6% (P=0.7) | |||
| 1 month | Cosgrove 3+: 10% - 12% - | |||
| 1 year | 12% - NA 4+: 5.3% - 6% - 6% - NA | |||
| 5 years | (P=0.05) | |||
| 8 years | ||||
| De Vega 3+: 9% - 12% - 17% - | ||||
| 20% 4+: 4.6 - 6% - 11% - 13% | ||||
| (P=0.002) | ||||
| Peri-Guard 3+: 10% - 13% - | ||||
| 19% - 22% 4+: 5.4% - 7% - 13% - | ||||
| 15% (P=0.0009) | ||||
| Pacemaker lead | Preop PMK Lead vs. No PMK | |||
| influence on 3+ and 4+ | Lead | |||
| TR prevalence | ||||
| 16% - 42% vs. 15% - 23% | ||||
| (1 month–5 years) | ||||
| Preop TR influence of | 9% - 14% - 22% at 1 month | |||
| late TR development | ||||
| (Prevalence of 3+ or | 18% - 23% - 29% at 5 years | |||
| 4+) | ||||
| 1. grades 0 vs. 1+ | ||||
| 2. 2+ vs. 3+ | ||||
| 3. vs. 4+ | ||||
| Risk factors for late TR | LV dysfunction (P=0.0002) | |||
| worsening | One-system disease (P=0.007) | |||
| AF (P=0.01) PMK lead | ||||
| (P=0.04) | ||||
| Tang et al., | Between 1978 and | Follow-up duration | 5.9±4.9 years (range | Majority of patients undergoing TV repair |
| (2006), Circulation, | 2003, 702 patients | 0–21 years) | have secondary (‘functional’) regurgitation | |
| Canada, [13] | underwent TV | |||
| repair in the setting | TR repair | De Vega procedure 493 | Uncorrected moderate and severe TR may | |
| Retrospective | of concomitant | patients | persist or even worsen after mitral valve | |
| study (level IIb) | left-sided valve | surgery | ||
| surgery and | ‘Ring’ annuloplasty 209 patients: | |||
| revascularization | Carpentier n. 114 (54%) | Annuloplasty ring refers significant | ||
| Duran n. 52 (25%) | improvement over De Vega repair in long- | |||
| Cosgrove n. 43 (21%) | term survival and event-free survival, as | |||
| well as recurrence of TR | ||||
| Functional class | Ring vs. non ring TV repair | |||
| NYHA III–IV 20% vs. 25% | Beneficial effects of a TV annuloplasty | |||
| ring were independent of the type of | ||||
| Late TR | Ring group No TR 15% | mitral valve surgery performed | ||
| Trivial-to-mild TR 55% | ||||
| Moderate-to-severe TR 30% | Recurrence of TR was not significantly | |||
| associated with the recurrence of MR | ||||
| Non-ring group No TR 10% | ||||
| Trivial-to-mild TR 54% | ||||
| Moderate-to-severe TR 36% | ||||
| Outcomes | No ring vs. ring (15 years) | |||
| Freedom from TR 39±11% vs. | ||||
| 82±5% (P=0.003) | ||||
| Long-term survival 36±8% vs. | ||||
| 49±5% (P=0.007) | ||||
| Event-free survival 17±6% | ||||
| vs. 34±5% | ||||
| Predictors | Annuloplasty ring | |||
| Long-term survival (HR 0.7; | ||||
| P=0.03) | ||||
| Event-free survival (HR 0.8; | ||||
| P=0.04) | ||||
| Kim et al., | From January | Distribution of patients | Carpentier: 139 patients (17%) | Retrospective study |
| (2005), | 1994 to December | according to TV repair | ||
| Circulation, | 1997, 170 patients | technique | Cosgrove: 291 patients (37%) | Long follow-up |
| Korea, [14] | underwent left- | |||
| side valve surgery | De Vega: 116 patients (15%) | Tricuspid repair techniques used are also | ||
| Retrospective | and MAZE (Cox | known to be burden by high late TR | ||
| study | III) operation for | Peri-Guard: 243 patients (31%) | recurrence | |
| (level IIb) | AF Group I 44 | |||
| patients in sinus | Reoperation rate | Freedom from reoperation | AF affects the worsening of TR over time | |
| rhythm; Group II | 1 month: 99% | |||
| 48 patients in AF | 8 years: 97% | MAZE can prevent this course | ||
| with MAZE and | ||||
| Group III 78 | Preoperative TR grade | Group I 12 patients (27.3%) | Recovery and maintenance of atrial | |
| patients without | Group II 8 patients (16.7%) | mechanical activity are of great value for | ||
| MAZE | Group III 26 patients (33.3%) | such a benefit | ||
| Progression of TR at | Immediate results (significant | |||
| follow-up | TR) Group I 3 patients | |||
| (6.8%) Group II 1 pt (2.1%) | ||||
| Group III 11 patients (14.1%) | ||||
| P=NS among groups | ||||
| Post-op results (significant TR) | ||||
| Group I 3/41 patients | ||||
| (7.3%) Group II 6/47 pt (12.8%) | ||||
| Group III 26/67 patients (38.8%) | ||||
| P=0.001 Group I vs. Group III | ||||
| P=0.005 Group II vs. Group III | ||||
| Atrial contractility | Group II (+MAZE) 38 patients | |||
| contribution and | of Group II maintained sinus | |||
| analysis | rhythm (Group IIa) 10 patients | |||
| with no LA mechanical activity | ||||
| (AF, accelerated junctional | ||||
| rhythm, sinus rhythm) | ||||
| Group IIa had smaller | ||||
| LA size preoperatively and | ||||
| lower TR grade at the final | ||||
| follow-up than those in Group IIb | ||||
| (P=0.038; P=0.025) | ||||
| Left-side valve surgery | MVR/MVRep 174 patients | |||
| (51.9%) | ||||
| AV surgery alone 74 patients | ||||
| (22.1%) | ||||
| Combined MV+AV surgery | ||||
| 87 patients (4.5%) MVR/MVRep | ||||
| 174 patients (51.9%) | ||||
| AV surgery alone 74 patients | ||||
| (22.1%) | ||||
| Combined MV+AV surgery | ||||
| 87 patients (4.5%) | ||||
| TV surgery and | Annuloplasty 15 patients (4.5%) | |||
| technique | ||||
| TR development | Significant: 90 patients (26.9%) | |||
| Severe in 25 patients (7.5%) | ||||
| TR population and risk | Age (47.6±13.4 vs. 44.3±13.2 | |||
| factors (TR+ vs. TR-) | years, P=0.04) | |||
| Preop AF (83.3 vs. 46.5%, | ||||
| P<0.001) | ||||
| LA dimension (56.9±13.2 | ||||
| vs. 52.4 ±11.5 mm, P=0.006) | ||||
| Prior valve surgery (40.0 vs. | ||||
| 25.3%, P=0.01). | ||||
| Event-free survival | TR- group | |||
| at 100, 140, 160 and | 97.0±1.1% | |||
| 175 months | 87.7±2.8% | |||
| 85.9±2.6% | ||||
| 85.9±2.6% | ||||
| TR+ group | ||||
| 94.4±2.4% | ||||
| 86.2±3.7% | ||||
| 70.9±5.9% | ||||
| 62.0±9.8% | ||||
| P=0.03 | ||||
| Jonjev et al., | From July 1994 | Follow-up duration | Mean 42 months (range | In end-stage heart disease and selected |
| (2007), J Card | to July 2004, | 1–120 months) | patient population the RADO procedure is | |
| Surg, Serbia and | 226 of 294 | effective | ||
| Montenegro, [16] | patients who | Functional status | Preopertative NYHA class III | |
| underwent surgical | 70 patients (39.88%) | Concomitant reduction of mitral and | ||
| Prospective | intervention for | NYHA class IV 126 patients | tricuspid insufficiency provides early and | |
| study (level IIb) | chronic ischemic | (69.02%) mean NYHA class | long-term beneficial effect, according with | |
| mitral | 3.9 | the natural history of the disease | ||
| regurgitation | ||||
| had reductive | Surgical procedure | Mitral valve surgery | No data are provided about the long-term | |
| annuloplasty of | efficacy of De Vega annuloplasty for the | |||
| double orifices | Carpentier mitral ring | prevention of late TR development | ||
| (RADO) | 37 patients (16.38%) | |||
| Semicircular posterior annuloplasty | ||||
| 189 patients (69.02%) | ||||
| TV surgery | ||||
| De Vega annuloplasty | ||||
| 226 patients (100%) | ||||
| Follow-up | Mean NYHA class 1.9 mean | |||
| EF preoperative 25% to | ||||
| postoperative 34% | ||||
| RADO results | Mitral valve insufficiency | |||
| mean grade 3.7±0.4 | ||||
| preoperative to 0.7±0.3 | ||||
| postoperative | ||||
| TV insufficiency mean grade | ||||
| 3.4±0.4 preoperative to | ||||
| 0.9±0.2 prostoperative | ||||
| Survival | 5 years–10 years | |||
| 61.5±4.0% – 38.05±8.0% | ||||
| Freedom from | At 10 years 60.0±6.7% | |||
| decompensation | ||||
| De Bonis et al., | Ninety-one DCM | Follow-up | 1.8±1.2 years (range 0.5–5.7 | Retrospective study |
| (2008), Eur J | patients (mean age | years) | ||
| Cardiothorac Surg, | 61±11.3) | No consistent, accurate data were available | ||
| Italy, [17] | submitted to MV | Left-sided surgery | Edge-to-edge+undersized | preoperatively and at follow-up regarding |
| repair (±tricuspid | and concomitant | annuloplasty 46 patients | right atrial dimension, tricuspid annular size | |
| Cohort study | repair) for | procedures | (50.5%) undersized | and degree of leaflet tethering |
| (level IIb) | functional MR | annuloplasty 45 patients (49.4%) | ||
| Small number of patients included | ||||
| CABG 41 patients (45%) | ||||
| uncorrected moderate or less TR in patients | ||||
| AF surgery 14 patients (15.3%) | with functional MR often persist and | |||
| worsen over time | ||||
| TV surgical | 13 patients (3+/4+ or | |||
| intervention | >TR) had TV annuloplasty: | Annular dilatation and tethering as | ||
| underlying mechanisms of late TR | ||||
| De Vega Procedure: 7 patients | ||||
| Ring annuloplasty: | RV function assessment is essential to | |||
| 6 patients | guide the surgical intervention | |||
| No TV annuloplasty: 78 patients | Absence of ‘reverse remodelling’ influences | |||
| (with TR<2+/4+) | late TR development | |||
| Evolution of fTR | Absent/mild 52 patients (57.1%) | |||
| Moderate 28 patients (30.7%) | ||||
| Moderately severe 9 patients | ||||
| (9.8%) | ||||
| Severe 2 patients (2.2%) | ||||
| 11 of 91 patients (12%) had | ||||
| progression of TR | ||||
| 14 of the 78 patients (17.9%) | ||||
| no-TR had worsening of TR at | ||||
| least of 2 grades | ||||
| TR evolution | Annular dilatation in 75 patients | |||
| mechanisms | tethering in 6 patients | |||
| Predictors of significant | RV dilatation (OR 8.3, P=0.009) | |||
| late TR | ||||
| Pre-op. RV dysfunction (OR | ||||
| 13.7, P=0.0001) | ||||
| TR grade at discharge (OR 5.4, | ||||
| P=0.01) | ||||
| Pulmonary | Significant (>3+) TR at | |||
| hypertension | follow-up: | |||
| 37% (9/24) among the patients | ||||
| with pulmonary hypertension | ||||
| 3% (2/67) among those with | ||||
| SPAP <40 mmHg at the last | ||||
| echocardiogram | ||||
| (P<0.0001) | ||||
| Pattern of LV | ‘reverse remodeling’ group: | |||
| remodeling | Significant TR in only 1 of 49 | |||
| patients (2%) that demonstrated | ||||
| reverse remodeling | ||||
| No ‘reverse remodeling group’ | ||||
| significant TR in 10 of 42 | ||||
| patients (23.8%) | ||||
| (P=0.04) | ||||
fMR, functional mitral regurgitation; MVRep, mitral valve repair; FTR, functional tricuspid regurgitation; TVRep, tricuspid valve repair; PMK, pacemaker; TTE, trans-thoracic echocardiography; TA, tricuspid annulus; MR, mitral regurgitation; AVR, aortic valve replacement; AVRep, aortic valve repair; AV, aortic valve; HR, hazard ratio; OR, odds ratio.
6. Results
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 ≥21 mm/m2. At follow-up, 83.9% of patients who underwent tricuspid procedure had absent or mild and mild-to-moderate TR.
In 2005, Dreyfus et al. [11] reported a series of 148 patients where an intra-operative TV annular diameter [tricuspid annulus (TA)] ≥70 mm was used as criterion for repair, regardless of the preoperative TR grade (equivalent to 4 cm by echocardiography [A. Berrebi, personal communication, November 2006]). TR increased more than two grades in 48% of patients in the no-TV repair group and only in 2% of the MVR+TVRep group. No correlation has been found between preoperative TA dilatation and regurgitation grade.
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).
7. Clinical bottom line
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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Topic:
- atrial fibrillation
- tricuspid valve disorders
- tricuspid valve insufficiency
- balloon valvuloplasty
- echocardiography
- rheumatic disorders
- cardiac surgery procedures
- pacemaker leads
- mitral valve
- tricuspid valve
- pulmonary hypertension
- mitral valve replacement surgery
- adhesions
- dilatation, pathologic
- preoperative care
- surgical procedures, operative
- survival rate
- vomiting
- guidelines
- pleural pressure
- multiple valve disease
- mitral valve procedures
- tricuspid valve anulus
- diameter
Issue Section:
Best evidence topic - Valves
