Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery

Umberto Benedetto, Giovanni Melina, Emiliano Angeloni, Simone Refice, Antonino Roscitano, Cosimo Comito, Riccardo Sinatra
Journal of Thoracic and Cardiovascular Surgery 2012, 143 (3): 632-8

OBJECTIVE: Progression of functional tricuspid regurgitation is not uncommon after mitral valve surgery and is associated with poor outcomes. We tested the hypothesis that concomitant tricuspid valve annuloplasty in patients with tricuspid annulus dilatation (≥40 mm) prevents tricuspid regurgitation progression after mitral valve surgery.

METHODS: We enrolled 44 patients undergoing mitral valve surgery (both repair or replacement) showing less than moderate (≤+2) tricuspid regurgitation and dilated tricuspid annulus (≥40 mm) at preoperative echocardiography. They were randomized to receive (n = 22) or not receive (n = 22) concomitant tricuspid annuloplasty (Cosgrove-Edwards annuloplasty ring; Edwards Lifesciences, Irvine, Calif) at the time of mitral valve surgery. Clinical and echocardiographic follow-up was 100% completed at 12 months after surgery.

RESULTS: Preoperative clinical and echocardiographic characteristics were comparable in the 2 groups. Operative mortality was 4.4% (1 death in each group). At 12 months follow-up, tricuspid regurgitation was absent in 71% (n = 15) versus 19% (n = 4) of patients in the treatment and control groups, respectively (P = .001). Moderate to severe tricuspid regurgitation (≥+3) was present in 0% versus 28% (n = 6) of patients in the treatment and control groups, respectively (P = .02). Pulmonary artery systolic pressure significantly decreased from baseline in all cases (P < .001) and was comparable in the 2 groups (41 ± 8 mm Hg vs 40 ± 5 mm Hg; P = .4). Right ventricular reverse remodeling was marked in the treatment group (right ventricular long axis: 71 ± 7 mm vs 65 ± 8 mm; P = .01; short axis: 33 ± 4 mm vs 27 ± 5 mm; P = .001) but only minimal in the control group (right ventricular long axis: 72 ± 6 mm vs 70 ± 7 mm; P = .08; short axis: 34 ± 5 mm vs 33 ± 5 mm; P = .1). The 6-minute walk test improved from baseline in both groups (P < .001), but this improvement was greater in the treatment group (+115 ± 23 m from baseline vs +75 ± 35 m; P = .008).

CONCLUSIONS: Prophylactic tricuspid valve annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery was associated with a reduced rate of tricuspid regurgitation progression, improved right ventricular remodeling, and better functional outcomes.

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