Outcomes of Guideline-Directed Concomitant Annuloplasty for Functional Tricuspid Regurgitation.

BACKGROUND: Despite guideline recommendations, rates of concomitant tricuspid valve repair are suboptimal, possibly due to fear of complications. We reviewed morbidity, mortality, recurrent tricuspid regurgitation, and right ventricular remodeling after guideline-directed concomitant tricuspid valve repair. METHODS: We performed guideline-directed concomitant tricuspid valve repair on 171 consecutive patients who underwent left-sided valve surgery (degenerative mitral surgery or aortic valve replacement) between May 2012 and March 2016. Exclusion criteria included functional mitral regurgitation, rheumatic disease, active endocarditis, and concomitant coronary artery bypass grafting or complex aortic surgery. RESULTS: Mean age was 68 ± 12 years, and 47% (81 of 171) were women. Preoperative atrial fibrillation was present in 57% (98 of 171), and preoperative tricuspid regurgitation was moderate or higher in 64% (108 of 171). The rate of de novo pacemaker placement was 4.1% (7 of 171), and the 30-day mortality rate was 0.6% (1 of 171). Estimated survival was 95% ± 4% at 1 year and 92% ± 5% at 5 years. Freedom from moderate or worse residual/recurrent tricuspid regurgitation was 93% ± 6% at 6 months and 89% ± 8% at 3 years. Quantitative echocardiography found no significant increase in right ventricular dimensions or area at 1 year in subgroup analysis. Mean echocardiographic follow-up was 14.1 months, and mean clinical follow-up was 33.9 months. CONCLUSIONS: Guideline-directed concomitant tricuspid valve repair resulted in excellent safety end points and survival. At 14 months, freedom from moderate or worse tricuspid regurgitation was high, right ventricular performance did not worsen, and the pacemaker rate was comparable to rates after isolated mitral repair. Given these findings, adherence to current guidelines regarding functional tricuspid regurgitation should be encouraged.

Effect of Tricuspid Valve Repair in Patients with Moderate Tricuspid Regurgitation undergoing Left-Sided Valve Surgery.

BACKGROUND: The benefits of tricuspid valve (TV) repair in patients with moderate tricuspid regurgitation (TR) during left-sided valve surgery are under debate. We investigated independent predictors for reduction in TR severity following left-sided valve surgery in patients with moderate TR. METHODS: In this study, we included 106 patients (male: 33%) with a mean age of 4.23 ± 12.61 years who had moderate TR and underwent mitral or aortic valve surgery between March 2012 and November 2016. Concomitant tricuspid annuloplasty was done for one group of patients based on surgeon's decision. Transthoracic echocardiography was done before and at a median followup of 4.71 months for all patients. The patients were divided into improved and unimproved TR groups, with the term "improved" signifying a reduction of at least one grade in TR severity. RESULTS: Tricuspid annuloplasty was performed on 65 (61.3%) patients. TR improvement was observed in 87.7% of patients in the TV repair group and 56.1% of patients in the no-TV repair group, indicating a significant difference (P < 0.001). Tricuspid annulus diameter was not significantly different between the two groups (32.41 ± 4.68 mm in no-TV repair group and 33.87 ± 4.34 mm in TV repair group, P = 0.128). At follow-up with echocardiography, 80 (75.5%) patients were placed in the improved group and the majority of patients (71.3% vs. 30.8%; P < 0.001) underwent tricuspid repair in the improved group. TV annuloplasty was correlated with reduced TR severity following left-sided valve surgery (odds ratio [OR]: 5.19, 95% CI: 1.70-15.85, P < 0.001). TR changed from moderate to severe in 17 (17.1%) patients with no concomitant tricuspid repair, while only one patient (1.5%) with tricuspid repair showed an increased TR severity. CONCLUSION: Tricuspid annuloplasty may be useful in patients who have moderate TR undergoing left-sided valve surgery regardless of the tricuspid annulus diameter, and it can play an effective role in the improvement of TR at mid-term follow-up.

Toward standardization of valve-sparing root replacement and annuloplasty.

INTRODUCTION: The current guidelines for surgical intervention of aortic regurgitation were developed by assuming aortic valve replacement. However, when aortic valve repair is considered, earlier intervention may provide more durable repair. Standardization of the procedures may be required to achieve stable outcomes. The possibility of standardization of valve-sparing root replacement (VSRR) and annuloplasty will be discussed. METHODS AND RESULTS: The differences between the two VSRRs have decreased with technical modifications, reimplantation using a graft with sinuses, and remodeling with annuloplasty. The minor differences are the maintenance of root distensibility, less root dissection, shorter procedure time, and higher risk of bleeding in the latter. Stable outcomes may be expected by choosing the appropriate graft size according to the root dimensions in the former. In the latter, postoperative commissure height depends on the skill of the surgeon, which can be resolved using a graft with sinuses. There is still controversy regarding the equal arrangement of the commissure heights and angle, but it has been accepted in clinical use provided that postoperative effective heights of each cusp are set equally. External suture annuloplasty maintains the advantages of remodeling because it requires less root dissection and a shorter procedure time. It can accurately predict postoperative annulus diameter. External ring annuloplasty can stabilize the basal ring exactly, but it is time-consuming and postoperative annulus diameter cannot be predicted accurately. CONCLUSIONS: Standardization of VSRR may be feasible, and VSRR is expected to be more widely adopted, which will improve the guidelines.

Developing a mitral valve center of excellence.

PURPOSE OF REVIEW: Despite the proven superiority of mitral repair over replacement for degenerative mitral disease, mitral valve replacement remains common. Guidelines now recommend referral of patients, particularly those whom are asymptomatic, to valve centers of excellence, although criteria that define such centers remain to be established. The purpose of this review is to define the structure of a mitral center of excellence and to review current clinical outcomes which are possible in such a center. RECENT FINDINGS: Recently, American College of Cardiology/American Heart Association as well as the European Society of Cardiology/European Association of Cardiothoracic Surgery guidelines define mitral centers of excellence as either centers in which the likelihood of successful and durable repair exceeds 95% and with an operative mortality risk of less than 1% (American College of Cardiology/American Heart Association definition) or centers with high repair rates, low operative mortality, and a record of durable results (European Society of Cardiology/European Association of Cardiothoracic Surgery definition). There is however less clarity about the structure and function of a center that achieves these outcomes. SUMMARY: The importance of centers of excellence in mitral valve surgery are now well recognized, and this review will highlight the key components and outcomes of an established mitral valve reference center.

Tricuspid annuloplasty versus a conservative approach in patients with functional tricuspid regurgitation undergoing left-sided heart valve surgery: A study-level meta-analysis.

BACKGROUND: Tricuspid valve (TV) repair at the time of left-sided valve surgery is indicated in patients with either severe functional tricuspid regurgitation (TR) or mild-to-moderate TR with coexistent tricuspid annular dilation or right heart failure. We assessed the benefits of a concomitant TV repair strategy during left-sided surgical valve interventions, focusing on mortality and echocardiographic TR-related outcomes. METHODS: A meta-analysis was performed of studies reporting outcomes of patients who underwent left-sided (mitral and/or aortic) valve surgery with or without concomitant TV repair. Primary endpoints were all-cause and cardiac-related mortality; secondary endpoints were the presence of more-than-moderate TR, TR progression, and TR severity grade. All endpoints were evaluated at the longest available follow-up. RESULTS: Fifteen studies were included for a total of 2840 patients. TV repair at the time of left-sided valve surgery was associated with a significantly lower risk of cardiac-related mortality (odds ratio [OR] 0.38; 95% confidence interval [CI]: 0.25-0.58; p<0.001), with a trend towards a lower risk of all-cause mortality (OR 0.57; 95% CI: 0.32-1.05; p=0.07) at a mean weighted follow-up of 6years. The presence of more-than-moderate TR (OR 0.19; 95% CI: 0.12-0.30; p<0.001), TR progression (OR 0.03; 95% CI: 0.01-0.05; p<0.001), and TR grade (standardized mean difference -1.11; 95% CI: -1.57 to -0.65; p<0.001) were significantly lower in the TV repair group at a mean weighted follow-up of 4.7years. CONCLUSIONS: A concomitant TV repair strategy during left-sided valve surgery is associated with a reduction in cardiac-related mortality and improved echocardiographic TR outcomes at follow-up.

Changes in Right Ventricular Volume and Function After Tricuspid Valve Surgery　- Tricuspid Annuloplasty vs. Tricuspid Valve Replacement.

BACKGROUND: There is a concern that clinical outcome of tricuspid valve replacement (TVR) is inferior compared with tricuspid annuloplasty (TAP). The aim of this study was therefore to compare changes in right ventricular (RV) volume and function following TAP with that following TVR on cardiac magnetic resonance imaging (CMR) in patients with severe functional tricuspid regurgitation (TR). METHODS AND RESULTS: Forty patients who underwent surgery for severe functional TR and who underwent CMR preoperatively and on postoperative follow-up (24.8±13.3 months after surgery) were enrolled. Thirteen patients underwent TAP (TAP group) and 27 patients underwent TVR (TVR group). Both RV end-diastolic and end-systolic volume indices decreased significantly after surgery (from 178.9±53.9 to 116.3±26.7 ml/m(2), P<0.001, and from 95.7±36.1 to 67.3±28.0 ml/m(2), P<0.001, respectively), without intergroup differences. In the TAP group, RV ejection fraction (EF) was preserved following surgery (from 43.3±9.5 to 46.9±10.9%, P=0.312). In the TVR group, however, it decreased significantly following surgery (from 51.8±9.2 to 42.4±12.3%, P<0.001). In addition, postoperative RVEF was lower in the TVR than TAP group, with a marginal significance (mean difference, -6.967; 95% confidence interval: -14.529 to 0.595; P=0.070). CONCLUSIONS: For patients with severe functional TR, both TAP and TVR are beneficial for reduction of RV volume indices. TAP, however, might be superior to TVR, because RVEF is well preserved following surgery. (Circ J 2016; 80: 1142-1147).

Tricuspid valve repair: is ring annuloplasty superior?

OBJECTIVES: Tricuspid regurgitation (TR) secondary to left heart disease is the most common aetiology of tricuspid valve (TV) insufficiency. Valve annuloplasty is the primary treatment for TV insufficiency. Several studies have shown the superiority of annuloplasty with a prosthetic ring over other repair techniques. We reviewed our experience with different surgical techniques for the treatment of acquired TV disease focusing on long-term survival and incidence of reoperation. METHODS: A retrospective analysis of 717 consecutive patients who underwent TV surgery between 1975 and 2009 with either a ring annuloplasty [Group R: N = 433 (60%)] or a De Vega suture annuloplasty [Group NR: no ring; N = 255 (36%)]. Twenty-nine (4%) patients underwent other types of TV repair. A ring annuloplasty was performed predominantly in the late study period of 2000-09. TV aetiology was functional in 67% (479/717) of the patients. Ninety-one percent of the patients (n = 649) underwent concomitant coronary artery bypass grafting and/or mitral/aortic valve surgery. RESULTS: Patients who received a ring annuloplasty were older (67 ± 13 vs 60 ± 13 years; P < 0.001). Overall 30-day mortality was 13.8% (n = 95) [Group R: n = 55 (12.7%) and Group NR: n = 40 (15.7%)]. Ten-year actuarial survival after TV repair with either the De Vega suture or ring annuloplasty was 39 ± 3 and 46 ± 7%, respectively (P = 0.01). Twenty-eight (4%) patients required a TV reoperation after 5.9 ± 5.1 years. Freedom from TV reoperation 10 years after repair with a De Vega annuloplasty was 87.9 ± 3% compared with 98.4 ± 1% after the ring annuloplasty (P = 0.034). CONCLUSIONS: Patients who require TV surgery either as an isolated or a combined procedure constitute a high-risk group. The long-term survival is poor. Tricuspid valve repair with a ring annuloplasty is associated with improved survival and a lower reoperation rate than that with a suture annuloplasty.