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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 1  |  Page : 34-37

Concomitant repair of moderate tricuspid regurge in patients undergoing mitral valve surgery


1 Cardiothoracic Surgery Department, Menoufia University, Menoufia, Egypt
2 General Surgery Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Cardiothoracic Surgery Department, Dammietta Cardiology and Gastroenterology Center, Dammietta, Egypt

Date of Submission11-Oct-2014
Date of Acceptance28-Nov-2014
Date of Web Publication29-Apr-2015

Correspondence Address:
Hany Mehany Mohamed
52/4 New Dammietta, Dammietta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.155935

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  Abstract 

Objectives
The aim of this study was to evaluate surgical results in patients with moderate tricuspid regurge undergoing mitral valve surgery either with or without concomitant tricuspid repair 6 months after surgery.
Background
Moderate tricuspid regurge has a variable natural history, as it may regress after mitral valve surgery without tricuspid repair, or may progress; hence, the decision to repair moderate tricuspid regurge in concomitant tricuspid repair with mitral valve surgery remains controversial.
Patients and methods
This study was conducted from January 2010 to June 2013. A total of 50 patients underwent mitral valve replacement for the first time with concomitant moderate tricuspid valve regurge. They were divided into two groups: group A (26 patients) who underwent mitral valve replacement alone, and group B (24 patients) who underwent mitral valve replacement and tricuspid valve repair using De Vega annuloplasty technique.
Results
The result showed that the tricuspid regurgitation improved postoperatively, irrespective of whether the repair was performed or not. However, statistical differences between group A and group B were significant.
Conclusion
Concomitant tricuspid valve repair with mitral valve surgery offered better early postoperative tricuspid valve function in patients with moderate tricuspid regurge, who underwent mitral valve surgery for chronic mitral valve disease.

Keywords: De Vega annuloplasty, mitral valve surgery, tricuspid regurge, tricuspid repair


How to cite this article:
Dokhan AL, Ibrahim IM, Alkhateep YM, Mohamed HM. Concomitant repair of moderate tricuspid regurge in patients undergoing mitral valve surgery. Menoufia Med J 2015;28:34-7

How to cite this URL:
Dokhan AL, Ibrahim IM, Alkhateep YM, Mohamed HM. Concomitant repair of moderate tricuspid regurge in patients undergoing mitral valve surgery. Menoufia Med J [serial online] 2015 [cited 2019 Jun 27];28:34-7. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/34/155935


  Introduction Top


Tricuspid regurgitation (TR) is a disorder in which the heart's tricuspid valve does not close properly, causing blood to flow backward into the atrium when the right ventricle contracts. The most common cause of TR is enlargement of the right ventricle [1]. Mitral valve disease is often accompanied by concomitant tricuspid valve disease. The most common indication for tricuspid valve intervention is TR, and the presence of significant TR has been reported to be an important prognostic indicator of outcomes following mitral valve surgery [2]. Surgical treatment of TR with left-sided valvular disease still remains a challenge for the cardiac surgeon. Uncorrected TR after repair of the left-sided valvular lesion has been reported to have an adverse effect on early and late results. Thus, surgical management of moderate to severe TR is now widely recommended to achieve better early and late clinical outcome [3]. Moderate tricuspid regurge presents a surgical dilemma during mitral valve surgery, as it may regress after successful mitral valve surgery without repair, or may progress requiring repair with increasing risk of redo cardiac surgery [4].


  Patients and methods Top


The study was a retrospective study conducted from January 2010 to June 2013. It included 50 patients with moderate tricuspid regurge associated with mitral valve disease, who underwent elective mitral valve surgery for the first time. Tricuspid regurge was defined as tricuspid regurge without organic pathology includes leaflets and or subvalvular apparatus; hence, patients with tricuspid valve prolapse, Ebstein anomaly, and organic tricuspid valve disease were excluded from the study. In addition, patients older than 60 years old, with left ventricular dysfunction (ejection fraction <50%), redone mitral valve surgery, ischemic mitral valve regurge, and patients with chronic pulmonary diseases were excluded.

Patients were divided into two groups. Group A (N = 26 patients) included patients who underwent mitral replacement alone. Group B (N = 24 patients) included patients who underwent mitral valve replacement and tricuspid valve repair using the De Vega annuloplasty technique.

All patients' medical history including their age, sex, functional class according to New York Heart Association (NYHA) classification, and data about clinical general and local cardiological examination was collected from our patients' database.

Echocardiography was the cornerstone in the evaluation of all patients before and 6 months after surgery. The degree of tricuspid regurge was evaluated using the apical four-chamber view and graded as mild, moderate, or severe when the distal jet area was less than 5-5 : 10 cm 2 or greater than 10 cm 2 , respectively. Tricuspid regurge grading system is as follows: mild TR = grade I TR, moderate = grade II and III TR, and severe = grade IV TR.

In all patients' ejection fraction, left ventricular end diastolic diameter, left ventricular end systolic diameter, left atrial dimension, and right ventricular dimension measurement were obtained.

Surgical procedures

First, a median sternotomy was performed, and then a longitudinal right-sided left atriotomy was carried out. All patients underwent a bileaflet mitral mechanical valve replacement. After the mitral valve replacement was performed, the left atrium was closed. In group B, the aortic cross-clamp was taken off, the right atrium was opened obliquely, and the TV was carefully explored in a beating heart. The tricuspid annulus was identified, and De Vega annuloplasty was performed for group B. Then assessment of the tricuspid valve was done using the water test for detection of any residual regurgitation, after MVR replacement alone as in group A, or MVR and tricuspid valve repair in group B weaning from the cardiopulmonary bypass.

Statistical analysis

Data were collected, verified, tabulated, and analyzed by SPSS (Statistical Package for the Social Sciences), EPICalc software program to get the final results.

The following tests were used:

  1. Arithmetic mean, SD, and hypothesis t-test (Student's t-test) for quantitative values.
  2. The c2 -test for qualitative values expressed as proportions.


For all statistical comparisons, a P-value of greater than 0.05 was considered nonsignificant, a P-value of less than 0.05 was considered significant, and a P-value of less than 0.01 was considered highly significant.


  Results Top


Preoperative clinical assessment of the patients was classified [Table 1] according to the NYHA classification. In group A, there were 19 patients with grade II NYHA class (73%), and seven patients with grade II NYHA class (26%), whereas in group B there were 16 patients with grade II NYHA class (66%), and eight patients with grade II NYHA class (33%).
Table 1: Preoperative clinical and echocardiographic data

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Postoperative clinical and echocardiographic data showed in [Table 2] the patients' rythm postoperatively, there were 11 patients (42%) with AF and 15 patients (57%) with sinus rhythm in group A. Whereas in group B there were nine patients (37%) with AF and 15 patients (62%) with sinus rhythm. Statistically the differences between group A and group B were not significant (P > 0.05).
Table 2: Postoperative clinical and echocardiographic data

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  Discussion Top


The decision to perform tricuspid annuloplasty often depends on surgeons' bias, with little data to guide decision making. It is well accepted that severe tricuspid regurge should be treated at the time of surgical correction of left-sided valve pathology. However, surgical indication for the correction of moderate TR remains controversial, with many surgeons still favoring a conservative approach. An increasing number of studies have shown that such a conservative TR management may lead to a progressive worsening of tricuspid insufficiency [5].

Management of moderate tricuspid regurge presents a surgical dilemma as there are two extreme opinions; some surgeons advised a conservative (no touch) approach to TR. It was thought that appropriate correction of the left-sided valve disease would most probably result in a decrease in the TR [6]. Other surgeons reported that patients undergoing tricuspid valve repair at the time of mitral valve surgery did better in the long term compared with patients who did not. An increasing wealth of observational data now supports surgical treatment of functional TR [7].

Therefore, till now, the decision to perform tricuspid repair, specially in mild and moderate FTR, depends on surgeon preference.

De Vega annuloplasty was the technique of choice for tricuspid repair in our study, as it offers a readily available, technically less demanding, and cheap alternative to annuloplasty ring; furthermore, it is associated with good postoperative result as believed by many authors [4,8].

Preoperative clinical assessment of the patients was classified according to the NYHA classification. In group A, there were 19 patients with grade II NYHA class (73%), and seven patients with grade II NYHA class (26%), whereas in group B there were 16 patients with grade II NYHA class (66%), and eight patients with grade II NYHA class (33%). There was no statistical significant difference between both groups.

The preoperative ECHO shows that the ejection fraction in group A was 63.3 ± 3.2%, whereas in group B it was 62.5 ± 3.5%. The left atrial dimension in group A was 5.7 ± 0.6, and in group B it was 6.0 ± 0.69. Therefore, the left atrial dimension was slightly more in group B. Left ventricular end diastolic in group A was 5.5 ± 0.67, and in group B it was 5.51 ± 0.60, without statistical significance. Left ventricular end systolic in group A was 3.54 ± 0.63, and in group B it was 3.8 ± 0.39, also without statistical significance. The right ventricle dimension in group A was 2.4 ± 0.63, and in group B it was 2.6 ± 0.29, also without statistical significance.

There is one value with significance, which is the pulmonary artery pressure. In group A, the pulmonary artery pressure was 39.5 ± 6.2, whereas in group B it was 46.7 ± 8.9. This indicates that in the repaired group the pulmonary pressure was higher than in the nonrepaired group, which may make the surgeon take the decision to repair the tricuspid valve.

The intraoperative surgical data, for example, cross-clamp time and perfusion time, were comparable in the study groups. There was no statistical significance between the two groups with regard to the cross-clamp time and perfusion time. The perfusion time in group A was 73.9 ± 10.0 min, whereas in group B it was 72.9 ± 8.8 min. Cross-clamp time in group A was 49.0 ± 8.9 min, whereas in group B it was 50.8 ± 9.2 min.

All patients in both groups required postoperative mechanical ventilation; we also used fast track technique in the anesthesia, and no patients were extubated in the operating theater. The ventilation time for group A was 206.6 ± 37.7 min, whereas in group B the ventilation time was 186.7 ± 41.4 min; therefore, there is a statistically significant difference between the two groups with regard to postoperative mechanical ventilation time. The ventilation time in repair group was shorter.

With regard to the patients' rythm postoperatively, there were 11 patients (42%) with AF and 15 patients (57%) with sinus rhythm in group A. Whereas in group B there were nine patients (37%) with AF and 15 patients (62%) with sinus rhythm. Statistically the differences between group A and group B were not significant (P > 0.05).

No complications occurred in 50% of the patients in group A and in 66% of the patients of group B. The arrhythmia and low cardiac output were more in the nonrepaired group, but with no significant differences between the two groups.

With regard to the postoperative echocardiographic assessment, there where 36 patients (72%) with no tricuspid regurge, five patients (10%) with grade I tricuspid regurge, and nine patients (18%) with grade II tricuspid regurge. In group A, there were 15 patients (57%) with no tricuspid regurge, seven patients (26%) with grade I tricuspid regurge, and four patients (15%) with grade II tricuspid regurge, whereas in group B there were 21 patients (87%) with no tricuspid regurge, two patients (8%) with grade I tricuspid regurge, one patient (4%) with grade II tricuspid regurge. Statistically the differences between group A and group B were significant (P < 0.05).

The same result was almost reported by Musharaf et al. [9] in a study of 77 patients divided into two groups. In group A, 51 patients had MVR, and in group B 26 patients had MVR and TVR. Echocardiographic assessment of the tricuspid valve postoperative revealed that in group A 22 patients had moderate TR and 29 patients had mild TR. In group B nine patients had mild TR, and nine patients had no TR.

In the postoperative evaluation of NYHA classification of dyspnea, both groups showed improvement in the activity and lifestyle. Group A showed 19 patients (73%) with grade I, five patients (19%) with grade II, two patients (7%) with grade III, and no patients in grade IV. Whereas group B showed 21 patients (88%) with grade I dyspnea, two patients (8%) with grade II, one patient (4%) with grade III, and no patients in grade IV. However, there was a difference between the functional classification of dyspnea (NYHA class) in both groups A and B postoperative. The statistical difference between both the groups was nonsignificant (P > 0.05); these results indicate that the correction of the left-sided lesion alone improves the lifestyle of the patients; however, there is more improvement with the repair of the tricuspid valve.

This result was also reported by Kim et al. [10] in a follow-up of 225 of 256 patients with mild-to-moderate functional TR, where the patients underwent isolated mechanical MV replacement, for the first time (123 patients in the repaired group and 133 patients in the nonrepaired group), with a median follow-up of 48.7 months, during which time 991 echocardiographic assessments were done. Freedom from moderate-to-severe TR at 5 years was 92.9 ± 2.9% in the repair group, and 60.8 ± 6.9% in the nonrepair group.

In our study, with regard to the pulmonary artery pressure, there was a significant decrease in the pulmonary artery pressure in both groups, but more significant in group B (repaired group) than in group A (nonrepaired group).

Limitation of the study

The short period of follow-up enable us to determine the progression of tricuspid regurge, especially persistent TR after surgery. In addition, we did not measure the preoperative tricuspid annular diameter.


  Conclusion Top


Surgically untreated TR can persist or even worsen, despite correction of the associated left-sided valve pathology, suggesting that a more aggressive approach toward this disease should be advocated; whether preoperative TR will regress or progress late after surgery is unknown.

The result showed that the TR is improved postoperatively, irrespective of whether the repair was performed or not; however, the differences between group A and group B were statistically significant.

There is growing conscience to correct moderate TR. Therefore, moderate TR owing to left-sided valve diseases should be treated to improve patient outcomes by giving benefit of doubt to prevent regurgitation progression and RV dysfunction.

De Vega annuloplasty is a safe, efficacious, and inexpensive method that avoids the use of a foreign material in repairing the TR.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

1.
Carabello BA, Goldman LA, Schafer AI. Valvular heart disease Cecil medicine. 24th ed. Philadelphia, PA: Saunders Elsevier; 2011.  Back to cited text no. 1
    
2.
DJ LaPar, Mulloy DP, Stone ML. Concomitant tricuspid valve surgery affects outcomes following mitral operations: a multi-institutional, statewide analysis. Ann Thorac Surg 2012; 94 :52-58.  Back to cited text no. 2
    
3.
Kuwaki K, Morishita K, Tsukamoto M, Abe T Tricuspid valve surgery for functional tricuspid valve regurgitation associated with left-sided valvular disease. Eur J Cardiothorac Surg 2001; 20 :577-582.   Back to cited text no. 3
    
4.
Kim JB, Yoo DG, Kim SG, et al. Mild to moderate functional tricuspid regurgitation in patients underlying valve replacement for rheumatic mitral disease. Heart 2012; 98 :24-30.  Back to cited text no. 4
    
5.
Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol 2004; 43 :405-409.  Back to cited text no. 5
    
6.
Antunes MJ, Barlow JB. Management of tricuspid valve regurgitation. Heart 2007; 93 :271-276.   Back to cited text no. 6
    
7.
Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg 2005; 79 :127-132.  Back to cited text no. 7
    
8.
Pradhan S, Gutman NC, Singh MY, et al. Tricuspid valve repair: De Vega′s tricuspid annuloplasty in moderate secondary tricuspid regurgitation. Kathmandu Univ Med J 2011; 9 :64-68.  Back to cited text no. 8
    
9.
Musharaf M, Pathan IH, Junejo S, et al. Surgical repair of moderate tricuspid regurgitation has better outcome early hospital results. PJC 2013; 24 :39.  Back to cited text no. 9
    
10.
Kim JB, Yoo DG, Kim GS, Song H, Jung SH, Choo SJ, et al. Mild-to-moderate functional tricuspid regurgitation in patients undergoing valve replacement for rheumatic mitral disease: the influence of tricuspid valve repair on clinical and echocardiographic outcomes. Heart 2012; 98 :24-30.  Back to cited text no. 10
    



 
 
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Introduction
Patients and methods
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