|Year : 2019 | Volume
| Issue : 2 | Page : 587-591
Impact of tricuspid ring annuloplasty on functional tricuspid regurgitation after mitral valve surgery
Ahmed L Dokhan1, Mohammed E Abdelraof2, Amr M Allama1, Shahzad G Raja3, Hesham H Ahmed1
1 Cardiothoracic Surgery Department, Faculty of Medicine, Menoufia University, London, UK
2 Cardiothoracic Surgery Department, Faculty of Medicine, Alazhar University, London, UK
3 Department of Cardiac Surgery, Harefield Hospital, London, UK
|Date of Submission||13-Sep-2017|
|Date of Acceptance||03-Dec-2017|
|Date of Web Publication||25-Jun-2019|
Hesham H Ahmed
Abo Bakrst, Shebin El-kom, Menoufia
Source of Support: None, Conflict of Interest: None
The objective of this study was to evaluate tricuspid valve (TV) ring annuloplasty for moderate functional tricuspid regurgitation (FTR) in patients undergoing mitral valve (MV) surgery.
TV ring annuloplasty during MV surgery for severe FTR is recommended but for moderate FTR is controversial.
Patients and methods
Eighty patients with moderate FTR who were listed for MV surgery were classified into group A, the TV annuloplasty group which included 34 patients who underwent MV surgery and TV annuloplasty and group B, the TV nonrepair group, 46 patients who underwent MV surgery alone.
At 1-month follow-up, in group A: no, mild, and severe FTR were detected in 70.6, 26.5, and 2.9% of patients, respectively, whereas in group B, no, mild, moderate, and severe FTR were detected in 26.1, 58.7, 13, and 2.9% of patients, respectively (P = 0.001). Pulmonary artery pressure (PAP) in groups A and B was 27.2 ± 5.1 and 31.7 ± 6.8 mmHg, respectively (P = 0.001). At 6-month follow-up, in group A no, mild, and severe FTR were detected in 64.7, 32.4, and 2.9% of patients, respectively, whereas in group B, no, mild, moderate, and severe FTR were detected in 32.6, 50, 15.2, and 2.2% of patients, respectively (P = 0.01). PAP in groups A and B was 27.6 ± 5.1 and 32.2 ± 7.1 mmHg, respectively (P = 0.003).
Intervention for moderate FTR is recommended during MV surgery to avoid persistence or progression of the TR especially in patients with high PAP.
Keywords: cardiac valve annuloplasty, echocardiography, mitral valve insufficiency, pulmonary artery, tricuspid valve insufficiency
|How to cite this article:|
Dokhan AL, Abdelraof ME, Allama AM, Raja SG, Ahmed HH. Impact of tricuspid ring annuloplasty on functional tricuspid regurgitation after mitral valve surgery. Menoufia Med J 2019;32:587-91
|How to cite this URL:|
Dokhan AL, Abdelraof ME, Allama AM, Raja SG, Ahmed HH. Impact of tricuspid ring annuloplasty on functional tricuspid regurgitation after mitral valve surgery. Menoufia Med J [serial online] 2019 [cited 2019 Sep 20];32:587-91. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/587/260904
| Introduction|| |
Tricuspid regurgitation (TR) is either primary or secondary (functional). Primary TR is because of organic valve lesions such as congenital anomalies and bacterial endocarditis. Functional tricuspid regurgitation (FTR) is mostly secondary to left-sided heart valvular lesion mostly mitral valve disease (MVD). When high pulmonary pressure develops, it can attribute to right ventricle (RV) and annular dilatation and, eventually, to tricuspid valve (TV) tenting. The tricuspid leaflets are morphologically normal but do not coapt adequately. However, not all patients with pulmonary hypertension develop TR, the cause for which seems to be multifactorial and related to other factors such as atrial fibrillation (AF) and right heart enlargement. The most common causes of secondary FTR are left-sided heart disease, significant aortic or MVD, or left ventricular (LV) dysfunction, chronic pulmonary disease, and primary pulmonary hypertension.
FTR is commonly associated with MVD, and the presence of significant TR is reported to be an alarming sign of poor prognosis after the surgical intervention of MVD. FTR may decrease or totally corrected after resolution of the left heart lesion responsible for the overloading of the RV. However, TR progression occurs in as many as one-half of the patients. Moderate TR is associated with poor long-term survival, because of the difficulties in predicting the patients in whom moderate regurgitation will resolve or progress after mitral valve (MV) surgery. Concomitant TV repair at the time of MV surgery has been recommended in patients with severe FTR to improve long-term clinical outcomes. However, the decision to repair moderate FTR during MV surgery remains controversial. Our study focused on the effect of tricuspid ring annuloplasty on moderate TR during MV surgery.
| Patients and Methods|| |
This study was approved by the Ethics Committee of Menoufia Faculty of Medicine. This prospective study was conducted on 80 patients in Menoufia University Hospital from 2015 to 2017. Informed consent was taken from each patient. All patients had concomitant moderate TR and were listed for MV surgery. They were classified into group A, tricuspid valve ring annuloplasty (TVA) group, including 34 patients who underwent MV surgery and TV repair and group B, tricuspid valve nonrepair (TVN) group, with 46 patients who underwent MV surgery alone.
Exclusion criteria were TR with definite organic leaflet or subvalvular deformities, such as prolapse, Ebstein anomaly, rheumatic, infective endocarditis, and patients who have concomitant surgical procedures other than mitral and tricuspid.
Patient's medical history including age, sex, New York Heart Association classification, and preoperative risk factors were recorded. Echocardiography was done for all patients and assessment was done for all patients before surgery and after 1 and 6 months. Echocardiographic study was done to assess TR using the apical four-chamber view and graded as mild, moderate, or severe when the distal jet area was less than 5, 5–10, or greater than 10 cm, respectively, in addition to assessment of ejection fraction (EF), diameter of LV, and pulmonary artery pressure (PAP).
The decision to perform TV repair was affected by the degree of TR, tricuspid annular dimension, but was ultimately at the discretion of the attending surgeon. TV annular dimension was not routinely measured preoperatively or intraoperatively; annular size was not an indispensable indicator for a combination of TV repair. So the cases were randomly selected.
The data were collected, tabulated, and statistically analyzed by the statistical package for social sciences (version 22.0; IBM Corp., Armonk, New York, USA) on IBM compatible computer. Two types of statistics were used. Descriptive statistics as percentage, mean, and SD and analytic statistics as χ2-test which is used to study the association between two qualitative variables and Fisher's exact test which is used to study the association between two qualitative variables and at least one cell of expected count of less than 5. Student's t-test is a test of significance used for comparison between two groups having normally distributed quantitative variables; Mann–Whitney test (U) (nonparametric test) is a test of significance used for comparison between two groups having not normally distributed quantitative variables and paired t-test was used as a test of significance used for one group of units that has been tested twice (a 'repeated measures' t-test) – that is, between two related normally distributed quantitative variables.
| Results|| |
The mean age of the patients in group A was 64.2 ± 13.2 years (44.9%) and 19 (55.1%) were women, whereas in group B the mean age was 61.6 ± 13.5 years. There was 14 (30.4%) men and 32 (69.6%) women [Table 1].
|Table 1: Sociodemographic characteristics and anthropometric measurements of studied groups|
Click here to view
The mean of EF in group A was 60.7 ± 10.4, whereas in group B it was 62.7 ± 7.8. The mean of PAP in group A was 43.8 ± 12.0 mmHg, whereas in group B it was 47.9 ± 14.8 mmHg [Table 2].
|Table 2: Comparison between studied groups regarding preoperative echo data|
Click here to view
One-month postoperative echocardiographic data: in group A, no TR was detected in 24 (70.6%) cases, mild TR in nine (26.5%) cases and one (2.9%) case developed severe TR, whereas in group B, no TR was detected in 12 (26.1%) cases, mild TR in 27 (58.7%) cases, moderate TR was detected in six (13%) cases and severe TR was detected in one (2.9%) case. There was statistical significance regarding 1-month follow-up of TR (P = 0.001). PAP in group A was 27.2 ± 5.1 mmHg, whereas in group B it was 31.7 ± 6.8 mmHg. There was statistical significance regarding 1-month follow-up of PAP (P = 0.001) [Table 3].
|Table 3: Comparison between studied groups regarding 1-month postoperative echo data|
Click here to view
Six-month postoperative echocardiographic data: in group A, no TR was detected in 22 (70.6%) cases, mild TR in 11 (32.4%) cases, and one (2.9%) case developed severe TR, whereas in group B, no TR was detected in 15 (32.6%) cases, mild TR in 23 (50%) cases, moderate TR were detected in seven (15.2%) cases and severe TR was detected in one (2.2%) case. There was statistical significance regarding 1-month follow-up of TR (P = 0.01). The PAP in group A was 27.6 ± 6.1 mmHg, whereas in group B it was 32.7 ± 7.1 mmHg. There was statistical significance regarding 1-month follow-up of PAP (P = 0.003) [Table 4].
|Table 4: Comparison between studied groups regarding 6-month postoperative echo data|
Click here to view
| Discussion|| |
Traditionally, surgical management of moderate FTR has been a subject of controversy. Moreover, the current era of minimal invasive techniques may focus attention on a single valve, ignoring moderate TR, even though the TV is accessible. When repair was performed, surgeons documented RV morphological changes, such as annular and RV dilation, RV dysfunction, and pulmonary hypertension, all harbingers of progression of right-sided diseases.
Risk factors for TR progression include pulmonary hypertension, high RV diameter with TV annulus dilatation, and decreased RV EF. AF and huge left atrium are also considered risk factors for progression of TR if left untreated which is a common finding in patients who have left-sided heart lesions.
Even after a small decrease in TR in the immediate postoperative period, the mean TR grade subsequently increases which mean that moderate regurgitation can progress to severe regurgitation.
Moderate TR because of MVDs should be treated to improve patient's outcomes by giving benefit of doubt to prevent regurgitation progression and RV dysfunction.
In our study, there was no significant difference between the two groups regarding the demographic data. There was also no significant difference between the two groups regarding preoperative LV end-systolic diameter and LV end-diastolic diameter as well as EF. Our preoperative LV study is similar to that reported by Kim et al. who reported the presence of moderate FTR in most of the cases without significant LV dysfunction.
The preoperative PAP in group A was 43.8 ± 12.0 mmHg, whereas in group B it was 47.9 ± 14.8 mmHg with no significant difference. Our results were higher than those reported in a study by Chikwe et al. which reported that PAP for the TVA group was 37.6 ± 14.4 mmHg, whereas in the TVN group the PAP was 31.8 ± 12.3 mmHg. This difference can be explained as we had higher incidence of AF resulting in a rise in PAP.
One-month postoperative echocardiographic data for both groups showed that there was a statistical difference between the two groups regarding TR and. Our result is similar to the study by Musharaf et al. who showed a better outcome in the TVA group with regard to the grade of TR. They reported persistence of moderate TR in the TVN group in about 43% of patients. This difference can be explained by higher preoperative PAP in their study in which 84% of cases had a PAP of more than 50 mmHg. Also our result was similar to that reported by Ren et al. in which FTR recurrence including mild degree was 23.5% in the TVA group. Meanwhile, moderate to severe FTR recurrence was 2.5%.
Postoperative data for both groups after 6 months showed that there was a statistical difference between the two groups regarding TR and PAP (P < 0.05). Our results are not similar to the study reported by Dokhan et al. in which the TVR group had 21 (87.6%) patients with no TR, two (8.3%) patients with mild TR, and one patient (4.2%) with moderate TR, whereas in the TVN group there were 15 (57.7%) patients with no TR, seven (26.9%) patients with mild TR, and four (15.4%) patients with moderate TR.
PAP in group A was 27.2 ± 5.1 mmHg, whereas in group B it was 31.7 ± 6.8. Our result is different from the study by Dokhan et al. in which the PAP in the TVR group was 36.7 ± 5.0 mmHg, whereas in the TVN group it was 41.6 ± 7 mmHg. This can be explained on the basis of prevalence of MV stenosis and mixed MV lesions in their study and the prevalence of MV regurgitation in our study.
RV diameter in group A was 24.2 ± 5.6 mm, whereas in group B it was 24.2 ± 4.8 mm. Tricuspid annular plane systolic excursion in group A was 12.5 ± 4 mm, whereas in group B it was 12.2 ± 3.4 mm with no significant difference between the two groups. Our result is similar to the study reported by Smid et al. in which RV diameter in the TVR group was 26.5 ± 3.3 mm. However it was different in the TVN group which was 32.3 ± 3.9 mm. This can be explained as a progression of TR by one grade in about 34% of cases in the TVN group.
Small sample size, observer variability in interpretation of the echocardiographic findings, and difficult assessment of postoperative medications as diuretics on the severity of TR are the limitations of the present study.
| Conclusion|| |
Intervention for moderate TR by tricuspid annuloplasty is recommended during MV surgery to avoid persistence or progression of the TR.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Smid M, Cech J, Rokyta R, Hajek T. Mild to moderate functional tricuspidregurgitation: retrospective comparison of surgical andconservative treatment. Cardiol Res Pract 2010; 2010
Mutlak D, Aronson D, Lessick J, Reisner SA, Dabbah S, Agmon Y. Functional tricuspid regurgitation in patients with pulmonary hypetension: is pulmonary artery pressure the only determinant of regurgitation severity? Chest 2009; 135
Filsoufi F, Anyanwu A, Salzberg S, Frankel T, Cohn L, Adams D. Long-term outcomes of tricuspid valve replacement in the current era. Ann thorac surg 2005; 80
Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol 2004; 43
Dreyfus GD, Corbi PJ, Chan KMJ, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair. Ann thorac surg 2005; 79
Taramasso M, Vanermen H, Maisano F, Guidotti A, La Canna G, Alfieri O. The growing clinical importance of secondary tricuspid regurgitation. J Am Coll Cardiol 2012; 59
Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, et al
. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118
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
Dreyfus GD, Chan KM. Functional tricuspid regurgitation: a more complex entity than it appears. Heart 2009; 95
Park YH, Song JM, Lee EY, Kim YJ, Kang DH, Song JK. Geometric and hemodynamic determinants of functional tricuspid regurgitation: a real-time three-dimensional echocardiography study. Int J Cardiol 2008; 124
Yilmaz O, Suri RM, Dearani JA, Sundt TM, Daly RC, Burkhart HM, et al
. Functional tricuspid regurgitation at the time of mitral valve repair for degenerative leaflet prolapse: the case for a selective approach. J Thorac Cardiovasc Surg 2011; 142
Navia JL, Brozzi NA, Klein AL, Ling LF, Kittayarak C, Nowicki ER, et al
. Moderate tricuspid regurgitation with left-sided degenerative heart valve disease: to repair or not to repair? Ann Thorac Surg 2012; 93
:59–67. discussion 68–69
Chikwe J, Itagaki S, Anyanwu A, Adams DH. Impact of concomitant tricuspid annuloplasty on tricuspid regurgitation, right ventricular function, and pulmonary artery hypertension after repair of mitral valve prolapse. J Am Coll Cardiol 2015; 65
Musharaf M, Pathan IH, Junejo S, Khushk SA, Qureshi MJ. Surgical repair of moderate tricuspid regurgitation has better outcome early hospital results. PJC 2013; 24
Ren WJ, Zhang BG, Liu JS, Qian YJ, Guo YQ. Outcomes of tricuspid annuloplasty with and without prosthetic rings: a retrospective follow-up study. J Cardiothorac Surg 2015; 10
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
[Table 1], [Table 2], [Table 3], [Table 4]