Should Moderate Functional Tricuspid Regurgitation Be Repaired During Surgery for Rheumatic Mitral Valve Disease?

Effect of concomitant tricuspid annuloplasty on postoperative wound complications in heart failure patients undergoing mitral valve repair

Tricuspid valve repair (TVR) combined with mitral valve surgery (MVS) has been a controversial issue. It is not clear whether the combined surgery has any influence on the occurrence of postoperative complications. The aim of this study was to compare the occurrence of complications including wound infection, wound bleeding, and mortality after MVS combined with or without TVR. By meta-analysis, a total of 1576 papers were collected from 3 databases, and 7 of them were included. We provided the necessary data of 7 included studies such as the authors, publication date, country, surgical approach and case number, patient age, and so on. Statistical analysis was carried out with RevMan 5.3 software. We found that patients with heart failure accepting MVS combined with or without TVR, performed no statistically significant difference in postoperative wound infection (OR: 0.88; 95% CI: 0.29, 2.62; P = 0.81), wound bleeding (OR: 0.74; 95% CI: 0.3, 1.48; P = 0.39), and mortality (OR: 1.05; 95% CI: 0.42, 2.61; P = 0.92). In conclusion, current evidence indicated that the combined surgery had no additional risk of postoperative complications, and might be an effective alternative surgical approach to mitral valve diseases accompany with tricuspid regurgitation. However, for the limited case size, it was required to support the findings with a large number of cases in further studies.

Concomitant tricuspid valve repair for mild-moderate tricuspid regurgitation patients undergoing mitral valve surgery? A meta-analysis and meta-regression

The development of tricuspid regurgitation (TR) is a common complication of mitral valve disease. Although severe TR is usually operated on at the same time of mitral valve surgery (MVS), controversies remain regarding whether mild to moderate TR patients should be operated. Concomitant tricuspid valve repair with MVS for mild-moderate TR patients. Electronic databases were searched from inception to November 20, 2022 to include any observational or randomized controlled trials (RCT) that compare concomitant tricuspid repair with MVS versus MVS alone. Mantel-Haenszel method was used to pool study estimates and calculate odds ratios (OR) with 95% confidence intervals (CI). A total of 9813 patients from 25 studies were included. Regarding primary outcomes, concomitant repair group had significantly lower 30 days mortality (OR: 0.66; 95% CI 0.45 to 0.96), all-cause mortality-based on RCTs- (OR: 0.40; 95% CI 0.22 to 0.71), cardiovascular mortality (OR: 0.53; 95% CI: 0.33 to 0.86) and heart failure hospitalizations (OR: 0.41; 95% CI: 0.26 to 0.63). However, was associated with higher permanent pacemaker implantation rates (OR: 2.09; 95% CI: 1.45 to 3.00). There were no significant differences in terms of secondary outcomes: tricuspid valve reinterventions, stroke and acute kidney injury. Furthermore, repair group showed lower risk for TR progression degrees (OR 0.08; 95% CI 0.05 to 0.16) and decreased mean of TR progression (MD -1.85; 95% CI -1.92 to -1.77). Concomitant tricuspid valve repair in mild or moderate TR at time of MVS appears to reduce not only 30 days but also long-term all-cause and cardiovascular mortality weighed against the increased risk of pacemaker implantation.

Long-Term Effects of Postoperative Atrial Fibrillation following Mitral Valve Surgery

BACKGROUND

New-onset postoperative atrial fibrillation (PoAF) is one of the most frequent yet serious complications following cardiac surgery. Long-term consequences have not been thoroughly investigated, and studies have included different cardiac operations. The objectives were to report the incidence and short- and long-term outcomes in patients with PoAF after mitral valve surgery.

METHODS

This is a retrospective cohort study of 1401 patients who underwent mitral valve surgery from 2009 to 2020. Patients were grouped according to the occurrence of PoAF (n = 236) and the nonoccurrence of PoAF (n = 1165). Long-term outcomes included mortality, heart failure rehospitalization, stroke, and mitral valve reinterventions.

RESULTS

The overall incidence of PoAF was 16.8%. PoAF was associated with higher rates of operative mortality (8.9% vs. 3.3%, p < 0.001), stroke (6.9% vs. 1.5%, p < 0.001), and dialysis (13.6% vs. 3.5%, p < 0.001). ICU and hospital stays were significantly longer in patients with PoAF (p < 0.001 for both). PoAF was significantly associated with an increased risk of mortality [HR: 1.613 (95% CI: 1.048-2.483); p = 0.03], heart failure rehospitalization [HR: 2.156 (95% CI: 1.276-3.642); p = 0.004], and stroke [HR: 2.722 (95% CI: 1.321-5.607); p = 0.007]. However, PoAF was not associated with increased mitral valve reinterventions [HR: 0.938 (95% CI: 0.422-2.087); p = 0.875].

CONCLUSIONS

Atrial fibrillation after mitral valve surgery is a common complication, with an increased risk of operative mortality. PoAF was associated with lower long-term survival, increased heart failure rehospitalization, and stroke risk. Future studies are needed to evaluate strategies that can be implemented to improve the outcomes of these patients.

Concomitant tricuspid annuloplasty in patients with mild to moderate tricuspid valve regurgitation undergoing mitral valve surgery: meta-analysis

INTRODUCTION

Clinical effects of concomitant tricuspid annuloplasty (TA) in patients with mild to moderate tricuspid regurgitation at the time of mitral valve surgery (MVS) remains indefinite. We aimed to perform a meta-analysis to determine the long-term clinical and echocardiographic effects of concomitant TA in patients undergoing MVS.

EVIDENCE ACQUISITION

MEDLINE and EMBASE were searched through January 2022 to identify randomized controlled trials (RCT) and observational studies with adjusted outcomes that investigated outcomes of concomitant TA versus conservative management for mild to moderate tricuspid regurgitation in patients undergoing MVS.

EVIDENCE SYNTHESIS

Two RCT and 11 observational studies included in the meta-analysis with a total of 3,953 patients underwent MVS with (N.=1837) or without (N.=2166) concomitant TA. Mean follow-up period ranged from 24 to 115.5 months. MVS with concomitant TA was associated with all-cause mortality (hazard ratio [HR] 1.15; 95% confidence interval [CI]: 0.81-1.55; P=0.34, I²=0%) compared with MVS alone. Similarly, heart failure events (HR 0.74; 95% CI: 0.46-1.20; P=0.22, I²=0%) as well as rates of tricuspid reoperation (HR 0.55; 95% CI: 0.27-1.10; P=0.09, I²=1%) were comparable between the groups. However, MVS with concomitant TA was associated with a significant reduction in TR progression (HR 0.30; 95% CI: 0.17-0.53; P<0.00001, I²=11%).

CONCLUSIONS

Concomitant TA for patients undergoing MVS was associated with similar long-term clinical outcomes compared to MVS alone. However, concomitant TA was associated with a significant reduction in TR progression. Longer follow-up is necessary to assess the effect on further clinical outcomes.

Persisting burden and challenges of rheumatic heart disease

Rheumatic heart disease (RHD) is the result of episodes of acute rheumatic fever with valvular (and other cardiac) damage caused by an abnormal immune response to group A streptococcal infections, usually during childhood and adolescence. As a result of improved living conditions and the introduction of penicillin, RHD was almost eradicated in the developed world by the 1980s. However, being a disease of poverty, its burden remains disproportionately high in the developing world, despite being a fundamentally preventable disease. Rheumatic heart disease generates relatively little attention from the medical and science communities, in contrast to other common infectious problems (such as malaria, HIV, tuberculosis), despite the major cardiovascular morbidity/mortality burden imposed by RHD. This relative neglect and paucity of funding have probably contributed to limited fundamental medical advances in this field for over 50 years. Given the importance of prevention before the onset of major valvular damage, the main challenges for RHD prevention are improving social circumstances, early diagnosis, and effective delivery of antibiotic prophylaxis. Early identification through ultrasound of silent, subclinical rheumatic valve lesions could provide an opportunity for early intervention. Simple echocardiographic diagnostic criteria and appropriately trained personnel can be valuable aids in large-scale public health efforts. In addition, a better understanding of the immunogenic determinants of the disease may provide potential routes to vaccine development and other novel therapies.

Impact of concomitant tricuspid annuloplasty on right ventricular remodeling in patients with rheumatic mitral valve disease

Background

Studies on the management of functional tricuspid regurgitation (TR) during mitral valve operations have drawn inconsistent conclusions. This study was designed to compare the treatment strategy of concomitant tricuspid annuloplasty (TAP) against isolated mitral valve replacement (MVR) in rheumatic mitral valve disease patients, and to assess the effect of concomitant TAP on postoperative right ventricular (RV) remodeling and function.

Methods

One hundred-seventy patients with rheumatic mitral valve disease receiving MVR were categorized into TAP group (n = 124) and non-TAP group (n = 46). Clinical and echocardiographic data were collected preoperatively and at 1-year follow-up. Three-dimensional echocardiographic indices of RV geometry and function were analyzed.

Results

At baseline, concomitant TAP group had larger RV end-diastolic volume, more decreased RV ejection fraction and RV longitudinal strain than non-TAP group (all P <  0.001). At 1-year follow-up, TAP group had improved RV geometry and function. While adverse changes were observed in non-TAP group. In analysis of variance, the above indices demonstrated significant interaction with different treatment group (all P <  0.001). In multivariate regression analysis, independent of age and Maze procedure, concomitant TAP was associated with postoperative RV volume reduction (P <  0.001), improvement of RV ejection fraction (P <  0.001), and relieved postoperative functional TR severity (P = 0.025).

Conclusions

Our results suggest that concomitant TAP could improve RV remodeling and function for rheumatic mitral valve disease patients, while those with mild preoperative functional TR who had isolated MVR might experience RV dilation and deterioration of RV function at follow-up. Concomitant surgery for functional TR could be considered for patients undergoing MVR with rheumatic mitral valve disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-021-00245-2.