Outcomes of ring versus suture annuloplasty for tricuspid valve repair in patients undergoing mitral valve surgery

National Trends and Outcomes of Tricuspid Valve Surgery with Concomitant Mitral Valve Surgery: Results From a Ten-year Analysis of the National Inpatient Sample Database

According to an estimate, 20% of patients with heart valve disease have multivalve involvement necessitating combined valve surgery. There is a dearth of data about the clinical outcomes of patients with combined mitral and tricuspid valve disease who go through tricuspid valve surgery with concomitant mitral valve replacement or repair. We utilized National Inpatient Sample (NIS) between January 1, 2004, and December 31, 2014, to analyze the outcomes of patients who underwent tricuspid valve surgery with either mitral valve replacement or repair. We identified 21,141 weighted hospitalizations for combined TVS with MVr (TVS/MVr) or TVS with MVR (TVS/MVR). The overall inpatient mortality in the TVS/MVR cohort was higher than in the TVS/MVr cohort (7.36% vs 5.33%, P < 0.01). There was a trend toward decreased mortality over the years in the TVS/MVr cohort (P = 0.04) while mortality remained unchanged in the TVS/MVR cohort (P = 0.88). Overall, the TVS/MVr cohort had better clinical outcomes profile compared with TVS/MVR cohort.

Midterm comparison between different annuloplasty techniques for functional tricuspid regurgitation

BACKGROUND

Several tricuspid annuloplasty (TA) techniques are used for concomitant repair of functional tricuspid regurgitation. This study aims to compare the midterm clinical and valvular outcome between 3 annuloplasty techniques.

METHODS

TA was performed in 307 patients (age 75.9±10.4y) with a rigid ring (RA=184), a flexible band(FA=80) and a suture annuloplasty(SA=43). Study endpoints were survival and recurrence of TR > grade 2 at 5 years.

RESULTS

TA was performed concomitantly to mitral valve surgery (n=136, 44.3%), aortic valve surgery(n=18, 5.9%), CABG(n=13, 4.2%) or a combined procedure(n=140, 45.6%). The majority had TR>grade 2(78.5%) without significant differences between TA groups(p=0.878). Within a median follow-up of 3.4 y(IQR 2.2-5.0) the 5-year survival was 80.1±3.4% for RA, 83.5±4.7% for FA and 85.1±6.5% for SA(p=0.471). Independent risk factors for late mortality were renal impairment(HR 2.83, CI 1.16-6.89, p=0.022), diabetes(HR 2.10, CI 1.07-4.11, p=0.030) and severe RV dysfunction by TAPSE <10 mm(HR 11.52, CI 4.98-26.66, p<0.001). Pulmonary hypertension was nearly significant(HR 1.92, CI 0.98-3.74, p=0.057). The cumulative incidence of TR recurrence at 5 years was 15.9%, 19.4% and 21.1% for respectively RA, FA and SA(p=0.342). Severe pulmonary hypertension(HR 2.64, 95%CI 1.38-5.07, p=0.003) preoperative TR grade(HR 1.82, 95%CI 1.01-3.27, p=0.046) and residual TR>grade 2 at discharge(HR 3.38, 95%CI 1.64-6.96, p=0.001) were predictive for later TR recurrence, regardless of the annuloplasty technique.

CONCLUSIONS

This study demonstrates that advanced pathophysiological right circulatory impairment like severe pulmonary hypertension and RV dysfunction affects the midterm survival as well as TR recurrence rate more than the annuloplasty technique used for concomitant repair of functional tricuspid regurgitation.

Outcomes and Echocardiographic Follow-up After Surgical Management of Tricuspid Regurgitation in Patients With Transvenous Right Ventricular Leads

OBJECTIVE

To evaluate outcomes of elective surgical management of tricuspid regurgitation (TR) in patients with transvenous right ventricular leads, and compare results between non-lead-induced and lead-induced TR patients.

PATIENTS AND METHODS

We studied patients with right ventricular leads who underwent tricuspid valve surgery from January 1, 1993, through December 31, 2015, and categorized them as non-lead-induced and lead-induced TR. Propensity score (PS) for the tendency to have lead-induced TR was estimated from logistic regression and was used to adjust for group differences.

RESULTS

From the initial cohort of 470 patients, 444 were included in PS-adjustment analyses (174 non-lead-induced TRs [123 repairs, 51 replacements], 270 lead-induced TRs [129 repairs, 141 replacements]). In PS-adjusted multivariable analysis, lead-induced TR was not associated with mortality (P=.73), but tricuspid valve replacement was (hazard ratio, 1.59; 95% CI, 1.13 to 2.25; P=.008). Five-year freedom from tricuspid valve re-intervention was 100% for non-lead-induced TR and 92.3% for lead-induced TR; rates adjusted for PS differed between groups (P=.005). There was significant improvement in TR postoperatively in each group (P<.001). In patients having tricuspid valve repair, TR grades tended to worsen over time, but the difference in trends was not significantly different between groups.

CONCLUSION

Lead-induced TR did not affect long-term survival after elective tricuspid valve surgery. In patients with lead-induced TR, tricuspid valve re-intervention was more common. Improvement in TR was achieved in both groups after surgery; however, severity of TR tended to increase over follow-up after tricuspid valve repair.

Long-term results of tricuspid annuloplasty with 3-dimensional-shaped rings: effective and durable!

OBJECTIVES

3-Dimensional (3D)-shaped rings are largely adopted for tricuspid annuloplasty, but evidence about their long-term results is scanty. The goal of this study was to analyse the long-term results of tricuspid annuloplasty with 3D-shaped rings.

MATERIALS AND METHODS

A retrospective review of our prospectively maintained database was carried out to identify all patients who underwent tricuspid valve repair with 3D-shaped rings between January 2011 and December 2014. Kaplan-Meier methods were used to analyse long-term survival. Cumulative incidence function using death as the competitive outcome was used to estimate cardiac death.

RESULTS

A total of 168 patients were identified. The median age was 66 years. Eighty-two patients (49%) were in advanced New York Heart Association functional class III-IV. Atrial fibrillation (AF) was present in 101 (60%); the median ejection fraction was 60%. In 82 (49%) patients, a Medtronic 3D Contour annuloplasty ring was employed; in the remaining 86 (51%) patients, an Edwards MC3 ring was used. Cumulative incidence function of cardiac death, with non-cardiac death as a competing risk, was 1.9 ± 1.1%, 95% confidence interval (CI) (0.51-4.95) at 7 years. The cumulative incidence function of recurrence of tricuspid regurgitation (TR) ≥2+ at 7 years was 14 ± 3.17%, 95% CI (8.49-20.82). Recurrence of TR ≥2+ at 7 years was not significantly different between the Medtronic 3D Contour and the Edwards MC3 rings (P = 0.3). AF was identified as the only independent predictor of recurrence of TR ≥2+.

CONCLUSIONS

3D-shaped rings are effective and durable. TR recurrence was relatively low at 7 years and usually moderate (2+/4+) without a significant difference between the 2 types of rings. The role of AF as a predictor of TR recurrence was confirmed.

Durability of suture versus ring tricuspid annuloplasty: Looking at very long term (18 years)

BACKGROUND

Several papers already reported better outcomes of tricuspid valve repair with ring annuloplasty compared to suture techniques. However, the follow-up is usually limited to 10 years. With this study, we aim to analyze the results of tricuspid valve repair according to the technique employed when the follow-up is extended to more than 15 years.

MATERIALS AND METHODS

A retrospective review of our institutional database was carried on to find all patients who underwent tricuspid valve repair between January 1998 and December 2004. Kaplan-Meier method was employed to estimate survival and log-rank test was used to make intergroup comparison. Cox regression was employed to identify risk factor for mortality. Cumulative incidence function using death as competitive outcome was used to estimate cardiac death. To describe the time course of tricuspid regurgitation, a longitudinal analysis using generalized estimating equations with random intercept for correlated data was performed.

RESULTS

One hundred forty-six patients were identified: 89 in the suture group and 57 in the ring group. No difference in term of long-term survival and cardiac death was evident between the two groups. A significant higher rate of tricuspid regurgitation ≥2+ and ≥3+ recurrence was evident in the suture group during the whole follow-up (p < 0.001).

CONCLUSION

Our results corroborate the better results of tricuspid valve repair by means of ring implantation compared to suture techniques also when the follow-up is extended up to 18 years. Ring annuloplasty should be considered the first option for tricuspid valve repair due to a better durability.

Quantitating Mitral Regurgitation in Clinical Trials: The Need for a Uniform Approach

BACKGROUND

There is an established relationship between the degree of mitral regurgitation (MR) and prognosis. Quantitation of MR severity guides therapeutic approaches. Inconsistent definitions and categorization of MR severity in clinical studies limit meaningful comparisons between trials and compromise development of an effective evidence base. The purpose of this study was to quantify heterogeneity in grading systems for MR severity in the contemporary literature.

METHODS

We performed a systematic review of randomized (RCT) and propensity score (PS) adjusted clinical studies of MV interventions (surgical or percutaneous). A total of 35 articles from 2015-2020 were included (15 RCT, 20 PS).

RESULTS

There were 22 studies that reported MR severity in numerical categories, either values from the historical "plus" system or numerical MR grades, while 9 studies reported MR severity using text-only descriptive categories. Among the studies that used numerical categories, 2+ MR was defined as moderate in 64% of studies, mild in 27%, and mild-moderate in 9% and 3+ MR was defined as moderate in 14%, moderate-severe in 52%, and severe in 14%.

CONCLUSIONS

There was substantial variability in MR severity definition and reporting in contemporary clinical studies of MV interventions. We recommend the historical "plus" numerical grading system be abandoned and that inclusion and outcome criteria in MR clinical trials be based on American and European guideline-recommended categories as none/trace, mild, moderate, and severe. Adoption of these simple recommendations will improve the consistency and quality of MR clinical trial design and reporting.

The best approach for functional tricuspid regurgitation: A network meta-analysis

OBJECTIVE

For many years, functional tricuspid regurgitation (FTR) was considered negligible after treatment of left-sided heart valve surgery. The aim of the present network meta-analysis is to summarize the results of four approaches to establish the possible gold standard.

METHODS

A systematic search was performed to identify all publications reporting the outcomes of four approaches for FTR, not tricuspid annuloplasty (no TA), suture annuloplasty (SA), flexible (FRA), rigid rings (RRA). All studies reporting at least one the four endpoints (early and late mortality, early and late moderate or more TFR) were included in a Bayesian network meta-analysis.

RESULTS

There were 31 included studies with 9663 patients. Aggregate early mortality was 5.3% no TA, 7.2% SA, 6.6% FRA, and 6.4% RRA; early TR moderate-or-more was 9.6%, 4.8%, 4.6%, and 3.8%; late mortality was 22.5%, 18.2%, 11.9%, and 11.9%; late TR moderate-or-more was 27.9%, 18.3%, 14.3%, and 6.4%. Rigid or semirigid ring annuloplasty was the most effective approach for decreasing the risk of late moderate or more FTR (-85% vs. no TA; -64% vs. SA; -32% vs. FRA). Concerning late mortality, no significant differences were found among different surgical approaches; however, flexible or rigid rings reduced significantly the risk of late mortality (78% and 47%, respectively) compared with not performing TA mortality. No differences were found for early outcomes.

CONCLUSIONS

Ring annuloplasty seems to offer better late outcomes compare to either suture annuloplasty or not performing TA. In particular rigid or semirigid rings provide more stable FTR across time.

Tricuspid Valve Annuloplasty Alters Leaflet Mechanics

Tricuspid valve regurgitation is associated with significant morbidity and mortality. Its most common treatment option, tricuspid valve annuloplasty, is not optimally effective in the long-term. Toward identifying the causes for annuloplasty's ineffectiveness, we have previously investigated the technique's impact on the tricuspid annulus and the right ventricular epicardium. In our current work, we are extending our analysis to the anterior tricuspid valve leaflet. To this end, we adopted our previous strategy of performing DeVega suture annuloplasty as an experimental methodology that allows us to externally control the degree of cinching during annuloplasty. Thus, in ten sheep we successively cinched the annulus and quantified changes to leaflet motion, dynamics, and strain in the beating heart by combining sonomicrometry with our well-established mechanical framework. We found that successive cinching of the valve enforced earlier coaptation and thus reduced leaflet range of motion. Additionally, leaflet angular velocity during opening and closing decreased. Finally, we found that leaflet strains were also reduced. Specifically, radial and areal strains decreased as a function of annular cinching. Our findings are critical as they suggest that suture annuloplasty alters the mechanics of the tricuspid valve leaflets which may disrupt their resident cells' mechanobiological equilibrium. Long-term, such disruption may stimulate tissue maladaptation which could contribute to annuloplasty's sub-optimal effectiveness. Additionally, our data suggest that the extent to which annuloplasty alters leaflet mechanics can be controlled via degree of cinching. Hence, our data may provide direct surgical guidelines.

Impact of Different Annuloplasty Methods for Tricuspid Regurgitation: A Network Meta-Analysis

BACKGROUND

Although moderate to severe tricuspid valve regurgitation (TR) is an independent risk factor for progressive heart failure and increased mortality, the best method for tricuspid valve repair remains controversial. Therefore, this study conducted a network meta-analysis to compare early and late outcomes for suture, flexible band, and rigid ring as tricuspid annuloplasty (TAP) in patients with TR.

METHODS

Medline and EMBASE were searched through February 15, 2020 to identify randomized controlled trials and observational trials that investigated early and late outcomes after TAP for TR. The outcomes of interest were perioperative mortality, all-cause mortality, and TR recurrence with more than 1-year follow-up. TR recurrence was defined as at least moderate (TR grade 2) on serial echocardiograms.

RESULTS

Two randomized controlled trials and 15 observational trials were identified, including 6138 patients who underwent TAP. The median follow-up period was 1 to 7.4 years. There were no significant differences of perioperative and all-cause mortality among 3 TAP methods. Rigid ring TAP was associated with a significant reduction in TR recurrence compared with suture TAP (hazard ratio, 0.42; 95% confidence interval, 0.23 to 0.78; P = .005). There were no significant differences in TR recurrence were observed between flexible band and suture TAP or flexible band and rigid ring TAP.

CONCLUSIONS

This network meta-analysis demonstrated significant reduction in TR recurrence for rigid ring TAP compared with suture TAP, although no significant differences were observed between suture and flexible band TAP or between flexible band and rigid ring TAP. There were no significant mortality differences among suture, flexible band, and rigid ring TAP procedures.

Tricuspid annuloplasty: Too many, too few? Virtue may be in the middle!

BACKGROUND

Significant secondary tricuspid regurgitation, often accompanied by right ventricular dilation and dysfunction, occurs in a significant proportion of patients submitted to surgery for severe mitral valve disease. It appears a vicious circle that is not interrupted by the treatment of the left heart valve alone, hence it requires concomitant intervention on the tricuspid valve.

AIMS

In this commentary I will discuss a paper published in this issue of the Journal by Calafiore et al from Riyadh - Saudi Arabia, reporting a retrospective study that evaluated the influence of preoperative right ventricular and tricuspid valve (TV) remodeling on the fate of tricuspid annuloplasty (TA) and RV in 423 patients undergoing TA for functional TR operated on from May 2009 to December 2015 at their institution.

MATERIALS & METHODS

Current guidelines and other consensus documents recommend that tricuspid valve surgeryshould be considered (class IIa) in patients with mild/moderate secondary regurgitation and/or significant annular dilatation. However, rates of tricuspid annuloplasty performed during operations to left-heart valves are very variable, depending also on the etiology of the mitral disease.

RESULTS & DISCUSSION

Different methods of annuloplasty are used by the surgical community - suture, rings, bands - with widely variable results with regard to the recurrence of regurgitation and long-term survival. Not all these techniques are standardised and this may also be a cause for the disparate results.

CONCLUSION

In the absence of randomized studies, which are highly unlikely to be undertaken in this situation, more information is required from large series with longer follow-ups.

Late tricuspid regurgitation and right ventricular remodeling after tricuspid annuloplasty

BACKGROUND

The aim of the present retrospective study was to evaluate the influence of preoperative right ventricular (RV) and tricuspid valve (TV) remodeling on the fate of tricuspid annuloplasty (TA) and right ventricle.

METHODS

From May 2009 to December 2015, 423 patients who had undergone TA for functional tricuspid regurgitation (TR) were included in the study. Residual and recurrent TR were defined as moderate or more TR at discharge and follow-up, respectively. RV remodeling was defined as RV dysfunction and/or dilation.

RESULTS

Residual TR after TA was recorded in 54 patients (13%). Five-year freedom from TR recurrence was 81% ± 3% in patients without residual TR and 41 ± 8 in patients with residual TR (P < .001). In patients without residual TR, the following risk factors for recurrent TR and late RV remodeling were identified: preoperative systolic pulmonary artery pressure, preoperative RV remodeling, severe preoperative TR or less than severe TR but with TV apparatus remodeling, and etiology of mitral regurgitation. Cox analysis with time-dependent variables confirmed TR recurrence (hazard ratio [HR]: 3.1) and late RV remodeling (HR: 6.5) as risk factors for lower survival. No protective effect of either flexible band or rigid ring TA compared with DeVega procedure was found. Similarly, preoperative atrial fibrillation and pacemaker dependency, late failure of mitral valve surgery did not affect the fate of TR.

CONCLUSIONS

Prophylactic TA should be encouraged among surgeons. TA at the time of left-sided valve surgery should take into consideration not only annular size, but also tethering severity and RV remodeling.

The Effect of Downsizing on the Normal Tricuspid Annulus

Tricuspid annuloplasty is a surgical procedure that cinches the valve's annulus in order to reduce regurgitant blood flow. One of its critical parameters is the degree of downsizing. To provide insight into the effect of downsizing, we studied the annulus of healthy sheep during suture annuloplasty. To this end, we implanted fiduciary markers along the annulus of sheep and subsequently performed a DeVega suture annuloplasty. We performed five downsizing steps in each animal while recording hemodynamic and sonomicrometry data in beating hearts. Subsequently, we used splines to approximate the annulus at baseline and at each downsizing step. Based on these approximations we computed clinical metrics of annular shape and dynamics, and the continuous field metrics height, strain, and curvature. With these data, we demonstrated that annular area reduction during downsizing was primarily driven by compression of the anterior annulus. Similarly, reduction in annular dynamics was driven by reduced contractility in the anterior annulus. Finally, changes in global height and eccentricity of the annulus could be explained by focal changes in the continuous height profile and changes in annular curvature. Our findings are important as they provide insight into a regularly performed surgical procedure and may inform the design of transcatheter devices that mimic suture annuloplasty.

Long-term outcomes of rigid ring versus De Vega annuloplasty for functional tricuspid regurgitation: A propensity score-matching analysis

OBJECTIVE

This study was conducted to compare the outcomes of rigid ring versus De Vega annuloplasty for the treatment of functional tricuspid regurgitation (TR).

METHODS

From 2003 to 2017, De Vega annuloplasty (group D) was used in 231 patients, and rigid ring annuloplasty (group R) was used in 204 patients for the treatment of functional TR during left-sided valve surgery. A propensity score-matching analysis was used to pair group D (n = 109) with group R (n = 109). The primary outcomes were long-term overall survival and cardiac death, and the secondary outcomes were tricuspid valve-related events and TR recurrence (TR moderate or severe). The follow-up data were complete in 99.6% (447 out of 449) of the patients with a follow-up duration of 102 months.

RESULTS

There were no differences in the overall survival and cardiac death between the propensity score-matched groups (P = .793 and P = .175, respectively) up to 14 years after surgery. Tricuspid valve-related events, including cardiac death, permanent pacemaker implantation, thromboembolism, bleeding and tricuspid valve reoperation were also similar between the 2 matched groups during the follow-up (P > .999). However, cumulative incidence of TR recurrence was significantly higher in group R than in group D (P = .007). Multivariate analysis indicated the annuloplasty method (De Vega) and preoperative TR grade as risk factors for late TR recurrence.

CONCLUSIONS

In functional TR, annuloplasty methods did not influence long-term overall survival, cardiac mortality, and tricuspid valve-related events. However, rigid ring annuloplasty showed less late TR recurrence. Rigid ring annuloplasty can be considered for the treatment of functional TR in terms of its better durability.

Impact of tricuspid annular size reduction on right ventricular function, geometry and strain

OBJECTIVES

Restrictive tricuspid annuloplasty is a clinically accepted approach to treat functional tricuspid regurgitation. We set out to investigate the effect of varying degrees of tricuspid annular reduction on the right ventricular (RV) function, geometry and strain.

METHODS

Eight, healthy sheep (45 ± 4 kg) had 6 sonomicrometry crystals implanted around the tricuspid annulus and 20 onto the epicardium of the right ventricle defining 3 free wall regions: basal, mid and lower. A polypropylene annuloplasty suture was placed around the tricuspid annulus and externalized to an epicardial tourniquet. Simultaneous echocardiographic, haemodynamic and sonomicrometry data were acquired at baseline and during 5 consecutive annular reduction steps (TAR 1-5) with successive (5-7 mm) suture cinching. RV free wall circumferential, longitudinal and areal cardiac and interventional strains, RV radius of curvature (ROC), cross-sectional area and tricuspid annular dimensions were calculated from 3-dimensional crystal coordinates.

RESULTS

TAR 1-5 resulted in 19 ± 15%, 35 ± 15%, 51 ± 15%, 60 ± 15% and 68 ± 13% tricuspid annular area reduction, respectively. TAR 1 and 2 had minimal influence on the RV function, RV-ROC and strains. TAR 4 and 5 decreased RV-ROC in basal and mid-regions, but reduced the RV cross-sectional area change (from 19 ± 4% at baseline to 14 ± 3% and 13 ± 2%, respectively, P < 0.001) and circumferential and areal strains. TAR 3 significantly decreased free wall RV-ROC from 44.0 ± 1.5 to 42.6 ± 2.4 mm P < 0.001 at the RV base but maintained the regional ventricular function and strains.

CONCLUSIONS

In healthy ovine hearts, a tricuspid annular area reduction of ∼50% provides optimal conditions for reducing RV-ROC while maintaining regional RV function and strain patterns.

De Vega tricuspid valve annuloplasty - a rightly neglected surgical technique?

Introduction

There is a lot of discussion about the best surgical technique for tricuspid valve (TV) regurgitation in patients undergoing an operation for primary mitral valve disease.

Aim

To review and compare our results and experiences regarding the two main surgical strategies: tricuspid valve annuloplasty with a prosthetic ring (RING group) and suture annuloplasty (De Vega group).

Material and methods

We reviewed 570 patients who underwent TV surgery between 2000 and 2016 with either ring annuloplasty (RING group: n = 490 (85.9%)) or De Vega suture annuloplasty (De Vega group: n = 69 (12.1%)). The aetiology of TV insufficiency was secondary in 96.3% (538/559) of the patients, but 47.6% of the patients with primary aetiology had endocarditis of the permanent pacemaker stimulating wires.

Results

The age of the two study groups was similar (p = 0.6589), with a mean age of 66.7 years for the ring annuloplasty group and 67.9 years for the De Vega suture technique. The overall 30-day mortality was 10.9% (n = 61) (RING group n = 58 (11.8%) and De Vega group n = 3 (4.3%)). Ten years after TV surgery with either ring annuloplasty or the De Vega suture technique, 5.8% of patients in both study groups presented with a recurrence of severe tricuspid regurgitation ≥ 3.

Conclusions

Outcomes of tricuspid valve repair did not differ in terms of long-term stability and durability between the two evaluated techniques.

Flexible band versus rigid ring annuloplasty for tricuspid regurgitation: a systematic review and meta-analysis

BACKGROUND

Up to 20% of patients have pre-discharge residual moderate to severe tricuspid regurgitation (TR) after tricuspid repair. Reoperations for recurrent TR carry high mortality rates, which emphasizes the importance of identifying the optimal technique for the surgical management of TR. The present study is a systematic review and meta-analysis that aims to compare short and long term survival and freedom from TR of flexible band ring versus rigid ring for annuloplasty of TR.

METHODS

We conducted a systematic review and meta-analysis of comparative studies to evaluate these procedures. A systematic search of the literature was performed from six electronic databases. Pooled meta-analysis was conducted using odds ratio (OR) and weighted mean difference (WMD).

RESULTS

The rates of in-hospital mortality were not different between the two groups, with cumulative rates of 6.9% for flexible band and 7.3% for rigid ring (OR: 0.92; 95% CI: 0.49-1.71). Rates of stroke were also similar with 1.7% of flexible band and 1.3% of rigid rings suffering a perioperative stroke (OR: 1.29; 95% CI: 0.74-2.23). Rigid ring had significantly better freedom from grade ≥2 TR at 5 years (OR: 0.44; 95% CI: 0.20-0.99) and overall (P=0.005). There was no significant difference in overall rates of reoperation (P=0.232) and survival (P=0.086) between flexible band and rigid ring.

CONCLUSIONS

Both rigid ring and flexible band offer acceptable outcomes for the treatment of TR. Compared to flexible band, rates of TR are stable after rigid ring annuloplasty and long term freedom from TR are superior for rigid ring devices. Large prospective randomized trials are required in order to validate these findings and assess for improvements in patient survival.

Comparison of outcomes of tricuspid annuloplasty with 3D-rigid versus flexible prosthetic ring for functional tricuspid regurgitation secondary to rheumatic mitral valve disease

BACKGROUND

Annuloplasty bands and rings are widely used for repairing functional tricuspid regurgitation (FTR). However, the question regarding which is the ideal annuloplasty device remains unclear. The aim of this study was to compare the efficacy and mid-term durability of tricuspid ring annuloplasty for FTR secondary to rheumatic mitral valve disease using flexible Cosgrove-Edwards band and the rigid Edwards MC3 ring (Edwards Lifesciences, LLC, Irvine, CA, USA).

METHODS

We retrospectively collected the clinical data of those who underwent mitral valve replacement (MVR) in concomitant with tricuspid ring annuloplasty from 2009 to 2013. The flexible band was used in 46 patients (flexible group), and the 3D rigid ring was used in 60 patients (rigid group). Echocardiographic evaluation of tricuspid function was performed preoperatively and postoperatively.

RESULTS

The grade of TR was significantly improved compared to preoperative values in two groups. There was no significant difference regarding postoperative TR grade between the two groups at 1 week and 2-3 months but there was statistical significant difference at postoperative 6-12 months, and 2-3 years. During the follow up period, 25 of 46 patients (54.3%) in flexible group and 22 of 60 patients (30.3%) in rigid group developed recurrent TR. Freedom from recurrent TR in flexible group is significant lower than rigid group in each postoperative follow up period.

CONCLUSIONS

These findings suggest that 3D rigid ring annuloplasty might be more effective for tricuspid ring annuloplasty in FTR in mid-term postoperative periods when compared to flexible band.