Impact of the maze operation combined with left-sided valve surgery on the change in tricuspid regurgitation over time

Sinus rhythm restoration reverses tricuspid regurgitation in patients with atrial fibrillation: a systematic review and meta-analysis

BACKGROUND

Tricuspid regurgitation (TR) is a common valvular heart disease worldwide, and current guidelines for TR treatment are relatively conservative, as well as with detrimental outcomes. Restoration of sinus rhythm was reported to improve the TR severity in those TR patients with atrial fibrillation (AF). However, relevant research was limited. The aim of this meta-analysis was to evaluate the clinical outcomes of restoration of sinus rhythm in TR patients with AF.

METHODS

In this study, PubMed, Web of Science, and Scopus databases were searched for study enrollment until July 2023. This study was designed under the guidance of Preferred Reporting Items for Systematic Reviews and Meta-Analyses. These studies containing the patient's baseline characteristics, surgical procedure, and at least one of the clinical outcomes were included. The primary endpoint was TR grade during follow-up after restoration of sinus rhythm.

RESULTS

Out of 1074 records, 6 were enrolled. Restoration of sinus rhythm is associated with a reduction of TR severity (TR grade, odds ratio 0.11, 95% confidence interval (CI): 0.01 to 1.28, P = 0.08, I2 = 83%; TR area, mean difference (MD) -2.19 cm2, 95% CI: -4.17 to -0.21 cm2, P = 0.03, I2 = 96%). Additionally, remolding of right heart with a significant reduction of tricuspid valve annulus diameter (MD -0.36 cm, 95%CI: -0.47 to -0.26 cm, P < 0.00001, I2 = 29%) and right atrium volume index (MD -11.10 mL/m2, 95%CI: -16.81 to -5.39 mL/m2, P = 0.0001, I2 = 79%) was observed during follow-up.

CONCLUSIONS

In conclusion, rhythm-control therapy could reduce TR severity in AF patients with TR and is associated with right heart remodeling.

His-Purkinje system pacing reduced tricuspid regurgitation in patients with persistent atrial fibrillation after left-sided valve surgery

Background & objective

Tricuspid regurgitation after left-sided valve surgery was a common and difficult problem. Atrial fibrillation was considered to be an important etiology of tricuspid regurgitation. His-Purkinje system pacing (HPSP) was a physiological pacing method, which could prevent and treat heart failure and might reduce tricuspid regurgitation. Our study aimed to investigate the effect of HPSP on tricuspid regurgitation in patients with persistent atrial fibrillation after left-sided valve surgery.

Methods

This study was a retrospective study. The 3-year patient review focused on those who underwent permanent cardiac pacemaker implantation of HPSP after mitral valve and/or aortic valve replacement from Jan 1st, 2019 to Jan 1st, 2022. HPSP included His bundle pacing (HBP) or left bundle branch pacing (LBBP). Clinical data collected included electrocardiogram, pacing parameters, ultrasonic cardiogram parameters and chest x-ray at implantation and 3-month follow up. Univariate and multivariate linear regression analysis of tricuspid regurgitation velocity were performed.

Results

A total of 44 patients was retrospectively reviewed. Eight patients who had undergone implantation of HPSP after left-sided heart valve replacement were enrolled in the study. All patients had persistent atrial fibrillation. Three of them received HBP and five underwent LBBP. At 3-month follow-up, the tricuspid regurgitation grade was significantly lower than that before implantation (P = 0.007). The tricuspid regurgitation velocity significantly decreased (317 ± 74 cm/s vs. 261 ± 52 cm/s, P = 0.022) and tricuspid valve pressure gradient (PG) reduced (42 ± 21 mmHg vs. 28 ± 10 mmHg, P = 0.040). The cardiothoracic ratio of patients was significantly lower than that before implantation (0.61 ± 0.08 vs. 0.64 ± 0.09, P = 0.017). The NYHA classification of patients also improved (P = 0.013). In multivariate liner regression analysis, the pacing ratio (β = 0.736, P = 0.037) was an independent determinant of tricuspid regurgitation velocity variation.

Conclusion

HPSP might reduce tricuspid regurgitation and improve cardiac function in patients with persistent atrial fibrillation after left-sided valve surgery.

Surgical management of tricuspid regurgitation: a new algorithm to minimise recurrent tricuspid regurgitation

Introduction

Recurrent tricuspid regurgitation (TR) is frequently observed after cardiac surgery; however, the correct approach remains controversial. We developed an algorithm for action on the tricuspid valve (TV) and conducted a 1-year follow-up study. The aim was to assess the efficacy of the algorithm to minimise residual TR after TV surgery. The hypothesis was that the TR rate at 1 year would be reduced by selecting the surgical approach in accordance with a set of preoperative clinical and echocardiographic variables.

Methods

A prospective, observational, single-centre study was performed in 76 consecutive patients with TV involvement. A protocol was designed for their inclusion, and data on their clinical and echocardiographic characteristics were gathered at 3 months and 1-year postsurgery. The treatment of patients depended on the degree of TR. Surgery was performed in all patients with severe or moderate-to-severe TR and in those with mild or moderate TR alongside the presence of certain clinical or echocardiographic factors. They underwent annuloplasty or extended valve repair when the TV was distorted. If repair techniques were not feasible, a prosthesis was implanted. Residual TR rates were compared with published reports, and predictors of early/late mortality and residual TR were evaluated.

Results

TR was functional in 69.9% of patients. Rigid ring annuloplasty was performed in 35.7% of patients, De Vega annuloplasty in 27.1%, extended repair in 11.4% and prosthetic replacement in 25.7%. TR was moderate or worse in 8.19% of patients (severe in 3.27%) at 1 year postintervention. No clinical, surgical or epidemiological variables were significantly associated with residual TR persistence, although annulus diameter showed a close-to-significant association. Total mortality was 12.85% for all causes and 10% for cardiovascular causes. In multivariate analysis, left ventricular ejection fraction was related to both early and late mortality.

Conclusions

Severe residual TR was significantly less frequent than reported in other series, being observed in less than 4% of patients at 1-year postsurgery.

The role of left atrial strain in patients with functional tricuspid regurgitation before and after annuloplasty: a long-term follow-up study

Background

Functional tricuspid regurgitation (TR) is common among patients with left heart disease and may recur during the follow-up period after selective tricuspid valve annuloplasty (TVA). This study aims to analyse the relationship between left atrial (LA) strain and the degree of preoperative functional TR and to explore the role of LA strain in predicting TR recurrence.

Methods

This study included 63 patients with rheumatic mitral stenosis who underwent mitral valve replacement and concomitant TVA. Additionally, 20 healthy controls were enrolled. Preoperative conventional LA echocardiographic parameters and LA strain were measured. The association between LA strain and preoperative functional TR severity was analysed by Pearson correlation. Predictors of recurrent TR were determined by multivariate logistic regression analyses.

Results

Compared with the control group, the mitral stenosis group developed a significant impairment in terms of LA strain. The degree of preoperative functional TR exhibited moderate correlations with LA reservoir strain (r = − 0.57) and LA conduit strain (r = 0.48). During a median follow-up period of 66.4 ± 36.4 months, TR recurred in 18 patients. Preoperative LA reservoir strain and the mean transmitral gradient were predictors of postoperative TR recurrence. When the two indexes were combined to establish a prediction, the sensitivity and specificity of prediction increased. The area under the receiver operating characteristic curve of the combined indicator was higher than those of the single indicators (0.90 vs. 0.70 and 0.72).

Conclusions

LA strain correlates with preoperative functional TR severity in patients with rheumatic mitral stenosis. The LA reservoir strain and preoperative mean transmitral gradient are independent predictive factors for recurrent TR after TVA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-021-00264-z.

Mid-term functional recovery after tricuspid annuloplasty concomitant with left-sided valve surgery

BACKGROUND

To elucidate the impact of tricuspid annuloplasty concomitant with left-sided valve surgery on the right ventricular (RV) function in patients with mild or more tricuspid regurgitation (TR).

METHODS

We enrolled 136 patients with mild or more TR who underwent left-sided valve surgery. Seventy-three patients underwent left-sided valve surgery alone (group non-T) and 63 underwent concomitant tricuspid annuloplasty (group T). The echocardiographic data at the latest follow-up (mean 1019 days) were compared using multiple regression analysis to adjust cofounding factors. Propensity score was calculated and included in the analysis as a covariate. In addition, propensity score matching was used for sensitive analysis (12 pairs).

RESULTS

In group non-T, there were more aortic valve surgeries, and fewer mitral valve surgeries. At baseline, body surface area, New York Heart Association class, and prevalence of atrial fibrillation were significantly different between groups. On preoperative echocardiography, left and right atrial diameter, RV diameter, and tricuspid annular diameter were larger in group T, whereas there was no significant difference in RV fractional area change. In multiple regression analyses, RV diameter in diastole was significantly lower and RV fractional area change was significantly higher at the follow-up period in group T. These results were not attenuated even in subgroup analysis in patients with only mild TR or mitral valve surgery alone.

CONCLUSION

Among patients with mild or more TR, RV dimensional and functional recovery was not obtained with left-sided valve surgery alone. Adding tricuspid annuloplasty may potentially achieve both outcomes.

Sick Sinus Syndrome After the Maze Procedure Performed Concomitantly With Mitral Valve Surgery

Background

To characterize the development of sick sinus syndrome (SSS) after the additive maze procedure (MP) during mitral valve surgery.

Methods and Results

Follow‐up data (median, 3.6 years) of 750 patients with a prevalence of rheumatic cause of 57.6% were analyzed. SSS occurred in 35 patients with a time‐dependent increase: the incidence rates at 1, 2, and 4 years after surgery were 2.9%, 3.7%, and 4.3%, respectively. The additive MP showed higher risks of SSS development (hazard ratio, 7.44; 95% confidence interval, 3.45–16.05; P<0.001) and pacemaker implantation (hazard ratio, 3.61; 95% confidence interval, 1.95–6.67; P<0.001). Patients who developed SSS showed higher 4‐year rates of clinical events (death, stroke, and hospital admission) (67.5±8.5% versus 33.0±1.9%; P<0.001). After adjustment for age and preoperative peak systolic pulmonary artery pressure, the lesion extent (biatrial versus left atrial MP), not the underlying cause (rheumatic versus nonrheumatic), was independently associated with SSS development (hazard ratio, 3.58; 95% confidence interval, 1.08–11.86; P=0.037). The adverse effect of the biatrial MP was confirmed in patients with trivial or mild preoperative tricuspid regurgitation showing higher SSS incidence (4.6±1.4% versus 1.0±0.7%; P=0.023), not in those with moderate‐to‐severe tricuspid regurgitation (6.8±1.7% versus 3.8±3.8%; P=0.337). Recurrence of atrial fibrillation was not associated with the lesion extent of the MP.

Conclusions

After the additive MP, the ongoing risk of SSS development should be acknowledged irrespective of the underlying cause. Considering additive risk of biatrial MP with similar atrial fibrillation recurrence rate, minimizing lesion extent is warranted.

Survival analysis of patients with rheumatic MS after PBMV compared with MVS in a low-to-middle-income country

Introduction

Rheumatic mitral stenosis continues to be prevalent in developing countries, notably in endemic areas. Over the last few decades, percutaneous balloon mitral valvuloplasty (PBMV) has been established as a lower-cost alternative treatment for mitral stenosis (MS) in low-to-middle-income countries. PBMV has also been suggested to be an effective and safe alternative treatment modality. This study aims to analyse the survival of rheumatic MS patients treated with PBMV compared with those treated with mitral valve surgery (MVS).

Methods

This study was a national, single-centre, longitudinal study using a survival analysis method in 329 consecutive patients suffering from rheumatic heart disease with severe MS who underwent PBMV compared with 142 consecutive patients with similar characteristics who underwent MVS between January 2011 and December 2016. Survival analysis and event-free duration were determined over a median follow-up of 24 months in the PBMV group and 27 months in the MVS group.

Results

The results showed that of the 329 consecutive patients in the PBMV group, 61 patients (18.5) had an event (6 patients died and 55 patients were hospitalised), and of the 142 consecutive patients in the MVS group, 19 patients (13.4%) had an event (5 patients died, and 14 patients were hospitalised). The hazard ratio was 0.631 (95% confidence interval, 0.376–1.058; P = 0.081). Longer short-term survival was found in the MVS group but was not statistically significant. Event-free survival was significantly longer in the MVS group (P = 0.002), by 5 months.

Conclusions

In this study, the efficacy and safety of PBMV was reconfirmed, as PBMV proved to be non-inferior to MVS in survival prognosis, but sustained event-free duration was significantly better in the MVS group than in the PBMV group.

Sinus node dysfunction after surgical atrial fibrillation ablation with concomitant mitral valve surgery: Determinants and clinical outcomes

Objective

We sought to investigate determinants and prognosis of sinus node dysfunction (SND) after surgical ablation of atrial fibrillation (AF) with concomitant mitral valve (MV) surgery. A total of 202 patients who underwent surgical AF ablation with concomitant MV surgery were studied.

Study design and setting

SND was defined as electrocardiographic manifestations, such as junctional bradycardia, symptomatic sick sinus syndrome, or symptomatic sinus bradycardia, 7 days after surgery. Baseline clinical and echocardiographic characteristics, rhythm outcomes [AF recurrence or permanent pacemaker (PM) implantation] at 6 and 12 months, and clinical outcomes were compared between patients without SND (n = 165) and those with SND (n = 37) after surgery.

Results

Patients with SND showed a significantly larger left atrial volume index (LAVI) and a higher right ventricular systolic pressure than those without SND. In addition, there was a higher likelihood for AF recurrence and PM implantation in patients with SND than in those without SND. Although clinical outcomes did not differ between the two groups, patients with SND had a significantly longer length of hospital stay (p<0.001). In a multivariate analysis, preoperative LAVI was a structural risk factor for SND [hazard ratio (HR): 1.126 per 10 mL/m²; 95% confidence interval (CI): 1.0206–1.236; p = 0.001]. An LAVI cut-off value of 105 mL/m² showed significant predictive power for SND [sensitivity: 62%; specificity: 64%; area under the curve (AUC): 0.678; p = 0.002].

Conclusions

In conclusion, preoperative LA size was a structural risk factor for SND after surgical AF ablation during MV surgery. SND was associated with an increased risk for AF recurrence and implantation of permanent PM in patients undergoing concomitant surgical ablation of AF with MV surgery.

Early Clinical Outcomes of Tricuspid Valve Repair with a Tri-Ad Annuloplasty Ring in Comparison with the Outcomes Using an MC3 Ring

Background

We evaluated the early clinical outcomes of tricuspid valve annuloplasty (TAP) with the Tri-Ad annuloplasty ring for functional tricuspid regurgitation (TR).

Methods

From January 2015 to March 2017, 36 patients underwent TAP with a Tri-Ad ring for functional TR. To evaluate the early clinical outcomes of TAP with the Tri-Ad ring, we conducted a propensity score-matched analysis comparing the Tri-Ad and MC³ tricuspid annuloplasty rings (n=34 in each group). The follow-up duration was 11.0±7.07 months.

Results

There was 1 case of operative mortality (2.8%) and no cases of late mortality. Postoperative complications occurred in 15 patients (41%), including acute kidney injury in 6 patients (16%), bleeding requiring reoperation in 4 patients (11%), and low cardiac output syndrome in 4 patients (11%). There were no ring-related complications, such as atrioventricular block or ring dehiscence. The TR grade decreased significantly (from 2.03±1.06 to 1.18±0.92, p<0.01), as did the systolic pulmonary artery pressure (from 43.53±13.84 to 38.00±9.72 mm Hg, p=0.03). There were no cases of severe residual TR, but moderate TR was observed in 3 patients, all of whom had severe TR preoperatively. Severe preoperative TR was also associated with moderate in the univariate analysis (p<0.01). In the propensity score-matched analysis comparing the Tri-Ad and MC³ rings, there was no significant difference in early clinical outcomes.

Conclusion

TAP with the Tri-Ad ring corrected functional TR effectively and provided good early clinical and echocardiographic results without ring-related complications. However, severe preoperative TR was associated with moderate or severe residual TR in the immediate postoperative period. A follow-up study is necessary to confirm the stability of this procedure.

Effect of Patient-Prosthesis Mismatch in Aortic Position on Late-Onset Tricuspid Regurgitation and Clinical Outcomes after Double Valve Replacement

PURPOSE

Significant late-onset tricuspid regurgitation (TR) is unfortunately common after double valve replacement (DVR); however, its underlying factors remain undefined. We evaluated the effect of aortic patient-prosthesis mismatch (PPM) on late-onset TR and clinical outcomes after DVR.

MATERIALS AND METHODS

Of the 2392 consecutive patients who underwent aortic valve replacement between January 1990 and May 2014 at our institution, we retrospectively studied 462 patients who underwent DVR (excluding concomitant tricuspid valvular annuloplasty or replacement). Survival and freedom from grade >3 TR were compared between PPM (n=152) and non-PPM (n=310) groups using the Kaplan-Meier method.

RESULTS

Although the overall survival rates were similar between the two groups at 5 and 10 years (95%, 91% vs. 96%, 93%, p=0.412), grade >3 TR-free survival was significantly lower in the PPM group (98%, 91% vs. 99%, 95%, p=0.014). Small body-surface area, atrial fibrillation, PPM, and subaortic pannus were risk factors for TR progression. However, aortic prosthesis size and trans-valvular pressure gradient were not significant factors for either TR progression or overall survival.

CONCLUSION

Aortic PPM in DVR, regardless of mitral prosthesis size, was associated with late TR progression, but was not significantly correlated with overall survival. Therefore, we recommend careful echocardiographic follow-up for the early detection of TR progression in patients with aortic PPM in DVR.

The Absence of Atrial Contraction as a Predictor of Permanent Pacemaker Implantation after Maze Procedure with Cryoablation

BACKGROUND

The absence of atrial contraction (AC) after the maze procedure has been reported to cause subsequent annular dilatation and to increase the risk of embolic stroke. We hypothesized that the lack of AC could increase the risk of permanent pacemaker (PPM) implantation in patients undergoing the maze procedure.

METHODS

In 376 consecutive patients who had undergone a cryo-maze procedure and combined valve operation, recovery of AC was assessed at baseline and at immediate (≤2 weeks), early (≤1 year, 4.6±3.8 months), and late (>1 year, 3.5±1.1 years) postoperative stages.

RESULTS

With a median follow-up of 53 months, 10 patients underwent PPM implantation. Seven PPM implants were for sinus node dysfunction (pauses of 9.6±2.4 seconds), one was for marked sinus bradycardia, and two were for advanced/complete atrioventricular block. The median (interquartile range) time to PPM implantation was 13.8 (0.5-68.2) months. Our time-varying covariate Cox models showed that the absence of AC was a risk factor for PPM implantation (hazard ratio, 11.92; 95% confidence interval, 2.52 to 56.45; p=0.002).

CONCLUSION

The absence of AC may be associated with a subsequent risk of PPM implantation.

Impact of Isolated Tricuspid Valve Repair on Right Ventricular Remodelling in an Adult Congenital Heart Disease Population

Background

Surgical repair of isolated congenital tricuspid valve (TV) disease is rare with no well-defined indication and outcomes. Moreover, the role of right ventricle (RV) in this context has not yet been investigated.

Objectives

We sought to assess the impact of congenital TV repair on cardiac remodelling and clinical–functional status and the importance of the RV function in an adult congenital heart disease (ACHD) population.

Methods and results

From January 2005 to December 2015, 304 patients underwent TV surgery in our centre. Of these, 27 (ACHD) patients had isolated TV repair. Patients were evaluated with preoperative and postoperative transthoracic echocardiogram. Survival rate has been investigated with a mean clinical follow-up (FU) of 3.7 ± 2.3 years, whereas the mean echocardiographic FU was 2.9 ± 1.8 years. The clinical and functional status of patients showed a statistically significant improvement after the surgical repair in terms of New York Heart Association class (66.7 vs 7.4%; p < 0.01), clinical signs of heart failure (29.6 vs 7.4%; p < 0.01), and left ventricular function (14.8 vs 7.4%; p < 0.01). The RV and right atrium diameter were significantly reduced after surgery (5.15 ± 1.21 vs 4.32 ± 1.16; p < 0.01) and (44.7 ± 16.7 vs 26.7 ± 9.2; p < 0.01), respectively. The degree of postoperative pulmonary hypertension was also significantly reduced (40.7 vs 7.4%; p < 0.01). The survival rate was 96.3% at 1 year and 93.7% at 5 years. One patient (3.7%) had early failure of the tricuspid repair requiring a reoperation.

Conclusion

Isolated TV repair for adult congenital disease significantly improved patients’ clinical and functional status and allowed right ventricular remodelling and functional improvement.

Impact of Surgical Ablation of Atrial Fibrillation on the Progression of Tricuspid Regurgitation and Right-Sided Heart Remodeling After Mitral-Valve Surgery: A Propensity-Score Matching Analysis

BACKGROUND

This study assessed the role of surgical ablation for atrial fibrillation (AF) in decreasing tricuspid regurgitation (TR) and right-sided heart remodeling in patients after mitral valve procedure.

METHODS AND RESULTS

Between 1994 and 2014, 1568 consecutive patients with AF undergoing mitral valve procedure were identified. In 26.0% (n=408), surgical ablation of AF was used. Propensity-score matching (PSM) was performed on the basis of 41 known perioperative risk variables. Survival, reoperation, stroke, and moderate-to-severe TR, as well as echocardiography indices in long-term follow-up, were compared in 406 matched patient pairs (ablated and nonablated groups). The nonablated group showed significantly higher risks of death (hazard ratio [HR], 1.644; 95% CI, 1.081-2.501; P=0.020), reoperation (HR, 2.644; 95% CI, 1.299-5.466; P=0.008), and moderate-to-severe TR (HR, 1.436; 95% CI, 1.059-1.948; P=0.020), associated with a significantly deteriorated cardiac function, progression of TR, and right-sided heart remodeling after 5-year follow-up. In a subgroup comparison of ablated patients with sinus rhythm versus AF recurrence, a PSM analysis was performed at the 5-year follow-up. The recurrent group showed significantly higher risks of moderate-to-severe TR (HR, 2.427; 95% CI, 1.261-4.671; P=0.008). AF recurrence was associated with progressive TR and significant deterioration in right-sided heart remodeling.

CONCLUSIONS

In a retrospective PSM analysis, mitral valve disease with AF was associated with TR progression as well as right-sided heart remodeling, which are alleviated by surgical ablation.

Diagnosis and treatment of tricuspid valve disease: current and future perspectives

The assessment and management of tricuspid valve disease have evolved substantially during the past several years. Whereas tricuspid stenosis is uncommon, tricuspid regurgitation is frequently encountered and is most often secondary in nature and caused by annular dilatation and leaflet tethering from adverse right ventricular remodelling in response to any of several disease processes. Non-invasive assessment of tricuspid regurgitation must define its cause and severity; advanced three-dimensional echocardiography, MRI, and CT are gaining in clinical application. The indications for tricuspid valve surgery to treat tricuspid regurgitation are related to the cause of the disorder, the context in which it is encountered, its severity, and its effects on right ventricular function. Most operations for tricuspid regurgitation are done at the time of left-sided heart valve surgery. The threshold for restrictive ring annuloplasty repair of secondary tricuspid regurgitation at the time of left-sided valve surgery has decreased over time with recognition of the risk of progressive tricuspid regurgitation and right heart failure in patients with moderate or lesser degrees of tricuspid regurgitation and tricuspid annular dilatation, as well as with appreciation of the high risks of reoperative surgery for severe tricuspid regurgitation late after left-sided valve surgery. However, many patients with unoperated severe tricuspid regurgitation are also deemed at very high or prohibitive surgical risk. Novel transcatheter therapies have begun to emerge for the treatment of tricuspid regurgitation in such patients. Experience with such therapies is preliminary and further studies are needed to determine their role in the management of this disorder.

Predictors of Late-Onset Atrial Fibrillation Following Isolated Mitral Valve Repairs in Patients With Preserved Ejection Fraction

BACKGROUND

We sought to determine the incidence of and risk factors for late-onset atrial fibrillation (LOAF) in patients with preserved ejection fractions undergoing mitral valve repair

METHODS

We included patients undergoing isolated mitral valve repair (MVR) for degenerative disease between 1997-2014 at our institution with EF ≥60%. Patients who had AF preoperatively were excluded from the final analysis. Our primary outcome, LOAF, was defined as AF occurring after discharge following MVR (≥9 days).

RESULTS

223 patients were included in the study with a mean follow-up of 4.8 ± 4.6 years. A total of 25 patients developed LOAF, and freedom from LOAF was 93.9% at one year, and 87.3% at five years. Patients developing LOAF were of similar mean age (58 vs. 63 years in controls, p = 0.08) and had similar preoperative comorbidities, but did show a trend toward larger left atrial diameter (5.1 vs. 4.7 cm, p = 0.11). After risk adjustment with Cox regression analysis, only increasing left atrial size was associated with LOAF (HR 1.63, p = 0.04). On follow-up, 29 patients (10.8%) developed moderate or greater mitral regurgitation at a mean of 2.2 years. Using a mixed-effects model, we were unable to detect an association between recurrent mitral regurgitation following MVR and LOAF (OR 1.36, p = 0.42).

CONCLUSIONS

LOAF occurs in about 13% of preserved ejection fraction patients undergoing MVR by five years. Increasing left atrial diameter is an independent predictor of LOAF. Concomitant anti-arrhythmic procedures may warrant further investigation in patients with preserved ejection fraction and enlarged left atria undergoing MVR. doi: 10.1111/jocs.12774 (J Card Surg 2016;31:486-492).

Tricuspid annular dynamics before and after tricuspid annuloplasty- three-dimensional transesophageal echocardiography

BACKGROUND

Little is known about the impact of tricuspid annuloplasty (TAP) on annular dynamics. We assessed tricuspid annular dynamics using 3-D transesophageal echocardiography (3D-TEE) before and after TAP with different types of prosthetic ring.

METHODS AND RESULTS

3D-TEE of the tricuspid valve was acquired in 30 patients (TAP with rigid ring [RR], n=8; TAP with flexible ring [FR], n=10; control, n=12). Tricuspid annular dimensions (circumference, area, annular height, anteroposterior [AP], septolateral [SL] diameter) were measured throughout the cardiac cycle. All postoperative tricuspid annular dimension parameters were significantly reduced by TAP, while the AP/SL ratio was significantly increased (before, 0.96±0.16; after, 1.03±0.06; P<0.05). The difference in annular area between diastole and systole was significantly smaller in the TAP groups (11.6%) than in the control (27.9%, P<0.05). Annular height in the FR patients was significantly lower than in the RR group, while the postoperative AP/SL ratio was lower in the RR than the FR and control groups. Change in annular area was not seen in RR patients, while it was seen in the FR and control groups.

CONCLUSIONS

Annulus motion and shape differ according to the type of prosthetic ring used, although tricuspid regurgitation was well controlled by all types of ring utilized. The present results provide important information for selection of an appropriate prosthetic ring for TAP.

Risk factors for progression of functional tricuspid regurgitation

The aim of this study was to determine the risk factors for tricuspid regurgitation (TR) progression in a contemporary population of patients referred for echocardiography. In a case-control study, we compared 100 consecutive patients with TR progression on serial echocardiograms (trivial or mild TR on the first echocardiogram and moderate or severe functional TR on a follow-up echocardiogram) with 100 patients matched for age and gender, having mild TR at baseline and no TR progression. Mean age was 72 ± 10 years, 55% were males, and time to TR progression was 5.3 ± 2.9 years. Less than 10% had rheumatic heart disease. Left ventricular ejection fraction was preserved (≥50%) in 85% of the TR progression group and in 74% of the control group (p = 0.06). Pulmonary artery systolic pressure increased from 41 ± 16 to 56 ± 18 mm Hg in the TR progression group and decreased from 44 ± 13 to 41 ± 11 mm Hg in the control group (p <0.0001). Independent risk factors for TR progression were pulmonary artery systolic pressure change during follow-up (odds ratio per 1 mm Hg 1.14, 95% confidence interval 1.06 to 1.23, p <0.0001), permanent atrial fibrillation (odds ratio 14.3, 95% confidence interval 4.6 to 44.2, p <0.0001), and coronary artery disease (odds ratio 5.7, 95% confidence interval 1.4 to 22.8, p = 0.015). All-cause mortality at 3 years was 20% for patients without TR progression, 42% for moderate TR, and 63% for severe TR, p <0.0001. Progression-to-severe TR independently predicted subsequent mortality. In conclusion, in patients with low prevalence of rheumatic heart disease and preserved left ventricular ejection fraction, pulmonary artery systolic pressure increase and permanent atrial fibrillation were the most powerful risk factors for TR progression. Progression-to-severe TR was an independent predictor of subsequent mortality.

Right ventricular reverse remodeling, but not subjective clinical amelioration, predicts long-term outcome after surgery for isolated severe tricuspid regurgitation

BACKGROUND

Subjective clinical improvement does not always go hand-in-hand with right ventricular (RV) reverse remodeling after surgery for isolated severe tricuspid regurgitation (TR). This study aimed to evaluate the level of agreement between clinical improvement and echocardiographic RV reverse remodeling, and determine the relative prognostic powers of these 2 factors in terms of long-term prognosis for patients with isolated TR surgery.

METHODS AND RESULTS

Sixty-one consecutive patients (58±8 years) were included. During a median follow up of 55 months (IQR, 36.5∼71.5 months), a composite endpoint including death and admission for right heart failure was investigated. Extents of reductions in RV end-systolic area (RV-ESA) and subjective clinical improvement at 6 months were examined. There were 6 deaths and 5 admissions for right heart failure. A reduction in RV-ESA of >20% effectively predicted event-free survival, with a sensitivity of 90.9% and a specificity of 72.0% (AUC 0.81, P=0.001). With this cut-off, the agreement between a clinical and echocardiographic response was only 57.4% (35 patients). On Cox regression analysis, RV-ESA change emerged as the only independent predictor of event-free survival, whereas subjective clinical improvement did not.

CONCLUSIONS

A discrepancy between subjective and echocardiographic improvement at 6 months after isolated TR surgery was observed in 42.6% of the patients. Echocardiographic RV reverse remodeling, but not subjective clinical amelioration, was a strong prognosticator after surgery. 

Tricuspid regurgitation: clinical importance and its optimal surgical timing

Tricuspid regurgitation (TR) has long been neglected based on the false belief that it is substantially rare in prevalence and is not so important in determining prognosis. Recent consecutive publications refuted this concept surrounding TR, and now we are contemplating this entity from different point of view. In this review, we mainly focus on isolated form of severe TR. In our daily clinical practice, however, patients with problems in more than one valve are more frequently encountered. Hence, we briefly touch on the results of severe TR surgery with or without left side valve operations here and there, as well.

Tricuspid regurgitation after successful mitral valve surgery

The tricuspid valve (TV) is inseparably connected with the mitral valve (MV) in terms of function. Any pathophysiological condition concerning the MV is potentially a threat for the normal function of the TV as well. One of the most challenging cases is functional tricuspid regurgitation (TR) after surgical MV correction. In the past, TR was considered to progressively revert with time after left-sided valve restoration. Nevertheless, more recent studies showed that TR could develop and evolve postoperatively over time, as well as being closely associated with a poorer prognosis in terms of morbidity and mortality. Pressure and volume overload are usually the underlying pathophysiological mechanisms; structural alterations, like tricuspid annulus dilatation, increased leaflet tethering and right ventricular remodelling are almost always present when regurgitation develops. The most important risk factors associated with a higher probability of late TR development involve the elderly, female gender, larger left atrial size, atrial fibrillation, right chamber dilatation, higher pulmonary artery systolic pressures, longer times from the onset of MV disease to surgery, history of rheumatic heart disease, ischaemic heart disease and prosthetic valve malfunction. The time of TR manifestation can be up to 10 years or more after an MV surgery. Echocardiography, including the novel 3D Echo techniques, is crucial in the early diagnosis and prognosis of future TV disease development. Appropriate surgical technique and timing still need to be clarified.

Electrocardiographic QRS duration reflects right ventricular remodeling in patients undergoing corrective surgery for isolated tricuspid regurgitation: a comparative study with cardiac magnetic resonance imaging

BACKGROUND

The role of electrocardiogram (ECG) is unclear for the longitudinal follow-up of patients who undergo corrective surgery for isolated severe tricuspid regurgitation (TR).

HYPOTHESIS

This study sought to investigate the usefulness of changes in QRS duration of ECG after TR surgery in predicting right ventricular (RV) reverse remodeling as determined by cardiac magnetic resonance imaging (CMR).

METHODS

We enrolled 30 consecutive TR patients (27 women, aged 57.8 ± 9.6 years) who had undergone prior left-sided valve surgery. A computer-assisted analysis was performed for objective calculation of QRS duration before and after surgery.

RESULTS

At a median CMR follow-up of 27.5 months postsurgery, QRS duration was cut by 14.6%, from 110.4 ± 14.6 msec to 96.9 ± 11.9 msec (P < 0.001), while CMR showed a decrease in RV end-diastolic volume index (RV-EDVI) from 179.5 ± 59.7 to 119.1 ± 30.4 mL/m(2) (P < 0.001). QRS duration correlated significantly with RV-EDVI and RV end-systolic volume index (r = 0.65, P < 0.001 and r = 0.53, P < 0.001, respectively), and a percent change in QRS duration was significantly correlated with a percent change in RV-EDVI (r = 0.40, P = 0.03). When significant RV reverse remodeling was defined as a reduction in RV-EDVI ≥20% following TR surgery, the sensitivity and specificity for significant RV reverse remodeling were 75% and 78%, respectively, with a 9% reduction in QRS duration (P = 0.01, area underneath the receiver operator curve [AUC] = 0.81).

CONCLUSIONS

The extent of changes in postoperative QRS duration can be used as a useful, inexpensive, and simple index reflecting the occurrence of significant RV reverse remodeling in patients undergoing corrective TR surgery.

Evolving indications for tricuspid valve surgery

More attention has been paid to the mitral valve (MV) than the tricuspid valve (TV), and this relative paucity of data has led to confusion regarding the timing of TV surgery. We review the American College of Cardiology/American Heart Association and European Society of Cardiology guidelines to identify areas of concordance (severe tricuspid regurgitation [TR] in a patient undergoing mitral valve surgery); discordance (less than severe TR but with markers for late TR recurrence such as pulmonary hypertension, a dilated TV annulus, atrial fibrillation, permanent transtricuspid pacing wires and others); and disagreement (surgery for primary TR). We provide our perspective from Northwestern University on these issues and where the guidelines are silent (TR in patients undergoing non-mitral valve operations). Finally, we review recent publications on the results of TV repair and replacement. Although there have been scant publications in the past, there have been more useful publications in recent years to guide our decision making.

B-type natriuretic Peptide in isolated severe tricuspid regurgitation: determinants and impact on outcome

BACKGROUND

The plasma B-type natriuretic peptide (BNP) level is a useful prognostic marker in heart failure and valvular heart disease. In patients with isolated severe tricuspid regurgitation (TR), little is known about the determinants of plasma BNP levels and the correlation with future outcome. The purpose of this study was to identify the determinants of plasma BNP levels in patients with isolated severe TR and the value of the BNP level in predicting postoperative outcomes after corrective surgery.

METHODS

We prospectively enrolled 39 patients with isolated, severe TR undergoing corrective surgery. A plasma BNP assay and cardiac magnetic resonance (CMR) imaging were performed before surgery. The combined end-point was the occurrence of cardiac death or readmission due to heart failure.

RESULTS

Linear regression analysis showed that the left ventricular ejection fraction and right ventricular end systolic volume were the most important determinants of the BNP levels (p = 0.002, R(2) = 0.315). Based on the receiver operating characteristics (ROC) curve, we were able to derive an optimal cutoff value (200 pg/mL) to predict postoperative cardiac death with a sensitivity of 80% and a specificity of 85%. The one-year survival rate was 96% in patients with a BNP < 200 pg/mL and 53% in patients with a BNP ≥ 200 pg/dL (p = 0.001).

CONCLUSION

An elevation in the BNP level is determined by the functional status of the right and left ventricles in patients with isolated, severe TR. An elevated BNP predicts adverse events after corrective surgery. Therefore, the BNP level should be included in the clinical evaluation and risk stratification of patients with isolated TR.

Assessment of haemodynamic effects of surgical correction for severe functional tricuspid regurgitation: cardiac magnetic resonance imaging study

AIMS

There has been growing attention for the development of functional tricuspid regurgitation (TR) long after left-sided valve surgery. We attempted to determine the long-term haemodynamic effects of corrective surgery for severe functional TR in patients who had prior left-sided valve surgery using cardiac magnetic resonance imaging (CMR).

METHODS AND RESULTS

Thirty-one patients with severe functional TR (TR fraction of 46.0+/-16.2% by CMR) were analysed. CMR was performed within 1 month before and at a median 27.0 months after surgery. Long after TR surgery, 28 of the 31 patients had no or mild residual TR, two had mild-to-moderate TR, and one showed moderate TR. Remarkable reductions in the right ventricular (RV) end-diastolic volume index (RV-EDVI) (177.4+/-59.1 mL/m(2) vs. 118.2+/-31.2 mL/m(2), P<0.001) and end-systolic volume index (RV-ESVI) (88.5+/-30.1 mL/m(2) vs. 67.2+/-31.0 mL/m(2), P=0.002) were observed, whereas RV ejection fraction (RV-EF) showed no change (49.7+/-8.3% vs. 44.9+/-12.5%, P=0.09). Pre-operative RV-EDVI (R=-0.86, P<0.001) and RV-ESVI (R=-0.55, P=0.001) were significantly associated with their respective changes after corrective surgery. Post-surgery, a normal RV-EF was achieved in 14 patients (42.5%). Pre-operative RV-EDVI of 164 mL/m(2) effectively discriminated patients with normal RV-EF from those without post-surgery, with a sensitivity of 77% and a specificity of 72% (P=0.01). A significant rise in the left ventricular (LV) EDVI and cardiac index (CI) was found after surgery (from 92.9+/-24.4 to 123.2+/-31.6 mL/m(2) for LV-EDVI, P<0.001; from 3.8+/-1.3 to 4.2+/-0.8 L/min/m(2) for CI, P=0.03). Functional capacity as assessed by NYHA class showed a significant improvement from 2.7+/-0.6 before surgery to 2.0+/-0.6 long after surgery (P<0.001).

CONCLUSION

Successful TR surgery can remarkably reduce RV volumes and preserve RV systolic function. In addition, successful TR surgery led to a significant rise in LV preload and CI, which may significantly contribute to a significant amelioration in the functional capacity of the patients. It seems that RV volume measurement by CMR is helpful for determining optimal timing for TR surgery.

Development of tricuspid regurgitation late after left-sided valve surgery: a single-center experience with long-term echocardiographic examinations

OBJECTIVES

This study sought to investigate the incidence and identify the predictors of significant tricuspid regurgitation (TR) development long after left-sided valve surgery.

METHODS

Of 615 patients who underwent surgery for left-sided valve disease between 1992 and 1995, 335 patients without significant TR who completed at least 5 years of clinical and echocardiographic follow-up were enrolled. Late significant TR development was assessed by echocardiography with a mean follow-up duration of 11.6 +/- 2.1 years.

RESULTS

Significant late TR was found in 90 patients (26.9%). Patients with late TR showed an advanced age (47.6 +/- 13.4 vs 44.3 +/- 13.2 years, P = .04), a higher prevalence of preoperative atrial fibrillation (83.3 vs 46.5%, P < .001), a greater left atrial dimension (56.9 +/- 13.2 vs 52.4 +/- 11.5 mm, P = .006), and a higher prevalence of prior valve surgery (40.0 vs 25.3%, P = .01). In addition, late TR occurred more frequently in patients who had undergone mitral valve surgery than in those who did not (93.3 vs 72.2%, P < .001). However, multivariate analysis showed that the presence of preoperative atrial fibrillation (odds ratio 5.37; 95% CI 2.71-10.65; P < .001) was the only independent factor of late TR development. Patients who developed late TR had a lower event-free survival rate than those who did not (P = .03).

CONCLUSIONS

The development of significant TR long after left-sided valve surgery is not uncommon with an estimated incidence of 27% and is closely associated with a poor prognosis. The presence of preoperative atrial fibrillation was identified as the only independent predictor of the development of late TR.

Geometric and hemodynamic determinants of functional tricuspid regurgitation: A real-time three-dimensional echocardiography study

BACKGROUND

The geometric and hemodynamic determinants of functional tricuspid regurgitation (FTR) have not yet been established. Geometric alterations in the tricuspid valve can be accurately determined using 3-dimensional echocardiography.

METHODS

Real-time 3-dimensional echocardiography was performed in 54 patients with various degrees of FTR to obtain real-time zoom 3D images of the tricuspid valve. The angles between the tricuspid annulus plane and the 3 leaflets (anterior: Aalpha, posterior: Palpha, septal: Salpha), the septal-lateral and anterior-posterior annulus diameters, and the tricuspid tenting volume were measured on a mid-systole frame. Pulmonary artery systolic pressure (PASP) was assessed using the maximal velocity of FTR, and the severity of FTR was quantified as the ratio of the distal jet area to the right atrial area (DJ/RA) using color Doppler 2D echocardiographic images.

RESULTS

In patients with mild (DJ/RA<0.2) and moderate (0.2< or =DJ/RA<0.5) FTR, Palpha and Salpha were significantly larger than Aalpha, whereas in patients with severe (DJ/RA> or =0.5) FTR, only Salpha was larger than Aalpha. All geometric variables and PASP correlated significantly with DJ/RA. Multiple stepwise regression analysis showed that Salpha, septal-lateral annulus diameter and PASP were independent determinants of FTR severity. The tricuspid tenting volume strongly correlated (r=0.84, p<0.001) with the FTR distal jet area, and was the only determinant of the jet area.

CONCLUSION

FTR severity is mainly determined by septal leaflet tethering, septal-lateral annular dilatation, and the severity of pulmonary hypertension.

Percutaneous Mitral Valvuloplasty Versus Surgical Treatment in Mitral Stenosis With Severe Tricuspid Regurgitation

BACKGROUND

The persistence of significant tricuspid regurgitation (TR) after percutaneous mitral valvuloplasty (PMV) is known to be an independent predictor of adverse outcome in mitral stenosis (MS). However, it remains unclear whether mitral valve (MV) surgery combined with surgical correction of TR is the better treatment option than PMV in patients with severe MS and severe functional TR.

METHODS AND RESULTS

We included a total of 92 consecutive patients (18 men, age 49+/-13 years) with severe MS and severe functional TR, who were potential candidates for PMV from 1997 to 2005, and the exclusion criteria were defined as the presence of left atrial thrombi, mitral regurgitation > or = grade 3, echo score > 10, and left ventricular ejection fraction (EF) < 35%. PMV was performed on 48 patients (PMV group), and MV surgery combined with tricuspid valve (TV) repair was performed on 44 patients (TVP group). The clinical events were defined as death, repeat surgical or percutaneous intervention, and readmission because of heart failure. There were no significant differences between the 2 groups in terms of gender, baseline EF, and baseline severity of pulmonary hypertension, but patients in the TVP group were older and had a higher echo score and a higher incidence of atrial fibrillation than those in the PMV group. During follow-up of 57+/-35 months, 2 deaths occurred in the TVP group, and there were 2 deaths, 7 cases of heart failure requiring surgical intervention in the PMV group. The difference of event rates between the 2 groups showed borderline significance (P=0.05), but no difference in mortality was observed. The estimated actuarial 7-year event-free survival rate was 77+/-8% in the PMV group and 95+/-3% in the TVP group. Severe TR was improved to mild or absent TR in 43 (98%) patients in the TVP group, and this was significantly higher than in the PMV group (22/48, 46%; P<0.001). In the TVP group, the right ventricle (RV) size was significantly decreased in 18 (90%) patients among 20 patients with preoperative significant RV enlargement. On stepwise multivariate logistic regression analysis, TVP group and baseline sinus rhythm were independent predictors for improvement of TR (P<0.001).

CONCLUSIONS

TV repair combined with MV surgery was related to better clinical outcomes than PMV alone, and we recommend that this surgical option should be considered preferentially in severe MS with severe functional TR, especially if atrial fibrillation or enlarged RV is associated.