The Fate of the Tricuspid Valve in Rheumatic Mitral Valve Surgery: When and How to Touch?

Abstract

Objective: Indications for concomitant surgery for tricuspid valve involvement in rheumatic mitral valve surgery is limited in the literature. We aimed to investigate the long-term course of unrepaired tricuspid valves during rheumatic mitral valve surgery in addition to characteristics of surgical technique in tricuspid repair. Methods: The data of all patients who underwent mitral valve replacement due to rheumatic pathology between January 2011 and December 2014 were evaluated. Besides mitral valve replacement, patients were divided into three groups: non-repair (Group I), concomitant tricuspid valve repair either with DeVega annuloplasty (Group II) or ring annuloplasty (Group III). A total of 333 patients were included in the study. Primary outcomes as; the rate of severe tricuspid valve regurgitation in long-term, re-intervention requirement for the tricuspid valve, and long-term functional capacity of the patients were assessed. Results: The mean age was 45.2±9.7 years (min 18, max 60, female 69.1%). Tricuspid valve repair was performed in 178 patients (53.4%). Of them, 100 patients (30%) received De Vega suture annuloplasty, while 78 (23.4%) were treated with the ring annuloplasty. In the late period, severe tricuspid valve regurgitation and the need for reintervention were not observed in group III, also there was a statistically significant difference compared to the other groups (p <0.001 and 0.05; group I and II, respectively). In terms of functional capacity, the incidence of NYHA III and IV in group III was significantly lower in the late-term compared to the other groups(p= 0.02). Conclusions: Simultaneous tricuspid valve surgery should be performed with mitral valve surgery in patients with rheumatic heart disease. The long-term results of ring annuloplasty are superior to the suture (de Vega) annuloplasty for rheumatic tricuspid regurgitation. Table. Long term results according to tricuspid valve intervention type (in surviving patients) Non repair(n=151) TDVA(n=94) Ring annuloplasty(n=75) p-value Follow-up (years) 3.7 (2.3-4.7) 3.7 (2.1-4.2) 3.1 (2.3-4.4) 0.59 NYHA Class III/IV 47 (31.1) 32 (34.0) 12 (16.0) 0.02* Echocardiography findings EF (%) 60 (50-65) 60 (55-65) 60 (50-65) 0.55 LVESD (cm) 3.6 (3.0-4.3) 3.2 (3.0-3.9) 3.2 (3.0-4.0) 0.11 LVEDD (cm) 5.0 (4.6-5.5) 5.0 (4.6-5.2) 4.9 (4.7-5.2) 0.53 LAD (cm) 4.2 (3.9-4.7) 4.5 (4.0-4.8) 4.6 (4.2-5.2) <0.001* PAP (mmHg) 35 (1-45) 35 (35-45) 30 (25-35) <0.001* TR degreeMildModerateSevere 81 (53.6)36 (23.8)23 (15.6) 54 (57.4)28 (29.8)8 (8.5) 39 (52.0)15 (20.0)0 <0.001* Need for reintervention for the tricuspid valve 7 (4.6) 2 (2.1) 0 0.05* EF: ejection fraction, NYHA: New York Heart Association, PAP: pulmonary artery pressure, LAD: left atrium diameter, LVESD: left ventricular end-systolic diameter, LVEDD: left ventricular end-diastolic diameter, TDVA: tricuspid de Vega annuloplasty, TR: tricuspid regurgitation.