Tricuspid regurgitation and right ventricular function after mitral valve surgery with or without concomitant tricuspid valve procedure

Abstract

Objectives: To study the effect of mitral valve repair with or without concomitant tricuspid valve repair on functional tricuspid regurgitation and right ventricular function.

Methods: From 2001 to 2007, 1833 patients with degenerative mitral valve disease, a structurally normal tricuspid valve, and no coronary artery disease underwent mitral valve repair, and 67 underwent concomitant tricuspid valve repair. Right ventricular function (myocardial performance index and tricuspid annular plane systolic excursion) was measured before and after surgery using transthoracic echocardiography for randomly selected patients with tricuspid regurgitation grade 0, 1+, and 2+ (100 patients for each grade) and 93 with grade 3+/4+, 393 patients in total.

Results: In patients with mild (<3+) preoperative tricuspid regurgitation, mitral valve repair alone was associated with reduced tricuspid regurgitation and mild worsening of right ventricular function. Tricuspid regurgitation of 2+ or greater developed in fewer than 20%, and right ventricular function had improved, but not to preoperative levels, at 3 years. In patients with severe (3+/4+) preoperative tricuspid regurgitation, mitral valve repair alone reduced tricuspid regurgitation and improved right ventricular function; however, tricuspid regurgitation of 2+ or greater returned and right ventricular function worsened toward preoperative levels within 3 years. Concomitant tricuspid valve repair effectively eliminated severe tricuspid regurgitation and improved right ventricular function. Also, over time, tricuspid regurgitation did not return and right ventricular function continued to improve to levels comparable to that of patients with lower grades of preoperative tricuspid regurgitation.

Conclusions: In patients with mitral valve disease and severe tricuspid regurgitation, mitral valve repair alone was associated with improved tricuspid regurgitation and right ventricular function. However, the improvements were incomplete and temporary. In contrast, concomitant tricuspid valve repair effectively and durably eliminated severe tricuspid regurgitation and improved right ventricular function toward normal, supporting an aggressive approach to important functional tricuspid regurgitation.

Keywords: 35; MPI; MR; MVR; RV; TAPSE; TR; TTE; TV; TVR; mitral regurgitation; mitral valve repair; myocardial performance index; right ventricular; transthoracic echocardiogram; tricuspid annular plane systolic excursion; tricuspid regurgitation; tricuspid valve; tricuspid valve repair.

FIGURE 1

Percentage of patients with grade 2+/3+/4+tricuspid regurgitation (TR) grades postoperatively over time stratified by preoperative (pre-op) TR grades. Open diamonds and blue line indicate patients with preoperative TR grade 0; open circles and green line, those with preoperative grade 1+; open squares and purple line, those with preoperative grade 2+; closed circles and black line, those with preoperative grade 3+/4+and undergoing a tricuspid valve (TV) procedure; and open triangles and red line, those with preoperative grade 3+/4+and no TV procedure. A, TR grade 2+/3+/4+postoperatively according to preoperative TR grade and TV procedure; and (B) TR grade 2+/3+/4+postoperatively for patients with severe preoperative TR according to whether a TV procedure was performed.

FIGURE 2

Tricuspid annular plane systolic excursion (TAPSE) over time stratified by preoperative tricuspid regurgitation (TR) grade. Depiction by preoperative TR grade and tricuspid valve (TV) procedure as in Figure 1. A, TAPSE for all preoperative TR grades and TV procedure. B, TAPSE for patients with severe preoperative TR according to whether a TV procedure was performed.

FIGURE 3

Mean myocardial performance index (MPI) over time stratified by preoperative tricuspid regurgitation (TR) grades and tricuspid valve (TV) procedure. Depiction by preoperative TR grade and TV procedure as in Figure 1. A, MPI for all preoperative TR grades and TV procedure. B, MPI for patients with severe preoperative TR according to whether a TV procedure was performed.

FIGURE 4

Scattergram of preoperative (pre-op) versus postoperative (predischarge) myocardial performance index (MPI) according to preoperative grade of tricuspid regurgitation (TR). Each symbol represents 1 patient. Open circles indicate no tricuspid procedure was performed; filled circles indicate tricuspid procedure was performed. Dashed lines represent upper limit of normal. Corresponding data for tricuspid annular plane systolic excursion presented in Figure E7. A, n = 83; (B) n = 89; (C) n = 91; and (D) n = 86.