Long-term echocardiographic follow-up of untreated 2+ functional tricuspid regurgitation in patients undergoing mitral valve surgery

Abstract

Objectives: Concomitant tricuspid valve surgery with mitral valve surgery is recommended for patients with severe functional tricuspid regurgitation (TR). However, the treatment for 2+ TR (mild TR) remains controversial. Here, we evaluated the long-term results of untreated 2+ TR in patients undergoing mitral valve surgery.

Methods: We retrospectively reviewed the records of 96 patients with untreated 2+ TR among 885 patients who underwent mitral valve surgery from 2003 to 2010. Exclusion criteria were tricuspid valve surgery (TVS), emergency surgery, primary TR and pacemaker lead through the tricuspid valve. We assessed survival and freedom from heart failure. The freedom from 3+ (moderate) or 4+ (severe) TR was investigated by echocardiographic data at pre- and postoperative week 1, then at 1, 3, 5, 7 and 10 postoperative years, which were compared with those in patients who had 2+ TR preoperatively and underwent concomitant TVS in the same period (n = 47).

Results: The mean follow-up was 7.1 ± 2.7 years. There was no 30-day mortality. The survival rate was 97.5% at 5 years and 87.5% at 10 years. The independent risk factors for mortality were age (OR 1.2, P = 0.03) and left ventricular ejection fraction (OR 0.9, P = 0.03). Untreated 2+ TR improved transiently within the first postoperative year (P < 0.001), but progressed again in the mid- to long term. Freedom from ≥3+ TR was 64.2% at 5 years and 46.7% at 10 years, which was significantly lower than that from ≥3+ TR in patients who underwent concomitant TVS (P = 0.006). The independent risk factors for TR progression (≥3 + TR) were age (OR 1.1, P = 0.005), atrial fibrillation (OR 2.2, P = 0.04) and tricuspid annular diameter (TAD) index (mm/m(2); OR 1.1, P = 0.02). Receiver operating characteristic curves showed that the optimal TAD index cut-off value was 21.0 for long-term survival [area under the curve (AUC) = 0.72] and 21.2 for TR progression (AUC = 0.64).

Conclusions: Although untreated, 2+ TR significantly improved after mitral valve surgery, it then progressed again in the mid- to long term. Therefore, concomitant TVS should be considered in patients with 2+ TR who have dilated tricuspid annulus or atrial fibrillation, if feasible.

Keywords: Atrial fibrillation; Long term; Mitral valve surgery; Tricuspid annular diameter; Tricuspid regurgitation.

Figure 1:

Study algorithm. MVS: mitral valve surgery; TR: tricuspid regurgitation; TVS+: with concomitant tricuspid valve surgery; TVS−: without concomitant tricuspid valve surgery; PMI: pre- or postoperative implantation of pacemaker through the tricuspid annulus.

Figure 2:

(A) Actuarial survival rate, analysed using the Kaplan–Meier method. (B) Actuarial freedom from heart failure (HF; NYHA class ≥3).

Figure 3:

(A) The proportion of tricuspid regurgitation (TR) grade at different points relative to operation. (B) Mean tricuspid regurgitation (TR) grade at different points relative to operation. Follow-up echocardiography examinations were performed at 1 week, and 1, 3, 5, 7 and 10 years postoperative. Pre: preoperative. *P < 0.001 compared with the preoperative grade.

Figure 4:

Comparison of actuarial rate of freedom from postoperative tricuspid regurgitation (TR) progression (≥3) between the two groups. TVS− group: without concomitant tricuspid valve surgery, solid line; TVS+ group: with concomitant tricuspid valve surgery, dashed line.

Figure 5:

Receiver operating characteristic (ROC) curves for late mortality (A) and postoperative tricuspid regurgitation (TR) progression (≥3) (B). The optimal tricuspid annular diameter (TAD) index cut-off values were 21.0 and 21.2 mm/m², respectively. The sensitivities were 83 and 46%, respectively, and the specificities were 64 and 69%, respectively. The areas under the ROC curves (AUC) were 0.72 and 0.64, respectively.