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Randomized Controlled Trial
. 2021 Feb 16;77(6):713-724.
doi: 10.1016/j.jacc.2020.11.066.

Progression of Tricuspid Regurgitation After Surgery for Ischemic Mitral Regurgitation

Philippe B Bertrand  1 , Jessica R Overbey  2 , Xin Zeng  1 , Robert A Levine  1 , Gorav Ailawadi  3 , Michael A Acker  4 , Peter K Smith  5 , Vinod H Thourani  6 , Emilia Bagiella  2 , Marissa A Miller  7 , Lopa Gupta  2 , Michael J Mack  8 , A Marc Gillinov  9 , Gennaro Giustino  2 , Alan J Moskowitz  2 , Annetine C Gelijns  10 , Michael E Bowdish  11 , Patrick T O'Gara  12 , James S Gammie  13 , Judy Hung  1 ; Cardiothoracic Surgical Trials Network (CTSN)
Collaborators, Affiliations
Randomized Controlled Trial

Progression of Tricuspid Regurgitation After Surgery for Ischemic Mitral Regurgitation

Philippe B Bertrand et al. J Am Coll Cardiol. .

Abstract

Background: Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.

Objectives: The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.

Methods: Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.

Results: Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).

Conclusions: After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).

Keywords: ischemic heart disease; mitral valve regurgitation; mitral valve surgery; tricuspid annular dilation; tricuspid valve regurgitation.

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Conflict of interest statement

Funding Support and Author Disclosures The Cardiothoracic Surgical Trials Network (CTSN) is supported by a cooperative agreement (U01 HL088942) funded by the National Heart, Lung, and Blood Institute and the National Institute of Neurological Disorders and Stroke of the National Institutes of Health, and the Canadian Institutes for Health Research. The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute, the National Institute of Neurological Disorders and Stroke, the National Institutes of Health, or the U.S. Department of Health and Human Services. Dr. Ailawadi has received honoraria (modest) from Medtronic, Edwards, Abbott, Admedus, and Gore. Dr. Thourani has served on the Advisory Board (modest) for Gore Vascular; and has received research grants (modest) from Abbott Vascular, Boston Scientific, Edwards Lifesciences, and Jenavalve. Dr. Mack has received honoraria (modest) from Gore; and has received research grants (modest) from Edwards Lifesciences, Medtronic, and Abbott. Dr. Gillinov has served as a consultant (significant) for Medtronic, AtriCure, Edwards Lifesciences, Abbott, CryoLife, and ClearFlow; and has an ownership interest (significant) in ClearFlow. Dr. Giustino has received honoraria (modest) from Bristol Myers Squibb. Dr. O’Gara has been a member of the Executive Committee for the Apollo Trial (TMVR) (modest) for Medtronic; has served as a member of the Executive Committee for the Early TAVR trial (modest) for Edwards Lifesciences; and has served as a member of the Scientific Advisory Board (modest) for MedTrace. Dr. Gammie has served as a consultant (modest) for Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

Figure 1 –
Figure 1 –. Study flow chart
CABG, coronary artery bypass graft; IMR, ischemic mitral regurgitation; MV, mitral valve; TR, Tricuspid Regurgitation; TVR, Tricuspid Valve Repair.
Figure 2 –
Figure 2 –. Tricuspid regurgitation at baseline and at different stages of follow-up
(A) Tricuspid regurgitation grade in the study cohort at baseline, and six months, 1 year and 2 years after the index surgery. (B) Tricuspid regurgitation grade at baseline and at 2 years after the index surgery for the patients with 2-year follow-up available (n=323, excluding one patient with 2-year echo follow-up that underwent interim tricuspid valve surgery). Changes in TR from baseline to 2 years (absolute numbers of patients) are presented.
Figure 3 –
Figure 3 –. Discriminative value of baseline tricuspid annular dilation for TR progression and >=moderate TR after surgery
Tricuspid regurgitation (TR) at 2 years according to tricuspid annular dilation (TAD) at baseline, applying the non-indexed, indexed and combined dilation cut-off respectively. Patients without annular dilation based on the cut-off are displayed in blue, and patients with annular dilation are displayed in orange. The number of patients that had either TR progression (n=20) or ≥moderate TR (n=37) are highlighted in dark colors, whereas the patients without TR progression or
Central Illustration –
Central Illustration –. Progression of TR after Cardiac Surgery for Ischemic Mitral Regurgitation
At 2 years after surgery for ischemic mitral regurgitation (IMR) progression of Tricuspid Regurgitation (TR) is not as common as generally expected. Postoperative TR depends not only on preoperative risk factors (baseline TR, tricuspid annular size, or atrial fibrillation), but is associated with postoperative factors such as MR recurrence and permanent pacemaker/defibrillator as well. *S, severe IMR trial; *M, moderate IMR trial CABG, coronary artery bypass graft; ICD, implantable cardioverter defibrillator; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
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References

    1. Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg 2005;79:127–32. - PubMed
    1. David TE, David CM, Manhiolt C. When is tricuspid valve annuloplasty necessary during mitral valve surgery? J Thorac Cardiovasc Surg 2015;150:1043–4. - PubMed
    1. Dion RA. Is the air in Toronto, Rochester, and Cleveland different from that in London, Monaco, Leiden, Genk, Milan, and New York? J Thorac Cardiovasc Surg 2015;150:1040–3. - PubMed
    1. Gillinov M, Mick S, McCurry K, Navia J. The tricuspid valve: If it's not broken, don't fix it. J Thorac Cardiovasc Surg 2017;154:108–109. - PubMed
    1. Nishimura RA, Otto CM, Bonow RO et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:e57–185. - PubMed

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