Morphological diversity of the tricuspid posterior leaflet affects surgical complexity for control of tricuspid regurgitation

Abstract

Objective: We investigated the effect of morphological diversity of the tricuspid valve with multiple posterior leaflets on the technical outcomes of tricuspid valve repair.

Methods: From April 2016 to November 2020, 141 patients were diagnosed with secondary tricuspid regurgitation associated with left heart disease and underwent tricuspid valve repair. We retrospectively analyzed the clinical and echocardiographic data of patients who underwent both preoperative and postoperative transthoracic echocardiography. We divided the patients into two groups according to the surgical technique used to treat tricuspid regurgitation: ring annuloplasty alone (Group 1, n = 109) or additional approximation of leaflet edges (edge-to-edge repair) with ring annuloplasty (Group 2, n = 32). We measured the morphological diversity of the tricuspid valve during the operation in all patients.

Results: The preoperative tricuspid regurgitation score was higher in Group 2 than in Group 1 (2.1 ± 0.78 vs. 1.6 ± 0.7, respectively; p = 0.0046), and Group 2 contained more patients with two posterior leaflets than Group 1 [20 (63%) vs. 36 (33%), respectively; p = 0.003]. The univariate and multivariate logistic regression analyses showed that the presence of two posterior leaflets was an independent risk factor for additional procedures during tricuspid valve repair (odds ratio, 2.6; 95% confidence interval, 1.1-6.1; p = 0.033).

Conclusions: Additional procedures to reduce tricuspid regurgitation were required more frequently in patients with two posterior leaflets of the tricuspid valve. The morphological diversity of two posterior leaflets is a potential risk factor for a more complicated tricuspid repair.

Keywords: Residual tricuspid regurgitation; Tricuspid valve; Two posterior leaflets.

Fig. 1

Flow diagram of patient selection. TR, tricuspid regurgitation

Fig. 2

Operative findings of tricuspid valve with two posterior leaflets. A, anterior leaflet; P1 and P2, posterior leaflets; S, septal leaflet

Fig. 3

The Tailor ring was sutured with the running suture technique. We avoided placing sutures around the septal leaflet’s annulus near the atrioventricular node. We confirmed significant coaptation of each valve by the saline injection test. The blue arrow indicates the shoulder point. A, anterior leaflet; P, posterior leaflet; S, septal leaflet

Fig. 4

saline test after tricuspid valve repair. a Motion of septal leaflet was restricted and all leaflets could not have same coaptation height. b Only one posterior leaflet raised and other leaflets did not get adequate tension. There were gaps between a posterior leaflet and other leaflets. The yellow arrow indicated restricted septal leaflet. The red arrow indicated different height of posterior leaflet