Tricuspid Annulus Dilation in Patients With Combined Functional Tricuspid Regurgitation and Left-Heart Valvular Disease: Does Septal Annulus Not Dilate?

Abstract

Background: This study aimed to investigate the course of tricuspid annulus dilation in functional tricuspid regurgitation with varied severities by direct intraoperative assessment.

Methods: A total of 317 patients who underwent left heart surgery and concomitant tricuspid repair were divided into three groups according to the severity of the functional tricuspid regurgitation (mild, moderate and severe). Demographic and echocardiographic data were collected. The length of each tricuspid annulus segment was measured intraoperatively. The risk factors for preoperative severe functional tricuspid regurgitation and its postoperative recurrence were identified, and the impact of each tricuspid annulus segment on postoperative recurrence was compared.

Results: In the course of tricuspid annulus dilation, the posterior annulus dilated 17% (group 1: 33.31 ± 6.94 mm vs. group 2: 35.56 ± 7.63 vs. group 3: 38.98 ± 8.70, p < 0.01), the anterior annulus dilated 13.4% (group 1: 36.71 ± 6.30 mm vs. group 2: 38.21 ± 8.35 vs. group 3: 41.63 ± 9.20, p < 0.01), and the septal annulus dilated 11.4% (group 1: 38.11 ± 5.28 mm vs. group 2: 39.76 ± 6.90 vs. group 3: 42.46 ± 7.50, p < 0.01). Tricuspid annulus circumference index (p < 0.01) independently correlated with preoperative severe tricuspid regurgitation and postoperative recurrence. When patients were grouped based on the length of each segment, the septal annulus demonstrated significantly higher sensitivity (p < 0.001) to postoperative recurrence than the anterior (p = 0.085) or posterior annulus (p = 0.262).

Conclusions: This study revealed that each segment of tricuspid annulus could dilate in functional tricuspid regurgitation and highlighted the potential benefits of septal annulus plication in tricuspid annuloplasty, which may aid in the development of a methodology for prosthetic ring annuloplasty.

Keywords: functional tricuspid regurgitation; tricuspid annular dilation; tricuspid annulus (TA); tricuspid repair; tricuspid valve annuloplasty.

Figure 1

The length of each segment of tricuspid annulus (TA) was measured intraoperatively. Each segment of TA [(A) anterior annulus; (B) posterior annulus; (C) septal annulus] was compared between three groups [group 1 (G1), group 2 (G2), and group 3 (G3)]. The percentage of dilation of each segment of TA was illustrated. *p < 0.05, **p < 0.01.

Figure 2

Receiver-operator characteristic curve showing the tricuspid annulus circumference index (TACI) (red line) and combined multivariate analysis model (blue line) including the TACI, NYHA classification, preoperative atrial fibrillation (AF), and preoperative mitral stenosis (MS) as the independent predictors of preoperative severe functional tricuspid regurgitation (FTR).

Figure 3

Freedom from postoperative functional tricuspid regurgitation (FTR) recurrence according to the length of each segment of tricuspid annulus. Patients were grouped into tertiles (T1 shortest length and T3 longest length). (A) Patients were trisected based on the length of anterior annulus. (B) Patients were trisected based on the length of posterior annulus. (C) Patients were trisected grouped based on the length of septal annulus.