HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Katsuhiko Matsuyama Masahiko Matsumoto Takaaki Sugita Junichiro Nishizawa Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Matsuyama, K. Articles by Matsuo, T. Search for Related Content PubMed PubMed Citation Articles by Matsuyama, K. Articles by Matsuo, T.

Ann Thorac Surg 2003;75:1826-1828
© 2003 The Society of Thoracic Surgeons

---

Original article: cardiovascular

Predictors of residual tricuspid regurgitation after mitral valve surgery

^a Department of Cardiovascular Surgery, Tenri Hospital, Tenri, Nara, Japan

Accepted for publication December 31, 2002.

^* Address reprint requests to Dr Matsuyama, Department of Cardiovascular Surgery, Tenri Hospital, 200 Mishima, Tenri, Nara, 632-8552 Japan
e-mail: k-matsuy{at}f3.dion.ne.jp

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: Whether preoperative tricuspid regurgitation (TR) will regress or progress late after surgery is unknown. The aim of this study was to evaluate predictors of significant TR late after mitral valve surgery.

METHODS: A retrospective analysis was performed on a total of 174 patients who underwent mitral valve surgery without tricuspid valve surgery. Preoperatively, 46 patients (26%) had 2+ TR, and 128 patients (74%) had 1+ or less TR. Postoperative 3+ TR was considered significant TR. Variables were used to evaluate predictors of TR development by univariate or multivariate analysis.

RESULTS: The mean follow-up was 8.2 years (range 1.0 to 14.5 years) after surgery. There was progressive TR (3+ or more) in 28 patients (16%) during the follow-up period. In univariate analysis, atrial fibrillation, rheumatic etiology, huge left atrium, left ventricular dysfunction, and preoperative 2+ TR were significant risk factors for TR development. Multivariate analysis identified preoperative 2+ TR, atrial fibrillation, and huge left atrium as statistically significant predictors for late TR after surgery.

CONCLUSIONS: Aggressive repair of accompanying TR should be undertaken at the time of initial surgery in patients with huge left atrium or atrial fibrillation, even if preoperative TR is 2+.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Tricuspid regurgitation (TR) often accompanies mitral or aortic valve disease. This condition is functional rather than organic, and is associated with pulmonary hypertension or right ventricular dilatation [1]. Significant TR can contribute to increased morbidity and mortality, despite adequate left-sided valve correction [2]. TR may decrease gradually after surgery because repair of the left-sided valve lesions can decrease the right ventricular pressure or reduce volume overload [3]. However, in some cases, TR does not necessarily regress spontaneously after repair of the cardiac lesions [4–6]. Whether preoperative TR will regress or progress late after surgery is unknown. The fate of TR in patients undergoing mitral valve replacement (MVR) has been published previously [6]. However, the report lacked detail regarding preoperative TR, and the study population was composed of only late survivors. We retrospectively studied 174 patients to evaluate predictors of significant late TR after mitral valve surgery without tricuspid valve surgery.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Between March 1988 and September 2001, 274 patients had mitral valve surgery at our institution. Of these patients, 175 consecutive patients underwent mitral valve surgery without tricuspid valve surgery, and their records were retrospectively reviewed. Patients with concomitant procedures, such as coronary artery bypass grafting or aortic valve replacement, were excluded form this study. All patients had complete physical examinations preoperatively, with echocardiographic studies and cardiac catheterization. The preoperative and intraoperative patient characteristics are summarized in Table 1. The amount of TR was graded conventionally 1 through 4+ as determined by echocardiography before and after operation as previously reported [7]. Preoperatively, 46 patients (26%) had 2+ TR, and 128 patients (74%) had 1+ or less TR. The decision of concomitant tricuspid valve repair in patients with 2+ TR was based on the surgeon’s inspection or direct digital exploration of the valve during surgery, whereas all patients with 3+ or more TR had tricuspid valve surgery. Three surgeons were involved during the study period. Significant postoperative TR was defined as 3+ or more TR. Preoperative pulmonary artery pressure (PAP) was measured by cardiac catheterization. Pulmonary hypertension was defined as a systolic PAP of more than 40 mm Hg. After discharge from our hospital, all echocardiographic studies were carried out every 6 months or every year by a skilled echocardiography technician. The latest echocardiographic examination was regarded as the end of the follow-up period.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
There was one operative death. A total of 174 patients were included in this study. MVR was undergone in 76 patients, (44%) and mitral valve repair was 92 patients (56%). MVR was performed using a St. Jude Medical prosthesis (St. Paul, MN) in all patients. The mean follow-up was 8.2 ± 3.6 years (range 1.0 to 14.5 years) after surgery. There were 14 late deaths (8%). The cause of death was sudden death in 2 patients, cardiac failure in 1 patient, brain infarction or bleeding in 3 patients, respiratory failure in 2 patients, hepatic failure in 2 patients, renal failure in 1 patient, and cancer in 3 patients. Valve-related complication included brain infarction in 4 patients (1 death), intracranial bleeding in 3 patients (1 death), and gastrointestinal bleeding in 1 patient. There were no patients requiring reoperation for significant TR during the follow-up period. Data were available for all 174 patients on both preoperative and postoperative echocardiography. Immediately after surgery there was significant TR (3+ or more) in only 4 patients (2%). However, there was significant TR in 28 patients (16%) during the follow-up period (Table 2). Of the 46 patients with preoperative 2+ TR, TR progressed in 17 patients (37%). In univariate analysis, atrial fibrillation, rheumatic etiology, huge left atrium, left ventricular dysfunction, and preoperative 2+ TR were significant risk factors for TR development. Multivariate analysis identified preoperative 2+ TR, atrial fibrillation, and huge left atrium as statistically significant predictors for late TR after surgery (Table 3).

	Comment

Top Abstract Introduction Material and methods Results Comment References

Several mechanisms may be responsible for the high prevalence of late TR. First, persistent pressure overload due to pulmonary hypertension may contribute to TR progression [8]. However, a recent report demonstrated that preoperative pulmonary hypertension was not a risk factor for residual TR [6]. In this study, 17% patients without preoperative pulmonary hypertension had progressive TR, whereas TR developed in 13% patients with pulmonary hypertension. Preoperative pulmonary hypertension failed to be a significant risk factor for late TR. Second, TR may be caused by right ventricular dysfunction and tricuspid annular dilatation [9], although these factors were not assessed in the present study. Right ventricular dysfunction and tricuspid annular dilatation are irreversible and do not regress despite successful MVR [10]. A recent report has indicated that an enlarged tricuspid annulus with decreased systolic reduction in annular size is associated with a poor prognosis [9]. Although intraoperative inspection or palpation of the tricuspid valve by surgeons has been the most widely used methods to assess the need for tricuspid repair, tricuspid annulus function or annulus diameter could be important as an indication for tricuspid valve repair [9, 11].

Atrial fibrillation has been reported to be associated with right atrial size [12]. In this series, atrial fibrillation was a risk factor for late TR, which was probably caused by tricuspid annulus dilatation. Another possible mechanism of late TR includes the postoperative increase in cardiac output, which may stop the regression of tricuspid annular dilatation [6]. A huge left atrium, which was probably associated with atrial fibrillation, was an independent predictor for TR development in this study. Long-standing volume or pressure overload to the left ventricle may contribute to the enlarged left atrium, although left ventricular dysfunction failed to be a risk factor for late TR by multivariate analysis.

Preoperative 2+ TR was the most significant risk factor. As our policy, if tricuspid annulus dilatation was judged intraoperatively to be mild, even with 2+ TR, the tricuspid lesion was left alone with the expectation of a reduction in right ventricular overload after surgery. However, preoperative 2+ TR progressed in 37% patients late after surgery. This TR progression may be strongly associated with irreversible right ventricular dysfunction, which was present before surgery.

There are several limitations of this retrospective study. First, the function of the right ventricle and tricuspid annular size were not assessed. Further studies should be carried out regarding the relationship between the occurrence of late TR and right ventricular dysfunction or tricuspid annulus dilatation. Second, the present study had a relatively small number of patients to accurately evaluate predictors. Third, preoperative mitral valve lesions were variable including nonrheumatic disease, although mitral valve etiology failed to be a significant risk factor by multivariate analysis. Rheumatic disease may have relatively long duration effects on the volume or pressure overload to the right ventricle. Fourth, the follow-up period ranged from 1.0 to 14.5 years. For patients with short follow-up period, the study duration can be too short to find TR regression or progression.

In conclusion, the development of late TR is an important complication of MVR. Tricuspid valve repair itself, described by De Vega [13] or by using a ring, is a simple, short, and relatively inexpensive procedure with few complications. Aggressive repair of accompanying TR should be undertaken at the time of initial surgery in patients with a huge left atrium or atrial fibrillation, even if preoperative TR is 2+.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. King R.M., Schaff H.V., Danielson G.K., et al. Surgery for tricuspid regurgitation late after mitral valve replacement. Circulation 1984;70(3 Pt 2):I193-I197.
2. Groves P.H., Hall R.J. Late tricuspid regurgitation following mitral valve surgery. J Heart Valve Dis 1992;1:80-86.[Medline]
3. Braunwald NS, Ross J Jr, Morrow AG. Conservative management of tricuspid regurgitation in patients undergoing mitral valve replacement. Circulation 1967;35(4 Suppl):I63–9
4. McGrath L.B., Gonzalez-Lavin L., Bailey B.M., Grunkemeier G.L., Fernandez J., Laub G.W. Tricuspid valve operations in 530 patients. Twenty-five-year assessment of early and late phase events. J Thorac Cardiovasc Surg 1990;99:124-133.[Abstract]
5. Fukuda N., Oki T., Iuchi A., et al. Tricuspid inflow and regurgitant flow dynamics after mitral valve replacement: differences relating to surgical repair of the tricuspid valve. Heart Valve Dis 1997;6:184-188.
6. Porter A., Shapira Y., Wurzel M., et al. Tricuspid regurgitation late after mitral valve replacement: clinical and echocardiographic evaluation. J Heart Valve Dis 1999;8:57-62.[Medline]
7. Yada I., Tani K., Shimono T., Shikano K., Okabe M., Kusagawa M. Preoperative evaluation and surgical treatment for tricuspid regurgitation associated with acquired valvular heart disease. The Kay-Boyd method vs the Carpentier-Edwards ring method. J Cardiovasc Surg 1990;31:771-777.[Medline]
8. Sagie A., Schwammenthal E., Palacios I.F., et al. Significant tricuspid regurgitation does not resolve after percutaneous balloon mitral valvotomy. J Thorac Cardiovasc Surg 1994;108:727-735.[Abstract/Free Full Text]
9. Colombo T., Russo C., Ciliberto G.R., et al. Tricuspid regurgitation secondary to mitral valve disease: tricuspid annulus function as guide to tricuspid valve repair. Cardiovasc Surg 2001;9:369-377.[Medline]
10. Kaul T.K., Ramsdale D.R., Mercer J.L. Functional tricuspid regurgitation following replacement of the mitral valve. Int J Cardiol 1991;33:305-313.[Medline]
11. Tager R., Skudicky D., Mueller U., Essop R., Hammond G., Sareli P. Long-term follow-up of rheumatic patients undergoing left-sided valve replacement with tricuspid annuloplasty–validity of preoperative echocardiographic criteria in the decision to perform tricuspid annuloplasty. Am J Cardiol 1998;81:1013-1016.[Medline]
12. Vaturi M., Sagie A., Shapira Y., et al. Impact of atrial fibrillation on clinical status, atrial size and hemodynamics in patients after mitral valve replacement. J Heart Valve Dis 2001;10:763-766.[Medline]
13. De Vega N.G. Selective, adjustable and permanent annuloplasty. An original technique for the treatment of tricuspid insufficiency. Rev Esp Cardiol 1972;25:555-556.[Medline]

This article has been cited by other articles:

				Y.-J. Kim, D.-A Kwon, H.-K. Kim, J.-S. Park, S. Hahn, K.-H. Kim, K.-B. Kim, D.-W. Sohn, H. Ahn, B.-H. Oh, et al. Determinants of Surgical Outcome in Patients With Isolated Tricuspid Regurgitation Circulation, October 27, 2009; 120(17): 1672 - 1678. [Abstract] [Full Text] [PDF]

				V. Chan, I. G. Burwash, B.-K. Lam, T. Auyeung, A. Tran, T. G. Mesana, and M. Ruel Clinical and echocardiographic impact of functional tricuspid regurgitation repair at the time of mitral valve replacement. Ann. Thorac. Surg., October 1, 2009; 88(4): 1209 - 1215. [Abstract] [Full Text] [PDF]

				F. Onorati, G. Santarpino, D. Marturano, A. S. Rubino, E. Pasceri, S. Zinzi, G. Mascaro, L. Cristodoro, and A. Renzulli Successful surgical treatment of chronic ischemic mitral regurgitation achieves left ventricular reverse remodeling but does not affect right ventricular function. J. Thorac. Cardiovasc. Surg., August 1, 2009; 138(2): 341 - 351. [Abstract] [Full Text] [PDF]

				H Song, M-J Kim, C H Chung, S J Choo, M G Song, J-M Song, D-H Kang, J W Lee, and J-K Song Factors associated with development of late significant tricuspid regurgitation after successful left-sided valve surgery Heart, June 1, 2009; 95(11): 931 - 936. [Abstract] [Full Text] [PDF]

				J. H. Rogers and S. F. Bolling The Tricuspid Valve: Current Perspective and Evolving Management of Tricuspid Regurgitation Circulation, May 26, 2009; 119(20): 2718 - 2725. [Abstract] [Full Text] [PDF]

				M. Di Mauro, A. Bivona, A. L. Iaco, M. Contini, M. Gagliardi, E. Varone, S. Gallina, and A. M. Calafiore Mitral valve surgery for functional mitral regurgitation: prognostic role of tricuspid regurgitation Eur. J. Cardiothorac. Surg., April 1, 2009; 35(4): 635 - 640. [Abstract] [Full Text] [PDF]

				A. M. Calafiore, S. Gallina, A. L. Iaco, M. Contini, A. Bivona, M. Gagliardi, P. Bosco, and M. Di Mauro Mitral Valve Surgery for Functional Mitral Regurgitation: Should Moderate-or-More Tricuspid Regurgitation Be Treated? A Propensity Score Analysis. Ann. Thorac. Surg., March 1, 2009; 87(3): 698 - 703. [Abstract] [Full Text] [PDF]

				A. Shiran and A. Sagie Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism, and management. J. Am. Coll. Cardiol., February 3, 2009; 53(5): 401 - 408. [Abstract] [Full Text] [PDF]

				H. G. Je, H. Song, S. H. Jung, S. J. Choo, J. M. Song, D. H. Kang, S. C. Yun, C. H. Chung, J. K. Song, and J. W. Lee Impact of the Maze operation on the progression of mild functional tricuspid regurgitation. J. Thorac. Cardiovasc. Surg., November 1, 2008; 136(5): 1187 - 1192. [Abstract] [Full Text] [PDF]

				J. M. Stulak, H. V. Schaff, J. A. Dearani, T. A. Orszulak, R. C. Daly, and T. M. Sundt III Restoration of Sinus Rhythm by the Maze Procedure Halts Progression of Tricuspid Regurgitation After Mitral Surgery Ann. Thorac. Surg., July 1, 2008; 86(1): 40 - 45. [Abstract] [Full Text] [PDF]

				M. De Bonis, E. Lapenna, F. Sorrentino, G. La Canna, A. Grimaldi, F. Maisano, L. Torracca, and O. Alfieri Evolution of tricuspid regurgitation after mitral valve repair for functional mitral regurgitation in dilated cardiomyopathy Eur. J. Cardiothorac. Surg., April 1, 2008; 33(4): 600 - 606. [Abstract] [Full Text] [PDF]

				K. C. Kim, K. R. Cho, Y.-J. Kim, D.-W. Sohn, and K.-B. Kim Long-term results of the Cox-Maze III procedure for persistent atrial fibrillation associated with rheumatic mitral valve disease: 10-year experience Eur. J. Cardiothorac. Surg., February 1, 2007; 31(2): 261 - 266. [Abstract] [Full Text] [PDF]

				R. K. Ghanta, R. Chen, N. Narayanasamy, S. McGurk, S. Lipsitz, F. Y. Chen, and L. H. Cohn Suture bicuspidization of the tricuspid valve versus ring annuloplasty for repair of functional tricuspid regurgitation: Midterm results of 237 consecutive patients J. Thorac. Cardiovasc. Surg., January 1, 2007; 133(1): 117 - 126. [Abstract] [Full Text] [PDF]

				G. H. L. Tang, T. E. David, S. K. Singh, M. D. Maganti, S. Armstrong, and M. A. Borger Tricuspid Valve Repair With an Annuloplasty Ring Results in Improved Long-Term Outcomes Circulation, July 4, 2006; 114(1_suppl): I-577 - I-581. [Abstract] [Full Text] [PDF]

				H.-K. Kim, Y.-J. Kim, K.-I. Kim, S.-H. Jo, K.-B. Kim, H. Ahn, D.-W. Sohn, B.-H. Oh, M.-M. Lee, Y.-B. Park, et al. Impact of the Maze Operation Combined With Left-Sided Valve Surgery on the Change in Tricuspid Regurgitation Over Time Circulation, August 30, 2005; 112(9_suppl): I-14 - I-19. [Abstract] [Full Text] [PDF]

				A. Matsunaga and C. M. G. Duran Progression of Tricuspid Regurgitation After Repaired Functional Ischemic Mitral Regurgitation Circulation, August 30, 2005; 112(9_suppl): I-453 - I-457. [Abstract] [Full Text] [PDF]

				J. M. Bernal, D. Morales, C. Revuelta, J. Llorca, J. Gutierrez-Morlote, and J. M. Revuelta Reoperations after tricuspid valve repair J. Thorac. Cardiovasc. Surg., August 1, 2005; 130(2): 498 - 503. [Abstract] [Full Text] [PDF]

				J. M. Bernal, J. Gutierrez-Morlote, J. Llorca, J. M. San Jose, D. Morales, and J. M. Revuelta Tricuspid Valve Repair: An Old Disease, a Modern Experience Ann. Thorac. Surg., December 1, 2004; 78(6): 2069 - 2074. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Katsuhiko Matsuyama Masahiko Matsumoto Takaaki Sugita Junichiro Nishizawa Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Matsuyama, K. Articles by Matsuo, T. Search for Related Content PubMed PubMed Citation Articles by Matsuyama, K. Articles by Matsuo, T.