Clinical Pearls & Morning Reports
The best treatment approach for patients with moderate or less-than-moderate tricuspid regurgitation at the time of surgery for degenerative mitral regurgitation is uncertain. Gammie et al. conducted a randomized trial in which patients with moderate tricuspid regurgitation or less-than-moderate tricuspid regurgitation with annular dilatation who were undergoing surgery for degenerative mitral regurgitation were randomized to concomitant tricuspid annuloplasty or mitral-valve surgery alone. Read the NEJM Original Article here.
Q: Is there consensus regarding the management of severe tricuspid regurgitation in patients undergoing mitral-valve surgery for degenerative mitral regurgitation?
A: Tricuspid regurgitation is common among patients undergoing mitral-valve surgery for degenerative mitral regurgitation. The recommendations for management of tricuspid regurgitation during mitral-valve surgery are based largely on observational data. There is broad agreement that severe tricuspid regurgitation may not predictably improve after left-sided cardiac surgery and should be addressed during the index procedure. Late reoperation for severe tricuspid regurgitation in patients with right heart failure is associated with high perioperative mortality.
Q: What are the benefits and risks that are weighed when considering tricuspid annuloplasty for the management of less-than-severe tricuspid regurgitation at the time of left-sided cardiac surgery?
A: The operative management of lesser degrees of tricuspid regurgitation is widely debated. Mild or moderate tricuspid regurgitation that is not corrected at the time of left-sided cardiac surgery may progress in approximately 25% of patients and result in poorer late survival and functional outcomes. Several single-center observational studies and a small randomized trial with an unblinded end-point assessment have suggested that concomitant tricuspid-valve repair in patients with moderate tricuspid regurgitation or less-than-moderate (i.e., none, trace, or mild) regurgitation with annular dilatation is associated with less disease progression and better outcomes than conservative management. Enthusiasm for uniform adoption of tricuspid-valve repair under these circumstances is tempered by concern regarding the excess risk of postoperative conduction disturbances resulting in permanent pacemaker implantation, an increase in cardiopulmonary bypass times, the small chance that tricuspid-valve replacement (rather than annuloplasty repair) may be needed, and the reality that tricuspid regurgitation does not progress in all patients.
A: In this international, randomized trial, the authors found that patients with moderate or less-than-moderate tricuspid regurgitation who were receiving tricuspid annuloplasty at the time of mitral-valve surgery for degenerative mitral regurgitation had a significantly lower 2-year incidence of a composite end point of reoperation for tricuspid regurgitation, progression of tricuspid regurgitation, or death than those undergoing mitral-valve surgery alone (3.9% vs. 10.2%; P=0.02). This difference was driven by a substantially lower incidence of progression of tricuspid regurgitation among patients assigned to receive tricuspid annuloplasty.
A: An important finding in this trial was the higher incidence of permanent pacemaker implantation in the tricuspid annuloplasty group (14.1% vs. 2.5%), with nearly 80% of procedures occurring during the index hospitalization. Permanent pacemaker implantation has been associated with the risks of device malfunction, thrombosis, infection, recurrent or progressive tricuspid regurgitation, right ventricular remodeling, and reduced survival. The use of leadless pacemakers and evolving transcatheter approaches may circumvent some of these issues, and additional study may help in the identification of procedural factors associated with permanent pacemaker implantation. Although the clinical effect of pacemaker implantation was not evident during the 2-year period, longer-term follow-up is needed to gain further insight.