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Ann Thorac Surg 2005;79:127-132
© 2005 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Trust, Harefield Hospital, Harefield, Middlesex, United Kingdom
Accepted for publication June 4, 2004.
* Address reprint requests to Dr Dreyfus, Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Trust, Harefield Hospital, Hill End Rd, Harefield, Middlesex UB9 6JH, UK (E-mail: g.dreyfus{at}rbh.nthames.nhs.uk).
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Abstract |
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METHODS: Between 1989 and 2001, 311 patients underwent mitral valve repair (MVR). The tricuspid valve was examined in each patient. Tricuspid annuloplasty was performed only if the tricuspid annular diameter was greater than twice the normal size (
70 mm) regardless of the grade of regurgitation. Patients in group 1 (163 patients; 52.4%) received MVR alone. Patients in group 2 (148 patients; 47.6%) received MVR plus tricuspid annuloplasty.
RESULTS: Although not significant there was a difference with regard to hospital mortality (group 1 = 1.8%, group 2 = 0.7%) and actuarial survival rate (Kaplan–Meier: group 1 = 97.3%, 96.2%, and 85.5%; group 2 = 98.5%, 98.5%, and 90.3% at 3, 5, and 10 years, respectively). The New York Heart Association (NYHA) functional class was significantly improved in group 2 (group 1 = 1.59 ± 0.84; group 2 = 1.11 ± 0.31; p1). TR increased by more than two grades in 48% of the patients in group 1 and in only 2% of the patients in group 2 (p < 0.001).
CONCLUSIONS: Remodeling annuloplasty of the tricuspid valve based on tricuspid dilation improves functional status irrespective of the grade of regurgitation. Considerable tricuspid dilatation can be present even in the absence of substantial TR. Tricuspid dilatation is an ongoing disease process that will, with time, lead to severe TR.
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Introduction |
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An understanding of the pathological process of functional TR is necessary to determine the optimal management strategy for this condition. The tricuspid annulus is a component of both the tricuspid valve and the right ventricle. For the tricuspid valve to leak, the tricuspid annulus and hence the right ventricle has to be dilated [3–6]. If the tricuspid annulus and the right ventricle are not dilated, there is a very low probability that TR can occur [4, 5]. Dilatation of the tricuspid annulus is only possibility with regard to its anterior and posterior aspects. These correspond to the free wall of the right ventricle (Fig 1). In addition to tricuspid dilatation, three important factors determine whether TR occurs: the preload, the afterload, and the right ventricular function. This may explain why TR is difficult to accurately assess because these factors can interfere with regard to the severity of TR under different conditions. Significant TR may not be detected echocardiographically despite considerable pathology in the tricuspid valve and yet this may exhibit an influence on the functional capacity of patients and subsequent progression of TR [6].
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As tricuspid annular dilatation seems to be the underlying mechanism regarding nonorganic TR, it may be a more reliable indicator of tricuspid valve pathology compared with TR. Moreover successful treatment of secondary tricuspid valve pathology may necessitate the correction of tricuspid annular dilatation in addition to mitral valve surgery. This has been our practice during the past 12 years. We have prospectively recorded all the patient data to determine if tricuspid valve repair (TVR) for secondary tricuspid valve dilatation irrespective of the severity of TR improves outcome.
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Material and Methods |
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As a first stage the mitral valve was approached through a left atriotomy in the atrial-ventricular groove. The mitral valve was repaired using standard techniques. Ring annuloplasty was used in all cases. As a second stage the right atrium was opened vertically in all patients irrespective of the grading of preoperative TR. The tricuspid annular diameter was measured from the anteroseptal commissure to the anteroposterior commissure using a supple ruler (Fig 2). Patients with a tricuspid annular dimension greater than or equal to 70 mm underwent a remodeling tricuspid annuloplasty: 144 patients were operated on using a semirigid Carpentier-Edwards ring that was inserted using a series of 3-0 ethibond mattress sutures and 4 patients were operated on using a De Vega annuloplasty. The ring was manually distorted to fit the geometry of the tricuspid annulus that is deeper in the septal area than it is in the anterior area. A size 34 mm ring was routinely used for males and a size 32 mm ring was routinely used for females. Patients were divided into two groups according to the presence or absence of tricuspid dilatation: group 1 patients did not exhibit tricuspid dilatation (ie, tricuspid annular dimension was < 70 mm) and received isolated MVR (n = 163). Group 2 patients underwent tricuspid dilatation (ie, tricuspid annular dimension was 70 mm) and received MVR and TVR (n = 148).
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The two-sample t test was used when the data in each sample exhibited approximately normal distributions; the means ± standard deviations are given. The Mann–Whitney (nonparametric) test was used when the data was not normally distributed. The 
2 test was used for binary data; in these instances, we have provided the percentages and the frequencies. The survival rate was estimated using the Kaplan–Meier method and the log-rank test was used to compare survival curves. Computations were carried out using Minitab Release 12 (Minitab Inc., State College, PA) and S-Plus (Insightful Corp., Seattle, WA). Values of p less than 0.05 indicate significant evidence of a difference in the two groups.
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Results |
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TopAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Postoperative in-hospital morbidity comparisons are listed in Table 4. There was no statistical evidence of a difference regarding postoperative morbidity in the two groups. No systolic anterior motion occurred among the 311 patients who underwent MVR. In group 2 there was 1 patient who required reoperation for a failed DeVega annuloplasty 4 days after the initial operation.
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Echocardiographic data are given in Table 5. The mean MR grade was 0.4 ± 0.5 in group 1 and 0.6 ± 0.7 in group 2 (p = 0.015). The TR grade was significantly improved for group 2 (0.4 ± 0.6) compared with group 1 (2.1 ± 1.0) (p = 0.0001). Postoperative TR grading is provided in Table 3. The TR grade increased by 1.4 ± 1.1 in group 1 and decreased by 0.5 ± 0.9 in group 2 (p < 0.001). More late TR (p = 0.085) did not significantly develop in patients with Barlow's disease.
Five late deaths occurred in group 1 and two late deaths occurred in group 2. The causes of deaths were cardiac related for 2 patients in group 1 (1 patient died post-TVR 7 years after undergoing the first operation and 1 patient died at 83 years of age 8 years after the initial operation attributable to a subsequent cardiac arrest). The actuarial survival rate was 97.3% (confidence interval [CI] 94.7%–99.9%), 94.5% (90%–99.1%), and 85.4% (72.5%–98.4%) at 3.3, 6.5, and 9.5 years, respectively, in group 1 and 98.5% (96.5%–100%) and 90.3% (74.8%–100%) at 1.2 and 8 years, respectively, in group 2 (Fig 3). There was no evidence that the survival curves differed (p = 0.45).
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Comment |
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TopAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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The converse, however, is not true and considerable functional TR can only occur when there is considerable tricuspid annular dilatation, however little is known regarding the normal and pathological size of the tricuspid valve. As tricuspid dilatation is the only constant feature with regard to secondary tricuspid pathology, we have prospectively analyzed all tricuspid orifices in patients undergoing MVR. All patients whose tricuspid annular dimension was dilated to greater than twice the normal size (ie, > 70 mm) underwent TVR in addition to MVR. Although this threshold size for tricuspid annuloplasty was not correlated to patient size, the body surface area was the same in both groups as is indicated in Table 4. Significant TR was not detected for the majority of these patients during preoperative assessment even though the tricuspid annular diameter was dilated to greater than twice the normal size. Most of the patients with tricuspid dilatation (88%) indicated grade 0 or 1 TR at preoperative echocardiographic assessment. There is thus no correlation between TR and tricuspid dilatation. We therefore believe that tricuspid dilatation is a more reliable indicator of tricuspid pathology as, unlike TR, it is a constant measurement and not related to any other factors.
Our method of assessing the tricuspid annular dimension in the arrested heart measures the maximal diastolic size of the tricuspid annulus between the anteroseptal and anteroposterior commissure (ie, the part of the annulus that dilates [Fig 1 and 2]). This measurement is reliable, reproducible, and allows comparison with regard to different tricuspid orifices. We do not measure the total circumference of the tricuspid orifice, which would give the true diameter, for two reasons: (1) echocardiographic data validating the assessment of tricuspid circumference has not been indicated and (2) commercially available sizers for such large orifices are not currently available.
This method has indicated reliability (ie, free of preload and afterload). The importance of measuring the tricuspid annular diameter is supported by many authors [10] and echocardiographic studies have indicated that tricuspid annular dilatation is the most consistent and most important predictor of TR [6, 11]. However preoperative assessment of tricuspid annular diameter using echocardiography or even using cardiac magnetic resonance scans is problematic because it is still dependent upon the preload and afterload conditions of the patient at the time of measurement. We are aware that this intraoperative sizing does not reflect reality as in systole. Even in diastole the size of the tricuspid orifice cannot be as wide. However tricuspid annular dilatation (similar to mitral annular dilatation) is associated with a decrease of systolic contraction of the annulus and the tricuspid annulus remains in a more or less permanent diastolic position. Just as in mitral annuloplasty, tricuspid annuloplasty changes an orifice that remains permanently in a diastolic position into a permanent systolic position.
Because we did not possess reliable preoperative sizing of the tricuspid annulus, we have systematically examined all tricuspid orifices irrespective of the preoperative grading of TR. Two important points can be stated with regard to our practice. First we have been very conservative as we decided not to correct annular dilatation that did not reach greater than twice the normal size. Therefore all orifices measuring less than 70 mm were left untreated. An increase in tricuspid annular diameter to twice the normal size would, in fact, correspond to and cross-sectionally increase to four times its normal size. Some authors have suggested treating dilatation at an earlier stage. This might be correct however the necessity exists to perform further studies to determine the threshold size for tricuspid annular dilatation beyond which it should be repaired. Second the incidence of tricuspid valve treatment approaches 48% for all patients undergoing mitral valve surgery at our practice. This is extremely high [12, 13] and specifies an incidence rate approaching 30%.
For many decades it has been thought that functional tricuspid valve disease was strictly related to left-sided lesions such as mitral stenosis or MR. It was thought that once the left-sided lesions were treated, functional tricuspid pathology would regress spontaneously. The term "functional" is probably misleading in this instance as it is now well-established that the main factor causing TR is tricuspid dilatation indicating that anatomical abnormalities do exist. This suggests the notion that once the annulus is dilated, perhaps it can return to normal. This, however, seems very unlikely [11]. The annulus is partly a component of the valve, but it is also a ventricular component. Therefore if the annulus is dilated, the right ventricle is also dilated. Our study demonstrates that secondary TR is an ongoing process, as during follow-up an increase in the TR by at least two grades subsequently developed in 45% of the patients who received isolated MVR. Eleven patients graded 0 preoperatively were assessed as grade IV at follow-up and 38 patients graded I preoperatively were assessed as grade III at follow-up. We have analyzed whether other factors could have influenced this outcome. Residual pulmonary pressures were not substantially different in both groups. Even pulmonary hypertension greater than 50 mm Hg systolic preoperatively did not play any role in the postoperative assessment. We have also analyzed the residual MR. Surprisingly the residual MR was significantly greater at 0.60 in group 2 as opposed to 0.41 in group 1 (although not significantly so). This clearly demonstrates that without considerable MR, TR can worsen. Contrary to current beliefs, TR does not spontaneously disappear once the left lesion has been corrected. The data demonstrates that once the annulus is dilated and, consequently, the right ventricular function mildly impaired, the process of TR is progressive and will subsequently become clinically relevant.
The slightly longer cross-clamp time and the addition of a new prosthetic ring did not seem to influence morbidity as indicated by similar inotropic requirements and the intensive care duration of the two groups. Although the patients in group 2 were slightly more debilitated when the surgery was performed, their functional capacity at late follow-up was markedly improved compared with those in group 1.
Functional class and echocardiographic data were obtained during follow-up by local cardiologists and not by the team who had treated the patients. We, therefore, believe these results to be unbiased. Although actuarial survival rates were not significantly different for both groups, it seems quite favorable that extremely ill patients with larger right ventricles manifest the same late survival rate as those without annular dilatation. One could speculate that treating tricuspid dilatation impacts right ventricular function and subsequently aids in preventing deaths related to such a condition. Only 1 patient in group 1 required repeat surgery 8 years after the initial operation and subsequently died in the postoperative period. However it is well-known that hospital mortality is extremely high with regard to redo surgery of isolated secondary severe TR [10] and that medical treatment for such patients is rather limited and inefficient.
This study was apportioned with more than 300 patients, some of whom have also been followed-up for more than 10 years. Follow-up analysis has revealed that tricuspid annuloplasty performed at the time of mitral valve surgery improves functional capacity. A precise method used for sizing the tricuspid orifice has been defined. It is simple, expedient, and reproducible. However the threshold size to correct tricuspid dilatation requires further study and perhaps lesser degrees of tricuspid dilatation should also be corrected. Finally this study demonstrates that there is little or no correlation between tricuspid dilatation and regurgitation and that tricuspid dilatation is more reliable than TR when assessing secondary tricuspid valve disease. The aim of treating tricuspid annular dilatation at the same time that mitral valve surgery is performed is to prevent future treatment of symptomatic TR. This approach, which is based on tricuspid dilatation and not TR, allows more adequate treatment with regard to tricuspid pathology&mdasha condition that typically remains indiscriminate for extended periods of time, but becomes a considerable challenge when clinically relevant.
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