The relationship of atrial fibrillation and tricuspid annular dilation to late tricuspid regurgitation in patients with degenerative mitral repair

Abstract

Objectives: Guidelines do not address preoperative atrial fibrillation when considering adding tricuspid annuloplasty to mitral surgery. Our purpose was to determine the occurrence of late tricuspid regurgitation in patients with less than moderate tricuspid regurgitation undergoing surgery for degenerative mitral regurgitation and the importance of atrial fibrillation and tricuspid annular dilation.

Methods: From 2004 to 2017, 1021 patients underwent surgery for degenerative mitral regurgitation; 869 (85%) had less than moderate tricuspid regurgitation, and 846 (97%) underwent repair. Preoperative atrial fibrillation was present in 199 patients and ablated in 194 patients (97%). Tricuspid annular diameter was measured in 657 of 869 patients (76%).

Results: For patients who did not receive tricuspid annuloplasty, recurrent moderate or more late tricuspid regurgitation was 8% (45/576) in the no atrial fibrillation group and 25% (38/154) in the atrial fibrillation group (P < .001; odds ratio, 2.42). In 75.2% of patients (494/657), the tricuspid annulus was less than 4.0 cm; in 17% of patients (112), the tricuspid annulus was 4.0 to 4.4 mm (mean 41.1 mm); and in 7.8% of patients (51), the tricuspid annulus was 45 mm or more (47.8 mm). Only tricuspid diameter 45 mm or more was a risk for late tricuspid regurgitation (P = .002; odds ratio, 3.25). Progression to moderate or higher tricuspid regurgitation was associated with an increase in long-term mortality: unadjusted hazard ratio, 3.58 (2.04-6.29) (P < .001); adjusted hazard ratio, 2.37 (1.23-4.57) (P = .010).

Conclusions: Preoperative atrial fibrillation is an important risk factor for late tricuspid regurgitation despite concomitant ablation surgery. Tricuspid annular dilation was not associated with late tricuspid regurgitation until the annulus was 45 mm or greater. Progression to moderate or greater tricuspid regurgitation was associated with an increase in late mortality.

Keywords: atrial fibrillation; degenerative mitral regurgitation; mitral valve repair; tricuspid annular dilation; tricuspid regurgitation.