Outcome of consistent guideline-based tricuspid management in patients undergoing degenerative mitral regurgitation correction

Gilles D Dreyfus; Benjamin Essayagh; Giovanni Benfari; Filip Dulguerov; Shelley Rahman Haley; Carine Dommerc; Adelin Albert; Maurice Enriquez-Sarano

doi:10.1016/j.xjon.2021.07.010

Outcome of consistent guideline-based tricuspid management in patients undergoing degenerative mitral regurgitation correction

JTCVS Open. 2021 Jul 20:7:125-138. doi: 10.1016/j.xjon.2021.07.010. eCollection 2021 Sep.

Authors

Gilles D Dreyfus^{1

2

3}, Benjamin Essayagh^{3

4

5}, Giovanni Benfari⁵, Filip Dulguerov³, Shelley Rahman Haley², Carine Dommerc³, Adelin Albert⁶, Maurice Enriquez-Sarano⁵

Affiliations

¹ Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France.
² Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
³ Cardiothoracic Center of Monaco, Monte Carlo, Monaco.
⁴ Department of Cardiovascular Medicine, Simone Veil Hospital, Cannes, France.
⁵ Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn.
⁶ Department of Biostatistics, University Hospital of Liege, Liege, Belgium.

Abstract

Objectives: Despite coherent guidelines, management of functional tricuspid regurgitation (FTR) consequences on outcome in the context of degenerative mitral regurgitation (DMR) remains controversial due to lacking series of large magnitude with rigorous application of tricuspid guidelines and strict long-term echocardiographic follow-up. Thus, we aimed at gathering such a cohort to examine outcomes of patients undergoing DMR surgery following tricuspid surgery guidelines.

Methods: All consecutive patients with isolated DMR 2005-2015 operated on with baseline FTR assessment and tricuspid annulus diameter measurement were identified. Operative complications, postoperative tricuspid regurgitation incidence, and survival were assessed overall and stratified by guideline-based tricuspid annuloplasty (TA) indication (severe FTR or tricuspid annulus diameter ≥40 mm).

Results: Among 441 patients with DMR undergoing mitral repair (66 ± 13 years, 30% female, ejection fraction 66 ± 10%, systolic pulmonary artery pressures 39 ± 12 mm Hg) followed 6 [3-9] years, patients with TA (n = 234, 53%) had generally similar presentation versus without TA (n = 207, 47%; all P ≥ .2) except for more atrial fibrillation and larger left ventricle (both P ≥ .0003). Patients with TA showed longer bypass time, more maze procedures (all P ≤ .001), but hospital stay, renal-failure, pacemaker implantation, and operative mortality (overall 0.9%) were comparable (all P ≥ .2). Postoperative incidence of moderate/severe FTR (0% at 1 year) became over time greater among patients without TA (5-year 8% [4%-13%] vs 3% [1%-11%] and 10-year 10% [6%-16%] vs 4% [1%-16%], P = .01). Survival (95% confidence interval) throughout follow-up was 85% (77%-89%) at 10 years, with hazard ratio 0.57 (0.29-1.10), P = .09. for patients with TA versus without.

Conclusions: In this large surgical DMR cohort, guideline-based FTR management was safe and effective. While long-term mortality did not reach significance, postoperative incidence of moderate/severe FTR, overall low, was nevertheless greater in patients who did not appear to require TA at surgery and linked to tricuspid annular dimension. Thus, future multicenter prospective cohorts with long-term follow-up are warranted to re-examine thresholds for TA performance and impact on survival.

Keywords: ACC/AHA guidelines; AFib, atrial fibrillation; CI, confidence interval; DMR, degenerative mitral regurgitation; FTR, functional tricuspid regurgitation; GLMM, generalized linear mixed model; LV, left ventricle; MR, mitral regurgitation; NYHA, New York Heart Association; OR, odds ratio; TA, tricuspid annuloplasty; TAd, tricuspid annulus diameter; TR, tricuspid regurgitation; mitral valve repair; tricuspid annular diameter; tricuspid regurgitation.