Long-Term Outcomes of Tricuspid Valve Repair or Replacement in Patients Undergoing Mitral Valve Replacement for Reumatic Mitral Valve Disease with Severe Tricuspid Regurgitation

Background: Current guidelines recommend concomitant tricuspid valve surgery; either repair (TVr) or replacement (TVR) in patients with moderate to severe tricuspid regurgitation undergoing mitral valve replacement. However, limited evidence is available regarding the long-term results of such operation in the presence of severe TR.

Aim: To analyze major clinical outcomes and echocardiographic variables of concomitant TVr or TVR for severe TR among patients undergoing mitral valve replacement (MVR) for rheumatic mitral valve disease.

Methods: between 1/2000- 12/2011, 130 patients underwent MVR due to rheumatic heart disease at Rabin Medical Center. Of them, 39 had severe TR. Twenty patients underwent TVR and 19 TVr. Long term echocardiographic and clinical data (mean follow-up 8.6±4.4 years) was retrospectively collected. TR was graded as mild=1, moderate=2; severe=3.

Results: Compared with the TVr group, in the TVR group there were more patients with re-operations, tricuspid stenosis and organic tricuspid valve disease (p<0.05). The tricuspid valve annular diameter was similar between groups (40.4±4.4 vs 37.5±4.2, respectively, p=0.07). Follow-up analysis demonstrated comparable survival rate between groups (p=0.3). In the TVR group, 3 patients underwent re-intervention d/t structural tricuspid valve deterioration (SVD): 2 transcatheter valve in valve (VIV) replacement and 1 surgical re-operation compared with 2 surgical TVR d/t recurrent TR (p=ns) in the TVr group. A similar residual TR but higher TV gradients were observed in the TVR group (1.1±1.3 vs 1.1±0.6, p=0.8 and 4.8±1.8mmHg vs 2.8±0.5 mmHg, respectively, p<0.001).

Conclusions: Combined TVr or TVR in rheumatic patients with severe TR undergoing MVR is associated with similar long term mortality. TVr results in lower trans TV gradient, comparable degree of late recurrence TR and similar rate of re-intervention when compared to TVR. However, the contemporary availability of VIV procedure for SVD after TVR avoids the need for re-operation.