Central Annals of Vascular Medicine & Research

Cite this article: Saitto G, Russo M, Nardi P, Gislao V, Scafuri A, et al. (2016) Tricuspid Valve Annuloplasty during Mitral Valve Surgery: A Risk or an Additional Benefit? Ann Vasc Med Res 3(1): 1026.

*Corresponding authorGuglielmo Saitto, Department of Cardiac Surgery, Tor Vergata University of Rome, Viale Oxford 81, Rome, Italy, Tel: 390620908235; Fax: 390620903868; E-mail:

Submitted: 04 April 2016

Accepted: 15 April 2016

Published: 19 April 2016

ISSN: 2378-9344

Copyright© 2016 Saitto et al.

OPEN ACCESS

Keywords•Tricuspid valve•Mitral valve•Right ventricle•Surgical risk

Research Article

Tricuspid Valve Annuloplasty during Mitral Valve Surgery: A Risk or an Additional Benefit?Guglielmo Saitto1*, Marco Russo1, Paolo Nardi1, Valentina Gislao1, Antonio Scafuri1, Antonio Pellegrino1 and Giovanni Ruvolo1

Department of Cardiac Surgery, Tor Vergata University of Rome, Italy

Abstract

The association of Tricuspid Regurgitation (TR) to left side heart valve diseases is common but surgical indications during left side heart surgery is still controversial and tricuspid valve annuloplasty (TVA) ranging from more than 60% to 6% depending on each single institution strategy. This study aims to evaluate clinical and instrumental results of adjunctive TVA during left side heart valve surgery also in case of non-severe TR but only annular dilation. We retrospectively analyzed 20 consecutive patients (mean age 71±7 yo, 70% females) who underwent during 2015 to adjunctive TVA by means of De Vega (12 patients) or Kay (8 patients) techniques during left side heart operation for mitral valve regurgitation or steno insufficiency: 14 patients underwent mitral valve replacement (6 combined operation: 2 CABG, 2 AVR and 2 PFO) and 6 to repair (one combined for PFO). Mean CBP and cross clamp time was 126±34 and 101±27minutes respectively. Mean Euroscore II was 4.9±4.4%. In-hospital mortality was 5%. No postoperative MI or strokes were noticed. Three patients had a new atrial fibrillation (15%), but no onset of BAV was noticed and no PPMK was necessary. At discharge, 18 patients (90%) had no TR more than 1+, and only 1 patient had mild (2+). Mean postoperative in hospital stay was 13±18 days. At short term follow up (8.7±3.8 months) no patients had a TR >2+. In conclusion additional TVA takes short operative time and seems to be a low-risk procedure with stable good results at short term follow up.

ABBREVIATIONSAVR: Aortic Valve Replacement; BAV: AtrioVentricular Block;

CABG: Coronary Artery Bypass Grafting; CPB: Cardiopulmonary Bypass; CVVH: ContinuosVeno-Venous Hemofiltration; ECC: Extracorporeal Circulation; FU: Follow-up; IABP: Intra Aortic Ballon Pump; ICU: Intensive Care Unit; MI: Myocardial Infarction; MVR: Mitral Valve Replacement; MVRep: Mitral Valve Repair; PAH: Pulmonary Artery Hypertension; PFO: Patent Forame Ovale; PPM: Patient Prosthesis Mismatch; PPMI: Permanent Pacemaker Implantation; TR: Tricuspid Regurgitation; TVA: Tricuspid Valve Annuloplasty

INTRODUCTIONSurgical indications in tricuspid regurgitation (TR) in

patients with less than severe tricuspid regurgitation that are undergoing left side heart surgery are still controversial. Usually TR is associated to mitral regurgitation (MR), mitral stenosis, and aortic stenosis [1]. Approximately 30% to 50% of patients with severe MR have significant FTR [2,3]. In these settings the range

of concomitant tricuspid valve annuloplasty ranging from more than 60% to <6% depending on more or less aggressive strategy point of view of each single institution [4-7] The safety and efficacy of tricuspid annuloplasty [8-10] associated to the high incidence of significant TR after isolated MV operation [11,12] to the adverse impact of TR on long-term mortality [11,13,14] morbidity [8,13] and functional outcome [11] led more and more surgeons to perform a TVR also on less than severe TR in case of annulus dilation [15]. Data on the effect and on the benefits of concomitant tricuspid annuloplasty on progression of TR, ventricular remodeling, and pulmonary artery hypertension (PAH) and clinical status after degenerative MV repair are lacking. The aim our study was to retrospectively analyze the impact on clinical outcomes of adjunctive TVR procedure at time of left heart valve surgery performed in our center during 2015 to evaluate the need and the benefits of this procedure.

MATERIALS AND METHODS In 2015, at Cardiac Surgery Unit of Tor Vergata University of

Rome, 20 consecutive patients (mean age 71±7 yo, 70% females)

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underwent left side heart surgery for mitral valve regurgitation or steno insufficiency received a concomitant tricuspid valve annuloplasty (TVA). 15 patients (65%) had indication for surgery for severe mitral valve regurgitation: in 9 of there a concomitant surgery was needed for coronary artery disease in 2 cases, aortic valve stenosis (1 patient) or regurgitation (1 patient) and for patent of foramen ovale in 3 cases; 5 patients had mitral valve steno insufficiency. Among the patients, 4 (20%) were in NYHA class II, 16 (80%) were in NYHA class III or IV. No patients were symptomatic for angina in Canadian Cardiothoracic Society class III/IV. Hypertension was present in 15 (75%) patients. No patient had a history of previous myocardial infarction. 2 patients (10%) had a coronary artery disease needing CABG. 7 (35%) had diabetes mellitus dependent by insulin. 5 (25%) patients had chronic renal failure no one required preoperative dialysis. No one patient had chronic pulmonary disease. Preoperative atrial fibrillation was present in 14 patients (70%). Just one patient (4%) had a history of cerebral stroke and previous cardiac surgery. One patient (4%) had a previous percutaneous mitral valvulopasty. All patients (100%) ha moderate to severe pulmonary hypertension at the preoperative echocardiography with a mean value of 61±22 mmHg. The mean EuroSCORE II was 4.9±4.4. The main preoperative features for the patients are listed in (Table 1).

All patients underwent conventional sternotomy except one who had minimally invasive surgery by means of right thoracotomy. In patients underwent conventional sternotomy, the heart was exposed through a median longitudinal sternotomy. After heparinization and aortic cannulation, a venous cannula was placed into the superior and into the inferior vena cava. The extra- corporeal circulation (ECC) system comprised a roller pump and a membrane oxygenator and a tubing system. Following aortic cross- clamping, in 10 patients (50%) we used

a hematic warm cardioplegic solution administered via the aortic root for 4 min and repeated every 20 min according to Calafiore protocol. The other 10 patients (50%) had a single dose of crystalloid solution by means of Custodiol HTK administered directly in aortic root or in coronary ostia in case of aortic regurgitation. After valve reconstruction and weaning from ECC, protamine was administered to antagonize the effect of heparin. In the patient who underwent minimally invasive surgery (MVRp and TVP), the cardio- pulmonary bypass system was connected by cannulating the femoral vessels. A venous cannula was advanced into the superior vena cava (tubing system, Edwards Life sciences Ltd, Irvine, CA, USA) and a second venous cannula was percutaneously placed into the internal jugular vein. After commencing ECC, a right anterolateral mini-thoracotomy was performed. Additionally, two incisions were made for the camera port, the left atrial retractor. The aortic Endo-clamp (Edwards Life sciences Ltd, Irvine, CA, USA) was used and cardioplegic arrest was achieved by instilling via the aortic root a Custodiol HTK solution, once. All patients affected by mitral stenoinsufficiency underwent MVR. In case of mitral regurgitation the decision to perform repair or replacement and the prostheses used were at the surgeon’s discretion. The left atrium was opened through the interatrial sulcus in all cases. In the two case of concomitant AVR; a biological prosthesis was used in both cases. Concomitant CABG was performed before valvular procedure on main coronary vessels or branches that displayed luminal stenoses of 70% or more on preoperative angiography. Left Internal Thoracic Artery was used in one of two patients who underwent CABG for anterior descending artery. Other grafts were performed with autologous saphenous vein. For exposure of tricuspid valve an oblique right atriotomy was made in all patients. Kay procedure was performed by a 2-0 polyester suture passed through the tricuspid annulus at the anteroposterior commissure and then at the center of the posterior leaflet and than through the annulus at the posteroseptal commissure. A second suture was passed for reinforcement. De Vega technique was perfomed by means of a 2-0 polyester suture passed counterclockwise and then clockwise as a circular stitch in the tricuspid annulus starting from 1 cm medial to the posteroseptal commissure to the base of the anterior leaflet 2cm medial to the anteroseptal commissure with a single pladgets incorporated at each end. Than the suture was tightened and tied after sizing new annular dimension. The mean duration of the adjunctive TVA procedure was 5±2 and 6±3 minutes for Kay and De Vega procedures respectively. All Intraoperative variables are shown in (Table 2). Statistical analysis was performed with the Stat View 4.5 program (SAS Institute Inc, Abacus Concepts, and Berkeley, CA, USA). The Student’s t test was used to analyze continuous data. All continuous variables were expressed as mean plus or minus 1 standard deviation of the mean. A p Value less than 0.05 were considered statistically significant.

RESULTS One patient had in-hospital mortality (5%) in the XV

postoperative days for low cardiac output and subsequently cardiogenic shock. No myocardial infarction or cerebral stroke was noticed. Three patients (15%) had an acute kidney injury in the postoperative stay and in two patients (8%) a postoperative CVVH therapy was needed. No atrio-ventricular conduction

Table 1: Preoperative Characteristics.

Characteristic

Age, years 71±7

Male gender, n.(%) 6 (30)New York Heart Association class, n(%)

IIIIIIIV

0(0)4(20)

11(55)5(25)

Hypertension, n.(%) 15(75)

Smoking habit, n.(%) 8(40)

Diabetes mellitus, n.(%) 7(35)

Hyperlipidemia, n.(%) 7(35)

Chronic renal dysfunction, n.(%) 5(25)

Previous stroke, n.(%) 1(5)Previous pacemaker implantation,

n.(%) 0(0)

Atrial Fibrillation Rhythm, n.(%)Pulmonary hypertension, n.(%)Previous cardiac surgery, n.(%)

EuroSCORE II, mean*

14(70)20(100)

1(4)4.9±4.4

*= +SDAbbreviations: SD: Standard Deviation

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disturbance was noticed and no patients needed a permanent pacemaker implantation. A new onset of atrial fibrillation was noticed in three patients (15%). One patient needed a mechanical circulatory assistance by means of postoperative IABP (5%). In three patients (15%) a pulmonary dysfunction was noticed and prolonged mechanical ventilation was needed. Mean ICU stays was 5.9 days (range 1–63) and the mean postoperative stay was 13.9 days (range 6–89). At time of discharge a postoperative echocardiograpy was performed in all patients and no patients showed a tricuspid regurgitation >2/4+. In 10 patients there were trivial TR, in 8 patients was 1+ and in one patients was 2+. The mean systolic pulmonary artery pressure was significantly reduced (31.4+7.3 mmHg) vs, preoperative value (p<0.0001). No differences were found between the two surgical techniques in terms of residual TR. Comparison between preoperative and echocardiographic variables at Hospital Discharge is shown in (Table 3).

At short follow up (mean follow up 8±3 months) we found no cardiac death or late death. No patients experienced thromboembolic events or endocarditis. No new permanent pacemaker implantation was needed. No patients needed a re-intervention. We found a significantly improvement of symptoms and functional class, mean NYHA class value at FU was 1.5±0.5 (p<0.0001 vs preoperative) and at FU echocardiography we found a significantly reduction of mean systolic pulmonary artery pressure, mean value 32.6±9mmHg (p<0.0001 vs preoperative; similar to discharge value). No patients had at follow up a TR value >2+ with a mean value of TR of 0.6±0.6 (p<0.0001 vs preoperative). Functional class improvement and tricuspid regurgitation value at follow-up is shown in (Table 4).

DISCUSSIONThe assessment of severity of TR is usually based on

qualitative method like color flow visualization but this is often

variable by many factors such as echocardiographic window used, instrument setting and hemodynamics. The most recent American Heart Association (AHA)/American College of Cardiology (ACC) guidelines [16] have evolved to the one from the European Society of Cardiology and the European Association for CardioThoracic Surgery [17] and suggest a much more aggressive approach to tricuspid valve surgery. This changed point of view is probably due to many recent articles and results showed a higher freedom from moderate TR at long term follow up and an improved recovery of right ventricle function and a reduction of pulmonary systolic artery pressure [5,15,18] especially when performing during mitral valve surgery [10]. The vena contracta width has been included in the latest ACC/AHA and European Society of Cardiology/European Association of Cardio- Thoracic Surgery guidelines as a method for judging the severity of TR and also in the recent ACC/AHA guidelines vena contact a width >7.0 mm is used to judge a TR as severe but is usually difficult to measure for multiple jet or elliptic valve

Table 2: Intra-operative Variables.

Variable

Cardiopulmonary By-pass, minutes 123±32

Aortic X-clamp, minutes 100±25Mitral Valve Replacement

+ AVR+ CABG

+ PFO closure

14 (60)222

Mitral Valve Repair+ PFO closure

6 (26)1

Tricuspid associated surgical procedures, n.(%)

KayDe Vega

20(100)8 (40)

12 (60)

Mean duration of TVA procedures, minKay

De Vega5±26±3

Mitral valve prostheses implanted:Mechanical, n.(%)Biological, n.(%)

5 (35)9 (65)

Abbreviations: AVR: Aortic Valve Replacement; CABG: Coronary Artery Bypass Grafting; PFO: Patent Forame Ovale; TVA: Tricuspid Valve

Annuloplasty

Table 3: Preoperative v/s Discharge Echocardiographic Values.

Variable Preoperative Discharge P ValueLeft ventricular end-diastolic

diameter, mm 56±11 49±9* ns

Left ventricular end-systolic diameter, mm 38±10 36±10* ns

Left ventricular end-diastolic volume, ml 121±65 101±66* ns

Left ventricular end-systolic volume, ml 55±52 54±50* ns

Left ventricular septum thickness, mm 11±2 11±2* ns

Posterior wall thickness, mm 11±2 11±2* nsLeft ventricular ejection

fraction, (%) 59±13 52±11* ns

Systolic Pulmonary Art. Pressure, mmHg 61±22 31±7° 0,000029

Tricuspid Regurgitation, mean value/4+ 2.9±1 0.5±0.6° 7e-12

Tricuspid Regurgitation >2+ 13 0 -

Tricuspid Annulus, mm 43±4 - -*p= ns vs. preoperative°p<0.0001 vs. preoperative

Table 4: Functional Class and TR value at follow-up.

Preoperative Discharge At Follow up p Value

New York Heart Association class 3±1 - 1.5±0.5 <0.0001*

Tricuspid Regurgitation, mean

value/4+2.9±1 0.5±0.6° 0.6±0.6°

Tricuspid Regurgitation >2+, n. 13 0 0

Systolic Pulmonary Art. Pressure, mmHg 61±22 31±7° 32±9°

*preoperative vs. follow up value°p<0.0001 vs. preoperativeAbbreviations: TR: Tricuspid Regurgitation

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orifice. Also a TA > 40 mm (or 21 mm/m2 diameter indexed to body surface area) is mentioned in the most recent (ACC/AHA; ESC) guidelines, as a Level IIa indication for a tricuspid surgical annuloplasty when associated with mild or moderate TR [16,17]. A lot of study showed that without surgical treatment any TR will worsen at long term follow up and won’t disappear after left heart surgery, after successful mitral valve repair [5,19]. In the last decades the approach to FTR is so changed and now is considered not a benign condition also when less than severe; in a recent meta-analysis of 2488 patients with mild to moderate FTR Kara et al. showed how TVA is associated to an higher freedom from progression to significant FTR and death at follow up [20]. The benefits of adjunctive TVA, especially in mitral valve surgery, result in a decreased risk of cardiac mortality and hospitalization for heart failure in patients with preoperative TR>2+ [21]. The risk factors for recurrent TR after TVA appear to be the lack of a ring annuloplasty, atrial fibrillation and the new significant left sided valvular lesion, primarily a development of mitral valve regurgitation after MVRep [22]. In case of mitral valve replacement one more consideration could be done on patient prosthesis mismatch (PPM). PPM is equated to residual mitral stenosis and could be associated to late TR and PAH especially during follow up after mitral valve replacement; for these reasons when PPM is anticipated at the time of operation an adjunctive TVA could find its surgical indication for the low surgical additive risk [23]. We need a longer follow up to assess the possible role and effect of PPM on development of recurrent TR and PAH in our patients.

In these settings we can imagine that a surgical procedure on TV can bring just benefits without incremental of surgical risk and some surgeons suggest a more aggressive strategy of an early repair also in moderate or mild TR at time of left heart surgery for mitral valve in case of annular dilation [15].

CONCLUSIONIn case of left heart valve surgery in which adjunctive TVA

is needed, also in case of high risk and long surgery we found DeVega or Kay procedure, a secure and reproducible techniques that requires very short additional operative time with low grade of TR at short follow up and good clinical improvements in terms of functional class and RV restoration. The operative risk of patients seems to be not so much increased by these adjunctive procedures. Of course our study has a short follow up and is the cohort of patients is too small but the perioperative results seem to be encouraging and the short term follow up confirms a stable result. More patients and a longer follow up are required to confirm these findings.

REFERENCES1. Carpentier A, Deloche A, Hanania G, Forman J, Sellier P, Piwnica A, et

al. Surgical management of acquired tricuspid valve disease. J Thorac Cardiovasc Surg. 1974; 67: 53-65.

2. Koelling TM, Aaronson KD, Cody RJ, Bach DS, Armstrong WF. Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. Am Heart J. 2002; 144: 524-529.

3. Cohen SR, Sell JE, McIntosh CL, Clark RE. Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. I.

Prevalence, diagnosis, and comparison of preoperative clinical and hemodynamic features in patients with and without tricuspid regurgitation. J Thorac Cardiovasc Surg. 1987; 94: 481-487.

4. Castillo JG, Anyanwu AC, Fuster V, Adams DH. A near 100% repair rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines. J Thorac Cardiovasc Surg. 2012; 144: 308–312.

5. Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair?. Ann Thorac Surg. 2005; 79: 127-132.

6. Gillinov AM, Mihaljevic T, Blackstone EH, George K, Svensson LG, Nowicki ER, et al. Should patients with severe degenerative mitral regurgitation delay surgery until symp- toms develop? Ann Thorac Surg. 2010; 90: 481-488.

7. Seeburger J, Borger MA, Falk V, Kuntze T, Czesla M, Walther T, et al. Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients. Eur J Cardiothorac Surg. 2008; 34: 760-765.

8. McCarthy PM, Bhudia SK, Rajeswaran J, Hoercher KJ, Lytle BW, Cosgrove DM, et al. Tricuspid valve repair: durability and risk factors for failure. J Thorac Cardiovasc Surg. 2004; 127: 674-685.

9. Filsoufi F, Salzberg SP, Coutu M, Adams DH. A three-dimensional ring annuloplasty for the treatment of tricuspid regurgitation. Ann Thorac Surg. 2006; 81: 2273-2277.

10. Benedetto U, Melina G, Angeloni E, Refice S, Roscitano A, Comito C, et al. Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery. J Thorac Cardiovasc Surg. 2012; 143: 632-638.

11. Calafiore AM, Gallina S, Iacò AL, Contini M, Bivona A, Gagliardi M, et al. Mitral valve surgery for functional mitral regurgitation: should moderate-or-more tricuspid regurgitation be treated? a propensity score analysis. Ann Thorac Surg. 2009; 87: 698-703.

12. Van de Veire NR, Braun J, Delgado V, Versteegh MI, Dion RA, Klautz RJ, et al. Tricuspid annuloplasty prevents right ventricular dilatation and progression of tricuspid regurgitation in patients with tricuspid annular dilatation undergoing mitral valve repair. J Thorac Cardiovasc Surg. 2011; 141: 1431–1439.

13. Sagie A, Schwammenthal E, Newell JB, Harrell L, Joziatis TB, Weyman AE, et al. Significant tricuspid regurgitation is a marker for adverse outcome in patients undergoing percuta- neous balloon mitral valvuloplasty. J Am CollCardiol. 1994; 24: 696-702.

14. Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol. 2004; 43: 405-409.

15. Chikwe J, Itagaki S, Anyanwu A, Adams DH. Impact of Concomitant Tricuspid Annuloplasty on Tricuspid Regurgitation, Right Ventricular Function, and Pulmonary Artery Hypertension After Repair of Mitral Valve Prolapse. J Am CollCardiol. 2015; 65: 1931-1938.

16. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. J Am CollCardiol. 2014; 63: 57-185.

17. Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, et al. Guidelines on the management of valvular heart disease (version 2012). Joint Task Force on the Manage- ment of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2012; 33: 2451-2496.

18. Desai RR, Vargas Abello LM, Klein AL, Marwick TH, Krasuski RA, Ye

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Saitto et al. (2016)Email:

Ann Vasc Med Res 3(1): 1026 (2016) 5/5

Saitto G, Russo M, Nardi P, Gislao V, Scafuri A, et al. (2016) Tricuspid Valve Annuloplasty during Mitral Valve Surgery: A Risk or an Additional Benefit? Ann Vasc Med Res 3(1): 1026.

Cite this article

Y, et al. Tricuspid regurgitation and right ventricular function after mitral valve surgery with or without concomitant tricuspid valve procedure. J Thorac Cardiovasc Surg. 2013; 146: 1126-1132.

19. Navia JL, Brozzi NA, Klein AL, Ling LF, Kittayarak C, Nowicki ER, et al. Moderate tricuspid regurgitation with left-sided degenerative heart valve disease: to repair or not to repair? Ann Thorac Surg. 2012; 93: 59-67.

20. Ibrahim K, Cengiz K, Alper E, Hakan S, Mucahit D, Bilal P, et al. Otucomes of mild to moderate functional tricuspid regurgitation in patients undergoing mitral valve operations: a meta-analysis of 2.488 patients. Ann Thorac Surg. 2015; 100: 2398-2407.

21. De Meester P, De Cock D, Van De Bruaene A, Gabriels C, Buys R, Helsen F, et al. Additional tricuspid annuloplasty in mitral valve surgery results in better clinical outcome. Heart. 2015; 101: 720-726.

22. Gatti G, Dell’Angela L, Morosin M, Maschietto L, Pinamonti B, Forti G, et al. Tricuspid Annuloplasty for Tricuspid Regurgitation Secondary to Left Sided Heart Valve Disease: Immediate Outcomes and Risk Factors for Late Failure. Can J Cardiol. 2015; In press article.

23. Angeloni E, Melina G, Benedetto U, Roscitano A, Refice S, Quarto C, et al. Impact of prosthesis-patient mismatch on tricuspid valve regurgitation and pulmonary hypertension following mitral valve replacement. Int J Cardiol. 2013; 168: 4150-4154.